2001 Legislative Session: 2nd Session, 37th Parliament
SELECT STANDING COMMITTEE ON HEALTH
MINUTES AND HANSARD

MINUTES SELECT STANDING COMMITTEE ON HEALTH Wednesday, November 7, 2001 9 a.m. Sheraton Guildford Hotel Surrey, B.C.

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON 
HEALTH

WEDNESDAY, NOVEMBER 7, 2001

Issue No. 14

ISSN 1499-4232

[ Page 597 ]

 WEDNESDAY, NOVEMBER 7, 2001

           The committee met at 9:01 a.m.

           [V. Roddick in the chair.]

           V. Roddick (Chair): Good morning, everyone. Welcome. As Chair of the Select Standing Committee on Health, which last sat in 1993-94, I just have a few opening comments. This committee has travelled to communities on Vancouver Island and above Hope to hear rural solutions for the betterment of health care. The turnout was terrific, positive, enthusiastic and exceedingly productive.

           We have chosen this spot on Highway 1 to listen to urban solutions, because it is absolutely central to both the Fraser Valley and the lower mainland, and it is readily accessible by bus, SkyTrain and car.

           A primary goal of the government of British Columbia is to save our health care. While we have suggestions and possible solutions emanating from such places as Europe, Singapore, Australia and the U.S., we also have a large pool of homegrown talent to draw upon. It is the mandate of this committee to seek out the expertise, imagination and commitment of British Columbians as we bring health back to health care.

           Simply throwing money at the system has proved to be a dismal failure. We need solutions, not rhetoric and certainly not allegiance to the status quo. We need a sound financial foundation on which to build. New management models must be explored, tested and applied across this province and across this country. The age of entitlement ended on September 11. We can no longer demand services as our due. We have to accept responsibility along with our rights. Even patients and their families have responsibility in using health care services prudently. This committee is committed to solutions, not just producing another dusty tome to be shelved somewhere. Health care is not a big-p political issue. It's a problem facing each and every one of us.

           There's $9.5 billion per year that has been committed. That's $2,375 per person in health care alone. This doesn't include the many more millions of dollars that come out of various other ministries including Human Resources, Children and Family Development, Aboriginal and Women's Services, nor the many millions of dollars raised by the tireless volunteers and volunteer fundraisers.

           Our patients and their families are not receiving the care that they are actually paying for through their tax dollars. In practical terms, we currently have a multi-tiered system. ICBC, WCB, professional athletes and a growing number of private clinics attest to that. We have reached a point where we need to visit all avenues of health, expertise and suggestions, both internal and external, to reach workable solutions.

[0905]

            Senator Michael Kirby and his Senate committee on health have given Canadians an uncomfortable set of choices if we want to save medicine. What services should be covered? How should those services be financed? How should those services be delivered? These three questions are the nuts and bolts of our whole country's health care. Even my local community newspaper, the Delta Optimist, has started carrying articles on such issues as long term care insurance to reduce reliance on government.

           In closing, I would like to quote Conservative Senator Marjory LeBreton: "We want to stop bailing and fix the boat." We are delighted with the packed agenda we have over the next three days. Ladies and gentlemen, please present the solutions.

           Good morning, Brian.

Presentations

            B. Schmidt: Good morning, hon. members. Thank you very much for the opportunity to present on behalf of the British Columbia Cancer Agency. I'm really here to tell you about a provincial program that's providing good services to British Columbians. We have some challenges, but what I want to say over the next few minutes is that we have a program that may be a model and may be a way to look at services in a way that provides a coherent and consistent framework for care and for services throughout the province. That's really what we do at the British Columbia Cancer Agency.

           It's because we have a government-mandated program for a comprehensive program of cancer control — which means prevention, early detection, diagnosis and treatment, rehabilitation, palliative care, support, and of course research and education — that we have some very good results on a Canadian basis. We provide results and outcomes that are equal to or better than anywhere else in Canada. We have, by Canadian standards, a very effective use of our resources when we look at our other colleagues and partners throughout the country.

           Currently, we have no significant wait-lists for cancer treatment. That, of course, is a very different story to two or three years ago, when we had significant wait-lists. It's really because of our ability to allocate resources and to use those resources most effectively, with the addition of appropriate capital resources, that we've been able to solve some of these problems. It doesn't mean the problems are not going to come back or will go away, but certainly we have more of a good-news story at this point in time. It's a matter of how to maintain that.

           The focus of the presentation today will be how to maintain and improve programs, recognizing constraints; how to utilize innovation and business relationships to mutual benefit; and a bit of a summary of where we see the hot spots in our provincial cancer control program. In terms of some of the facts, you may already be aware of some of these. On the second page of your outline I've mentioned that even though the population is growing at less than 1 percent a year, our cancer incidence is growing at 3 percent a year. Because we're getting more successful at treating patients, our cancer prevalence — the number of patients that prevail in the population and require ongoing support

[ Page 598 ]

and treatment — is increasing by almost 7 to 10 percent a year.

           Of course, part of the good news, because we are more successful, is that mortality is coming down slightly and our survival rates are also improving. Because of this we are also experiencing greater demands for increased treatments. We have, as I'm sure you've heard in other areas of drug therapy, horrendous demands for drugs and also other significant demands for the recapitalization of our very expensive radiation therapy equipment.

           Human resources. I don't think you've heard anyone say that human resources isn't a problem. In our particular provincial program there's not one professional group that doesn't have some challenge around the attraction, retention and training of the necessary human resources we need. This is a problem that we've seen across Canada in cancer programs, which will become much more significant over the next five to ten years. Of course, we believe strongly that research is a basis for improved knowledge. Knowledge will be the only way that we will eventually eliminate this disease.

[0910]

            What I'm presenting to you on the third page of the handout is what we believe to be the essential elements of any provincial program, really. I'm going to focus on the essential elements of our provincial cancer control program. You'll see by the check-marked areas that we have a program that is intact and is doing a good system job of providing cancer care services to the province. We're fortunate, because of our mandate, to have good provincial leadership and to have a population cancer registry and information base that allow us to identify population needs and to plan for them.

           We have the ability to define and maintain standards and guidelines for cancer care and treatment, and we apply those consistently across the province. We've maintained appropriate access throughout the province. I'll mention today that even though we're a tertiary program, over 60 percent of our care is provided outside of Vancouver. That's important for us, because access for patients with cancer treatment needs or screening needs or whatever has to be applied equally throughout the province.

           We also have been successful as a provincial organization in rebalancing and reallocating resources as needed. This has helped us to cope with the very serious problems that we've had over the last three to five years around wait-lists. We've been able to move resources from place to place so that we can contain problems in various areas of the province where we do provide cancer services.

           We have also developed workload and productivity standards within our provincial programs. That is an important element of a provincial program. We do provide, in concert with partners, patient and public education.

           We have the important capacity to evaluate the quality of our cancer control programs so that we can continuously improve them. We are also able to demonstrate effective outcomes through our research programs and to ensure the effective use of resources. We've developed, and need to continue to develop, opportunities for process redesign and program innovation. I'm saying to this assembly today that we could certainly do that better with more flexibility around how we can manage our human resources and other things.

           We also have business opportunities. There are opportunities for revenue generation in our sector without harming access to care for British Columbians. I think that's something you may want to discuss in the way of further opportunities.

           As well, we truly want to be accountable in this system. How we would like to relate to the very excellent partnerships we've had with government is that we want to be accountable for the outputs and the outcomes of our care. Sometimes we feel that it's a bit more process- and micromanagement-oriented. Really, where we're at is being given the accountability to provide a program and to produce certain outputs that are in accordance with the needs of the public.

           We also require, as a provincial program, an integrated and linked information system. We've been very successful in doing this. We're now providing further services to all of our partners and access information electronically around patient records. We're doing this in concert with the province to ensure confidentiality and that kind of thing. We're doing video conferencing of patient cases throughout the province. We see that a lot of the technology we've developed is applicable to other provincial programs or services. We're going to be making a presentation to the ministry in the next couple of weeks to tell them about that and to see how we can help and how we can learn from others as well.

           We also, as a provincial program, need to establish the system-wide needs for cancer control. In this regard, we've done a pretty good job of putting together our needs for treatment programs. As you know, we've been very fortunate to be able to open a new cancer centre in Victoria and that kind of thing. In addition to that, an important part of our cancer control program is our prevention and early detection programs. We have probably the nation's best screening mammography program and also a cervical cytology program that's seen as a standard throughout the world, really.

           There are other very, very essential screening programs that have strong evidence, in fact, around their efficacy for reducing mortality, which we are unable to do. We will look at reallocating resources, but there's only so much potential there. Certainly, colorectal cancer screening, for instance, is now a screening program that we must see as something to introduce into B.C. in the next little while.

[0915]

            We also work with regional health care authorities. A provincial program is, I believe, only as good as it can integrate with regional authorities to make this delivery seamless and use the strengths of the provincial program and also the strengths of the region to ensure that this is delivered in a way that meets the needs of the regions and the population inside those regions. We believe that working with fewer regions would be highly beneficial for us in doing that. That's

[ Page 599 ]

not to say that we haven't had good relationships now, but it's a little tougher, with so many regions, to really integrate care. We really see a need for creating more transparency of information and have been working with many authorities on doing that. There's much more to do, but I think it's really going to be a gold standard for the future to provide seamless care throughout all of our regional partners.

           The capacity to generate knowledge I won't dwell on any further, but it is extremely important. I would also say that the area of cancer research is one with tremendous economic development opportunities. Through Canadian and provincial grants and fundraising efforts we're going to be developing a state-of-the-art research facility in Vancouver. That facility will have the ability to bring in many millions of dollars in research grants. The spinoff effects for the province and for biotechnology and new biotechnology companies in this province, especially in the area of genomics, are tremendous. Any support that we can receive from you in that regard would be very, very helpful.

           The last three areas on my list are the ones that I would say are the hot spots. The area of establishing and allocating human capital resources — we do that, as a provincial program, within the resources we have, and we think we've done a pretty good job of that. We can always do better.

           There are two areas that are of serious concern. One is the area of drug costs. In the area of drug costs we know that there are serious constraints on the ability to meet all those needs. We have a provincewide program where we develop evidence around any cancer drug that we put forward to government. This year, for instance, that's in the range of about a $10 million increase in our $48 million budget. We think our budget, if it was left unconstrained, could easily be doubled within three or four years. It's a horrendous problem. We know that there are issues with the ability of government to meet those kinds of costs. What we would say in this regard is that if that is not possible, we need to work together on ethical frameworks and decision frameworks. This is not something simply that the B.C. Cancer Agency can do. We need partnerships and support from government to develop the decision-making tools to allow us to make the choices — the difficult choices, sometimes — that would be required.

           In the area of radiation therapy, we have a lot of machines that provide excellent service. They need to be replaced. We're going to be in the position of having to replace those on an ongoing basis. We are currently looking at some alternative service provider scenarios where we may be able to find some support for the capital costs. We're looking at those in the context of PPP arrangements, etc., — again, a serious problem.

           The attraction and maintenance of a sufficient specialized cancer care workforce is critical. These are generally individuals who aren't used to any great degree other than nursing in other parts of the health care system. They are really nationally competitive. They move easily all over the province, all over the country and, in fact, internationally. We need to ensure, in this case in particular, that we maintain competitive standards — compensation standards as well — that will allow us to attract and retain these people. I know that's going to be difficult sometimes, but we are facing problems as we speak around people who are being taken away into Ontario, for instance, where there are three new cancer centres being developed and opened in the next year. There are very, very few resources to train these individuals, and that's the last area of the planning of educational capacity. We are doing that, but we need to ensure that we do have at least a fair share of opportunity for residency positions. Unfortunately, we don't have that at this time.

           I'll leave it at that. The fourth page I've provided to you is simply a take-away which elaborates on the essential elements of a provincial cancer program and puts it into sentences as opposed to the cryptic of what I've just described. Thank you very much.

           V. Roddick (Chair): Thank you very much.

           Are there any questions from the members?

           K. Johnston: I was very interested, Brian, in talking about integrated information systems for cancer care. A couple of questions. First of all, did you develop that yourself, as an agency?

[0920]

            B. Schmidt: We did.

           K. Johnston: I also wanted to know how you've developed dealing with the privacy issue on electronic records and if you could just expand, in 30 seconds, on the video conferencing. Is that on diagnosis? I'm most interested in those three things.

           B. Schmidt: Our provincial program has been based on not only our…. We've driven our computer programs through the processes that we've developed to do our work. In fact, we shied away, about five years ago, from buying systems off the shelf unless they were really good for us. They just didn't have the flexibility to change and innovate and make your programs more efficient. It was kind of the other way around.

           We've developed this. We have one piece of software for all of our cancer centres. We have fibre-optic links. We work seamlessly throughout the system. We are readying the development of an electronic record for internal use within 18 months, and we have technology that the ministry is very interested in. We are part of ministry committees to look at the privacy issues. In fact, we're being used as a pilot centre for dealing with the transmission of electronic information over the Internet with encrypted technology and that kind of thing. We're doing this very much in lockstep with the Ministry of Health and its activities to ensure confidentiality.

           In addition, the video conferencing is really based on the fact that as a provincial program, we have about 11 or 12 what we call tumour groups. These are groups that focus their expertise on breast cancer or lung cancer or whatever and have weekly or bi-weekly meetings to conference all the patients. We have an oppor-

[ Page 600 ]

tunity to do that and share information across all of our cancer centres. Just last week we actually were doing that with some remote sites up north.

           Our vision here is to be able to have a general practitioner or to have a specialist who's up there be able to take part in a conference with professionals to decide on the best cancer treatment. We also have the opportunity to actually take that video clip and place it onto the clinical record, so it can be referenced later by individuals in the community.

           Our focus over the next year, through this extranet development, is on getting information to the community around cancer patients and their care and service.

           K. Johnston: As we've travelled across the north, specifically, there are some real challenges delivering and diagnosing health care. The specialists aren't there and that type of thing. I certainly hope that you'll be part of putting your programs and software forward to the total health care system. I'm happy to hear that you're on committees and stuff. It sounds as if you are already partway to a solution. Thank you very much.

           R. Hawes: Brian, I have a question that is a general question, but I'll take it down to a specific to demonstrate what I'm trying to find out from you.

           You spoke about the problem with being able to afford the wide regimen of drugs that maybe, if you had unlimited funds, you would want, and so you need to develop an ethical framework around what drugs you will fund. We had a lady in Fort. St. John, I think, whose husband has a melanoma and requires Interon A. I think that's what it was called.

           V. Roddick (Chair): Interferon.

           R. Hawes: Well, I think she called it Interon. I don't know, but it's not a drug that's funded in this province. It is available, and she can get it by prescription — through her doctor, I guess — through the drugstore. It will cost $30,000 for a one-year course of treatment, which is what he needs.

           She claims that if the Cancer Agency approved that drug, even though you didn't fund it, you could get it wholesale, and the cost would be $16,000 rather than the $30,000 she would have to pay. Is it possible for you then, for those drugs which you can't afford to supply, to make drugs available at cost to those who need them, so they don't have to go bankrupt, basically?

           B. Schmidt: That's possible, but what I do want to say is that I mentioned these tumour groups. These tumour groups meet on a regular basis. They survey the scientific literature, and regardless of whether there is an ability to pay or not, when they bring forward recommendations for drug therapy, they're bringing them forward on the basis of first-level evidence. That's what we expect of them. When they bring forward these drugs, they say: "These are the ones that we believe are going to be the most effective for the population of British Columbia." It doesn't say that there might be an individual that wouldn't benefit from something else.

[0925]

            In the main, if there's a drug that hasn't been approved through those tumour groups, it means that on an international standard, those drugs would not be considered to be as effective. I don't know enough about the specific case to give you a judgment, but I think that's probably likely what we'd be doing anyway. We'll be bringing forward those evidence-based drugs. Government may not have the ability to pay. We're going to need to decide how those drugs will be provided, if they can be provided.

           R. Hawes: In this particular case, I think the drug is available through Ontario. If you were an Ontario resident, it would be supplied by the government. All she wanted to know was: can she buy that drug through you? Even if it hasn't gone through your panel and it's a drug prescribed by a physician, could you consider…?

           B. Schmidt: With your advice on that, we certainly could. All I would say is that I think the way we've developed as good a relationship as we have with government is that we've brought the straight goods to them, and we've told them where we think there is and isn't effective therapy. I'm not sure in this case, but I'm just saying that if it is truly something that would've benefited the population in general, we would've brought it forward a long time ago.

           V. Roddick (Chair): I just have a quick question so you can clarify it on Hansard. You mentioned a $48 million budget on drugs, which was up $10 million from last year. Do you get that figure through the Ministry of Health, or is that $48 million raised by fundraisers, etc.?

           B. Schmidt: I'm sorry for the lack of clarity. We have a $48 million budget this year. We're asking for $10 million more for next year.

           V. Roddick (Chair): Oh, I see. Okay.

           B. Schmidt: It could double within a period of three to five years, depending on how quickly that goes.

           V. Roddick (Chair): All right. So that's definitely Ministry of Health money. It's not fundraised money.

           B. Schmidt: Right. We have the only 100 percent funded…. Well, it's not 100 percent funded, but we have responsibility for the entire drug budget. In fact, last year we brought in all the drugs that were considered cancer-related from Pharmacare and placed them into our budget. We believe there are significant economies in that framework. We essentially have the ability to control the outlay of cancer drugs throughout the province based on our standards and guidelines. We adjudicate all the drugs that come in for payment from the regional authorities.

 [ Page 601 ]

            V. Roddick (Chair): Do you have at your fingertips how much money you do fundraise, which you bring into your agency?

           B. Schmidt: The B.C. Cancer Foundation is an independent fundraising organization which is closely associated with us. At this time I would say that 98 percent of their fundraising is directed towards the development of research infrastructure in our province for cancer control. As you may have read in the papers, we have a millennium campaign. They're trying to raise about $30 million over the next two or three years to essentially complete their commitment, along with the knowledge development fund and the Canadian Foundation for Innovation, to build and then to operate the research centre. Unfortunately, we don't get much benefit in terms of treatment programs from our foundation. They would like to do more, but research is their focus.

           V. Roddick (Chair): I think there's probably confusion, too, in the general populace between the B.C. Cancer Foundation and the B.C. Cancer Agency and the Canadian Cancer Society.

           B. Schmidt: Yes, there is confusion with the Canadian Cancer Society.

           V. Roddick (Chair): One wonders how seamless you are.

           B. Schmidt: The foundation, the society and the cancer agency meet frequently together as a board and as management to sort out those things. We currently enjoy an excellent working relationship. We're trying to clarify some of those issues.

           V. Roddick (Chair): Any other questions?

           Well, thank you very much, sir. We appreciate your input this morning.

           We have a slight presentation problem. I gather our next presenter, Roderick Louis, is not here. He also has Amy Pollen….

           A Voice: Yes, he is here.

           V. Roddick (Chair): Oh, he is. All right. If Roderick Louis could come up to the front.

           I must say that I'm sorry. I forgot to do the general introductions. If I could start to my left with Harold, we will do the introductions of the panel.

           H. Long: I'm Harold Long, the MLA for Powell River–Sunshine Coast.

           J. Bray: Jeff Bray, representing Victoria–Beacon Hill.

           K. Johnston: Ken Johnston, Vancouver-Fraserview.

           V. Roddick (Chair): Valerie Roddick, Delta South.

           S. Brice (Deputy Chair): Susan Brice, Saanich South.

           P. Sahota: Patty Sahota, Burnaby-Edmonds.

           R. Hawes: Randy Hawes, Maple Ridge–Mission.

           B. Suffredine: Blair Suffredine, Nelson-Creston.

[0930]

           V. Roddick (Chair): Good morning, sir.

           R. Louis: Are you guys all ready? It's been a battle getting here.

           V. Roddick (Chair): That's all right. Would you like to take a couple of minutes? Our 9:45 a.m. presenter is here.

           R. Louis: If that is convenient with the panel, I'd appreciate that very much. I only just got here, and I want to have a chance to get my mind around what I want to say, if that's okay.

           V. Roddick (Chair): Let's put it this way. Our 9:45 presenter is from the provincial brain injury program, Jerry Stanger. Is Jerry here? Would you mind stepping in and helping this fellow?

           Interjection.

           R. Louis: Thank you.

           V. Roddick (Chair): Well, thank Jerry.

           J. Stanger: My name is Jerry Stanger. I am the acting provincial coordinator of the provincial brain injury program. With me today is Charles Ottewell, who is a survivor of a brain injury.

           Thank you to the Chair and to the committee members for this opportunity to speak to you today. We would like to discuss our concerns regarding brain injury services in British Columbia. I'd like to outline two concerns, specifically. First is the shortage of rehabilitation, residential and community support services for people with brain injuries. Second is the proposed devolution of the provincial brain injury program.

           However, before I discuss these service issues, I would like to answer the question: what is a brain injury? A brain injury is a traumatic or organic injury to the brain — traumatic if it is the result of a car accident, a fall or a physical blow to the head; organic if it is the result of a stroke, aneurysm or physiological event. A brain injury usually happens suddenly and provides the individual and family with no time to prepare in either practical or emotional terms. Those with lived experience tell us that a brain injury happens to the family. They say this because the family must manage such issues as physical disability, anger, memory and fatigue or social disinhibition.

           Approximately 6,000 to 10,000 people experience a brain injury each year. Most will have a complete or

[ Page 602 ]

near complete recovery. However, 10 to 15 percent will require ongoing services. This means as many as 600 to 1,200 individuals a year are permanently injured and require lifetime services. The kinds of services that they require are rehabilitation, community support and residential. Rehabilitation services include occupational therapy, physical therapy, neuropsychology or speech and language therapy. It is absolutely critical that we maximize people's rehabilitation potential. To fail in this task is not only devastating for the person but has significant consequences on health care costs. Without full rehabilitation, the individual has increased service needs for a lifetime.

           Who delivers these services in B.C.? Rehabilitation hospitals, such as Gorge Road in Victoria or G.F. Strong in Vancouver, provide post-acute rehab. The provincial brain injury program, which I'll speak of momentarily, provides services. There are brain injury associations around the province that provide mostly community support services. Health regions provide some services, but most do not have dedicated programs for brain injury. Many of their generic programs, such as continuing care or mental health, do not see brain injuries as part of their mandate.

           I believe it is important to note the role of the profit and not-for-profit service sectors. Much of the expertise in the field of brain injury in B.C. lies with private and non-profit organizations that provide services to ICBC and WCB clients. The provincial brain injury program has piggybacked on this system and contracts all of its services with these agencies.

[0935]

           My second concern relates to the proposed devolution of the provincial brain injury program. The provincial brain injury program began in 1989. It was situated within the Ministry of Health for nine years. It has four regional offices in Victoria, Coquitlam, Kelowna and Prince George. It was administratively transferred to the Vancouver-Richmond health board in 1997. We provide rehabilitation, community support and residential services. We also provide funding to brain injury associations around the province. We have a budget of approximately $10 million, but 97 percent of our budget is tied to annualized services. These are ongoing commitments to clients year after year.

           In January 2001 the Ministry of Health decided to fully regionalize the provincial brain injury program. As of March 31, 2002, the program is scheduled to cease operating as a provincial service, and the 13 staff and resources are to be devolved to health regions around the province. Is this a good plan? Frankly, the answer to this could be yes or no, depending on two things: will the Ministry of Health adequately resource health regions to fund for brain injury services? Or, second, will the health regions embrace brain injury and provide a comprehensive package of services?

           In terms of the first question, I'm deeply concerned that health regions will be given the full responsibility for brain injury services but not the funding needed to develop programs. Please hear me on this point. To develop comprehensive brain injury programming, health regions will need significant funding. Several hundred thousand dollars spread across the province will not create the critical mass needed. We have worked closely with health regions for the last four years. For the most part there's been resistance to serving people with brain injuries. This is largely because regions have not had adequate funding and so must find or take dollars from other program areas to serve people with brain injuries.

           The Ministry of Health has just produced a draft policy on brain injury services. I have two copies here if you'd like one. It was 53 pages, so I didn't make copies for everyone.

           V. Roddick (Chair): Thank you.

           J. Stanger: In conclusion, we must develop a service system that capitalizes on the expertise and resources of brain injury associations, private and non-profit service providers, and the experience of the provincial brain injury program in health regions. Please do not misunderstand my concerns. Keeping the provincial brain injury program without adequate funding is also not the answer. The complete regionalization of brain injury services in B.C. may in fact be the next best step in the evolution of brain injury services. However, this process must be properly resourced and built on existing strengths, expertise and best practice.

           The handouts that I provided today are, first, expanded notes on what I've just discussed; an article by Charles Ottewell, who will speak now, that was published in the Journal of Cognitive Rehabilitation in 1992; and some facts and figures on brain injury.

           C. Ottewell: Thank you for allowing me to address you today. I guess I'm coming from a different point of view than most in my field. I'm coming from a survivor's point of view. Jerry gave you my article that will sort of explain a lot of my trials, emotions and stuff like this. I'll just try sticking to my points here as a survivor.

           My name's Charles. I'm an 18-year survivor of a traumatic brain injury. Persons suffering a major brain injury face a future of uncertainty. Their lives and the lives of those close to them are forever changed. After their trauma, most TBI survivors reappear with new personalities along with social, emotional and physical deficits. Unlike most injuries, there isn't a protocol or treatment that works for all or even most survivors. We are the walking wounded. Medical science keeps us alive, but once the hospital treatment is done, what is to become of us?

           We require special consideration in the education field: teaching assistance, specialized counselling and often modified hours of instruction. We require life-skills training from people who are expressly trained to understand the complexity of TBI survivors. We are not mentally challenged from birth; we have acquired our brain injury and require assistance designed to meet our unique circumstances.

           We require specialized employment retraining. Because of fatigue, most cannot hold a full-time job. That's me. As a result, our financial concerns cause depression and a sense of worthlessness and failure.

[ Page 603 ]

Prospective employers must be educated to understand the unique characteristics of an employee suffering from TBI. A traumatic brain injury employee can offer to an employer services worth having. The number of hours of work or number of days' work may require adjustments.

           Authorities are using the word "epidemic" to describe the number of traumatic brain injuries. Seatbelts and airbags are saving lives, but the number of head injury survivors has greatly increased. Every year it goes up, I think.

           Many survivors are still being treated by the medical system in the same way the mentally handicapped are treated. I repeat: we are not in the same category as those born with a mental handicap. We have, through circumstance, acquired a brain trauma. We must have support from the government to educate and assist persons with TBI. The public and the government also must be educated to understand the unique needs of persons with TBI.

           I think my couple of minutes are up, so thank you for allowing me to address you.

[0940]

           V. Roddick (Chair): Thank you very much for coming forward and delivering that. It's terrific of you. It makes a great deal of difference when we have people really from the front line, which you are.

           Are there any questions from the panel?

           I just wanted you to clarify. You say that the brain injury program is supposed to split within all the regions at the end of 2002. Is that right?

           J. Stanger: The scheduled date for the devolution is March 31, 2002.

           V. Roddick (Chair): What you're saying is that if it does devolve, then it's going to require a good chunk of cash to go to each region to be able to maintain. So are you, in effect, saying that if we can't find the cash to go to each region, it's better to keep it contained as one basic unit at G.F. Strong?

           J. Stanger: The provincial brain injury program is affiliated with Vancouver Hospital and Health Sciences Centre, but we are a stand-alone program. I think that if there isn't significant funding going to be made available to health regions, the whole process needs to be rethought. I'm very clear that devolving the program without adequate resources isn't going to be better for brain injury. At present, health regions are telling us — and have told us repeatedly — that they don't have any money. How is that going to change if they simply are given the responsibility but no money? I think that is a serious concern and really needs to be looked at.

           We're a small program. We're only 13 people for the entire province. We work on a business model. Unlike many health care organizations where 85 percent of their budgets are taken up in staffing, all of our services are contracted. We have been underbudget or within 1 percent for the last four years, because we managed on a business model. We purchase services from private and non-profit agencies. So we provide $9 million worth of services, but it's all contracted.

           V. Roddick (Chair): So in other words, your patients kept the value of the dollars.

           J. Stanger: Yeah. We manage our money extremely well, and as I say, we haven't been over budget. We've been within 1 percent of our budget every year. I think that's reflective of our management system and our finance system.

           V. Roddick (Chair): Thank you both very much indeed for coming this morning.

           C. Ottewell: I just want to say thank God there are some groups like the provincial brain injury association, or I would have been really lost. That's my only point. It's a very scary thing to happen to a person. If you read my article, you'll understand it thoroughly.

           V. Roddick (Chair): How old were you?

           C. Ottewell: Seventeen — grade 11 in high school.

           V. Roddick (Chair): Thank you for coming.

           Now I think we have Roderick Louis from the Patient Empowerment Society.

           Good morning.

           R. Louis: Can I stand? Is that going to be okay with you guys? A lot of times I speak better on my feet.

[0945]

           V. Roddick (Chair): I think the mike might prove a problem. Can we take it off? If Hansard finds it's not….

           R. Louis: Well, I've got a pretty loud voice, I'm told. Hopefully, you guys will speak up if you don't catch my enunciations.

           Basically, I'm here to speak on behalf of mainly mental health–related health issues. Not all services relating to supports for adults with mental illness are funded by the Ministry of Health. Some of the information that I present today I'm hoping that committee members can consider and even, perhaps, lobby to other committees, if there are committees that have a say over Human Resources, which is a major ministry that's responsible for mental health.

           Just to summarize, basically, I'm speaking on behalf of an advocacy organization made up of patients and former patients of Riverview Hospital. The subject matter we want to speak to and that I'm here to present on behalf of them is mainly services relating to supports for adults with mental illness.

           Most people with mental illness don't get the bulk of their supports in the community from the Ministry of Health, believe it or not. So some of what I'm going to be saying today and trying to do a good sales pitch around will relate to other ministries, such as the Ministry of

[ Page 604 ]

Human Resources, particularly, because that's where important supports like rent and the basics come from for people with mental illnesses living in the community.

           I'm the chairperson of the Patient Empowerment Society. We're based at Riverview Hospital. Effectively, the first three matters I want to speak to relate to a community housing support program and services in the community.

           In Vancouver-Richmond there are about 6,000 adults with mental illness being cared for by the Vancouver-Richmond health board. So there are a large number of people with severe mental illnesses. Most people with a severe mental illness, such as schizophrenia or manic depression — you may know this — are seen by what's called a community care team.

           Other than the services provided by the health board–funded community care team in greater Vancouver, there are about 18 non-profit organizations that are contracted by the health board. I want to loop into that the Simon Fraser health board as well the South Fraser region, so we get the total of 18 non-profit groups contracted by these health boards to provide roughly the same services — services such as drop-in centres, which are places where adults with mental illness can go to socialize, for recreation, often for a subsidized meal; services such as supported housing and providing public education, for example.

           Having so many organizations, each delivering the same service, we see as a tremendous amount of unnecessary duplication. We feel it would be far more sensible and far more businesslike to have…. Rather than, for example, five agencies in Surrey providing education, drop-in centre and housing services, with each of these five agencies having its own executive director at $80,000 a pop and each of these agencies having a program manager responsible for housing plus a program manager responsible for running the drop-in centre…. Whether it's Surrey or greater Vancouver, where there are even more non-profit groups, why not have just one or perhaps two organizations, so there would be competition, responsible for running — to pick a service — the drop-in centres?

[0950]

           Effectively, in point one, we're arguing that amalgamation of at least some of the non-profit groups in the lower mainland would be sensible, because it would be more efficient. We're not only arguing there should be an amalgamation of contracts; we're also arguing, or suggesting, that it would be very productive for this committee and health boards generally to examine the question: is it sensible to have every contracted mental health group allowed to provide a mishmash of very diverse services, to the point where they don't become focused on any particular kind of service, particularly, if you have a group?

           I'll give you an example: the Mental Patients Association. It's a group based in Vancouver which has a great deal of housing. They also have outreach workers and some public education services. They also have an advocacy component. It's a conflict of interest to have the group that relies on public money annually for their senior employees' salaries, and to provide housing, to also purport to provide advocacy, when the advocates, by the nature of their jobs, would be obligated to lobby their funder for the creation of more housing. It's rather a misleading name — the Mental Patients Association, also known as MPA. It's not really run by mental patients. It's just a label.

           To focus organizations and improve their delivery of services, we're suggesting that it would be very appropriate to have groups that are contracted to provide services for the mentally ill confined or restricted to only providing one or two specific services and keep advocacy out of it, particularly.

           Point No. 2. I want to speak to a particular model of community housing that is very popular in the province for adults with mental illness. It's known as the semi-independent living program. This housing program effectively relies on funding from the Ministry of Health, which is used to provide a mentally ill client with a rent subsidy, which is one part of the SIL program, semi-independent living. The cost for a SIL unit per year is about $10,000 in the global figure. Out of this SIL unit of $10,000, the client would receive anywhere from $200 to $300 per month as a rent subsidy, depending on the region. This enables adults with a mental illness to be able to afford a place to live that's not in skid row, which, I would argue, is a very inappropriate place for people who are very vulnerable and who are suffering from severe mental illness.

           A rent subsidy is one part of the SIL program. The other side, the other deliverable, is outreach support. The problem I want to throw on the table here — and if my language is not quite committee-like or politically correct, I'm going to use it anyway just to make sure people remember this — is that the SIL program is a scam. It's effectively been used by many non-profit groups as a way of justifying their own annualized funding to pay their senior employees and guarantee their organization's ongoing operations funds.

           The health board would ordinarily contract with a non-profit group. The health board would then flow the rent subsidy money to the non-profit group, which would then flow this money through B.C. Housing, which would then flow this money to the client's residence, which is very often a market housing unit. Each time the money gets diverted from the health board to B.C. Housing or to the non-profit group to B.C. Housing to the rental apartment, there is an administrative cost charged of 2.5 percent. So two or three stops, and you're losing between 5 and 10 percent of that rent subsidy money every month.

           What we're suggesting is: take all these loops out of the picture. Don't provide the SIL rent subsidy through the health board and then through a non-profit group and then through B.C. Housing. Instead, provide the rent subsidy directly connected to and part of the other part of the client's rent money each month, which comes from the Ministry of Human Resources. That way you're not going to be unnecessarily wasting money on administrative charges.

           That isn't the worst part of the scam. The worst part of the scam is the outreach support. Most people who

[ Page 605 ]

live in semi-independent living apartments, whether they're market housing or purpose-built mental health units, are not seen more than about once every six weeks for 20 minutes by their outreach worker. I say that based upon interviews of well over 100 people in the last several years who are in SIL apartments.

[0955]

           Some quick arithmetic by anyone in this room, even without a calculator, could figure out their rent subsidy of about $300 a month for a year would be about $3,600, leaving $6,400 out of the approximate $10,000-a-year SIL charge. For $6,400 a year, if a client is only being seen in total about three hours, that's a pretty heavily subsidized outreach support. It's ridiculous; it's a waste of money. We're not suggesting for a second that outreach support is not important. It's very important, but there are no checks and balances presently existing in the system, at least in greater Vancouver, to have the clients' outreach support evaluated every single month.

           We're suggesting that this committee would recommend that every contract that health boards establish with a non-profit group be accompanied by a guarantee that this group would keep a record. I'll make myself more clear. Mentally ill people with illnesses such as schizophrenia will see a mental health care team, which is effectively where doctors, social workers and nurses employed directly by the health board work. Most people, on average, will see their doctor or nurse ranging from once every three weeks to six weeks. We are suggesting that there would be a semi-independent living evaluation form developed to be filled out by the mental health care team. Take it out of the hands of the group that delivers the service. We don't believe that the non-profit group — let's just use as an example one of the branches of the B.C. Schizophrenia Society that's delivering this SIL — should evaluate their own SILs. We believe there should be a form that would ask clients that are in the SIL program, for example, how often they're being seen, whether they're satisfied with how often they're being seen and whether their needs being met. What needs do they have per month in terms of outreach support that aren't being met? If these forms were filled out at the care team with the assistance of care team social workers or nurses, it would be a way of the Ministry of Health compiling data to show how well this program's being delivered. It might even encourage some of the non-profit groups that are providing this outreach support to actually go and see their clients more often than they are.

           We believe that outreach support, as part of the SIL program, should be put in the…. The money that pays for the outreach support should be put in the hands of the client indirectly so that the client can, without touching the money, choose an agency to provide the outreach support perhaps in three-month or six-month stints. Geriatric people living in the community have the ability to choose agencies that send workers to come and assist them with chores around the house, shopping, etc. We feel that adults under 65 with mental illnesses should have the same ability to shop, for lack of a better term, for outreach support.

           The last three very quick items that I want to move on to here…. It's too bad Joy MacPhail's not here. She's effectively the main person that's responsible for point 3, 4 and 5 problems in this province. In 1998 there was a mental health plan developed by the NDP government. I spent 11 days hunger-striking in front of Glen Clark's office over Christmas '97-98 trying to have this draft mental health plan made public so that it could be developed with input from stakeholders. Joy refused. The plan gets released in January 1998, and this plan contains no time lines. A seven-year plan purported to cost $125 million to deliver — how could you call it a real plan without time lines or without cost projections for the very vague motherhood statements that are used in place of promises? We are proposing that this committee would recommend that there be a rewriting of the so-called new mental health plan for B.C. so that it would contain the basics that a business plan would have to contain: namely, time lines showing, for example, what number of housing beds are going to be delivered every quarter and what will be the cost, etc.

[1000]

           Point 4. For those on the committee who may not be aware, Gulzar Cheema, the Minister of State for Mental Health, announced on October 30 that the provincial mental health advocate position was being terminated. This is a good thing, not bad. There should be applause provincewide for this occurrence. Why? Because the mental health advocate position was designed to be a ministry employee, not at arm's length from government. Nancy Hall, the mental health advocate, was in a conflict of interest. She was pretty much unheard for the last three years. Why was her job description designed in such a dysfunctional fashion? Because, effectively, Joy MacPhail wanted to have a showpiece, not real advocacy.

           We are suggesting that there be a redevelopment of the mental health advocate position that would allow for an arm's-length position that would be funded, perhaps, by the federal government. That's the main point I want to make around this issue: approach the federal government to fund an advocate or perhaps a mental health ombudsman or even a health ministry ombudsman, so that the federal government could fund, for lack of a better term, the police to monitor the services that they have the provinces responsible for delivering.

           The last point, point 5, is made on behalf of the 5,000 people in British Columbia who are, I think unarguably, the most disabled and most vulnerable: people who live in institutions such as Riverview psychiatric hospital and people who live in boarding homes — and not just mentally ill people but people with physical disabilities as well. In care facilities such as a hospital or a staffed boarding home, patients or clients rely on what's called comfort allowance for all their quality-of-life needs like clothing, makeup, hobbies and presents for their kids. Under the NDP, comfort allowance was raised $6 in ten years from $79 to $85 — 60 cents a year on average. How many committee members here

[ Page 606 ]

would even notice if you were given a 60-cents-a-month increase in your salary for the next year? You wouldn't notice it. You can't spend 60 cents on anything.

           In 1994 Joy MacPhail was presiding over the Ministry of Human Resources and a budget of $2.8 billion a year. That budget had been raised by $1.1 billion in the previous two years. MacPhail refused to raise the comfort allowance, saying she didn't have the money in her budget. At that time, comfort allowance was $82, so it's been raised $3 since then. Big deal. We're suggesting that the government and this committee recommend that the Ministry of Human Resources raise the comfort allowance to perhaps enough to allow the average client to have $4 a day to spend, which would be $120 a month, or $5 a day. B.C. has the second-lowest level of comfort allowance in the country. This obviously won't save money. Why would you want to raise comfort allowance? Because if you don't raise it, people in mental hospitals and in boarding homes live in far worse poverty and greater indignity than they would ever experience on welfare.

           Thank you for your patience. I think I've gone over my time a little bit there. If I have, let me know. I'd be glad to answer some questions if anyone has any.

           V. Roddick (Chair): Thank you very much for your presentation. We certainly appreciate it. Are there any questions from the panel? No. We appreciate your forthrightness and also the fact that you've come forward with some solutions. We appreciate that. Thank you.

           Our next presenter is Amy Pollen. Good morning. How are you? We've got your notes.

           A. Pollen: Good morning and warm greetings to you all. I have four main suggestions, mostly on how to save money on mental health. My son has been a patient at Riverview mental hospital for almost 18 years. The four main topics I will deal with are: ban smoking and tobacco products in all provincially funded hospital properties and boarding home properties; cut off provincial government advocacy funding to all or at least most B.C. mental health groups; amalgamate community mental health services contracts; and appoint a mental health advocate position at arm's length from government. Please find included a copy of several suggestions relating to mental health–related services that, if implemented, will not only help the Ministry of Health deliver services better but also save money and improve the quality of life for many mentally ill people.

[1005]

           My suggestions relate primarily to services for adults with mental illnesses. As a concerned parent with a mentally ill son who has been hospitalized at Riverview psychiatric hospital in Port Coquitlam for almost 18 years, I have made it my business to get to know what hospitalized mentally ill people experience and what types of community services there are for adults with mental illnesses and their relatives in greater Vancouver. My investigation and direct experiences lead me to feel strongly that there are ways to find significant cost savings in publicly funded services.

           First, ban smoking and tobacco products in all provincially funded hospital properties and boardinghouse properties. Mentally ill people as a group are far more addicted to smoking and tobacco than other groups in society.

           Mental patients only receive a tiny, inadequate monthly allowance of $85 that is supposed to be used for basic quality-of-life needs like clothing, makeup, hobbies, presents for friends, bus fare and the like. Almost every day that I visit my son at Riverview, I witness addiction so severe that mentally ill adults will scrape gutters and garbage cans for cigarette leftovers. This results in open sores and permanently black fingers on many patients' hands. For those addicted to tobacco, which is the vast majority of patients at Riverview, their monthly allowance is almost all spent for them by nursing staff on tobacco products at the beginning of the month. They are then doled out a few a day to the patient. This demeaning practice results in leaving most adult long-term patients with literally only nickels and dimes for their needs for the rest of the month, which, as well, are doled out to them by staff.

           Tobacco is presently banned by Riverview Hospital management orders from use except in designated areas on wards and in buildings. Since buildings and wards at Riverview are crowded, this does not protect those who do not smoke from being unwillingly exposed to tobacco smoke. Staff who smoke are supposed to smoke outside.

           I might add here that my son learned to smoke in there. He was motivated by cigarettes. He now is a very heavy smoker. He has very bad lungs. They say that it'll eventually kill him, his lungs are so bad. Yet I can't get them to break his habit. I wish they would.

           The hospital hypocritically has two small stores that sell a huge selection of tobacco products. Patients are not only overcharged for these life-wrecking products, but thanks to the hospital administration attempting for almost five and a half years to destroy the patient advocacy model recommended by the ombudsperson in her May 1994 report — which is called Listening: A Review of Riverview Hospital — patients and ex-patients are not enabled to have any say over profit margins or where profits from their purchases are applied. Selling tobacco to patients by the hospital is unethical, and since there is no competition for tobacco sales on the site, it's a clear conflict of interest.

           Most patients at Riverview live in worse poverty than people on welfare. Sadly, some even run away and choose life on the street.

           For decades the hospital has carried out studies regarding the sexuality of patients. These have shown that the sale of sex for mundane things like a cup of tea or tobacco is commonplace. I really think that's very reprehensible, because that hospital encourages all this stuff. Reprehensibly, despite these findings, for decades Riverview administration have continued directing line staff to forcibly buy patients tobacco and to

[ Page 607 ]

then give out a few cigarettes a day. Banning tobacco from the entire hospital site is needed to stop this.

           Second, cut off provincial government advocacy funding to all B.C. mental health groups or at least most. It is a conflict of interest for any group that claims to be an advocacy organization to be funded by the body — the provincial government — that, due to the nature of their purpose, they are expected to assertively lobby against. My experiences with mental health groups like the Canadian Mental Health Association, Mood Disorders Association, Mental Patients Association and other agencies that claim to be advocates for the mentally ill and are funded by the provincial government is very consistent: they don't do any real advocacy.

[1010]

           Instead, they practise a form of what I like to call make-believe advocacy, where their advocates spend all their time visiting with patients, giving them cookies and drinks and providing lip service to relatives like myself but never taking any action on the substantive issues. Most of the hundreds of thousands of taxpayer dollars these groups receive annually is invariably spent on make-work projects like producing tens of thousands of pamphlets and signs for buses and organizing never-ending, redundant conferences, awards dinners and the like.

           Functions like public education about mental illnesses could more effectively be carried out by the public school system. Information about schizophrenia and manic depression could easily be understood by children from grade 6 and up. Putting mental health definitions and information into the grade school curriculum could be very quickly and cheaply done.

           Advocacy for the mentally ill ought to be privately financed. Greenpeace, environmental and other types of advocacy groups do fine without allowing themselves to become addicted to public funding and toadies.

           Interjection.

           A. Pollen: Is my time up?

           V. Roddick (Chair): Your time's up, but we certainly are enjoying what you've got to say.

           A. Pollen: Well, thank you. I still have a page and a half. Is that okay?

           V. Roddick (Chair): Well, we'll read it, believe you me. Pick out your little highlighted nuggets.

           A. Pollen: Well, I'll just read this last part.

           Third, amalgamate community mental health contracts. The positive and very needed increase in community housing and support services to the mentally ill in most of B.C. between 1992 and 2001 was long overdue, but unfortunately, it has been done in a most wasteful and unbelievably unbusinesslike manner. For example, rather than contracting only one or two groups to run the drop-in centres or supported housing services in a particular health region — like Vancouver-Richmond, South Fraser or Simon Fraser — individual health boards have made it a practice to contract literally dozens of separate organizations. The consequence of this has been a huge amount of duplication of things like most senior staff positions, payroll departments, equipment and the like.

           If there was a Ministry of Health directive to health boards to only contract with one or two agencies for a particular type of mental health service and to not allow the contracted agency to carry out more than one or two types of service, this would not only save money by avoiding duplication; it would also likely improve the quality of the service by forcing the service-providing agency to focus more on their service.

           I know I'm kind of running through this, because I'm trying to hurry and get done. Unfortunately, if my time's up, then I thank you very much for listening. Perhaps, when you find time, you could read the pamphlet.

           V. Roddick (Chair): Is Lori Flamand, the 10 o'clock, in the room? I don't see that Lori is here.

           A. Pollen: Can I continue then?

           V. Roddick (Chair): You can continue. We'd like to hear it.

           A. Pollen: Well, thank you very much.

           Fourth, appoint, at arm's length from government, a mental health advocate position. The provincial mental health advocate position was recently terminated by the Ministry of Health on October 30, 2001, which is a good thing. This is because the position was not at arm's length from government. It was a Ministry of Health employee, which is a conflict of interest.

           For most of the three years that the position existed, it was seldom heard from by the public. Whenever the person, Nancy Hall, was approached with an issue that might put her into a position of having to not agree with other Ministry of Health employees and bureaucrats, she declined to get involved. One of the best examples is the many occasions that I approached her office about Riverview Hospital's administration trying to replace a model of advocacy that the ombudsperson recommended for patients at the hospital — the Patient Empowerment Society — with one that the hospital tendered for and that is almost the opposite of the model that the ombudsperson recommended.

           Nancy Hall always refused to investigate politically challenging issues and appeared to value her collegial relationship with senior hospital administration and board members far more than legitimately advocating for patients and ex-patients. Chapter 9 of the ombudsperson's report specifically defines a patient- and ex-patient-driven and -directed democratic model of advocacy for Riverview and most hospitals in the province. This model is mirrored by the Patient Empowerment Society. I should know, because it really helps a lot of patients and a lot of families.

 [ Page 608 ] 

[1015]

           Under duress, from 1993 to 1996 Riverview's administration accepted this model of advocacy and for the first time in the hospital's history agreed to allow patients and ex-patients on several dozen previously staff-only hospital decision-making committees. Also, every two weeks most of the hospital's senior administration met directly with patients and ex-patients through the Patient Empowerment Society. As well, during this period the Riverview board of directors met with patients and ex-patients four or five times a year. Unfortunately, when the hospital administration felt that the pressure was off to comply with the ombudsperson's recommendations, they went back to their old tyrannical ways. They launched a frivolous civil lawsuit in the B.C. Supreme Court in 1996 against the Patient Empowerment Society and its chairperson, Roderick Louis, attempting to have them evicted from the hospital site. The Patient Empowerment Society did not have a lawyer, due to lack of funding, but despite spending over $2.1 million in legal-related costs during 1996-2001, the hospital did not get the courts to agree to evict Roderick Louis of the Patient Empowerment Society. I know; I attended his court hearings.

           Unfortunately, the hospital administration was able to get away with breaching their contract with the Patient Empowerment Society and doing what any grade 2 pre-law student would be able to recognize as a blatantly inappropriate conflict-of-interest tender for advocacy in 1998. Unlike the Patient Empowerment Society, the model of advocacy Riverview administration put out for tender was entirely unaccountable to those it purportedly serves: patients and ex-patients.

           The hired-by-Riverview model of advocacy has no processes for election of executive committee members or evaluation of those in senior positions. Unlike the Patient Empowerment Society, Riverview administration preferred an advocacy model that has no executive committee. Nearly all of the dozens of hospital committees that for several years allowed patients and ex-patients to participate no longer do. In fact, I'm very seldom allowed to attend any, although I ask to.

           The Riverview senior administration has been allowed to refuse to meet with patients and ex-patients for over five and a half years. As well, the Riverview board of directors has refused to meet with patients and ex-patients for over five years. Despite all of the above very undeniable attempts by Riverview senior administration to sabotage legitimate advocacy and replace it with a façade, Nancy Hall refused get involved.

           Vulnerable and easily exploitable types of people, like those with severe mental illnesses, need advocates who have no compunction about doing real advocacy even when this may compromise their relationship with others in the health system. An independent mental health advocate office needs to be set up in this regard.

           Thank you for your time today and for accepting my suggestions regarding health services in B.C. and how to improve them, or at least save money, by changing the way services are delivered. I would be very happy to answer your questions, if you have any to ask. Thank you very much.

           V. Roddick (Chair): Thank you very much. That's terrific.

           Is our 10 o'clock presenter, Lori Flamand, present?

           The 10:15 one is Patricia Peach. Good morning. Hello there and welcome.

           P. Peach: Good morning. Hon. members, brothers and sisters, I am not the best public speaker, but I feel compelled to speak out on behalf of the community health workers and the clients we serve. Insofar as the cutbacks are affecting our members, we feel we are not able to give the continuity of care.

           For example, there are too many one-hour jobs and not enough time to complete the task effectively. As our clients get sicker, more tasks are added, but no more time is allowed. Housekeeping has become a large problem for our clients since it has been abolished. Our clients' homes are not getting the care and attention they need. Some fortunate clients can afford to hire help, but the less fortunate cannot. Therefore, their homes are in disarray.

           Another area of concern to the clients we serve are the changes that are going to take place in primary care. Also, they fear the rumours of the government abolishing rent controls and that there will be more cutbacks affecting their community health workers.

           Hon. members, I speak on behalf of my clients and my peers. We plead with you to stop the cutbacks, as we are suffering enough already.

[1020]

            V. Roddick (Chair): Well, thank you very much for taking the time out this morning and making that presentation. You're very good at public speaking.

           Are there any questions?

           J. Bray: Just very quickly. Patricia, thank you for coming forward. What do you mean by "abolishing rent controls"?

           P. Peach: Apparently in Victoria they have cut two houses out of rent controls. It's going to be a disaster if that really does happen. We need our rent control people to keep the rents down to a good level.

           J. Bray: Oh, you mean landlord-tenancy. Okay. Thank you.

           V. Roddick (Chair): Any further questions? We are working with our $9.5 billion budget to get to the patients. You are on the front lines working with the patients, so this is the sort of input we need. Thank you.

           P. Peach: You're very welcome.

           V. Roddick (Chair): Are Kim Montgomery and Renée Robert from the Family Violence Resource Centre here? Now, the next presenters after that, which

[ Page 609 ]

will be at 10:45 a.m., are Gordon Porter and Patrick Simpson from User Friendly Homes Ltd.

           G. Porter: We're here.

           V. Roddick (Chair): Excellent. Could you possibly come forward, then? Good morning, gentlemen.

           G. Porter: Good morning. Thank you for allowing us to be at this discussion. We at User Friendly Homes feel that we have a medium- and long-term solution to the costs of our health care system. Some of you may be aware of us. I imagine that right at the moment most of you haven't necessarily heard of us.

           We've constructed and implemented an inexpensive certification program that dramatically increases the safety and accessibility of our homes. This results in a major reduction in the cost of health care in a variety of ways.

           Prior to meeting with you, we've been putting together a program for B.C. Housing. We've received support from the Minister of Health Services, Colin Hansen, and other MLAs — Ken Stewart, Val Anderson, Richard Stewart — the municipality of Maple Ridge, the city of Vancouver and the city of Burnaby, along with a host of private businesses and non-profit organizations. In the back of what you've been handed out, there are letters of support from those people explaining how they support us and why. Please feel free to contact any of them after you've read the information and gone through it, if you have any questions as to how they viewed it.

           Our project brings education to the community on making our housing safer for children and seniors, making it part of the sustainable communities project and aging-in-place opportunities. We target new development and solve the access problem along with 70 percent of the other problems associated with our housing in a national way. The federal minister, Allan Rock, has stated that we spend nearly $3 billion just on falling accidents in the home associated with seniors. I couldn't believe that number when I heard it, but I checked a bunch of times, and it's $3 billion. Children's Hospital has stated that 80 percent of the children in their facility are there due to accidents in the home that were preventable.

[1025]

           This project that we have addresses these issues and is set to reduce those numbers in a very substantial way, with no really appreciable cost to the builders, the developers, the government or the homeowners.

           The benefits of a user-friendly home. This is a certification process to improve the design of the homes and how they're made. It increases the home's relative safety for the occupants. We do things like removing thresholds, widening doors — basic access issues that when you build the home are very, very inexpensive or cost nothing to implement.

           This makes the home accessible to those with disabilities, and it also keeps the elderly a little more independent and able to stay in their homes for a substantially longer time than previously possible. The aging-in-place scenario is what we're addressing there.

           Making housing that really does fit the sustainable community model, which is a model that has been coming forth probably over the last decade and is a very big issue these days…. It also supports electronic monitoring and support-systems facilities: automatic door openers, being able to see people at the front door without having to get up and go answer the door — that sort of thing.

           The concept is not expensive. The solutions are extremely cost-effective, and they're not institutional in nature at all. When you walk into a user-friendly home, of which we have well over a hundred in the lower mainland, you would not be able to tell you were in a home that was suitable for people with disabilities, wheelchairs, walkers, arthritis problems — you name it.

           Some of the other benefits included are lowering the rate of accidents, specifically with the aging population in mind. With $3 billion annually for falling accidents and children under five having the second most accidents in the home, if we reduce that by even 3 or 4 percent, we're talking a rather substantial amount of money.

           We're lowering the cost of health care by letting those who need medical attention live in their own homes rather than having to move to a more expensive facility that is government-run or government-built. We support all aspects of the disabled communities. We provide economic benefits to the community by having fewer people off work due to home accidents. We provide housing for the known aging demographic shift that's currently taking place. Mind you, I'm not aging, but a lot of other people are.

           Politically, this is something substantial that can be done to address the future needs of our largest population segment. That's both children and seniors. The way the house is built, we provide low-voltage wiring that delivers electronic links for both hospital and private monitoring. It promotes home-based business by having the home prewired for communication. Therefore, daily travel to and from work gets reduced. Electronically controlled access for emergency response employees — when an emergency comes to the home, they don't have to break the door down. The door can be electronically opened by the occupant who isn't able to get up. It is also going to reduce the number of social housing units needed to be built in the future. It creates a safer working environment for the home care worker when they're in there, because the home, just in general, is a safer place to live and be.

           With these and other benefits available to our aging population, I feel it's imperative that we get this program funded and underway immediately. We have confirmation from financial institutions willing to support the program by offering mortgage rebates or discounts and even paying for certification, which is an inexpensive process but is something that needs to be done in order to make sure all the bells and whistles have been checked.

[ Page 610 ]

           Educational information needs to be produced for the community at both the provincial and the federal levels. That can be implemented into private industry or educational systems with the aid of all levels of government. To further illustrate the importance, we have included a small window on statistics that are currently available. Our nation's baby-boomers are the largest demographic sector, and they're aging. Statistics Canada in 1996 reported that out of B.C.'s 3.7 million population, almost half a million are currently over the age of 65. That's 12.8 percent of the population, and that was in 1996. The shift is going to a higher percentage still. In 1997 CMHC stated that studies reveal that the housing industry needs to build or retrofit 50,000 units a year for every year in the next 20 years just to keep up with the needs of our seniors. CMHC in 1994 statistics revealed that by the year 2030, one in four Canadians will be over the age of 65. We've got a big shift going on.

[1030]

           As I mentioned earlier, Allan Rock was quoted in the Vancouver Sun in 1998 as saying that every time a senior falls and breaks their hip, it costs our health care system $118,000. We're spending more than $3 billion a year on seniors. In a United States federal housing study, it was found that seniors experienced more accidents in the home, while children under the age of five have the second most accidents. This 1996 study also reported that there were nine million reported tripping accidents in the home, of which 3.5 million led to permanent disabilities or death.

           These are just a few of the hundreds and hundreds of current statistics available documenting that there are hazards in the home. Our program is able to reduce at least 70 percent of these and have a serious effect on the cost of aging.

           The B.C. Rehab Foundation report this year states that the facts are startling. One in four baby-boomers already has a physical disability. By age 80, 72 percent of all people will have a significant disability. I've got a list of stats showing disability odds. For ages one to 21, it's 10 percent. When you get up to 65 to 79, almost 50 percent of the people have or will have a significant disability. For those 80-plus, it's almost 75 percent. Two-thirds of them have a significant disability. It's going to make it difficult for them to stay in their houses a long time. That just adds costs to the system. If you can age in place, the costs are reduced substantially.

           Lastly, 90 percent of all accidents happen in the home, and 50 percent of all accidents in the home happen on the stairs. This is a very easy thing to fix if your home is certified and the person has started and built it with virtually very little or no cost difference from the way they're being built today. We have a solution that's been tested. It's been proven in market housing. The consumer and developer both have embraced and accepted the building concept. The user-friendly program works for government as well as industry by raising the building criteria baseline that we use for our housing. This is not rocket science. It's just the incorporation of common sense and affordable building ideas, which has a significant and positive impact on our housing needs.

           A certification of houses that have met these building criteria is important to the longevity and credibility of the program. We invite you to take a tour of our demonstration home in Vancouver and take the time to assess the program and the merits and benefits that I've stated here.

           You've also been handed a brochure which most of you have in your hands. The demonstration house is on Southwest Marine Drive in Vancouver. That's the home that we invite you to come and see. We can set that up at any time for you. It's well worth coming to look at. You're walking into a very beautiful home that does not look like it's suitable, necessarily, for people with disabilities, wheelchairs, adaptability or any of those sorts of things.

           The other thing is that in the back of that brochure is a checklist on the very last page — not on the back but on the inside back — that shows you the kind of things we're doing in order to reduce the accident rate and increase the relative safety of the house. This includes, like I said before, taking away thresholds at the front and back doors, the access doors; having the stairs safer; widening of hallways and widening of doors, so there's access for virtually anybody.

           I've been in homes that were wheelchair-accessible, but you certainly couldn't live in them, because you couldn't get in the shower. You could visit, but you couldn't live there. In user-friendly homes, people can age in place if they end up with a disability. Altering the house later on isn't an $80,000 job for the government to retrofit the house for someone who's got the disability. It might be a $2,000 or $3,000 job. There's substantial savings. With people aging in place, it lets the home care system, which has proven cheaper to operate than the hospital system, grow a little bit and treat people in their homes instead of in the hospital.

           Anyways, I thank you for your time. I'd like to know if anyone has any questions.

           V. Roddick (Chair): Thank you for your time. I don't know if I want to go home tonight after all these statistics.

           G. Porter: Just watch your step while you're in there — okay?

           V. Roddick (Chair): Are there any questions from the members?

           S. Brice (Deputy Chair): Very interesting. I see that you're working with the Canadian Home Builders Association.

           G. Porter: Yes, we are.

           S. Brice (Deputy Chair): This is obviously brought to us for information so that we know kind of what's happening out in the industry. Are you looking for any other role or partnership with government?

[ Page 611 ]

[1035]

           G. Porter: We're looking for a partnership, specifically with B.C. Housing right at the moment, to give them a template or a workbook that they can take to their builders. All of their housing will be accessible as opposed to a percentage of it. It won't cost the builders any substantial amount of money to change. In a townhouse complex that's currently being built down by the border, I believe it was under $200 per townhouse to make them user-friendly while they were being built. If that were to be done later, you'd be looking at somewhere between $40,000 and $80,000, depending on what's necessary.

           V. Roddick (Chair): That was what I was going to ask. You say that if you have to retrofit….

           G. Porter: Retrofitting is a costly thing to do. Whereas, if the home was designed with a few things in it in the beginning, making those changes….

           V. Roddick (Chair): This is your particular idea — new as opposed to going into somebody's….

           G. Porter: We have retrofitted homes, but it is a more expensive proposition, yes. Just putting blocking around the bathtub so that you can screw in a bar…. If you do that when you build a house, you're adding about $5 or $6 worth of wood — maybe $20 worth. But if you have to rip that wall down to put in a bar when you have somebody living there who has a disability, you're looking at a $3,000 to $5,000 renovation job because there's nothing behind the tile. It's little things like that.

           P. Simpson: What's unique about what we're doing today is that this is actually an implementation program. We've got 40 years of studies. We keep going around in circles over and over again studying the same problem, and nobody's doing anything about it in the end. Our objective was to implement a program in the marketplace that worked. It's really simple, and it's very effective. In the testing of this, we found that consumers really understood what was going on. The other thing we found out was that if you tell women how to fix houses, they'll do it.

           G. Porter: Unfortunately, if you tell us men, we'll say yes and change the channel.

           V. Roddick (Chair): Well, thank you both very much. That's very interesting and very practical.

           P. Simpson: If you do get a chance, come and visit the demonstration house.

           V. Roddick (Chair): What is the address?

           P. Simpson: It's on the corner of Southwest Marine Drive and West 54th. It's 2281. We did run thousands of people through this house last year, and we gave them a hands-on experience. What we found was that when people come into a room environment and touch and feel these changes that we're suggesting, it becomes very real. People can then make decisions. This is why the homeowners and homebuilders have been grasping this program and running with it. To give you a bit of an idea of how strong this program is, CMHC has the flex house program. While they've created six houses on a national basis to demonstrate and illustrate their flex house program, we're not aware of any flex houses on the open market. We have 111 so far that have registered with us, and they're all market houses being built by homeowners and builders.

           G. Porter: Just as a point, a gentleman asked me if we were going to have to change building codes. All of what we've proposed fits into the current building codes all across North America. There's no issues with the different municipalities and cities as far as building the homes is concerned. These are just different ways to do it that make them safer.

           V. Roddick (Chair): Excellent. Thank you both very much.

           Now, I understand Kim Montgomery and Renée Robert are here from the Family Violence Resource Centre.

           R. Robert: Good morning. This is a little more intimidating than I thought it was going to be.

           V. Roddick (Chair): Don't be intimidated. We really appreciate you coming this morning.

[1040]

           R. Robert: It's nice to be here, and it's nice to be able to talk about not only what we do but what we hope to see in the future. So thank you for having us.

           We come from the Family Violence Resource Centre in Vancouver, which is operated out of the native education centre. What we do is offer a variety of things, actually, through the centre. Our funding comes from the SAIP program's funding. That's the sexual assault intervention program. We provide — as we say in our little piece here that we've given you in your packages — counselling as well as resources to the community on sexual abuse and family violence in the aboriginal community.

           Our counselling program is a fairly new one. We're offering group counselling, one-to-one therapy, education activities, prevention and intervention activities — a whole variety of things. We are really involved with the community, talking to them and asking them — and we have a good opportunity to do this, because we work with a lot of students in the school — what it is they want to see and how we can provide the best service for them.

           The FVRC program, the Family Violence Resource Centre itself, offers resources, pamphlets, books and videos to, in particular, our other SAIP contractors across the province and to any community that's looking for resources around aboriginal issues — again, in

[ Page 612 ]

particular, on sexual abuse and family violence issues in the aboriginal community.

           I'm sorry. I should have started off by introducing myself and getting Kim to introduce herself. I'll go there next. My name is Renée Robert. I am actually the counselling department coordinator at the native education centre. I'm from the Sahtu Dene nation in the Northwest Territories. Maybe I'll let Kim introduce herself.

           K. Montgomery: Hi, I'm Kim Montgomery. I'm from the Okanagan nation located in Keremeos. I am a sexual abuse counsellor. As well, I manage the Family Violence Resource Centre.

           R. Robert: The history of the organization is that we've actually been around seven years, and it's changed quite a bit throughout those years. Like I said, our counselling program is actually a fairly new one. What we have done in the seven years is build the Family Violence Resource Centre and our membership across the province. We really have spent the last year asking our membership what they would like to see in terms of services.

           Maybe Kim can talk a little bit about that too — about the counselling services and the resource centre.

           K. Montgomery: Currently, I'm doing one-to-one counselling mostly with the native education students. In the contract that we have, there are so many allotted hours — like 100 hours of community service, 255 hours of individual counselling. It's broken down into group counselling as well. With the individual counselling, if I have students that I can do sexual abuse counselling with, then that's where I'm mandated to go right now. With the group counselling, we do talking circles at the school, and we do outreach as well.

           I also do training with other organizations and other SAIP contractors as well, helping them to establish outreach material for their students in the schools.

           R. Robert: The other thing we're trying to do in terms of working with our own community is have our community involved in what we do in our intervention and prevention programs. We get volunteers from our own community to work in the program so they can become familiar with what we do and how we do it. We are both registered social workers and therapists, so we take students from the university and have them come and work at the program so they can get experience working with the community.

           I think that's where we're at. Are there any questions? I guess I should ask.

           V. Roddick (Chair): I notice you're on Fifth Avenue. Do you sort of integrate or link with the…? I thought it was a youth community centre. Or is it a community centre on Hastings Street?

           K. Montgomery: Yeah. It's Urban Native Youth. I know the workers there. We haven't had a chance to do some liaising with them as of yet. We do a lot with addictions counselling, a lot of referrals and stuff through there as well.

[1045]

           R. Robert: What our clients, the people that we work with, are asking for is to receive services within the aboriginal community. We have a really difficult time doing that. There's not enough services. There aren't enough registered therapists who are aboriginal working just with aboriginal clients. That's what our clients are asking for. We have a hard time providing what it is that they want and often find that we're really stretched. We do use the other services in the community quite a bit, sometimes for things that really…. It's not always where we would want to send a client, but it's the best we can do.

           We work with the community that we have. It's a pretty tight, small community. We know each other fairly well. Vancouver Native Health, the friendship centre, the Native Education Centre and a group of other community resources have gotten together to look at doing an agreement of how we can provide a case management kind of service delivery program that makes more sense for the clients we serve. That's how we're trying to address that. It's hard, though. We find that with the funding we have and the workers we have, we're all doing about two or three jobs. It gets difficult.

           So if there aren't any other questions, I'll go on to the recommendations that we have.

           P. Sahota: I just have a quick question in terms of the clients. Do you have any idea roughly of how many clients are accessing your resource centre?

           R. Robert: I guess Kim can answer that.

           K. Montgomery: Well, I just started in September, but from the quarterly reports, there's probably 100 to 150 per year. With sexual abuse counselling, that is a pretty high amount. You're only supposed to do 4½ hours per week of actual one-to-one counselling. I'm not sure of the group numbers, though. I just know the individual numbers.

           R. Robert: Our recommendations are probably what you're hearing from a lot of other people. What we'd like to see for this particular program — and for mental health funding in general, I think, for the aboriginal community — is multi-year funding. When we have funding that we have to reapply for every year, it's a great drain on our resources — to sit and do that every year and to keep justifying what we already know is a big problem within our own community. It's time-consuming, and it's difficult. I think it's also difficult psychologically, even for us, to have to keep going there and reapplying and justifying the kind of work that we do. Multi-year funding would be wonderful for us, not only because we can then do some long-term planning for our clients, but also so we can keep focused on the work we're doing. We can't do that right now. We're waiting every year to know whether we

[ Page 613 ]

can continue into the next year. It's really draining to have to do that.

           Our second recommendation is community-based work, meaning that social work and mental health services is supported and encouraged through local health councils, and provision of services is not hindered through bureaucratic processes. What we'd like to see is maintaining money at the local level as opposed to having to go through, perhaps, the health authority and through a lot of processes before we can actually get money and access that to provide services. We'd like to see it maintained at a local level. That way, if it's done at the local level, then people get immediate feedback from us, too, about what's going on, what's happening, what we need and how we can work best with each other.

           Management and delivery of health programs is led by aboriginal health practitioners in the aboriginal community. I say that because that's what our clients are asking for. We simply don't have enough. I think we have not been organized either in the aboriginal community in terms of linking together and providing resources. Mind you, part of that is not having the time to be able to do that. As I said, we're trying to get together the local resources and establish some kind of network with each other so that we can do some effective case management. Again, the clients are asking for aboriginal health practitioners and aboriginal resources.

[1050]

           My recommendation No. 4 is: mental health organizations are supported to work with each other within a positive case management service delivery model and not in an exclusionary and/or confrontational way due to funding and other political issues. Again, that's just more of what I've already been saying: trying to work more closely with each other and not having boundaries that are more or less artificial, in terms of having to find funding and running against each other to find funding, and then trying to work together, which is a very difficult thing to do.

           More mental health workers and social workers are on site at aboriginal organizations not specifically designed to provide mental health services — for example, at day care and employment offices. If we had more workers working more spread out at the local level, we wouldn't need to be providing the level of service that we do at our organization, for instance, which really stretches our ability to provide good services to the clients we have. I think those are all the recommendations we have to give you.

           K. Montgomery: I just wanted to mention that my position is half-time, or 0.5 sexual abuse and 0.5 the Family Violence Resource Centre. I just wanted to talk about the resource centre and its importance. I worked at the front-line level in a rural community. I was a social worker for my band for five years. Not having access to this type of material and not having the financial resources to buy these types of books to educate our communities and educate our staff…. I really see it as vital in that we have 345 members all over B.C., and that's from the tip of the Yukon right down to the Okanagan. We offer sexual abuse, drug and alcohol and solvent abuse and family violence. Our resources and all of our material are geared totally towards aboriginal issues — sexual abuse in relation to being aboriginal — and that is really hard to find. We really work hard to make our resource centre the best possible for all the communities that can access it.

           I just wanted to make that point. It is really hard when you're working front line, and you don't have the financial backing to buy the resources. We have a lot of books and a lot videos that people have been accessing.

           R. Robert: I think the other thing, too, is that all our services are of course free. We get calls from the community all the time about providing more service to the community members in general. We get other organizations phoning us and asking if we can do groups in their institutions, at their places of work or in the community. We just simply don't have enough time or hours to do that. I think there's just a real lack of money out there to support the services that we need to see, especially in the downtown east side, which is the community that we offer the front-line services to the most.

           I think that's all we have. Have you any questions of us?

           P. Sahota: Is your funding provincial funding?

           R. Robert: Yes.

           P. Sahota: What is your annual budget?

           R. Robert: It's $110,000. They get really good value for the money we get.

           V. Roddick (Chair): Any other questions?

           You answered a question on the fact that it was provincial funding. Do you get any federal funding at all in this particular instance?

           R. Robert: No.

           V. Roddick (Chair): This is something that as we've travelled the province…. I would really like to say: what terrific turnouts. It's really encouraging that every place we've gone, we've had aboriginal representation. It's obvious that we need to create some real links as far as the health care system and its delivery is concerned. We really appreciate the fact that you've come out as well. Obviously, there is a great inconsistency in people's understanding of where the funds come from. Conceptually, most people seem to think it's all federal, and that's obviously not the case. It has a lot of strings attached, which we're learning.

           R. Robert: I find most of our services…. In the downtown east side, too, we're non-profit societies, and we're constantly scrambling for money just to be able to do the basic things that we need to do. Most of it is provincial. It's difficult.

[ Page 614 ]

[1055]

           K. Montgomery: There always seems to be that line when you're dealing with aboriginals and federal and provincial moneys — right? Working in the rural community, it was always trying to get pushed to the provincial and wanting the federal government to fund us. It's a lot different working in the urban setting, where everything's provincial.

           V. Roddick (Chair): Yes. It's off-reserve; then it becomes provincial.

           Well, thank you both very much for presenting today. We really appreciate it. I hope that you will keep in touch. This is an ongoing standing committee. Just because we're having a report that comes out in mid-December doesn't mean we're folding our tents. We're definitely here for the long haul, so please keep in touch.

           K. Montgomery: Thank you very much.

           V. Roddick (Chair): Our 11 o'clock presenter is Ed….

           E. Koch: Koch, like the ex-mayor of New York.

           Good morning. I want to thank the committee for giving me this opportunity to present my case. I just ran into your little pamphlet at the door about preparing written submissions. I wish I'd had this before I came in today. But I hope I've covered the bases with the submission that I have presented. I'm dealing with the individual case of my son Alex, but I feel that this is representative of perhaps a larger category of cases and also of some questions as to access to laser surgery, etc., that are of a larger scope.

           My son has been afflicted with the problem of corneal erosion for approximately two years now. Sometime in July or August of 1999 — I think that's the correct date, but it might have been a little later or a little earlier — he was stricken with an attack of excruciating pain in the evening, and I drove him to the Royal Columbian Hospital. The hospital staff were not able to be very helpful at that point in time, and he started going to Dr. Gilani, an eye doctor, who provided him with a temporary prescription that alleviated some of the pain.

           Now, the pain wasn't there at all times; it would recur maybe once a month, maybe once every couple of weeks or so. He would apply this salve, but it was meant to be a short-term solution rather than one of a permanent nature. Dr. Gilani sent him to a Dr. Cottle in New West and subsequently to Dr. Holland, an ophthalmologist in Vancouver. In August we received a letter from Dr. Holland making some of the following points. He recommended phototherapeutic keratectomy. I'd never heard of this term up to reading this letter, so I did a bit of research for corneal erosion, and I've included in the appendix and documents in here some definitions from American and Canadian eye clinics.

[1100]

           Dr. Holland recommended a procedure. This procedure requires an excimer laser, which is unavailable in publicly funded hospitals — which, again, raises some questions. The excimer laser is only available in private laser clinics. MSP has determined that this type of laser surgery is medically necessary. It's not cosmetic. It's not because I don't want to wear glasses or anything of this sort. It is necessary because it's painful, and if left on its own, I guess it will ultimately result in a loss of sight. MSP said that it would insure this surgery. MSP has further stated that there can be no facility fee charged by the clinic, so even if you wanted to pay for it, you couldn't. Because PTK is medically necessary, Alex can't pay for any part of the facility fee. Again, there's been a prolonged wait. This has been close to about a two-year period of time that has lapsed while we were looking for some treatment or solution to this problem. Further, as I mentioned earlier, recurrent corneal erosions are disabling and extremely painful.

           I've researched the Internet; I've visited the London Place Eye Centre in New Westminster, which is, I think, the oldest laser clinic in Vancouver. Alex has called on his doctor to get some data and things of this sort. Included in my presentation are definitions from the Canadian and American laser clinics. There's a list of physicians treating Alex, and I have left with my MLA, Ms. Sahota, a statement giving permission to call these doctors to check on them and so forth, if need be.

           From my reading on this particular procedure, it takes anything from a few seconds to up to maybe five minutes to perform. A perusal of research indicates that it's got a very high rate of success. It's been around for several years. The London Place clinic has performed over 15,000 laser operations in, I think, a ten-year period. But these are not necessarily PTK; these are other types of things. I'm not a person who's medically sophisticated or knowledgable. I just know what I've read lately on this.

           From this limited inquiry there seem to be some questions that arise. My first point there is sort of tongue-in-cheek. I don't really believe there's a conspiracy to enrich doctors or anything of this sort, but again, it seems odd that the private clinics are the only source of the excimer lasers. I think it's worth looking into how this can be made more accessible to people who have medically necessary problems that need to be treated.

           Again, the wait has been quite some time. I think it's two years or over that we've been looking for some arrangements or some way that this problem can be addressed. I'm sure that my son is not the only case in B.C. This is a sort of a catch-22 situation: "You can have the operation. We'll pay for it, but you can't get access to the excimer laser on this."

           A further point that occurred to me later on was kind of a cost-benefit item. From what I gather, looking around, each eye would cost anywhere from $1,500 to $2,000 to do. Alex, if he is healthy and able, can be a working, tax-paying citizen. If he is disabled, it will cost the province hundreds of thousands of dollars. So

[ Page 615 ]

it just seems that it would be sensible to, if possible, have a tax-paying, working citizen, rather than a dependent one.

           Again, thanks for your attention. I'm ready to answer any questions that may arise if I know the answer.

           V. Roddick (Chair): Thank you very much for your presentation.

           R. Hawes: I'm sorry, Mr. Koch. I don't understand at all what you're talking about — that you can't get access.

           E. Koch: We can't get access to an excimer laser.

           R. Hawes: Well, does anyone get access to an excimer laser?

           E. Koch: I guess not; I don't know.

           R. Hawes: I mean, private clinics have excimer lasers, and they are unused. Is that what you're saying?

           E. Koch: No, no; they are used.

           R. Hawes: Well, who gets access to them then?

           E. Koch: I suppose paying customers.

           R. Hawes: But if this is paid for through MSP….

           E. Koch: I really don't have that information. I'm a bit puzzled too.

           R. Hawes: So what you're saying is that it's got something to do with this facilities fee?

[1105]

           E. Koch: Yeah. Dr. Holland has sort of said that Alex can't pay anything on this. The doctors have gotten together and offered to forgo their own fee as a partial facility fee thing, but as far as I know they are only available…. According to Dr. Holland's letter to me — and I don't know if this is accurate or not, but I assume it is — the eye clinics are the only ones that have these excimer lasers. They're not available in publicly funded hospitals.

           J. Bray: So, Mr. Koch, essentially what's happening is that MSP has said: "This is medically necessary. We'll pay for it."

           E. Koch: Yes.

           J. Bray: But because the laser only exists in a private clinic that charges a facility fee in order to make a profit, they won't pay for it. Is that essentially what's happening?

           E. Koch: Well, they said, "We can't pay for it," according to Dr. Holland's letter to us. We're not permitted to pay for the facility fee.

           J. Bray: MSP can't pay it.

           E. Koch: I guess they won't. I don't know if they can't. They pay a fee to the surgeon for performing the procedure, but no facility fee.

           J. Bray: So part of the thing is that the facility isn't going to do it just for cost.

           E. Koch: They're in business, and they expect to make some sort of a profit on the use of this machine.

           J. Bray: And MSP has told you that you can't pay the differential.

           E. Koch: Well, this is from Dr. Holland's letter to us: that we're not allowed, under whatever regulations or so forth they have, to pay the facility fee.

           V. Roddick (Chair): Well, thank you very much for your presentation, sir.

           E. Koch: Thank you for the opportunity.

           V. Roddick (Chair): Our next presenters this morning are from the cluster care South Fraser health region: Gwen Filippelli and Pat Neale. Good morning.

           G. Filippelli: Good morning. Welcome to our presentation on the cluster care model. As members of the cluster care committee in South Fraser, we are very privileged to share with the Select Standing Committee on Health a model for cost-effective and quality home support services.

           Presenting today are myself, Gwen Filippelli — I'm the continuing care case manager in White Rock, B.C. — and Pat Neale, the continuing care case manager in Langley, B.C. The PowerPoint presentation we're using is an abbreviated form of the slide presentation you will be given. The original presentation was given in a workshop to the international care case management conference in July of this year. We would like to acknowledge the financial contribution from the health transitional fund, Health Canada, in the cluster care project research and evaluation.

           I will now give you an overview of the cluster care project. The visuals you will see are of our clients and home support workers in the initial pilot project.

           On the screen in front of you are the visuals of the two high-density buildings chosen and presently using cluster care within them. They are the Rainbow Lodge in Langley and the Kinsmen Retirement Centre in Tsawwassen.

           The slide ahead of you shows that in June of 1997 a group of continuing care case managers began to investigate different ways to provide home support services. A literature review was done, and we found, internationally, that in New York there was a shared aid project. Nationally, in Waterloo, there's a shared care pilot project, and we also did a site visit to Kamloops, which is also doing a pilot program of home support.

[ Page 616 ]

[1110]

           We developed a regional cluster care committee, and we also received some health transitional funds in March 1999. The pilot project actually ran through April to October of 1999, and the evaluation and final report was off to Health Canada in March 2000.

           To give you an idea of what cluster care is, cluster care is a method of homemaking provision to individuals in high-density areas by utilizing a team approach to homemaking tasks. We acknowledge the Waterloo home care program for this definition.

           This slide shows you some of the differences between the traditional way we provide home support and what cluster care could provide. Basically, cluster care uses home attendant teams, rather than individual workers, to service clusters of clients at one time. It provides a multidisciplinary team approach to enhance the well-being of our clients, and it has the potential to provide equality of services and improve the relationship between home support workers and clients.

           Another service focus of the traditional model is that one home support worker would be dealing with one client in various tasks and have to stay for a block of time — let's say, two hours to do cleaning and bathing — whereas in cluster care we looked at what the need of the client was. If the bath was a half-hour, we stayed for a half-hour in the morning, did the bath, left, and perhaps it was more comfortable to do the laundry or cleaning in the afternoon. Because we were in the building, we could come and go. This seemed to please our clients a lot better.

           The mission of cluster care is to provide quality, client-centred care in designated high-density geographic areas and also to deliver and administer the care in a responsive and cost-effective manner. Our vision is to assist all continuing care clients in the South Fraser region to maintain their independence in their homes for as long as possible, supported by appropriate and flexible services.

           We also developed a set of values which we felt were the foundation of our service model. The first and foremost was that the client is a primary focus of our team. Shared decision-making is promoted with the client, the caregivers and the team participating together. The services are focused on the health care needs of the client. Service delivery is flexible, responsive, cost-effective and integrated. Cluster care values services which assist in the development of community. We feel that's a very strong component. Cluster care values services which encourage utilizing community resources, and it values the contribution of all members.

           The evaluation was done after the project ran from April to November of 1999. We used six questions. They were basically the structure requested by the health transition fund. Now Pat Neale will give us some of the key findings, also looking at the relevance of the program.

           P. Neale: Good morning. Some of our key findings were the same as regionally. The majority of our clients were 80 years and older; that was 71 percent. They were female — 88.4 percent. The majority were at the IC2 care level. We have four care levels from intermediate care 1 to extended care. We found that we were using only 74.4 percent of the maximum authorized hours. An extended care client would have a maximum of 120 allowable hours a month, which isn't a whole lot, but we were only using 75 percent of that. We found that the average cost was about $422.50 per month for the clients.

           We did a comparison between the clients before and after we had started cluster care. We found, due to the flexibility of the cluster care model, that we were able to keep the clients home longer. Also, by keeping them home longer, their care levels went up, because a lot of them have progressive diseases. Our hours increased. They were driven mostly by our intermediate care 3 and extended care clients. We did have an increase of about $20. Part of this was due to the charge-out rates of the homemaking agencies going up during our pilot period.

[1115]

           We did several surveys, and they all indicated that the clients, the caregivers and the families had a high level of support for the program. They found that the services were accessible. We had the right care at the right time. It was more task-oriented than time-oriented, so we weren't putting a homemaker in for two hours and making her stay there. They did their task, and then they went on to the next client.

           We were able to identify potential new clients in these seniors buildings. The team was there, and the homemakers were more accessible. So we reached a lot of clients before they got to a crisis situation. Our response to client needs was prompt. There are a number of falls in the seniors buildings. We had the team in the building, so we could respond to these falls. There was a fractured wrist. Fortunately, we didn't have any fractured hips.

           The clients and caregivers indicated a high level of satisfaction with the care. The home support workers worked really hard. It gave them a lot more job satisfaction, because they could meet clients' ongoing needs. There was the continuity, which is a big issue with our seniors — that they have the same homemaking team who know them and who are more familiar.

           The care providers felt they functioned better as a team. From our point of view, we had more feedback. It was more of a team approach. Our at-risk clients were monitored more closely. One of our big issues is medication and nutrition being given on time. We could do this within our resources because we could do 15-minute visits with the cluster care. That was a real bonus for us, and it did suit the majority of the clients in the building. We found that the only clients we couldn't service were the palliative clients who needed long hours — like four hours — and some of our respite clients. We gave the caregiver, who is usually in his eighties also, a break from care. So we do four-hour blocks, but we couldn't do that at this point.

           The relevance of the program. We needed six months to start the program. We wanted to update our assessments and have time to orient the homemakers

[ Page 617 ]

and the different agencies. We found the most appropriate target group for the cluster were the clients living in high-density buildings, usually in city cores. Rainbow is one of the largest in western Canada. It has six apartment blocks. We also can expand this concept to first nations or mobile home parks.

           A single home support agency should be assigned to the complex or the buildings to avoid double-billing and different communication. In the South Fraser region, Langley and Delta were the only areas with single support agencies. Surrey had four, which is now being changed through their homemaking review program.

           We wanted to make sure our care plans were current. A lot of these people, because of the numbers, we see once every two or three years. So we do update all our care plans to make sure they are appropriate.

           We introduced the program to the building site with the residents. We had tea and cake for the caregivers and the building manager. This was with respect to the clients who were experiencing this change of homemakers. They needed to be involved in the decision-making. We need to have the same service approach in the buildings. Rather than have a traditional and a cluster side by side, we can be inclusive of all the clients.

           It's important to establish a schedule for the homemakers based on the actual time they need for the task — so 30 minutes for a bath. It identifies what the clients really need and promotes their independence so that we're not doing more for them than they need to have done. They keep their independence as long as they can.

           The homemakers initially had a two-day orientation. Now this has been adjusted to six hours, because we've had ongoing education. We were able to do a wonderful homemaking orientation package for the homemakers during the pilot. We have weekly team meetings to assist the homemakers. That was to give them support, because it was a new role for them to be team players. It helped monitor the ongoing care too.

[1120]

           The present system of billing provided by home support agencies doesn't accommodate cluster care service delivery. Ideally, we bill our clients individually, which is the provincial policy. If we could use these buildings or complexes in a more global funding so that the building could be the client, it would save administration costs for all the billing that has to be hand done or duplicated with these clients. More flexible billing services are something that we would recommend.

           In the cluster care model, we did use the site as the unit. We had to get the collective bargaining unions together to verify that. They were very positive and supportive. A lot of the support came from the homemakers themselves. Because they're on one site and they're not travelling, we saved a lot of travel costs. The precedent has been set, and they've been very supportive of it. I'll turn it over to Gwen for the last summary.

           G. Filippelli: On the screen before you are the faces and words of the clients and home support workers. They are the heart and soul of cluster care.

           We thank you for the opportunity to provide innovative and cost-effective solutions to improve the health outcomes and quality of life for all British Columbians. Actually, as a parting gift from us, we will leave with you a box of Nutchos, which we feel demonstrates quite effectively the concept of clustering very good things together. In each of our presentations we've tried to provide the concept in a variety of ways, and Nutchos seemed to be the one that went over the best. So that's what you get.

           V. Roddick (Chair): Well, that's very innovative.

           G. Filippelli: Are there questions? We're certainly open to those.

           R. Hawes: You mentioned in your presentation that there could be BCGEU implications to this. Have you been able to work around that?

           G. Filippelli: Very much so. We actually approached the home support agencies with the concept. They worked alongside us and identified that the actual tasks and the job description were the same. It was just really empowering the workers to use more of their own skills. They have been very supportive. In fact, they've requested copies of the document. Their workers would really like to see this expanded.

           V. Roddick (Chair): That's terrific. It really is just the sort of commonsense approach that we need.

           S. Brice (Deputy Chair): You mentioned more flexibility in billing. Since billing is based on time and income, what do you think the client reaction would be to the building being considered one envelope? Have you any feedback from them?

           P. Neale: Our clients were subsidized low income, so their client charges were actually zero. They were fully subsidized. We did have some clients that did have client charges. They varied from $13 to $20, and they can go up as high as $50. We found that security was a huge issue with these clients. They were willing to pay their client charge because there was a team in the building. It gave them that added security, and security was one of the issues in these big apartment buildings that seniors were really struggling with. With the team in there, they would come out of their apartments. They would wander in the halls. They were much more able to build a community within. In Kamloops they have cluster care in all their big apartments. They have client charges, and they find the same thing. The clients are willing to pay because it's security. You can still pool those hours and make it equitable.

           S. Brice (Deputy Chair): Do you think it would translate into a housing situation where the income testing was a part of the formula?

           G. Filippelli: That, in fact, is the case.

           P. Neale: There is a variety. In Delta, where it was also piloted, they had client charges, and they were

[ Page 618 ]

willing to do that. It added the benefits of the pilot and the program. So it has worked.

           G. Filippelli: What would happen is that we would still authorize, say, two hours a week. The client might get eight 15-minute visits out of that, but they would only be billed for one visit, which would be the two hours a week. They received enhanced service without paying the extra money for it.

           P. Neale: That's where we can meet their needs a lot better — especially our dementias, where we need to get those medications and their meals to them on time.

[1125]

           V. Roddick (Chair): For instance, if you had an apartment building of an average size, how long would you spend in that building sort of at one fell swoop when you go in as a team cluster?

           P. Neale: We were in there from eight in the morning till nine at night. We had full-time workers through the morning, because everybody likes their bath in the morning. There are a few that like the evening, but we would provide most of their personal care in the morning. There'd be a team of two. We went by the hours. There were 500 hours within the two buildings that we used, so we could distribute those hours. They can clean up the bathroom after, in the afternoon, but it would be more task-oriented. That's how we managed to do it.

           In Delta they had…. Because our hours fluctuate, if one of these clients goes into a facility, the hours drop. We didn't make these positions full-time for the homemakers to start with. We kept them part-time and worked up to full-time hours. That gave a little more flexibility to the agencies. That's how we worked through that. But there is a team in there. There are usually two within the daytime, and there's one in the evening to settle people and for meds.

           V. Roddick (Chair): Well, thank you very much. That's really terrific to hear that. So that's two pilots that you've been doing.

           G. Filippelli: We have two pilots. But right now there is the continuing care review happening in South Fraser, and it is part of that review process. It should be expanded.

           We also have shared this with Singapore, Australia and a number of international places which are also quite excited about the concept.

           V. Roddick (Chair): Great. Thank you very much indeed.

           Our next presenters for Riverview Hospital are Marion Suski and Alastair Gordon. Good morning.

           M. Suski: Good morning. I'm Marion Suski. I'm the president and CEO of Riverview Hospital, and Alastair Gordon is with me. He's the director of communications at the hospital.

           We were encouraged to come and speak to you this morning by Dr. Cheema, the Minister of State for Mental Health. What I'd like to do is say that Riverview Hospital has a long history. Probably some of you know it much better than I do. I've only been at the hospital just a little over one year.

           Riverview Hospital actually started in 1913 and has helped many, many British Columbians with severe and persistent mental illness. Riverview Hospital had over 4,000 patients at one time. Today we have 808 patients. It has been downsized several times. I think the advent of new medications in the fifties, sixties and seventies made that transition. Many people were able to live in their own homes, in their own communities and in different types of accommodation. Riverview Hospital has many buildings on its site. It's located in Port Coquitlam — the address is Port Coquitlam; it's actually Coquitlam — on Lougheed Highway. So you probably know a bit about Riverview.

           We have a world-class arboretum on the site. Riverview Hospital, the buildings and the property are owned by B.C. Buildings Corporation. This is the only teaching hospital in North America that does not own its own property. I think Riverview Hospital is the oldest hospital in British Columbia.

[1130]

           Today we have these 808 patients. We have them in very old facilities. We have some of our patients living in dorms of eight and nine patients to a dorm. Our food is still delivered on trays. I guess you may say to me: "What's the difference?" I have been very involved in health care for the last 30 years, in acute care hospitals, in regions and now in mental health.

           Picture this: out of the 808 patients, about 259 stay from three months to one year at Riverview Hospital. About 181 of them stay one to three years, and 119 of them stay over three years. We have seven patients who were there over 50 years, and we have one patient who was there 80 years. When you say that we have patients entrusted to our care, it means something quite different when you have a patient entrusted to your care for two weeks or two days or one month and when you have patients entrusted to your care for 50 or 80 years.

           I think we have to look at quality-of-life issues and quality-of-care issues, and that's what we're trying to do. We're trying to make life better. Our vision is transforming mental illness into mental wellness. I think that's a great vision, because it's not only making tiny little steps, but it is transforming mental illness to mental wellness.

           I want you to know that one out of five Canadians will suffer from some type of mental illness in their lifetime. Not all will be severely or persistently mentally ill. We have a long way to go with mental illness. It is no secret that if you had two patients in an emergency department today and one was suffering from mental illness and one from a physical illness, the one with mental illness would wait a lot longer. Who is to blame? We are, all of us. It is people that work in the

[ Page 619 ]

system, people like me, who have expertise in health care, but it's also our societal culture and values. We must work on the stigma of mental illness. It's very close to home. It could be our families suffering from mental illness — our neighbours, our friends, our children.

           I'm not saying that you have to do everything. I think we have to do some things too. The first new building on Riverview property is happening right now. We are on time with our construction. We're building a prototype, a 20-bed facility. It will be completed in December, and we will have our patients moving in, in January. It is a new type. It's highly specialized residential care. It will be a different staffing pattern, and each patient will have their own bedroom, which is a major change. We are also supporting the building in Sevenoaks. We will be moving 24 patients to Sevenoaks in Victoria when that project is completed, hopefully before the end of the fiscal year, which is March, and ten patients to Prince George at this particular time.

           I don't think we're moving fast enough, and not everyone can be accommodated in the community. I did public health nursing, home care nursing, a long time ago. I also was CEO of an acute care hospital. I saw patients in an in-patient unit, and I saw them when I worked in the region. I think we have to look for solutions, but we also have to look to accommodate these patients in some better facilities.

[1135]

           I guess I'd like to say a couple of things. I know we all have challenges and opportunities, and I'd like to say that we would like to change things at Riverview for the betterment of our patients. They must be number one; everything else has to come second. I think it doesn't take just us to go with that vision; it takes all of us. I just completed 16 site visits around B.C. — I probably went to some of your areas — and asked the question: what's working with Riverview? What is not working with Riverview? How can we work together? We receive patients from all over the province at Riverview, and we discharge them back all over the province. We must work very closely together.

           In your packages you will also see a compilation. One is Challenges and Opportunities, and that is a paper we wrote in the summer about different challenges and opportunities at Riverview. I also gave you a copy. I did actually present back to the regions and Dr. Cheema and the Ministry of State for Mental Health on what we found from all the regions in B.C., on how we work at Riverview Hospital and our annual report.

           What I'd like to say is that it is costing a lot of money. When we talk about depression, schizophrenia and anxiety disorders, we talk in billions of dollars. From all those visits, what I did find was that I'm trying to hone the role of Riverview Hospital. When I came here last fall, many people told me: "It's closed." I said: "Well, it isn't, because I'm here." There are 800 patients and almost 1,800 staff that work at Riverview.

           What I came through with on the role of Riverview was that it should be a significantly sized psychiatric hospital with a provincial mandate. There should be a program for the severely and persistently mentally ill. I don't think it can be replicated in every place in the province. We must provide a place where there is safe, secure care. Again, it can't be replicated in every place in the province.

           Provide specialized care to a critical mass. There are certain conditions that people have. There is one in Prince George who suffers from this condition and one in Terrace and one in Cranbrook. I think we need to have the expertise and the critical mass at Riverview.

           Riverview is also a leader in education and research. Today we have over 50 research projects happening. We are a university teaching hospital. We provide education to approximately 450 students a year, which replicates into 1,200 sessions at a community college or a university.

           I think that even if we put different facilities around the province, somebody should be in charge of the provincial tertiary wait-list for mental illness, because, again, there are some beds that are open in different parts of the province. On this side we have this long waiting list. We should be an accredited, quality hospital. There is no doubt that if we're operating a hospital, it must be the best that it can be for the patients we serve.

           I just wanted to introduce you to Riverview. I would challenge you to come and visit us at any time. We will tour you through our facilities. Some of you probably, as I mentioned, know more about Riverview than I do, but I'm certainly willing to share information at any time and also to tour you around the hospital. Thank you very much.

           V. Roddick (Chair): Thank you very much indeed for such an impassioned presentation. That was terrific. Are there any questions? You've obviously done a bang-up job.

           Our next presenters are Dr. Marshall Dahl, Robert Hulyk and Darrell Thomson from the B.C. Medical Association. Good morning, gentlemen.

           M. Dahl: Good morning. Thank you very much for the opportunity to speak to you today. I hope to be able to represent the interests of doctors and their patients. I'm Marshall Dahl. I am now an internist, a diabetes specialist, in Vancouver. I used to be a family doctor in a number of small towns around British Columbia, and in fact I used to be a health care worker, an orderly at Riverview Hospital, which is an excellent institution. It's nice to be able to hear about it again today. I've practised in B.C. now since 1987. I'm past president of the B.C. Medical Association. I'm the chair of our BCMA council on health economics and policy.

[1140]

           I want to start by congratulating you for taking this important step. To have a committee seeking input from British Columbians through these hearings is, both symbolically and practically, quite important. It's good to have legislators here working hard to understand and improve health care in our province. I hope we can arrive at some solutions together that produce some meaningful change.

[ Page 620 ]

           Medicare as we know it today is unsustainable. I think it's fair to say that a majority of people in this province believe we do have some serious problems in our health care system. There are some real barriers to providing consistent care to those in need. I am concerned that those barriers will be more difficult to overcome in the future unless action is taken.

           Today I want to just share a few doctors' thoughts about some of these challenges in our health care system and about some of the solutions that exist. I want to talk on three areas: the pressures on the system, the need to re-establish a clear vision of what medicare should be in British Columbia and also what needs to be done in the immediate future.

           The first is a matter of pressure. We all know that many people in British Columbia have to wait for necessary medical care. We know that some of our facilities and equipment are crowded and aging, and this situation is likely to face additional pressure in the future due to the demographic effects of an aging population.

           There was a study by the Conference Board of Canada last spring that predicted the proportion of government revenues devoted to health care in B.C. would have to rise from 38 percent in '99 to 53 percent by 2020 simply to keep pace with demand and provide our current level of service, a level of service that I think is inadequate for some people. That study was done with some economic assumptions that now seem rather optimistic — 2.5 percent annual GDP growth and 4.9 percent growth in federal transfer payments.

           We also have the added challenge of a population that is spread along a very large land mass. I mean, our population density is 1/10 that of the United States, and it's 1/100 of that of several other industrialized countries. I think this produces a lot of additional barriers for the delivery of modern, high-quality health care in a rapidly accessible fashion.

           The demand for services also increases with every advance in diagnosis and treatment. There are many promising medical advances, good things that can be done to improve people's medical care and save lives, but a lot of these are expensive — expensive training, equipment and supplies. We have to figure out how to keep up, so in addition to our geographic challenges, we have dual pressures: we have more people who are going to need care in the future and more care options to provide.

           What we hear back is that regardless of how numerous and how large these problems are in our current system, governments everywhere, including B.C., are starting to say we can't just allocate more and more money to the system and hope that it fixes the problems. The announced freeze in health care spending highlights the need for a systemic change. I mean, governments across Canada are struggling with the same challenges. They're all reaching the same conclusions. The day has arrived when some more fundamental changes are needed if we're going to preserve this, our most cherished social program, into the future.

           Sometimes as a doctor I've got to break bad news to people, and you hear back from them. One of the first things that happens is that people have denial, or they say that maybe I've overlooked an easy solution. One of the easiest solutions for the system is: "We've just missed something. We haven't discovered some major operational changes and efficiencies. If we could just manage it a little differently, maybe that would do it, and we would find enough money in it."

           It's a very laudable goal, and I should think there are some remaining opportunities there, but I think B.C. doctors firmly believe that the real solution to our big sustainability problem goes well beyond tinkering with management and with efficiencies. The Kirby Senate committee on social affairs, science and technology is looking at the health care system across Canada, as you know, and the committee agrees with that view. We have to go beyond management efficiencies. The time has really come for a sensible and pragmatic look at what our medicare system should be and what it cannot be in the years ahead if we're going to preserve it.

[1145]

           That brings me to the second point that I want to talk about, which is the really pressing need for vision and leadership. I'm sorry to say that our health care system, as I see it on a day-to-day basis now as a practising doctor, is characterized by poor provider morale among all kinds of providers, waning public confidence — and that's clear in opinion polls and when you talk to people — and a conspicuous absence of a clear statement concerning what should be the basic objectives of a publicly funded medicare program should be. I think meaningful progress towards solutions has to begin with a very clear and widely communicated statement of vision for the ministry, one that tells citizens what they can expect from a publicly funded system and how we're collectively going to get there in the future. Creating this common understanding and a collective purpose among the public and providers is essential to success.

           Without wanting to oversimplify the process, what we really need to decide first is what matters most. What do we absolutely have to do? We've seen there are already a number of problems in the system. These problems are likely to worsen in the future. Yet there are some health care services that are absolutely essential. There are some things that common sense tells us. We simply have to be available quickly for citizens in need. If you or a loved one are having a heart attack or a stroke and there's something that could be done quickly to make it stop and to avoid the damage, you need to get that. If you break your leg, it has to be fixed. There are some things that have to be available quickly, which are just absolutely essential.

           If our system is going to meet those essential needs in the future, we have to identify them, preserve them and enhance these services. This kind of approach has to go beyond blunt, cost-cutting measures. It requires very intelligent choices that are driven by a vision of a hierarchy of importance. What do you have to do first? This goes to the heart of what Canadians need and support in their health care system. In the opinion of B.C. doctors and our patients, I know direct patient

[ Page 621 ]

care must explicitly be the number one priority. Look after the sickest people first. That's just common sense.

           What do we need to do? We have to accept that there's value to virtually everything going on in the health care services but that not all of these services provide sufficient value and benefit to warrant inclusion in a publicly funded program. To this end, we're welcoming the core services review process that's underway. That's a good model. We note that this core services review exercise is not construed as an attempt to identify services which have no underlying merit. It is a task, I think, in economic rationing. It should be based on economic factors, public opinion, provider input. What core services should be defined by is not what we'd like to have but rather how we can best afford to provide those services that are essential. We need to expand that concept to health care.

           In this context the Medical Association has suggested that the core review adhere to certain guidelines to ensure that the first priority goes to direct patient care — the sickest people need care the quickest — and to make sure that we allocate resources to deal first with those people who are most in need, people who are sick today. We should examine the effect from this on all our existing programs and services, including all types of providers and health prevention services. There's lots of good ideas there, but we should start measuring the outcomes and fund those programs that really have results. That's what needs to be enhanced and protected.

           I think that with public consultation, your committee can begin to provide the people of British Columbia with a clear vision for medicare. You've got the tools to get that input. Within that vision, then, the core review process can identify a way to prioritize the services that must be covered and that could be covered within today's fiscal environment. If you can do this, then I know that legislators and the government will have taken some very critical first steps. I think the quest for a sustainable health care system will have started with those steps.

           There are a number of other necessary steps, and they are addressed in more detail in documents that I'm going to leave with you. I'll just mention the key points in overview. These include improving public cost awareness and accountability and better use of the tax system to assist people with substantial out-of-pocket costs for health care services. They're already present, and they're going to rise in the future. Depoliticize the decision process of health care delivery at all levels, and streamline and clarify the roles and responsibilities of all governance levels.

           I think it's very important to create a provincewide service plan because of our big area and because we don't have the critical mass to provide services in all places. Start to incorporate the idea of regional care centres, and start to look at a rational and protected way to use the public and private interface. Also, find a way to facilitate primary care integration in practical ways that make sense to patients and make sense to doctors.

[1150]

           I know that what you're being asked to do is set priorities, and that's a big challenge in a complicated field. I don't underestimate the difficulty of this process or the fact that it causes a lot of public concern and concern for everybody who cares about it, but it's essential that we push on with that — that we collectively come to some redefinition of medicare. It's an unpopular thing to say, but we can't continue to believe that we can do all things for all people in all places. Some tough choices are going to have to be made in order that the essential health care services will be available in the future. Nobody can avoid that challenge. We've got to be prepared for those difficult decisions.

           I know those problems are daunting, but I believe we really have an opportunity to build a sustainable health care system for the future — a modern one that'll be there for my kids and my grandkids. That opportunity starts here with, I think, the very heartening example of a legislative committee actually out here in search of dialogue, understanding and solutions. It's great to be here.

           In closing, I'm pleased to provide your committee with a couple of documents: the BCMA submission to the core services review and a copy of our policy document, called A New Course for Health Care: Turning the Tide, which has 29 recommendations for restoring the health care system. I'd encourage you to have a look at both documents.

           I'm going to be a doctor and a citizen working and living in B.C. for many years. I'm going to be a consumer of the system at some point. I'm looking forward to a renewed health care system that lets me provide all my patients with the kind of care they deserve.

           Thank you very much for the opportunity to speak. I'd certainly be happy to answer any questions.

           S. Brice (Deputy Chair): At some previous hearings we've had health care providers advise us about the state of Oregon and its listing of 800-plus procedures and apparently a determination about the level down to which the system should be provided by the public. Does the BCMA have any position on such a procedure?

           M. Dahl: I think what we talked about as doctors was predominantly first identifying the philosophy of deciding what has to be done. Again, there are simply some people who have to be looked after first. The example which you give, of Oregon, was sort of a line-item accounting of what procedures should be covered under their public Medicare system and which should not. That's an example of one application of that philosophy. A made-in-Canada approach would probably look rather different, because we have a very different kind of system. In general, I agree with the philosophy of making the decisions and looking at what's important. That would be one example of how we get there, and it's certainly worth examining further.

           S. Brice (Deputy Chair): Do you have any model that you could suggest to us that would be of assis-

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tance to us, instead of the Oregon-type model, in terms of identifying a kind of hierarchy of procedures?

           M. Dahl: I think there are several ways we could begin to approach this. I think what we need is a process to do that. In terms of that, the first step would be a program-level review of the kinds of things that we're providing in terms of their benefit. With respect to individual line items, I don't think we're at that level of sophistication yet, but we should try and find a way to get there.

           R. Hawes: Thank you, doctor. I'm looking at your overview of your presentation. I'm quite interested in No. 8. It starts with full-spectrum family practice, and then it goes on to talk about integration of other providers. That brings me to several questions that I'm interested in. We have heard, in quite a few places throughout the province, about the drop-in clinic docs that don't do any family practice — the nine-to-five guys — and the kind of damage they're doing to family practitioners and the attraction of docs into family practice. Do you have solutions for that problem?

           M. Dahl: Yeah, I think it's quite important to recognize the value of good long-term care by a family doctor who knows you well. We're very supportive of that model: longitudinal, full-service, family practice care. There are a number of ways we want to get there, which is in terms of training. The family practice residency programs at the University of British Columbia really try to emphasize that approach.

           In terms of incentives and attracting people to that, that's the kind of thing which I know the section of general practice and family practice of the Medical Association is trying to advance now. I think that probably in January you will hear from the Medical Association a fairly comprehensive view of what we think family doctoring should look like, which includes exactly that full-spectrum care. So stay tuned. We hope to have it for you shortly.

           R. Hawes: In essence, there is a proliferation now of the guys who just want to do nine to five and have no interest in family medicine. Is there a way to provide disincentives for that type of practice?

           M. Dahl: I think there are a number of approaches that can be taken. Most people find it, I think, more stimulating to provide the full service. It's a complicated issue. In some urban areas, for example, unfortunately, family doctors felt pushed away from hospitals where they did provide that care. We need to find a way to make that a welcoming environment for them again.

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           In terms of incentives and disincentives, there are some ongoing issues with respect to negotiation and arbitration. I'm not really at liberty nor, in fact, have the knowledge to say what's in front of the arbitrator at the moment, but I know that's the kind of thing they would like to consider. I'm hoping that within the next few months, we'll have a fairly comprehensive approach to improving and promoting full-spectrum family practice.

           R. Hawes: The second part of that one is the integration of other providers all over the province. We've heard not just from patients but from chiropractors, repeatedly, about their value in treating low back pain. We've actually heard from some MDs who I think probably agree with that as well. What we hear repeatedly is that the relationship between BCMA and the Chiropractic College is cool, I guess I'll say. Is there a way to take a more collegial and collaborative approach to bring those two organizations together?

           M. Dahl: I think the big question there is: what do you do with the fact that there are many people who try to provide good care and provide value to the health system? One of the things I said a few minutes ago was that there is value in virtually everything. It's a matter of deciding what you're going to look after, what you're going to cover and what you're not going to cover. I would say that in my last two years as president, I can't remember any downside in terms of the relationship with colleagues in chiropractic. I don't remember any particular positives either. It's been a very distant relationship — in fact, probably not much interaction at all.

           In terms of regulatory issues, which are separate from where I was involved in the Medical Association, it's often been an issue between the colleges who provide regulatory oversight.

           R. Hawes: Do you see a way to improve the relationship?

           M. Dahl: It's probably easy enough to pick up the phone. I really don't know where that would go. Nobody's cold to it. There just hasn't been much in the way of discussion between those sets of providers.

           R. Hawes: When you say flexible integration of other providers, is that the sort of thing you're talking about here?

           M. Dahl: I think one in particular we've wondered about — you know, when you mentioned family practice a minute ago — was the issue of how you provide full-service care in clinical settings that involve nurses who have additional expertise and training, training that isn't actually available in British Columbia but is available in other jurisdictions. The Registered Nurses Association of B.C. is particularly interested in that. I think that's mostly what we were thinking about with that statement — nurse clinicians, nurse providers.

           J. Bray: A couple of questions. You touched very briefly — and you may have it more in the documents you provided — on the perspective and the buzzword of primary care reform and the pilots that are going on in various communities. At least in my own view, there

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are two distinct issues with primary care reform. One is the bricks and mortar and how many people work in it, which is one issue to discuss. The other one that has been raised a lot to us is the actual fee-for-service model for physicians in general and the change with respect to some of the pilot models. I'm wondering whether or not you could first of all just comment on the association's position with respect to any distinct changes to the fee-for-service model.

           M. Dahl: The Medical Association would be happy to support any doctors who want to work in any payment modality in primary care or, indeed, in specialty care. It's always been the position. We felt that it should be voluntary. Other than that, we're happy to do that. What had gone to negotiations, in fact, was looking at a number of flexible ways in which doctors could be paid salaries and service contracts, in addition to fee-for-service. As long as it does the basic things, we're happy with it. Basic things are professional autonomy. You make decisions based on what's right for the person sitting across from you, not on the basis of some business model. It means that clinical autonomy has to be protected. That's the most important issue, from our point of view. Other than that, it's not a big issue, frankly. We're very supportive of anybody who wants to go there. We thought it should be voluntary, as other contractual arrangements should be.

           The second point, though, as you mentioned, is pilot projects. I think the idea of doing pilot projects is very important when you're talking about changing the largest, most established part of our health care system. There are a number of primary care demonstration projects that have been underway. Most of them have not dealt with traditional large family practices but have been sort of specialty practices, with one exception. The evaluations are still ongoing. There's very little quantitative data back on whether they're being cost effective or not and not enough back on quality. They're probably not going to meet their March 2000 deadline on evaluations. We don't really know how those projects are going. I would encourage that projects in primary care reorganization be piloted and carefully evaluated before we go to the next step; otherwise, we might be jumping somewhere that we're not sure about. It's complicated.

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           J. Bray: Thank you very much. My second question is with respect to the current…. We basically have a private health care system with a public insurance model. That's really what we have. Does the BCMA have a position on whether or not MSP…? Certainly one can argue that's the minimum level, but we also have a system that to a large extent is also the maximum level. Everything's guided through that insurance model. Does the BCMA have a position on individuals purchasing additional insurance for services they may require through catastrophic illness or elective procedures that they could access through an additional add-on insurance?

           M. Dahl: No, I don't think we've ever formulated a policy for that. Of course, my understanding is that would not be legal. Obviously, it would require legislative changes. You may know that there is a market for so-called catastrophic illness insurance, which many British Columbia are beginning to buy. That's to receive that kind of coverage, often outside of Canada, for people who wish to do that. I wish there was a better model than that. We should be able to do things right for people here, given that they paid their taxes and premiums for years and expect to get good service when they get sick. So the best model would be to fix our system. That's a personal view.

           D. Thomson: If I could just add to that, to be clear, we do not advocate a parallel private system in operation and in competition with the public system. We certainly advocate more private delivery options within the publicly funded program.

           To go directly to your question in terms of down the road, what we have put into the report that you have a copy of there is that we do believe we need to be much more up front with the public at large to say that our ability to financially sustain a broad-based publicly funded program is diminishing. The likelihood that there's going to be a greater requirement to pay for some services out of pocket down the road is a reality. We should be planning now, putting programs into place and particularly looking at the tax system to provide opportunities for people or to provide some relief, at least, to those people that are facing those private, out-of-pocket charges.

           One of the specific things we mention in there is some type of RRSP-like program to which you might be able to make contributions for down-the-road, out-of-pocket costs, particularly with long-term care, as people approach….

           R. Hawes: I have one more question, and that has to do with the physician shortage that we now have in this province. We've heard around the province — and more than once, I think — that there are foreign-trained doctors practising in other provinces that have decided to move here but have been unable to get credentials in British Columbia. That leads me to believe that our credentialing system here is different than in other provinces. Is there a benefit to harmonizing across the country so that a doctor who can practise in one province can also practise here?

           M. Dahl: I would be very supportive of a way that a single licensing standard could be met in order to enhance the interprovincial mobility of physicians. We'd love to have those doctors working if they can be credentialed. I would be very supportive of that.

           R. Hawes: I'm a layman. I'm at a loss to understand why a doctor could practise in Saskatchewan and not in British Columbia. Maybe you could explain that. Why would that be?

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           M. Dahl: It sounds like the multiple-silo effect. Credentialing is quite separate, again, from the Medical Association; it's a College issue. I would be delighted to see a streamlining and a removal of red tape that would let us get more doctors into practice, particularly if they're sitting here geographically already and we just need to get that done.

           R. Hawes: How would one expedite that, then? How could one make that happen?

           M. Dahl: I think the Federation of Medical Licensing Authorities, FMLAC, is the group across Canada that represents all the colleges of physicians and surgeons who are responsible for credentialing doctors. Working either with the local B.C. College on that or with the FMLAC directly might be an approach.

           D. Thomson: On that particular issue, we are working with the other medical associations across the country and the Canadian Medical Association in putting together a submission to the Romanow commission. I believe that is in fact one of the recommendations that you'll see as part of that report.

           V. Roddick (Chair): Perhaps I could be so bold as to ask that when you make your presentation to the Romanow commission…. Would it be possible for this committee to receive a copy of your presentation?

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           M. Dahl: We'd be delighted.

           D. Thomson: If you're interested we can give you a copy of our presentation to the Kirby committee as well, if you'd like that.

           V. Roddick (Chair): Yes, we certainly would. Excellent.

           D. Thomson: We've got lots of submissions.

           A Voice: Is anyone listening?

           D. Thomson: Well, we're hoping that they're starting to.

           M. Dahl: This is good. This is unprecedented. This is a good way to listen.

           R. Harris: I just wanted to follow up a bit on one of Jeff's questions when he was talking about the delivery methods. When you made the comment about it being unsustainable, I think all of us agreed with that. Have you looked at other jurisdictions in terms of Singapore and Australia? We've certainly heard from physicians who have worked in other jurisdictions, who spoke of those systems of delivery. I haven't read your recommendations yet. When you evaluated or considered those in terms of, I guess, more the fundamental changes of how health care would be delivered in this province…. Have you looked at those or made recommendations around them?

           M. Dahl: It's interesting. Every jurisdiction wrestles with problems. Some have found other solutions, some of the European countries in particular. Sweden seems to have a very good system. People are always concerned about it because it's sort of a basic human need, so there's a certain amount of angst no matter what system it's in. A few years ago we did a paper on managed care, The World of Managed Care: Shopping For Solutions, that did multiple international comparisons. It was really quite instructive. We could probably add that to your already substantial reading pile, if that's of benefit.

           V. Roddick (Chair): Just one thing that's come out of our travels is the fact that communities are feeling isolated. They're lacking the community spirit, so to speak. I just wanted to leave you with this thought. We had a presentation earlier today about cluster teams that go around with home support. We've talked about walk-in clinics. If there's any way that you can give some thought — and I'm sure you probably have — to doctors, nurses, physios and chiropractors working together to deliver services but with follow-up, which people really seem to feel that they're lacking. They're concerned about availability with the different types of lives that everybody's leading today. The availability times seem to be a real problem.

           M. Dahl: I agree that good integration of care, no matter where you're receiving it, is important and probably is more cost-effective in the long run. I think it's a good aim for everybody in the health care system to work towards.

           V. Roddick (Chair): Thank you all very much. We really appreciate your coming out this morning.

           We will recess now until 1 o'clock.

           The committee recessed from 12:08 p.m. to 1:03 p.m.

           [V. Roddick in the chair.]

           V. Roddick (Chair): Good afternoon, everyone. We will resume. Our first presenter for this afternoon is the Physiotherapy Association of B.C., Rebecca Bing Tunnacliffe.

           Good afternoon.

           R. Bing Tunnacliffe: Good afternoon.

           The presentation folder that you've been given has some information on the association and some of the preventative brochures that we publish and circulate. I'll be making reference to some of the things in the brochure.

           I'm Rebecca Bing Tunnacliffe, executive director of the Physiotherapy Association of B.C. I'd first like to thank you for the opportunity of presenting some of our thoughts on physiotherapy as you're rethinking

[ Page 625 ]

about the health delivery model in B.C. PABC would like to commend the Liberal government for reinstating the standing committee of the Legislative Assembly to hear feedback from the public. We appreciate that.

           PABC has known for some time, as I think all health professionals have, that significant change is necessary. The current system is unsustainable. We have all watched health care costs rise from 33 to 40 percent of the entire provincial budget in just a few short years. We know that predictions are suggesting a 50 percent rise in this decade if we maintain the status quo.

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           As an organization that represents 2,500 physiotherapists in primary and preventative care, the Physiotherapy Association of B.C. is ready to embrace change. The members of PABC, comprising 80 percent of physiotherapists, are willing to work with you to find changes that benefit all. I'd like to take a moment to tell you about physiotherapy and what some of our members bring to the health care table and offer some suggestions that might meet your mandate.

           Physiotherapy is one of the oldest health care professions in Canada, dating back to World War I. Physiotherapists are university-educated, regulated professionals in public and private practice providing care to and education for a diverse group of patients. Physiotherapy plays an integral role in rehabilitation from surgical procedures, such as joint reconstruction, to neurological rehabilitation, such as brain injury and stroke recovery, from muscular and skeletal injuries common in debilitating workplace injuries to the management of chronic conditions, such as arthritis.

           Physiotherapy is a core health service. In a public opinion survey performed last month, we learned that in 69 percent of B.C. homes at least one person has had physiotherapy treatments, with 611,000 being treated last year with an 84 percent satisfaction rate. Physiotherapists have a specialized and unique training and education and knowledge. They work both independently and as part of the core health team with physicians and nurses. The BCMA recently stated to the Minister of Health: "Physicians and physiotherapists share a long and successful history of integrated, coordinated care, and physicians recognize the role of physiotherapists on the delivery team."

           Basic rehabilitative and treatment services provided by physiotherapists represent an integral component of many patients' care needs. As the population ages, the demand for physiotherapy will undoubtedly increase.

           The physiotherapy profession is focused on improved health outcomes by using treatment that is based on evidence of medical research with outcomes that are clinically measured. To keep physicians apprised of the latest physiotherapy research findings, PABC issues a semi-annual document entitled Physiotherapy Briefing, and you'll find that in your brochure. Briefing also facilitates appropriate referrals by highlighting areas of practice of which physicians may be unaware.

           Research proves that early intervention of physiotherapy-treatable conditions yields improved outcomes and speedier return to work and daily activity. Athletes are a perfect example of this principle. From junior sports teams to elite Olympic competitors, athletes know the value of immediate post-injury physiotherapy that allows them to continue with little interruption. As just one example, the Canadian national ski team always travels with their own physiotherapist. Yet the majority of British Columbians do not seek immediate rehabilitation for their injuries.

           Although physiotherapy has had primary care status since July 1992, our public opinion survey reveals that 52 percent believe that a physician's referral is necessary. Even knowing that a physician's referral is unnecessary, 59 percent still say they would see their physician first. An immediate solution to reducing redundancy in the system and therefore costs, while also reducing the burden on family physicians, is to better inform the public about making appropriate care choices by seeking immediate care of a physiotherapist for musculoskeletal conditions. One way to assist in this is for government to reinforce that physiotherapy is a core service.

           Senator Kirby at the Premier's dialogue on health last month suggested that incentives should be instituted for patients who make the right health care choices, because it will save health costs.

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           In the acute care setting, where perhaps the greatest pressure on the health care system is felt, early intervention of physiotherapy is equally effective in reducing health care costs. For instance, Royal Columbian Hospital has instituted a successful system in which an emergency room physiotherapist is the primary contact for patients with injuries related to their area of expertise and, in a surprising number of instances, is able to provide early intervention to shorten the stay, recommend a return home with the appropriate equipment or refer to out-patient services or private clinics. Adopting the Royal Columbian Hospital model province-wide would help reduce acute care costs.

           Hospital physiotherapists providing rehabilitation to orthopedic, oncology, respiratory and neurology patients facilitates their mobility and allows them earlier discharge, reducing the hospital stay. Furthermore, the establishment of a temporary loan pool for mobility equipment would also speed discharge, enabling patients to leave hospital without having to wait for their own equipment.

           With the trend to earlier release from hospital, a cost-saving measure, patients are discharged while still in an acute state and require primary medical and rehabilitative care. This means an increasing demand for home care services. An increased desire for the elderly, handicapped and economically disadvantaged to live independently in their homes as long as possible, keeping care facility costs down, means more need for community physiotherapy, as the 1991 Seaton report predicted.

           In a seamless integration of the continuum of rehabilitation care within the profession, community physiotherapists can, in an average of six visits, enhance mobility. Patients then access private clinics.

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Resources for community care are very limited, and while private clinics are able to provide treatment for most patients, there's a serious gap for neurology, spinal and brain-injured patients which private clinics and community care cannot address because of the long-term and high costs of treating this clientele. The solution for this, as the Seaton report recommended, is increasing the number of community physiotherapists or funding private clinics to treat these patients.

           A key component of physiotherapy treatment is education of the patient on the care and management of their injury with rehabilitation exercise and prevention of re-injury. Physiotherapists emphasize prevention, whether through ergonomic assessment in the workplace, education on pre-activity stretching — and there are some brochures in your packages — postpartum care to prevent related disorders in later life or advice for the elderly on keeping independent, also enclosed in your brochure. To encourage prevention and prevent re-injury, thereby reducing health care costs, a prevention incentive could be instituted for those taking exercise or diet class or using hip protectors, orthotics, walkers or other mobility equipment.

           Further to educating the public about health care, a measure to improve personal accountability for health care costs could include patients receiving a statement of the cost of care incurred, whether it is a visit to the physician, emergency room or clinic. Surveys show that few physiotherapy patients understand the funding structure of care, whereby MSP provides a subsidy toward the entire cost of treatment, while 92 percent believe that physiotherapy should continue to be partially covered.

           Physiotherapists work in a wide range of funding models including MSP, ICBC, WCB, DDA, extended health insurers, as well as fee-for-service, consulting and salaried environments. Accordingly, physiotherapy is flexible enough to accommodate virtually any funding model. We recognize that B.C.'s present system cannot rely exclusively on public funding, and we believe that the continuation and addition of co-payment funding must be considered throughout the delivery of care while ensuring that those who cannot afford to supplement their care are publicly funded.

           In conclusion, physiotherapy is a core service that affects measurable health outcomes through evidence-based practice. It helps sustain the current level of care while also helping to prevent injury requiring care. By helping to educate the public on direct and immediate access to appropriate intervention, health care costs can be further reduced and patients can return more quickly to productivity. Thank you.

           V. Roddick (Chair): Thank you very much.

           Are there any questions from members of the panel?

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           R. Harris: Thank you very much. I found that very interesting, especially the area around physiotherapy and its application as a source of primary care.

           In the Royal Columbian example, when you come into an emergency ward, who is the triage person that directs you? Would you still go through a doctor to be treated by a physio, or is that done through the RN or through the receiving end? How does it work in the emergency wards?

           R. Bing Tunnacliffe: Ideally, they're admitted, and their doctor sees them. As reality has it, they often see a physio first if the admitting nurse understands that it's a physiotherapy treatable condition. I'm not sure exactly what the….

           R. Harris: Okay. Thank you.

           V. Roddick (Chair): Thank you very much indeed.

           Our next presenter is Daphne Robertson. Good afternoon, Daphne.

           D. Robertson: Thank you for your interest and for coming to the public to determine our needs to deliver better health care in British Columbia.

           I have been ill for 28 years due to iatrogenics caused by the medical community. I have experienced a lot of abuse in the system, which has led to the destruction of my health care by the system. This presentation is due to the health care of breast implants. Breast implants are very personal, so women become easy targets and don't speak out about it. It was interesting listening to the lady before me. It was alternative health care that has saved my life in the system.

           I'll start. Dear Select Standing Committee on Health, thank you for allowing me to present my concerns on one huge, politically charged issue regarding breast health after receiving breast implants. Breast implants have never and will never be proven safe. Women are consistently being told that implants are new and improved and will last a lifetime. Inserting a toxic septic sack, with many deadly chemicals and who knows what materials, cannot be safe for any woman's body.

           After implanting the woman, when she becomes ill, doctors will steer her away from her implants and send her to a psychiatrist. When she dies, her report will read: non-specific, unknown, natural, mysterious, viral, bacterial, germs, heart attack, etc. The trusting families will not suspect the toxic implants. A lot of women don't tell their husbands or even partners about their implants. Women are an excellent target to earn an enormous profit. When women become ill, they become a burden on health care and social programs, ultimately at a huge cost to tax dollars. The medical community ends up collecting all the profits from the many ill women. Doctors implanted us and made us ill. They must be held accountable.

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           I met the Hon. Colin Hansen over a year ago when the Liberals were in opposition. He is very aware of the problems caused by implants: the forcing of women into ill health, the breastfed babies that will be exposed to toxins and the poverty that follows a long-term illness. That illness can break down the family. I have

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asked Mr. Hansen for a simple registry. This registry is to mandate all plastic surgeons to report all of their breast implant clients to ensure that they provide accurate information to the client; to show a video of what happens to the implants after implantation; to explain the types of bacteria and fungal growth that will occur; to follow the client for ten to 20 years to report and record all symptoms, syndromes and time off work due to illness; to indicate all the chemicals and materials in implants and what anti-rejection drugs will be used. Finally, the client, surgeon and government party will receive a detailed copy to monitor the safety of breast implants.

           How this profit-driven device impacts and destroys many women's health. Doctors take an oath to do no harm. They must be held accountable and prove that women are safe with implants. Hon. Hansen must be strongly supported and encouraged to establish this registry to keep women and babies safe from breast implants.

           I have given you — I won't read — all the letters that I have addressed to Hon. Hansen and to the BCMA president of plastic surgery, Dr. Ben Gelfant. I've also given you a list of the various chemicals that are in implants and why they make women sick.

           This is a very big subject that most people don't want to talk about, because it's very personal to women. Women are being sick and are not being treated for their illnesses in British Columbia and right across Canada. I, for one, almost died from breast implants. I've been in the system for 28 years.

           I just wanted to do a presentation to the Liberal government at this point. I appreciate all the work and the concerns. My number is on the bottom of the page and on the most recent letter that I submitted to Hon. Hansen. I want something to protect women. That's all I'm asking for. I thank you for your time.

           V. Roddick (Chair): Thank you for being courageous enough to come forward with this and with the problem. We're all aware of it.

           D. Robertson: It's huge, Val. It's huge.

           V. Roddick (Chair): We probably haven't thought of the ongoing costs to the system.

           D. Robertson: That's right, because you haven't been sick.

           You're on welfare, and you're sent to various doctors for whatever reasons. They keep you in the system, thinking it's your fault. It's not the women's fault. The women have to be educated. They're not shown and not given the full facts and the impact of what's actually in the breast implant.

           This is why I'm after a registry. There's nothing available in Canada. I'm more than willing and prepared to give you a lot of extra information to back up all my statements.

           V. Roddick (Chair): Thank you very much. Are there any questions? No. It was very straightforward.

           Our next presenter this afternoon is the B.C. Pharmacy Association: Bob Kucheron. Good afternoon. If the other two of you, Geoff and Linda, could give your names to Hansard.

           G. Squires: My name's Geoff Squires. I'm the president of the B.C. Pharmacy Association. This is Linda Gutenburg, vice-president of the B.C. Pharmacy Association, and Bob Kucheron is on my right. I'll be giving the presentation today, and I've brought my colleagues along to help answer any of your questions.

           The B.C. Pharmacy Association thanks the Select Standing Committee on Health for this opportunity to present our views regarding health care in British Columbia. The presentation we're making today is the second before this committee. On October 25 we focused on selected core recommendations from our position paper, Pharmacare in the New Era, which will save approximately $98 million per year on the Pharmacare budget. Today we will detail the six new areas of pharmacy practice that provide dramatic benefit for our patients and will save the health system approximately $129.7 million per year.

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           Our suggestions arise from a research paper co-commissioned by the BCPhA and summarized in a July 2001 document entitled Community Pharmacy–Based Solutions for British Columbia Health Care. This document is available in its entirety from our website at www.bcpharmacy.ca.

           New approaches are needed for delivering cost-effective health care services. Today we will provide suggestions for commonsense, practical programs that utilize the specialized knowledge, clinical skills and accessibility of community pharmacists to improve the delivery of health care in British Columbia. Our suggestions will help to relieve some of the current pressures on provincial resources, including emergency rooms, hospitals and family practices.

           Our complete document provides examples of pharmacists' payment rates required to engage our suggestions. The rates included in our recommendations are used throughout this presentation to demonstrate the magnitude of savings that will be available as a result of increased community pharmacist utilization. These rates will be subject to negotiation between the BCPhA and the Health ministry and may change as new practice areas are implemented.

           There is a concern over health care. Health care is one of the top concerns for British Columbians, as recent polls have stated. When it comes to the principles of the Canada Health Act, British Columbians have shown the most concerns about the accessibility of health care services.

           According to figures released by the Canadian Institute for Health Information, B.C. expenditures on hospitals increased by 42 percent between '91 and 2000 from $2.77 billion to $3.93 billion. During the same period, medications took on a greater role in health care. Expenditures on drugs increased by 97 percent from $797 million in '91 to $1.57 billion in 2000.

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           There's pressure on hospital, nurse and physician resources. I want to describe that briefly. The number of doctors per 100,000 population has been declining in B.C. over the past decade. In addition, practising physicians in this province, like the rest of us, are getting older. Demographics of all health care professionals are leading towards more acute shortages, while the very same demographics are predicting increasing demand for health care services.

           Lifestyle issues, like balancing work with family needs and with community service, are becoming more recognized and more important to physicians as well as to other health care providers.

           At the same time, the public is starting to question the appropriateness of care that's being provided by overworked and burned-out health care providers. Just last month in Vancouver — in fact, the same day that we were making our first presentation to you — the College of Family Physicians of Canada released a study indicating that a huge percent of family physicians are not capable of expanding their practices to accept new patients. Measures are needed across the board to address and relieve the strain on hospital, physician and nursing resources. A critical assessment of the allocation of these resources is also needed to ensure that the tasks which could be undertaken by other health care providers are redistributed to relieve the pressure on other key sectors of our health delivery system.

           I want to comment for one second on the value of medicine. In British Columbia the Pharmacare program has been one of the fastest-growing budget items. Although the cost of pain medications for our citizens has increased, so has the value of treatment achieved for the expenditure. This is something that's often missed and often overlooked in the discussion of cost increases related to the Pharmacare program. Yes, we are paying more for drugs, but we are also getting benefit from those expenditures in terms of less hospital cost, increased personal productivity of well-treated individuals and reductions in the complications of illness. Some of the benefits won't be seen for years down the road because of the nature of treating illness.

           The cost of medication misuse. Although medications are valuable and effective, they also need to be used properly to confer the desired health outcomes and to avoid undesired complications or additional problems. The cost of medication misuse has been recognized as a significant health problem and a source of significant health care expense. A new study from the United States estimates that the misuse of prescription drugs cost the U.S. economy $177.4 billion in 2000. That's over double the costs that were estimated in 1995.

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           The authors of the study conclude: "Drug-related morbidity and mortality continue to pose a serious health and economic problem for society. More attention should be directed towards developing solutions that reduce preventable morbidity, mortality and costs associated with drug-related problems."

           I want to comment on the overlooked potential of pharmacists. Pharmacists today are remarkably different from those in the past. The pharmacist's role has evolved from compounding, mixing and dispensing medications and drug products to taking responsibility for the results that people get from the medications and drug products that they use. The key goal of the profession of pharmacy is to ensure the responsible provision of drug therapy for the purpose of achieving health outcomes that improve a patient's quality of life.

           The recommended scope of practice for pharmacists, as defined by the Health Professions Council of B.C., includes monitoring of drug therapy and advising on therapeutic values and assessment and recommendations to prevent or resolve drug-related problems. Pharmacists undergo in-depth training to develop the skills that are necessary to fulfil this purpose, including five years of university training in biology, microbiology, biochemistry, medicinal chemistry, anatomy, physiology, and of course pharmacokinetics, pharmacology and therapeutics. There is no other health professional that has a comparable degree of specialty training in drug therapy as does a pharmacist. Pharmacists are medication experts.

           The role of the pharmacist in the provision of drug therapy and enhancement of drug therapy outcomes includes evaluation and reviewing drug therapy records, identifying and discussing actual or potential drug-related problems, advising patients, physicians and other health professionals about drug therapy, and delivering services to the community that reinforce these roles.

           In the past, when the pharmacist's primary role was to prepare physical mixtures of medicines, these services were compensated for with a dispensing fee. Today, in recognition of providing valuable services over and above simply dispensing medications, new payment models have been developed and are used in some jurisdictions to compensate pharmacists for their services.

           A substantial volume of evidence exists to show that pharmacists can have a significant clinical and economic impact on the quality and cost-effectiveness of medication therapy, leading to more cost-effective health outcomes for patients. As I'll say later in this presentation, the options that we'll be offering you today will save an additional $130 million per year in health care costs.

           One of the biggest challenges in health care today is establishing contact with people in need of preventative health care before the serious problems are taking hold. Most physicians don't see a patient until symptoms develop, and more costly treatment interventions are then often required. Pharmacists are the most accessible health care professionals and are positioned to make valuable contributions to our patients' health. Not only do community pharmacists improve the quality of health care outcomes, but we lessen the burden on physicians, we lessen the burden on nurses, and we lessen the burden on hospital resources. We should be encouraged and rewarded appropriately for spending

[ Page 629 ]

more time utilizing pharmacists' skills to provide direct patient care services.

           Expanding the role of community-based pharmacists is consistent with the recommendation by the Health Professions Council of B.C. Their recommendation is that exclusive scopes of practice between health professionals be eliminated. The preferred model is a system of shared scopes of practice between health professionals to remove barriers, to promote interdisciplinary practice and to improve the way health professionals work together within the health system.

           Community pharmacists are well positioned, willing and able to contribute to the creation of health care solutions for the province. Although numerous worthy opportunities exist, we have researched and are now recommending six specific community pharmacy-based programs that are practical and can be implemented immediately with relative ease. Those are: duration of treatment management, dose management in asthma, dose management of anticoagulants or blood thinners, reducing cardiovascular disease risk, travel medicine in pharmacy and reducing drug-related problems in seniors. Evidence of the need for these programs is very clear. Program frameworks already exist and training systems are in place to make these a reality. Taken together, these programs will generate annual health care savings of $129.7 million.

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           I'd like to go through these briefly one at a time and describe each one of these programs. The first one is duration of treatment management. Approximately 55 percent of all prescriptions dispensed in Canada today are being used to manage, control or prevent health conditions or symptoms over a long term. Once stabilized, patients usually and often stay on the same treatment regimen for years. Once a specific therapy has been started and then fine-tuned for desired results, most stabilized patients do not need to see their physician every few months just to confirm the treatment should continue. The pharmacist is well positioned to monitor progress at the community level and to refer appropriate issues to the physician for specific medical intervention if that is needed. This model utilizes ongoing communication between the pharmacist and the physician, and involves appropriate record-keeping and sharing of information between caregivers. The duration of treatment management program is designed to streamline the administrative, prescription refill aspects of ongoing patient treatment with medications.

           Here's how it will work. When the patient requests a refill prescription, the pharmacist will check the patient's medication record, ask specific questions of the patient according to established protocols and then either authorize the prescription refill directly on the spot in the drugstore or refer the patient to the physician for reassessment if problems are detected. At this time, patients are required to visit the physician for a refill authorization. The current approach to ongoing treatment results in the valuable use of a scarce resource — the physician's time — for something that could easily and expertly be done by community pharmacists.

           In B.C. alone, the current impact on the health system for physicians to administer prescription refill requests is substantial and conservatively estimated in excess of $94 million in costs to the health system. By shifting the responsibility for prescription refill requests and the monitoring of chronic long-term drug therapy to the pharmacists, the B.C. health care system would free up as much as 297,000 hours of physician time and generate a net savings to the system of over $31 million in fees annually. Pharmacists are in the best position to monitor prescription refills using established protocols because of our position of regular contact with patients, access to complete medication records through the PharmaNet program and ease of accessibility in virtually every B.C. community.

           The second initiative we're recommending is dose management in asthma. Asthma is a chronic condition that affects approximately 284,000 British Columbians, and prevalence of the disease is increasing. Overall, people with asthma are suffering a much lower quality of life than need be, and the health system is bearing an unnecessary burden. Asthma is the leading cause of hospital admissions for children and the number one cause of emergency-room visits in Canada. Six in ten Canadians with asthma do not have their illness adequately controlled. Poorly controlled asthma accounts for the majority of asthma-related hospitalizations, emergency room and urgent care visits. Absenteeism and activity limitations are also the results of poorly controlled asthma.

           Experience in other jurisdictions and in British Columbia illustrates the appropriateness and the value of pharmacist involvement in an asthma management program. The program that we're proposing involves a team approach with pharmacists, physicians and patients all participating to achieve improved health outcomes and significant cost savings for the system. This initiative is a pharmacist-managed asthma therapy program implemented through community pharmacies. Through the program, specially trained pharmacists will consult with poorly controlled asthma patients and work with both the patients and their physicians to develop individualized asthma care plans.

           The benefits of this initiative will decrease emergency room visits and will decrease the number of hospital stays required due to poorly controlled asthma. It will also decrease the burden on family physicians and their practices. The net cost savings to government and B.C. taxpayers will exceed $12 million annually. Our program proposal will also result in patient empowerment in the management of their disease. Better utilization of professional pharmacist services can and will improve the health of asthma patients and will lessen the social and economic costs of this disease.

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           The third area that we're recommending is dose management of anticoagulants, or blood thinners. An estimated 46,000 people in B.C. take anticoagulation therapy at any given time to prevent and treat blood

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clots associated with a variety of conditions, including atrial fibrillation, prosthetic heart valves, myocardial infarction, deep-vein thrombosis and pulmonary embolism. Poorly managed anticoagulation therapy can lead to hemorrhage or thromboembolic events, the result of which is increased emergency room visits, increased hospital admissions and increased use of physician time. Quality of life can be seriously compromised by a thromboembolic event, and the burden on the health care system for therapy after the fact is significant.

           This initiative is a pharmacist-managed anticoagulation management program implemented through community pharmacies by specially trained pharmacists. This is already happening in hospitals, and it's already happening on an out-patient basis, managed by pharmacists, in some hospitals. We see that community pharmacists consult with patients on their warfarin dosage and work with both the patients and their physicians to stabilize the lab values — referred to as INRs — within a therapeutic and safe range. Key to the program is the pharmacist taking responsibility for scheduling and monitoring lab value measurements, as well as adjusting doses as necessary and according to established protocols.

           The benefits of this initiative include better INR control, resulting in less bleeding and fewer clotting complications, reducing the need for hospital and physician resources to manage complications and improving the quality of life for warfarin patients. The benefits of good INR control have been quantified as varying from $573 per patient per year in Canada to $4,000 per year per patient in the U.S. An estimated direct cost savings to the Medical Services Plan of B.C., by having pharmacists monitor INR measurements and adjust warfarin dosages for our patients, is over $4.5 million annually.

           The fourth initiative is reducing cardiovascular disease risk. Cardiovascular disease is the leading cause of death in Canada. In '97, 35.9 percent of all deaths in B.C. were caused by cardiovascular disease. Cardiovascular disease is a group of medical conditions that are largely preventable and collectively cost Canadian society nearly $20 billion every year. It's clear that though preventative measures have been taken for over 30 years, we are still losing the battle in both human terms and financial terms.

           As the most accessible of all health professionals, pharmacists are in an ideal position to provide cardiovascular disease screening services and to assist physicians in managing higher-risk patients. Earlier detection and more comprehensive management of patients with cardiovascular disease should ensure better utilization of health care resources, as well as improved patient outcomes.

           Experience in other jurisdictions clearly indicates the value of involving pharmacists in such a program. Pharmacists would raise public awareness of cardiovascular disease risk factors and would provide a screening, referral and follow-up program that progresses in three steps, according to the patient's level of risk or stage of cardiovascular disease. The pharmacist would work with the patient and the physician in a team approach that would result in better treatment of this disease. A direct cost savings to MSPBC of $51.2 million annually would be realized by utilizing the pharmacist to actively participate in reduced cardiovascular disease risk factors in British Columbians.

           The fifth one is travel medicine and pharmacy. More British Columbians are travelling abroad for business, holidays and to visit homelands. The number of people contracting illnesses in foreign countries is also rising. Canada's per-capita incidence of malaria is ten times that of the U.S., and the gap is widening. Only 10 percent of people who travel to malarious regions get a pre-travel health consultation.

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           Public awareness of the importance of pre-travel health consultations and access to affordable consultation services and proper use of preventative medicines by travellers, particularly for malaria, are key to reducing the burden of treating malaria in British Columbia. A travel medicine pharmacy program would meet those needs for British Columbians. It's proposed that pharmacists receive specialty training in travel medicine and offer the following services: interviews and assessment of the needs for travellers, prescription of selected chemoprophylaxis agents on protocol for uncomplicated patient cases and referral of complex patients and vaccination requests to appropriate medical facilities.

           With current medical, nursing and public health resource shortages, the system is not able to manage the anticipated future demand for travel medicine services. At the same time, public awareness and use of these services must increase in order to stop this growing health care problem in Canada. Enabling pharmacists to manage travel health needs will increase public awareness and increase utilization of appropriate preventative medicines. From a public health perspective, an increase in awareness and access to travel medicine, chemoprophylaxis and education services could significantly reduce or in some cases virtually eliminate malaria or other tropical diseases in Canadian travellers. This, by the way, is a cost-neutral recommendation but a very worthwhile public health recommendation.

           Finally, reducing drug-related problems in seniors. Seniors are 13 percent of all residents in B.C., but they consume between 20 and 40 percent of all prescription medication. Unfortunately, 18 to 50 percent of medications used by seniors are used inappropriately, depending on which study you look at. The resulting drug-related problems in seniors can contribute to additional physician visits, most certainly to emergency room visits, to hospitalizations, institutional care or even death.

           In addition to the toll on health and quality of life, the cost of managing drug-related problems in B.C. is significant. The cost for emergency room visits and hospitalization of seniors due to drug-related problems is estimated at over $210 million per year. However, 28 to 42 percent of adverse drug events are preventable, and pharmacists are in an ideal position to assist in

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preventing, identifying and solving those drug-related problems to improve the health and overall quality of life of seniors.

           This initiative includes three pharmacist-directed, senior-focused programs that offer progressively more comprehensive strategies to identify, resolve and prevent drug-related problems in B.C. seniors. The programs are identified in our recommendations as phases 1, 2 and 3, and seniors may move between phases 1 through 3, depending on the severity of risk of drug-related problems that they face.

           The benefits of this initiative range from reduced utilization of emergency and hospital services to decreased burden on physicians and net cost savings to government and taxpayers. If phases 1 and 2, which are optimal medication use consultation and the use of compliance packaging, could result in a 30 percent reduction in emergency room visits and hospitalizations due to drug-related problems, there would be a net savings to the government in excess of $32 million. Even a reduction of less than 10 percent in drug-related problems would mean that our proposed initiative is cost-neutral.

           British Columbia faces an increasingly aging population and escalating health care costs. By focusing intervention programs towards seniors that are most at risk of drug-related problems, the high economic and social costs of drug-related problems in B.C. can be tempered. Our Health Services ministry is facing the responsibility of caring for more and more aging B.C. residents. How long can we ignore that drug-related problems are among the top five greatest health threats for seniors? The reality is that doing nothing is no longer an option, and pharmacists are there to help do something about this.

           I want to conclude with a brief paragraph. The six specific community-based programs we have outlined are practical. They can be implemented immediately and with relative ease. The need for programs in the area we have discussed is clear. Program frameworks already exist, and training programs are in place. The main goal of every one of the programs that we've recommended is to improve the health and quality of life of British Columbians. The benefits focus on managing health care resources more effectively through the efficient use of pharmacists, physicians and other health care professionals, as well as hospital and emergency room resources. Together, the six community-based pharmacy programs represent approximately $130 million in savings annually to the system.

           We look forward to working with your government to ensure that our patients benefit from enhanced pharmacist-delivered services, and we look forward to working with your government to ensure that the health system benefits from the cost savings that pharmacists are capable of generating. Thank you.

           V. Roddick (Chair): Thank you very much.

           Are there any questions?

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           R. Harris: I have just one question. Most of the recommendations revolve around pharmacists being, I guess, directly involved as opposed to going back to a physician to refill prescriptions. Are there any jurisdictional problems with that with the doctors or the MSA?

           G. Squires: There are some legislative problems or issues that we would have to deal with. For example, with the emergency contraceptive program, pharmacists were given the ability to prescribe emergency contraceptive agents for patients that were in need through consultation. Those kinds of arrangements have not been made for things such as authorizing refill authority or providing travel medicine consultation and appropriate medications. That's specifically what has to be done to enable those programs to exist. Perhaps Mr. Kucheron could comment on that as well.

           B. Kucheron: In fact, there's nothing there that is offside current regulations. You could establish protocols between physicians and pharmacists. What we propose is to do it on a structured or a provincewide basis. If a physician wishes to enter a protocol with a pharmacist in terms of managing refills, they can do that right now. Most of the other treatments described are already being practised in hospitals. We're just trying to bring it into the community to get to the people before they become ill enough to get into the hospital.

           R. Harris: Specifically with seniors, an overprescription or a mismatching of drugs is always quite critical, especially when you get into the areas of dementia and depression and how those are treated. They seem to be very specialty oriented in terms of getting physicians to agree to move from one type of drug regimen to another. This program specifically identifies seniors as one of the major areas of savings.

           Again, jurisdiction, to me, seems to be a problem on a provincewide basis. That was all. Is that an issue? Are you working with the College of Physicians to make them comfortable that in fact your organization is the one that can manage that?

           B. Kucheron: I think it's absolutely essential that pharmacists work with physicians and nurses and everybody else that's involved with dealing with seniors right now to make this work. Pharmacists are not capable on their own of making sure that they go into the homes and look after the medications of seniors. There's already public health nursing there, so we'll have to do that. We'll have to work with physicians in a similar way.

           I think you'll find that in some of the larger hospitals, certainly, where geriatricians are working with seniors, typically they will consult with a staff pharmacist to make sure that the medications are all in order. Once again, we're really trying to duplicate a system that already exists but do it in a way in which we can encounter the patient in the community much quicker.

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           P. Sahota: In terms of your experience in other jurisdictions with the community-based pharmacy solutions, are you going to give us some examples of what those jurisdictions are and where they are?

           G. Squires: Sorry. Which recommendation were you referring to?

           P. Sahota: Just your overall, community-based…. You just mentioned in "Reducing cardiovascular disease risk" that experience in other jurisdictions clearly indicates the value of involving pharmacists in such a program. I'm just wondering what other jurisdictions.

           G. Squires: As an example, Dr. Ross Tsuyuki, who's with the faculty of medicine at the University of Alberta, completed a study recently. Fifty community pharmacists in Saskatchewan and Alberta were involved, and over 1,000 patients were monitored and enrolled. The study was actually stopped early by the ethics committee, because it showed such a significant impact on the reduction of patients' cardiovascular risk through the involvement of the community pharmacists in identifying those risks for patients. It was a very well done study and has been published now. It shows a huge impact of community pharmacists on helping patients reduce their risk.

           Every one of our examples has studies in place and programs that have been trialed to show that these are real and implementable solutions.

           K. Johnston: I just wanted to ask a question on the delivery of the services you're proposing. I think that freeing up 219,000 hours of physician time is a noble thing. Somebody has to take up that slack, and you're proposing to do that. I guess my question, just on a simplistic basis, is: will pharmacists have the time to do consults? A lot of pharmacies I go to are fairly busy. I'm just wondering how you've thought that out in terms of your members and how they would feel about it.

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           G. Squires: Part of that is related to how pharmacists are remunerated for their services. Right now the remuneration focuses on dispensing fees for dispensing prescriptions. If that was changed to allow pharmacists to spend more time doing these services, you bet they'd be doing it. I mean, there are examples right now where pharmacists are doing some of these services, but it takes time away from the services that they need to do to run their pharmacies as a business.

           Perhaps Linda could comment on her experience in doing some of these interventions, if you'd like to hear that.

           K. Johnston: I wasn't clear. That's what I'm getting at here. You're looking, actually, for a fee schedule or a compensation for that consult. Is that part of it as well?

           G. Squires: Yes.

           B. Kucheron: Certainly we have to encourage that. If that's what we want delivered in the community, then it has to be encouraged. But the other issue and the other side of this is that an awful lot of the pharmacist's time right now is spent in doing things that they shouldn't be involved in: administrative activities and fairly low-grade activities. Part of our other submission to the minister has dealt with ways in which we can clean up that whole area of administrative overburden in the pharmacies to allow pharmacists to do the much more proactive job that we're describing here.

           V. Roddick (Chair): I just had one quick question. You were talking about malaria and other diseases brought in from foreign travel. When you travelled with your passport, you had a yellow card that had all sorts of special shots you were supposed to get plus smallpox vaccinations, etc., — I'm dating myself — which you carried with you. Would you suggest that this would be something that should be implemented again? I think that was a federal thing, but it's still something that people should be looking into possibly.

           G. Squires: What you're describing is somewhat related to what the pharmacist would do. A patient would visit the pharmacist and say: "I'm going to X country." There are protocols that the pharmacist would follow in terms of ensuring the patient had appropriate preparation for travel to that particular country or region of the world. Following that protocol, the pharmacist would either prescribe the medication, if it was a prophylactic medication required, and then dispense it to the patient or refer the patient for vaccinations or whatever else had to be done.

           Now, whether the federal government or the provincial government decides that a card like that is a good thing is related, but not directly, to our recommendations.

           J. Bray: I notice that you make reference to the Health Professions Council of B.C. Obviously, part of what this is, is a transfer of some work from one group of professionals to another. What's been the response to your policy from the BCMA?

           G. Squires: I don't know if I've seen an official response or any response at this point, although I certainly took notice of the Canadian College of Family Physicians press release and paper release on October 25, where they showed that family physicians are really burdened in terms of their workloads and are looking for relief from that. We can help that.

           V. Roddick (Chair): Thank you very much indeed. I appreciate your presentation as well. Good to see you again.

           Just before our next presenter, Harry Bloy is here. Do you have any words of wisdom or greetings, Harry?

           H. Bloy: I'll bring greetings. You're doing a great job.

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           V. Roddick (Chair): We have another group here. Are you all here together — that's the Arrow Lakes, Castlegar, Greater Trail, Columbia Valley and Kootenay-Boundary — or are you all separate?

           Interjection.

           V. Roddick (Chair): All separate — all right. Then it's the Arrow Lakes–Upper Slocan Valley health council: Judy Cameron. Good afternoon.

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           If you do speak, sir, would you put your name in so that Hansard will have it on file, please.

           J. Cameron: Good afternoon, hon. standing committee members, ladies and gentlemen. My name is Judy Cameron. I'm the chief executive officer of the Arrow Lakes–Upper Slocan Valley health council, and I'm pleased to have the opportunity to present this submission on behalf of our health council. Copies of this submission and supporting documentation have been made available to you.

           With ten minutes to present, I will not spend time telling you who we are other than to say that we are one of the smallest CHCs in the province. Our physicians do one-in-two and one-in-three call, as do our laboratory and X-ray technologists. Our nursing staff shortage is not as serious as in other places but is impacted by workload and by accompanying patients on ambulance transfers.

           We finished the fiscal year of 2000-01 with a small surplus, as we have in past years. This was not without considerable sacrifice and efforts by both our limited management and staff resources. However, in small communities we're dedicated to providing appropriate quality health services to our clients. Our total budget this year is about the same as the expected deficit of some medium-sized regional health boards. We have submitted a balanced budget.

           I won't spend my limited time telling you what is wrong with the system, as others have already given that input. I will instead concentrate on suggestions as to what the B.C. government could do to ensure the sustainability of a health care system that is based on the principles of accessibility, quality and prompt service delivery.

           You have the mandate from the people. You were elected with an overwhelming majority. You have said there will be changes, and people are waiting for action, not just rumours. Show us that you are truly serious about making a difference in health. Lead by example, and we will follow.

           Expect regional efficiencies. However, make sure the regions are a manageable size, taking into consideration geographic and demographic barriers to care. Have regions report to one ministry, not four. Stovepiping at the top sets us up to fail, as no one can successfully report to four bosses.

           Acknowledge that some programs are better managed and monitored centrally, such as ambulance, Pharmacare and physician payment. You have heard that CHCs have had difficulty coordinating services across one region and that there are serious concerns about equity. These services need central coordination to ensure equity and efficiencies across the province. Experienced staff, information and monitoring systems are already in place. Don't fix what isn't broken. Instead, make some firm decisions about how to control the spending of these highly developed services.

           Passing the problems down to regions, who have fewer resources and less expertise, is not the answer. For example, if the government, with unlimited access to funds for negotiators and legal expertise, has not been able to reach an agreement with physicians in more than a year, how will regions manage this on a finite budget?

           Carefully look at what drives the costs of health care up. We believe you will find that it is not the smaller community hospitals and long term care facilities in rural areas, who are providing care within their current budgets despite dwindling provincial funding.

           How many multiple organ transplants can the system afford? Do we do them because we can or because it enhances quality and quantity of life? Does it? Have we researched it? How many times should a patient who refuses to pursue a lifestyle change to improve his or her health be given a heart or a lung or a liver transplant at taxpayer expense? What procedures are deemed necessary, and which are done because they can be? People are asking for them, and physicians are doing them because they can and because they get paid for whatever they do. People are not telling us they're getting better service because of these elaborate procedures. In fact, sometimes it's the opposite.

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           Look at the solutions that have worked in other jurisdictions — the Oregon project, for example. Citizens there were stunned by the state's decision; however, it must have worked, as it's still in place as far as I'm aware.

           Ensure that there is emphasis on funding dedicated to health promotion and health education. Give prevention the priority that is necessary to help make a difference in the future of health. Look at the article in the Province dated October 24: "Canada's Critical Heart Shortage." The baby-boomers won't have the hearts they need for transplant, because wearing helmets saves lives and cuts the donor supply.

           What kind of a message are we giving here? Let's make sure we target the baby-boomers in our expectation for people to take more responsibility for their own health, like we have with the motorcyclists and the bicyclists. Stop rewarding those who need expensive hospital treatment and procedures and who insist on an instant fix but don't or won't change their lifestyle.

           Make the difficult decisions. Don't leave them to volunteer boards with no real authority or control over the money. Regionalization has been more about putting difficult decisions at arm's length from the government than about improving people's health. Micromanagement at the top and megamanagement at the bottom will not work. The Ministries of Health continue to tell us how much funding we have for acute

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care, continuing care, mental health, home care and other targeted funding, all in separate envelopes with separate reporting for each and often in different formats for each ministry. This is not regionalization; this is central control, especially when we don't even have the authority to move money among our current programs without first obtaining ministry permission.

           We have five CHCs and a CHSS in our region of West Kootenay–Boundary. Yes, we've tried all avenues to get support from the government to be a region. Within our region we provide 85 percent of the health services required to meet the health needs of our citizens. We have been singled out as having more funding per capita than any other region in the province.

           Obviously, we do as much or more with our funds as others do. Our population is as healthy or healthier than average in British Columbia. We provide emergency care within a reasonable distance and time for patients to get life-saving treatment such as thrombolysis therapy for heart attacks. We provide long-term care closer to home, so families and friends can easily be involved with their loved one's care. We provide pre- and post-tertiary care and palliative care close to family and friends. Our clients give accolades for the personal care and attention they receive in our small community hospitals compared to that received in larger hospitals.

           All our smaller facilities are not only operating within their budgets but are also providing health promotion programs such as diabetic teaching, respiratory, foot care, nutrition and oral hygiene clinics to provide people with the skills necessary to take responsibility for their own health. We ask you not to deprive our citizens of the core essential services they need only in order to preserve the high-tech, high-profile, sometimes unnecessary procedures that may or may not add quality or quantity to people's lives.

           In closing, I would like to emphasize that the tough and necessary decisions have to come from the funding source, not from volunteers in the community. These decisions, with realistic expectations, must be communicated appropriately to the stakeholders and then to the public in a timely manner.

           Also, before these essential decisions are implemented, please ensure that the principles of accessibility, quality and prompt service delivery are defined and measurable: that those services that constitute basic core services are defined; that the ratios of GP and specialist physicians to population are defined — this may be different for rural than urban; the reasonable distance people can be expected to drive for emergency care, for GP or specialist physician care, especially when the ambulance service is limited and public transportation is nonexistent; the distance from home and family that is reasonable for long-term residents to reside; and other basic services necessary to be in place before considering hospital closures, such as ambulance, home care, home support, and also the cost-effectiveness of replacing hospital care with these alternative services that are adequate for rural areas.

           Our written submission includes additional information for the standing committee's review and includes the Health Goals for British Columbia that the Ministry of Health has verified are still current and that I think should be addressed. Thank you.

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           V. Roddick (Chair): Thank you very much.

           Do we have any questions?

           J. Bray: Thank you very much for your presentation, Judy. I just want to have you expand a bit on the theme of how many transplants we provide to somebody who is there because of their own lifestyle as opposed to a genetic issue, because that's a key point. How do you in practical terms actually see that occurring? Somebody who continues to smoke comes in and has the doctors say, "Go home. You don't get the operation," or: "You're going to have to sell your house to pay for it, but we'll still provide you the service."

           Practically, how do you see that type of philosophical shift from we treat everything to we treat everything up to a point?

           J. Cameron: I could just say that's the responsibility of the funding source, couldn't I? I think my own philosophy is that there is a difference between health styles and genetic issues. I do believe that in some jurisdictions, people aren't even given the opportunity to be on a transplant list if their issue is due to smoking, if they have not quit smoking for at least six months or a year. The same with liver transplants. Some people are not even given the opportunity to be on the list unless they've been alcohol-free for a year. I think those are the kinds of implications or the kinds of criteria that need to be set for these things.

           Cataracts. Not as elaborate certainly as organ transplants, but definitely in the realm of how many cataract surgeries do show improvements? I think there was a research study done in the lower mainland that showed that 33 percent of people having cataracts didn't get any improvement or very little improvement. How many procedures are necessary?

           How many people can we afford to give five organ transplants to? When a person has an organ transplanted, if they have more than one transplanted, they have round-the-clock nurses — one for each organ.

           These are the kinds of things that drive the cost up. We have the technology to do them, so we do them. It doesn't necessarily mean that person's life is going to be of that much better quality. Heart transplants, on average, last five years.

           J. Bray: Just to follow that up. I appreciate your honesty, because this is a major issue that doesn't get talked about. We've talked about some other things.

           Following that, do you see the same argument being made for all the emergency admissions — for somebody who breaks their leg skiing? It's a lifestyle choice, and yet we see far more people in the emergency rooms around British Columbia for broken legs than we do multiple organ transplants. Would the logic not follow to those types of services? I'm not debating

[ Page 635 ]

with you; I'm just honestly trying to see what you think about that.

           J. Cameron: I guess in that regard, most of the people who have skiing accidents…. I don't see that as any different than car accidents. I don't think you can limit the things that happen, because that's what people do. With a broken limb, if you want your taxpayers to get back to work and provide tax income, I think you have to fix them and let them get back to work.

           I'm not talking about the first transplant or maybe even the second. I'm talking about people that have many transplants. How many are you going to do?

           R. Hawes: Could I just go back to regionalization? You've talked about it in here, and you've tried to be regionalized. What do you see — all of the CHCs and the CHSS in your area going into one region?

           J. Cameron: Yes.

           R. Hawes: Okay. The BCMA was here earlier. They talked about the importance of developing regional centres. If that were to happen, what would you see as being the regional centre in your region?

           J. Cameron: Trail has been identified as the regional centre in our region.

           R. Hawes: Okay, and you have no problem? You're very comfortable with that?

           J. Cameron: That's the one we have right now. We have some other services provided, but Trail has been designated as the regional hospital.

           R. Hawes: You are exceptional, because most CHCs want to hold on to what they've got, and they don't want to be put in with anybody else. They just want to remain their own little power base. That's very good.

[1415]

           J. Cameron: We already have a lot of shared services in our area, and others following me from the region will probably touch on that.

           Mr. Crockett, our chair, was just saying that we have available a draft, I believe, of the proposal on regionalization that was actually provided to government from our area.

           V. Roddick (Chair): Thank you very much, indeed. Do we have a copy of that proposal?

           J. Cameron: Yes, it has been supplied.

           V. Roddick (Chair): I'm assuming this is the Brian MacLure of the Boundary health council. Brian MacLure, good afternoon and welcome.

           B. MacLure: Good afternoon. I've passed out my speaking notes to you, and I'll just read from them if you don't mind. Thank you for the opportunity to present to the standing committee. The various health authorities in the West Kootenay–Boundary have shared their presentations prior to this forum in order that, while we have a common message, we are not repeating each other.

           I've attached background information from the health service delivery plan done by HMRG in 1999, which describes the demographics and general health status of the residents of our health authority, the Boundary health council. The council coordinates the provision of health services to the citizens resident in the communities of Beaverdell, Bridesville, Rock Creek, Midway, Greenwood, Grand Forks, Christina Lake and surrounding areas in south central B.C.

           Like the Arrow Lakes–Upper Slocan Valley health council, whose presentation preceded ours, we are a small health authority with a total budget of approximately $14 million. We had a small surplus in 2000-01 and anticipate having a balanced budget for the fiscal year 2001-02. While we take pride in this fact, this does not mean that we do not feel efficiencies cannot be attained. We strongly support the review of health services being conducted in B.C. and the establishment of an inventory of core services which takes into account the geographic constraints of many rural communities. We feel the government needs to take a leadership role in determining which services will be funded through our provincial health plan.

           We feel that there are important roles which can be played by the smaller hospitals in the province as satellites to larger regional centres. The infrastructure and management of programs do not need to be duplicated throughout the regions. The management and supervision of programs can be centralized while a portion of the delivery of those programs can be done in smaller centres. Examples of these types of programs are chemotherapy, kidney dialysis, cardiac stress testing, diabetic counselling, minor surgery, obstetrics and gynaecology, to name a few. Not only is it often less costly to provide services such as these in smaller settings, but it is a benefit to local residents in less frequent trips for health services outside the community.

           As stated earlier, the government needs to take leadership in establishing an inventory of core services which need to be done locally, and services or diagnostic procedures which should be performed regionally or at tertiary centres. We can no longer afford to duplicate costly equipment in several sites in a region, particularly for diagnostic procedures or tests which do not require immediate — i.e., less than 24-hour — turnaround times. Why do we require chemistry analyzers costing in excess of $100,000 at four different sites in a region serving 85,000 people? Should there not be one large central laboratory with satellite labs performing only predetermined stat tests which would require less costly equipment and reduced staffing? While this example refers specifically to the West Kootenays, the same scenario can be observed throughout the province.

           Can we afford to continue along that route? It must be determined which tests or procedures are critical or urgent and must be performed locally and those that

[ Page 636 ]

can be completed regionally. Small centres also need to enter into partnerships with regional centres for services such as teleradiography to reduce equipment and travel costs and to improve access to diagnostic services for their citizens.

[1420]

           In the West Kootenays we did not have the trained manpower to continue to staff five different laboratory, imaging and physiotherapy departments, nor can we afford to replace the required equipment for the five sites. We need to centralize specialties, thus maximizing manpower and providing outreach to smaller communities for services such as pharmacy, dietary, etc., to ensure the viability of these smaller centres. The use of satellite programs would avoid closure of smaller facilities and ensure universal access to health services for British Columbians living in these rural areas.

           One-third of the population served by Boundary Hospital is more than 40 kilometres from the hospital and over two hours from the nearest regional centre. Geography and weather can make travel outside the area difficult, if not impossible. It is therefore critical that there is local access to basic, core health services. The issue that has never adequately been addressed since the inception of medicare, however, is a clear identification of these core services. We believe that defining core services specific to a community, region or tertiary centres is the role of the provincial government and the Ministry of Health. We strongly urge you to proceed as quickly as possible with these important tasks.

           Other presenters from the West Kootenays will be speaking to you on issues related to governance, access to medical service, medical personnel, long-term care and important health issues. We've read all of their presentations and support their submissions. We have chosen to limit our submission to the above few salient issues in order to not duplicate these presentations. We hope the comments are of use to you. Thank you for the opportunity to speak to the committee.

           V. Roddick (Chair): Thank you very much.

           Are there any questions?

           R. Harris: At the beginning of your presentation you talked about the role in determining which services are funded. You're basically concurring with the previous speaker that we should be looking at something like what was done in Oregon in terms of defining what services should or shouldn't be provided by the health services plan.

           B. MacLure: That's correct, yes, and which services should be provided in what type of facility, whether it be regional, a small rural community hospital or a tertiary centre.

           V. Roddick (Chair): I just have one comment, and I don't know whether you or one of the other people who are presenting wants to answer this question. It will be interesting to us on the committee as to why or how you made the decision to come here as opposed to going to one of the other places that we went to, which look closer to you on a map.

           B. MacLure: You didn't go to the West Kootenays, and the East Kootenays was…. HABC and HAABC annual general meetings were held this week in Vancouver. We thought we'd save the province some dollars by coming here and talking to you. We're fiscally prudent in the West Kootenays.

           V. Roddick (Chair): Excellent — couldn't be better.

           R. Hawes: Could I just ask: with respect to core services, are you suggesting a broad menu of core services that the region could choose from?

           B. MacLure: No, what I'm saying is a basic list of things that need to be provided in a small centre.

           R. Hawes: I guess I'm asking: would that be broad enough? There are all kinds of differences between small centres demographically. To accommodate the different services that demographics would drive, would you be suggesting a fairly wide range of core services that you could pick from that would be appropriate for your community?

           B. MacLure: Yes, that would be one option for doing it.

           V. Roddick (Chair): Thank you very much indeed.

           The next presenter is Robert Jackson, Castlegar and District health council. Good afternoon.

           R. Jackson: Good afternoon. My name is Robert Jackson. I'm the chair of the Castlegar and District health council. I just want to warn you at the outset that I may deviate a little bit from the text that you have in front of you, because I've been tinkering with it, but I'll try not to get too far off.

           The Castlegar and District health council recognizes that there are many health care service issues facing the province. Some of them are ill-defined; others are complex. Many will only affect specific groups of service providers or clients. All must be addressed by a publicly funded and governed health care system.

[1425]

           In this submission we identify, describe and provide our recommendations with respect to four issues that are of current importance for our health authority in its quest to continue to provide and enhance quality patient care. These are governance structures; access to medical services, particularly specialists; long-term care; and the best use of available resources.

           In late 1996 the then Ministry of Health disbanded the West Kootenay–Boundary regional health board, leaving five community health councils and establishing the Kootenay-Boundary Community Health Services Society. This region has managed by creating committees and councils to achieve a degree of regional cooperation sufficient to meet government

[ Page 637 ]

requirements for planning. However, the regional decision-making process functions only under the duress of such requirements. In dealing with other issues, it is too easy and attractive for health authorities to act alone, even when their decision may have regional consequences.

           I want to point out here — and it's not in your text — that we do have regional arrangements, such as a regional laundry. Those have been brought about not through a regional governance system of any kind but through negotiations and agreements between the health authorities concerned, which takes a lot longer, I think, than a decision-making process would.

           In May 2000 the Castlegar and District health council reviewed the situation and concluded that a solution would be to disband the CHCs or reduce them to advisory status and establish a new West Kootenay–Boundary regional health board. We believe it should have the same boundaries as the previous regional health board because of the established patterns of interaction between local health areas and the geography that tends to isolate the region from the Okanagan and East Kootenay regions. This also would retain governor contact with the people they serve, which a larger region would not.

           We proposed a West Kootenay–Boundary regional health board knowing that there would be some risks, particularly a loss of community autonomy in governing health care services and facilities, which are often the result of intense community effort. We see a regional health board as an organization that guarantees smaller communities a voice in regional decisions as members of a body that must make decisions and has the power to implement them. To ensure this voice, we propose a regional health board that does not have weighted voting or population-based membership.

           We believe the advantages of a regional health board will include the following. It is a health authority with statutory powers and responsibilities. It will simplify recruitment of volunteer directors. It will eliminate conflicts of jurisdiction between CHCs and the CHSS. It should largely eliminate duplication of administrative and support staff. What are now small CHCs will have access to infrastructure and managerial expertise that is presently beyond their means. Individual CHCs will not be able to block change or discussion of change. Effective long-term regional planning will be easier, and implementation will be better coordinated. Gaps in service and duplication of programs can be addressed efficiently, and it will more effectively recruit, retain and utilize physicians and other health professionals.

           The continuation of basic medical specialty services in somewhat isolated, small urban-rural areas such as the West Kootenay–Boundary region is crucial to ensure reasonable access to these services for the citizens who live in the region. For West Kootenay–Boundary residents, travel to other regions for essential basic health care is costly and logistically difficult, particularly during the winter months when mountain passes become extremely challenging and sometimes treacherous.

           I don't know if members of your committee, Madam Chair, drove from Kelowna to Kimberley to conduct their hearings, but that week they would have noticed over the five or six mountain passes interesting conditions such as black ice, freezing fog, compact snow and probably a few deer on the road as well. I think such travel could result in further health care costs resulting from traffic accidents. Patients in any case are not well served if they have to travel four or more hours for appointments with specialists.

[1430]

           We recommend that the Ministries of Health provide flexibility to the regional health authority responsible for the West Kootenay–Boundary region, to enable them to restructure the way in which the specialty medical services are organized to ensure the sustainability, effectiveness and efficiency of quality services while eliminating haphazard and unnecessarily expensive duplication.

           We suggest that by operating all the acute care hospitals in the region as one entity, with one medical staff and all medical specialty services based exclusively in one location within the region, these specialty services will be more sustainable, effective and efficient in the following ways.

           All involved medical and nursing staff will participate in one work unit with improved on-call schedules, professional collegiality, continuing education, vacation relief, etc. These condition improvements will enhance both recruitment and retention capabilities, be more effective in providing uninterrupted services, as well as higher-quality services, through increased volume and less-stressed professional staff.

           Having needed specialists in two separate locations when both are required for the care of a trauma case would be eliminated. Outreach services from the single specialty base would be established in some specialties to improve local accessibility. It would be more efficient by eliminating the costly duplication of specialty medical services in more than one location with its inherent equipment and other resource duplication and its potential for overutilization, which seems to occur whenever the services available are greater than the real need.

           While the Ministries of Health continue to revise planning processes, our citizens continue to age. The needs for increased long term care beds and other home and community care services continue to grow. This increasing need results in our seniors moving away from their families and community contacts to long term care residential facilities elsewhere. This is simply unacceptable for longtime citizens whose health is enhanced by spending quality time living among their own families and friends and in their own communities. Their health deteriorates if they don't.

           The increasing need for continuing care also results in many seniors who require long-term care being admitted to acute care hospitals, awaiting placement, and where they are not able to receive the appropriate quality residential care they need. This inappropriate placement therefore results in further unnecessary deterioration.

[ Page 638 ]

           Clear incentives for partnerships with private developers or non-profit housing organizations to bring affordable assisted-living and supportive-housing facilities into all of our communities, with special subsidization arrangements for low-income seniors, should be considered so that this major gap in the housing continuum can be filled as quickly as possible.

           Enhanced and increased home care services, including the restoration of some basic housekeeping assistance, would also increase the ability for partially disabled seniors to continue to maintain quality lives in their homes, and thereby decrease the requirement for residential care beds.

           It appears to us that the Ministry of Health is reluctant to trust that health authorities are able to properly assess their local community needs. We suggest that representatives of the local communities, together with the professional assistance of their staff and consultants, are in fact the most capable of determining meaningful needs assessments. Different communities have varying needs dependent on a number of factors which don't necessarily show up in the universal formulas developed in Victoria.

           We think it is unacceptable to continue to plan, change the planning process and debate the validity of the growing need for additional services while our populations age and end up with either no care at all or inappropriate care in inappropriate places, at inappropriate costs.

           The CDHC believes that medical specialty services should be delivered through a single site, although this should not preclude appropriate outreach services elsewhere where facilities and patient needs dictate. At present, most are provided at the Trail Regional Hospital. New facilities should not be planned that duplicate services at a single site. That would mean increased capital costs and a heavier property tax burden on the whole region, an ongoing division of scarce resources to support two service locations, and the possibility of dividing the critical mass of patients needed to support the specialty service — with the result that it could be lost to the entire region.

[1435]

           Where existing resources are idle, such as the operating rooms at Castlegar and District Hospital, the possibility of putting them to appropriate use, including outreach services, should be examined before new duplicate facilities are built. This may mean adjusting plans to give existing resources and patient needs priority over physician convenience. The health authority should also have full discretion to determine alternate uses for idle resources, perhaps including promoting their use for patients or services not funded through the Medical Services Plan.

           We do not believe that the MSP, when it agrees to pay for diagnostic services, should dictate conditions such as limits on the hours of service or the method by which results may be transmitted to the appropriate specialist physician. It is false economy to arbitrarily restrict the hours of use of an ultrasound, for example. Patients needing this service either will be forced to wait longer or will travel elsewhere, thereby extending wait-times in other facilities. They will have their ultrasounds eventually, paid for by MSP. Similarly, it makes no sense to require a specialist such as a radiologist to interpret results, when they can be transmitted electronically to his or her normal workplace.

           In considering this point, we ask you to keep in mind that while some travel is unavoidable, patient travel especially is inconvenient, costly and sometimes dangerous. It's a cost item that's borne entirely by the patient, therefore significantly increasing the expense of medical diagnosis, consultation or treatment for rural patients compared to major urban centres. It is in the patient's interest to provide and maintain as high a level of service as possible within the region.

           In summary, we recommend that the Ministries of Health (1) establish a West Kootenay–Boundary regional health board and disband the present health councils and community health services society as soon as possible; (2) work with the regional health board to restructure the provision of acute care hospitals and specialty services to decrease duplication and ensure effectiveness and sustainability; (3) work with the regional health board to implement improvements in home and community care, including additional long term care beds, enhanced home care services, assisted living and supported housing alternatives now; (4) enable the best use of available resources by decreasing unnecessary specialty duplication and enabling health authorities to maximize the utilization of already existing resources, including the potential for providing services not funded through the Medical Services Plan.

           Madam Chair, that completes my submission. I thank you for your attention. I would be pleased to answer your questions.

           V. Roddick (Chair): Thank you for such excellent, concise recommendations. I think you summed it up beautifully on page 4: we all end up either with no care at all or with inappropriate care in inappropriate places at inappropriate costs.

           W. Cobb: Just one question. Actually, I had three questions, but you answered them all in the sum-up. Anyway, do you think the regional health board would be the best people, then, to determine, in the end, if and when the core services are listed, where these services should be provided within that health region?

           R. Jackson: Yes.

           W. Cobb: Or would you want the government to do that as well?

           R. Jackson: Well, the government is probably going to say what core services are provided within the region, given the region's ability to attract, or otherwise, the necessary professionals. But I think where they're provided in the region is the duty of the regional health board.

           R. Hawes: In your presentation you have one thing that I really wonder about, and that's a health board

[ Page 639 ]

that does not have weighted voting or population-based membership. Are you proposing — for example, with the 40-60 percent capital purchase arrangements that regional health districts now have — that population not be a factor?

           R. Jackson: Well, regional health boards don't have any taxation power.

           R. Hawes: No, but they work closely with regional health districts in the 40 percent funding for capital purchases that have to be put up. That goes with the weighted vote.

[1440]

           R. Jackson: Yeah, the regional hospital district has a weighted voting system, and it's made up of members of the regional districts. I don't envision the regional health board as needing a weighted vote system. Now, I know some people behind me disagree. When we had a regional health board before, we managed it with equal representation from each of the areas presently served by a CHC and with equal voting — one person, one vote. It seemed to work, because what we're doing is making health policy for the region.

           R. Hawes: I guess my only comment would be…. I'm not sure what the population distribution is within all of your CHCs.

           R. Jackson: The population distribution is not equal from the regions. The idea behind a regional health board is to ensure that those smaller areas have representation. It would be easy to conceive of a situation of weighted voting where perhaps two out of our five health councils could carry more weight at the board table than the other three. Assuming they could agree with one another, they would effectively be making the decisions.

           R. Hawes: It's an interesting concept. I'm just trying to think of it applying to some of the other health regions. Perhaps two small centres could be dictating how health care is delivered to the largest centre.

           R. Jackson: I don't think we're quite as disproportionate in our population as some of the other areas. Not like the Okanagan, for example, which might have Kelowna and Princeton. We're not quite that far apart.

           R. Hawes: It's an interesting concept. Thank you.

           V. Roddick (Chair): Thank you very much, sir.

           Greater Trail community health council: Marylynn Rakuson and Rick Riley.

           M. Rakuson: Good afternoon. My name is Marylynn Rakuson, and I'm the chair of the Greater Trail community health council. With me is Rick Riley, and he's the CEO of the Greater Trail community health council. We'd like to thank you and are pleased to present a submission on behalf of our health council.

           The Greater Trail community health council operates within an overall budget exceeding $50 million per annum from various sources. We are the largest integrated CHC in the province. We are the fifth-largest employer in the East and West Kootenays. We operate the Trail Regional Hospital, which is the regional referral for the West Kootenay–Boundary region. Patients from the East Kootenays also access our services; 8 percent of our overall admissions are from the East Kootenays. We also manage Mater Misericordiae hospital, three long term care facilities, home support and Alpha House.

           Today we wish to address some of the issues and concerns of this CHC. I am the co-chair of the West Kootenay–Boundary governance council, and Mr. Riley is the chair of the managers, so we meet as governors and managers. The managers did a review of the status of implementing the report, the West Kootenay–Boundary health services delivery plan done by HMRG in 1999. We have not attached the whole plan — it is definitely available if you want it — but we have recently done a status report on it, so we've attached that to our presentation.

           Now I'll let Mr. Riley proceed.

           R. Riley: Good afternoon, members of the select standing committee. We want to address two primary areas: equitable access to health services for people in rural B.C. and structural impediments to an effective health system.

[1445]

           Rural British Columbians should have as equitable access to core health services as urban residents in this province do. Specialist services such as orthopedic surgery and internal medicine complement one another. When specialist services are provided at more than one site in a region, they are diluted, and access to timely care is degraded. Specialists should therefore be concentrated at one regional referral centre.

           Regional services such as emergency, general medicine, surgery, psychiatry, pediatrics, obstetrics, respiratory therapy, clinical laboratories and diagnostic imaging should also be concentrated at one site. Specialty services require appropriate diagnostic and trained clinical support staff to provide treatment and care. Capital funding is required to ensure that each regional referral centre has the required equipment to provide the necessary services.

           Rural residents experience barriers to health services not experienced in urban centres. These include the high costs for air travel, poor road conditions that restrict travel in winter and large distances between our communities and to urban centres. Rural facilities must therefore be able to stabilize and treat patients when transportation out is impossible. Services should be accessible within the area at a regional referral centre.

           There's talk of very large mega-regions. Our presentation envisages a region the size of the West Kootenay–Boundary with one regional centre, but if we are talking mega-regions, it may be necessary to have

[ Page 640 ]

subregional centres in order to provide services in the large geographic area.

           Core services must be maintained in any communities that have their hospitals either closed or downsized or their services restricted. In the rural areas, ambulance service is therefore a major issue, and ambulance paramedical staffing is not as consistent in rural B.C. as it is in the urban areas. Often, RNs from our hospitals are required to accompany patients on ambulance transfers, many for large distances, because the ambulance paramedics do not have the necessary skills.

           Twenty-four-hour coverage is also necessary by paramedical staff and ambulances and should be available. Regions will have to coordinate their own ambulance services. We think the regions should have a role in managing ambulance services locally. Rural residents without ambulances in their communities should have access to ambulance services nearby.

           Residents requiring placement in long term care facilities should be placed within their region, as close to home as possible. As our population ages over the next 20 years, the need for long term care beds will increase. Innovative ways need to be found to fund these new facilities. New initiatives to keep people in their homes and care for them are also essential. There may be an opportunity to involve the non-government sector in this part of health care.

           The registered nurses could be used more effectively in supporting health care services to residents of B.C. Before they entered the main health care system, RNs could develop and implement wellness programs that prevent disease such as diabetes, chronic obstructive pulmonary disease, obesity-related disease processes. This would result in less morbidity in the long term. Less morbidity would impact the use of the health care system and result in savings of resources and improved health for B.C. residents.

           A patient in our province is able to pay for a superior intraocular lens for implantation. That's his decision. He pays a markup. That same person cannot pay for a superior hip prosthesis in this province. Patients who require renal services generally can access them fairly close to home. For many other services, however, they must travel to the lower mainland for treatment.

           Eye exams are not funded now, but eye surgery is. We think there should be a rational allocation of health services that are funded in this province.

           Volunteers provide many services in our hospitals, and they could be expanded into all parts of health services. The volunteers should be welcomed and their services expanded wherever possible. Volunteers should be welcomed and appreciated in the system for their contribution to care and encouraged to be involved.

[1450]

           Government has stated that the health system would best serve those who rely on it if it was integrated and seamless. A variety of structural impediments have developed over the years which inhibit the ability of the system to function in an integrated manner and in a cost-effective way. There is a proliferation of administrative tasks carried out at the expense of care and services.

           There are a number of structural impediments within the B.C. health system which increase costs without increasing the quality or quantity of care. There is a lack of flexibility within the system caused in part by the regulatory structure imposed by government, the organization of the system both in Victoria and in the field, and restrictive collective agreements. At the provincial level there's been a lack of anticipation of problems and trends in health care by those who are charged with planning for the health care service and delivery system.

           Frequently we hear that there is too much administration in the health care system. Many administrative positions exist just to provide information from the field to the administrators in the Ministry of Health, the Workers Compensation Board, the health unions and the Occupational Health and Safety Agency. I sometimes wonder if the health system, while it may be overadministered, is undermanaged because the management people are spending so much of their time focused on providing information to other agencies.

           The Ministry of Health generates much work for those of us who work in the field. The separation of decision-making between the Ministries of Health and of Finance has increased the complexity of obtaining decisions respecting capital funding for projects and for equipment.

           Five-year capital plans are developed in most health authorities in B.C. These plans are developed and prioritized with the expectation that resources will be made available. Funding from the regional hospital district is contingent upon release of funds by the Ministry of Health. The local funding is not provided unless the Ministry of Health commits. Inconsistent capital funding and delays in release of funds over the years inhibits planning and results in the purchase of equipment in crisis situations where the equipment actually fails. Over the past decade there's been inadequate equipment funding to the health sector to help maintain the industry's infrastructure and to acquire new technologies and information management technologies in a timely manner.

           The Ministry of Health itself creates new requirements for health authorities to supply more information to the bureaucracy. We seldom receive feedback on the information submitted with respect to how it is being reviewed, how it is being considered, and it is seldom returned to the field as useful information for management purposes.

           There are stovepipes still within the ministry, which extend out into the field. We have acute care, continuing care, mental health, addiction services, MSP, ambulance services. All are examples of the health system administered by separate bureaucracies in Victoria who may or may not communicate and coordinate in developing policies and services, particularly as they affect the regions. Directions and instructions from various parts of the Ministry of Health to the field often appear uncoordinated. We question

[ Page 641 ]

whether two Ministries of Health are going to improve the stovepipe problem.

           In rural areas the old public health structure, prior to New Directions, is retained in the community health services societies. Community health councils are responsible for acute residential care and home support services. The integration and efficiencies visualized in the urban areas under regional health boards are difficult, but they're even more difficult to achieve in rural B.C. with our structure.

           The Ministry of Health has recently developed the practice of requesting proposals akin to asking health authorities to bid on new program funding by submitting proposals. Those health authorities that are more sophisticated and have the staff capable of preparing grant requests succeed in getting these additional operating funds. Those that are not so blessed lose out.

           The Ministry of Children and Family Development funds alcohol and addiction services separately from Health Services. We believe they should be returned to the Ministry of Health where they were five years ago so those services can be integrated.

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           It's impossible to manage the health authority when we do not receive our annual operating budget allocation until six months into the fiscal year, as has happened this year. It's not the first year. It's happened many times in the past. It's difficult to respect budgetary allocations and to be held accountable in these circumstances. Notification of allocations prior to the start of the fiscal year would be desirable, and multi-year allocations or budgets would assist in long-term financial planning.

           We believe government should define the deliverables expected of the health authorities — i.e., the outputs — and not prescribe the processes by which they are to be achieved. It should be left to the regional health authority to determine the manner in which the services are to be provided locally. Deliverables, though, must be measurable in order to hold the health authority accountable, and the health authority should be held accountable. Local health authorities understand their communities, particularly in the rural areas.

           The current practice, which we see as applying a lens developed in urban B.C. to the rest of the province, is not valid. Local conditions need to be considered and local plans developed. Only a form of decentralized governance and management can achieve this. The delivery of care programs and case management must be delegated to health care workers at the front line to ensure that the care provided meets the needs of the clients, patients or residents and is not driven on a formula developed in urban B.C.

           Certain administrative support functions, however, could effectively be centralized in our regions, including laundry, purchasing, laboratory and others. Some of the services could be contracted out to the private sector, as well, and economies achieved.

           Over the past decade the health sector has focused more on the rights, benefits and entitlements of workers and less on the needs of patients, residents and clients. There are limitations on the flexibility for management to assign work in our industry and to manage the workforce caused by the restrictions of the collective agreements. Without competition in the health system, the health unions are under no obligation to recognize market forces, and they have been able to bypass the employers negotiator, HEABC, and continuously draw the provincial government into the process of finalizing collective agreements, whether negotiated or imposed.

           The current collective agreements virtually prohibit contracting out. Some unionized positions' salaries and benefits have escalated beyond comparable positions within our communities. Multiple reasons for staff leaves of absence have been created. A balance needs to be restored between management of the system and the health unions.

           It is difficult to manage the health system when physicians have little accountability to health authorities. They are independent practitioners who may or may not follow the commitments the BCMA has made on their behalf.

           The rural physician recruitment and retention program, however, has been very beneficial in assisting us in recruiting specialists and physicians to our communities in West Kootenay–Boundary. Recruitment of foreign physicians is made difficult by the requirements of the College of Physicians and Surgeons. Human Resources Development Canada also interferes in the recruitment process, establishing quotas and restrictions. Easier immigration for physicians is needed. The B.C. Nurses Union has an understanding with Human Resources Development Canada regarding the admission of foreign nurses into B.C. There should not be a requirement for an employer to get the support of the union prior to recruiting its workforce. RNABC screens the professional credentials of RNs entering the province, and that should be the body that works with our representative, HEABC, in this regard.

           Finally, the province needs to look at establishing information with which to manage the health system both in Victoria and in the regions. An analysis of demographics and the projection of trends in population health are required. The government should determine policy and funding allocations based on information and projections. Information needs to be provided to the local health authorities to assist them in decision-making, though. Incentives need to be developed to help health authorities restructure and redirect resources into less costly options for care and to develop new initiatives.

           In summary, we recommend the government review the health system with the goal to removing structural impediments to good management and good care and to ensure equitable access to services for people in rural B.C. Thank you.

           V. Roddick (Chair): Thank you very much.

           W. Cobb: Three questions. What is the population of your health region?

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           R. Riley: The health region of the West Kootenays is just over 80,000.

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           W. Cobb: Okay. You talked about nurses and having to go in ambulances. Do you have any idea how many transfers you have a year where a nurse would have to go in the ambulance with a patient? Would it be in the region?

           R. Riley: I don't have that type of information. In the region I wouldn't, because we're not operating as a region. We're divided into health councils and services societies. I could get that from the ambulance service, but I don't have that information.

           W. Cobb: Okay. The last question is to do with the doctors. Do the health boards — or somebody — not have the authority to withdraw doctors' privileges?

           R. Riley: We have that authority under the Hospital Act.

           W. Cobb: So you do have some control over a doctor?

           R. Riley: Well, to withdraw privileges it has to be an extreme situation. Obviously, in that situation you'd have to work with the doctors.

           W. Cobb: So where do you see the control coming from then? I mean, you're asking for control over doctors. What are you suggesting?

           R. Riley: The physician recruitment and retention program, which has in a sense given health authorities some money to pay doctors for doing certain services, is one tool. If the health authorities were the ones that held the funds and were deciding where they wanted to spend the funds, I think it would assist in managing the positions.

           R. Hawes: Just a quick question with respect to your statement here that regional services such as emergency, general medicine, surgery, psychiatry, pediatrics, obstetrics — all of the specialty services — should be on one site.

           R. Riley: That's what we're advocating.

           R. Hawes: I guess my question to you is twofold. Is there going to be an internal fight within your region for where that site should be? And the second part of that question is: is there a site that has bricks and mortar sufficient to take in all of the patients from the whole region for every single one of those specialties?

           R. Riley: I believe there is. The Trail hospital, to answer question No. 2. And yes, I think there will probably be disagreement within our region.

           R. Hawes: So would you be saying, then, that the province should be the ones that dictate where that should be in order to stave off or head off…?

           R. Riley: The province already has, under the previous administration, decided where the regional medical centre is in our region. But the current government needs to hold firm and perhaps define what that means, to make it clear for those of us working in the field. If the guidelines were clear, then we would move forward on those guidelines, I believe.

           V. Roddick (Chair): Further questions? Well, thank you both very much.

           We now have the Nelson and Area health council: Bob Nuyens and Brian Ryder.

           B. Nuyens: Good afternoon, Madam Chair and the by now, I think, weary members of the legislative standing committee.

           V. Roddick (Chair): Sitting committee. [Laughter.]

           B. Nuyens: Too much sitting and not enough standing.

           My name's Bob Nuyens, and I'm the vice-chair of the Nelson and Area health council. With me is Brian Ryder, one of our councillors who will assist me today with three overheads, which I hope you will have the opportunity to look at.

[1505]

           The background for this proposal. The Nelson and Area health council has learned from its extensive public consultation process across 14 communities and spanning eight years that the sustainability of health is directly related to the government's commitment to reorganize the health system to focus on wellness. Rapidly increasing knowledge, technology and an increasing and aging population provide us with the opportunity to evaluate the priorities for health in light of best practices and outcomes for a healthy society. The business of health must be to focus on wellness, best practices and qualitative measures to improve outcomes for the health of the population. A healthy population contributes to a healthy society, one which is economically vibrant and progressive — a new era.

           Our organization's perpetual challenge has been to provide the care and support required to meet the growing acute service requirements while staying focused on the long-term solutions to achieve healthy people and healthy communities. Multisectoral discussions across the spectrum lead to the vision statement of our organization: better health in the Kootenays. This vision is based on the knowledge that health is impacted by a number of interrelated factors known as the determinants of health.

           A focus of wellness requires that meaningful partnerships be developed within our workplaces, neighbourhoods and communities in concert with provincial and federal health goals. These partnerships exist to meet the needs of achieving better health by identifying and clarifying the roles of each and meeting

[ Page 643 ]

the vision. We support the provincial government's position that a strong economy ensures income and social status for a healthy population. These are significant determinants of health.

           In our area the average income is less than in British Columbia overall. Fewer people in the area are employed, and of those who are employed, fewer work full-time. Compared to the province as a whole, more people in this region receive B.C. Benefits and employment insurance. For people earning less here than on average, food costs are among the highest in the province. Twenty-five percent of children in this area live in poverty, which is higher than the provincial average of 20 percent. Of the children living below the low-income cutoff, almost half belong to single-parent families, most of them headed by women. Approximately 30 percent of seniors have incomes at or just below the low-income cutoff. The majority of the seniors affected are women. More single seniors live alone in this region than in British Columbia overall. Fewer than 20 percent live with relatives, and fewer than 5 percent live with non-relatives.

           There are 1,200 volunteers directly working for health care in our area. These 1,200 support the work of 650 employees. Economics is a major issue and determinant of health that communities are striving to address through a variety of initiatives supported by an economic development officer. Provincial, regional and municipal boards of management, community futures, Selkirk College and private business. Nelson and area has the largest population served in the West Kootenays and is projected to grow by 41 percent by the year 2026-27.

[1510]

           Wellness related to health services access: the health campus model. It's widely recognized that one-quarter of a person's wellness is directly related to access to health services. Equitable, user-friendly access is the key to wellness. During the last seven years our 14 communities have achieved consensus around health services. Nelson's proposed health campus model is the bricks and mortar that support a hub for wellness. The bricks and mortar of the health campus model bring together multilevel care; assisted living; adult day care; respite care; Meals on Wheels; home support; transportation; acute care; mental health; children and family services, including a parenting program and a life-after-birth program; health professionals, including traditional medicine, massage and dentistry; and the ambulance services of the urban centre of Nelson. Co-location of services would provide user-friendly access for residents of the area, while achieving economies of scale from the operational perspective. At present the Nelson and area health council operates these services from three sites: Kootenay Lake District Hospital, Mount St. Francis Hospital, Nelson and District Home Support Services. Kootenay-Boundary Community Health Services Society also operates services from an additional site, with Children and Family Development providing services from a fifth site.

           The health campus model affords opportunities for eliminating duplication of assessments, interviews and appointments with a multidisciplinary team of health professionals, including physicians, nurses with enhanced roles as nurse practitioners, midwives, mental health professionals and flexible ambulance attendants duties.

           Co-location would allow for maximum utilization of educational space, wellness-focused day programs, diabetic education and the healthy heart program. The health campus model is the hub of our integrated community care network, providing chronic disease management, shared care and quality improvement, clinical practice initiatives. Our participation in the national award-winning diabetic program has seen a 36 percent increase in the last year. Cancer treatment has increased by 40 percent.

           It is important to manage human resources prudently. As we have found, there are benefits to be had from offering outreach programs to our outlying communities. These programs allow people to remain close to their own homes and communities and be in charge of their wellness. Outreach services reduce utilization of acute care beds as the community supports are put in place. The health campus acute care services support ICU, maternity and general surgery with a focus on ambulatory care. The specialty service care team is instrumental in supporting the family physicians and ambulance attendants in primary care, as challenging travel conditions and distances are part of a lifestyle in the Kootenays. Sixty-five percent of the residents' health issues are presently being met by existing services by our health council. Regional plans to incorporate a renal dialysis unit in the health campus model would increase those services that can support wellness within the context of the community.

           An integral lifeline of rural health services continues to be ambulance services. Ambulance attendants require at least a level 2 when they are charged with extended travel times to connect with acute care supports. The health campus model and health professionals see utilizing the skills of level 2 ambulance attendants to support timely interventions in emergency situations and incorporating their expertise in the primary care model for first response.

           Early detection, diagnosis and treatment are other components of shifting a sick model to a wellness model of health. Treating sick and sicker people is not good business. It is expensive for the individual — lost days of work, drug therapy costs, hospitalization — and to society as a whole. Wellness requires that we continue to work with the federal government to ensure timely access to the technology of telehealth, telemedicine and provision for basic diagnostic equipment like CT scans and MRIs.

           Governance. As governors we know that quality of life is measured through civic, cultural and recreational involvement and that community involvement is essential to raising the health status with lower social costs. It improves participation, resulting in reduced rates of injury and incidents of violence and supports increased health in the workplace. 

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           We can see the benefits of a large rural health authority — southeastern B.C., East and West Kootenay and Revelstoke — to make policies that will facilitate the development and implementation of strategies that support wellness in rural communities through coordination. A coordinated effort would be beneficial and cost-effective to optimize accessibility to high-quality primary health care; to promote coordination of care, ensuring 24-by-7 access to medical care; to share on-call services; to provide multidisciplinary team-based care; to provide a full range of health care services, including health promotion and illness prevention based on best practices and outcomes in keeping with the challenges of rural health; to recruit and retain rural physicians and nurses; and to train nurse practitioners.

           Sustainability of health services requires that we move the business of health past treating the symptoms and the sick and that we invest our money in wellness. Current research on the relationship between early life and later events provides the opportunity to invest wisely in our next generation, with dramatic results to be achieved within five years.

           The partnership involves the Minister of State for Early Childhood Development, Ministry of Education, Ministry of Children and Family Development, Ministry of Health, Ministry of Advanced Education, Health Canada and communities across the province.

           Many school districts have already recognized an important determinant of health, and that is healthy child development as instrumental in achieving academic success. The increasing requests for head-start programs, early literacy programs, interventions, community school initiatives and day care programs can attest to this. From preconception until the age of five, we have the opportunity to maximize early childhood environments, developmental health and wealth of nations.

           In conclusion, we have a responsibility to contribute to our own wellness and the wellness of those around us. Community affordability, quality of employment, quality of housing, community safety, community stress, community participation, population resources and community health are good indicators of the wellness of a community. Much can be achieved in partnerships when a vision is shared. Sustaining health care requires a commitment to partnerships, innovation and a system of health that is focused on achieving wellness.

           Thank you, Madam Chair, and thank you, committee members.

           V. Roddick (Chair): Thank you, sir.

           Are there any questions from the committee?

           R. Hawes: I just have one question. You probably heard the previous presenter, and I guess you're both in the same potential region.

           B. Nuyens: I'd say we're both in the same region forever.

           R. Hawes: In terms of sharing services, is there a pretty common agreement?

           B. Nuyens: Yes, we do share services — possibly better now than we have at any time in the past. I would hope to see that continue.

           R. Hawes: Looking at your campus model here, though, the proposal for a new centre in Nelson — and then, in terms of a regional centre in Trail, with all of the specialists and with obstetrics there…. I think Nelson has a fairly substantial number of childbirths.

           B. Nuyens: We would not advocate that obstetrics be located entirely in Trail.

           R. Hawes: I'm asking more for my own edification, for where I live. How would you propose to resolve the kinds of disputes that happen territorially within regions among neighbours?

           B. Nuyens: With a great deal of patience and collaboration with the people that we share services with in our community, I think it's achievable. I would hope that no matter how regionalization does affect us, we will find the common denominators to make this happen.

           R. Hawes: Should these kinds of disputes be left to be settled within the region, or should the ministry be the one to resolve these types of disputes?

           B. Nuyens: I would like to think that we should be able to solve these problems internally, unless we reach an impasse and require an outside arbitrator.

           V. Roddick (Chair): Thank you very much indeed.

           Our next presenter is Kootenay-Boundary Community Health Services Society: Martin Oets.

           M. Oets: Good afternoon, Madam Chair and hon. members of the committee. Thank you for the opportunity to allow us to present to you today. As health authorities in the West Kootenay–Boundary area, we have tried to coordinate our presentations as much as is possible. Because of our society's emphasis on health promotion and prevention services, most of our comments will focus on this aspect.

[1520]

           Some general comments. Those who have studied the matter have determined that health status is not directly related to spending on the curative aspect of health care but is a complex variable more directly related to the structure of our society and to the place on various gradients that people find themselves. On one hand, it's quite clear that the disparities in socioeconomic status are a strong predictor of health status. We must resist the temptation to socially engineer our society in an attempt to level the disparities in health status. In today's environment of financial constraints, spending on health must be precise and justifiable. All spending on health-related matters should be viewed

[ Page 645 ]

not just as a social good but as an investment in the society of British Columbia.

           There also needs to be substantial thought given to a complete retooling of our health care delivery system. Many professionals are underutilized because the compensation structures favour current practices. If the government chooses to open the health care system to natural market forces, it must also be careful not to unnecessarily restrict practice. Health professions tend to guard reserved acts from a perspective of protecting the public. That indeed is laudable, but it must be evidence based. Generally speaking, it might be worth considering to notch up the capacity of the system by encouraging and structuring the roles of your various health care providers. This concept is particularly germane in the rural settings where recruitment issues are historically severe.

           The roles of community health care workers could be expanded to free up licensed practical nurses and registered nurses so they can work to the full capacity of their experience, training and education. Similarly, expanding the role of nurses would free up physicians to concentrate on the more complex health issues and invest time in shaping long-term care health improvements for their patients. Additional opportunities for expanded roles for general practitioners in rural areas should be considered as sustainability of specialist services in rural areas is in question today.

           Paying attention to the rural issues. As mentioned in the general comments above, there is a relationship between socioeconomic status and health status. There is also a relationship between the gradient of urban-rural and health status. Part of them may be linked to socioeconomic status, but we believe there are other variables at play. One of our main concerns is access to services. One of the major problems facing rural residents is adequate public transportation. The challenge will be to develop ongoing strategies that address some of these rural disparities in a manner that will return positive outcomes in direct proportion to the investment.

           As the possibility of hospital reconfiguration is distinct, a provincewide emergency and trauma strategy should be considered. In the West Kootenay–Boundary region, unpredictable weather has a distinct impact on timely access to higher-order emergency services. For example, consideration might be given to see if a business case could be developed for an all-weather rotary ambulance system. The capital operating costs would have to be offset by the reduction of need and costs for emergency trauma services in smaller centres.

           Governance and community involvement. Regionalization will get away from parochialism at the governance level if properly implemented. Some of the questions directed to the previous presenter touched on that. We must not forget that local commitment has served us in the past. We suggest that after a major restructuring task has been completed, a system of community participation for ongoing dialogue be encouraged.

[1525]

           Placing a priority on furthering and promoting volunteerism. We have come to believe that volunteerism is one of the greatest untapped resources in our system. In our estimation it may be one of the keys to making our health care system sustainable. The community's willingness to give their time and services should not be abridged through collective agreements. However, we must guard against falling into the trap of believing that it can be a substitute for knowledge-based, compensated health care workers. It will improve the work environment of the health care professional as some of the social aspects of the clients' needs will be better met. In the rural areas we have a significant problem of isolation. Improved volunteer services will go a long way to get citizens connected and to create better health outcomes.

           Public-private partnerships. We applaud the government's willingness to harness the power of the private sector. It may be the government's will to move away from licensing, particularly as it applies to supportive and assisted-living arrangements. The government cannot abrogate its responsibility to ensure that the most vulnerable in our society are protected.

           We suggest that agencies providing these services, as part of their freedom to operate, must agree to some sort of performance standard compliance and monitoring. Options could be: (1) purchasing the service from community facility licensing, (2) an industry self-regulatory body and perhaps (3) accreditation from an external body.

           I'm not going to read my whole presentation. There's lots of good stuff in it, but I only have so much time.

           Finally, using technology to further health goals. The HealthGuide program must be evaluated in its current expanded role. If indications are that this program is delivering on its intended outcomes, efforts should be directed to maintain currency, foster its use and look for opportunities to expand the self-help initiatives to British Columbians.

           You have probably heard much about the tyranny of providing information to the Ministry of Health Services. Over the past decades many false starts have taken place to try and align the collection and use of health information. Yet today the system is rife with duplication, unnecessary expenditures and gaps. The long and short of it is that B.C. needs a comprehensive health information strategy. We believe this is one area the private sector may hold the key to providing B.C. with the health information system it deserves. Thank you.

           V. Roddick (Chair): Thank you very much.

           Are there any questions from the members?

           R. Harris: I guess a question and a comment also. From the question side, when you talk about an all-weather rotary ambulance system, are you considering that local people or local businesses would have the capacity to provide that, as opposed to a provincial system?

           M. Oets: I would think that would have to come under the auspices of a provincial service. They're extremely expensive.

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           I just relate to some of my colleagues who have helicopters flying from Alberta to swoop people up. They seem to be very satisfied with it. It's very expensive technology. A business case would have to be developed, but it might be one way to offset the reconfiguration of some of the smaller hospitals.

           V. Roddick (Chair): Does your area use STARS?

           M. Oets: I'm not sure if we do or not. You're thinking of the East Kootenays.

           V. Roddick (Chair): Yes. Well, that was one of the areas. When we were in Kimberley, they were saying that they use STARS from Alberta.

           M. Oets: Yes, that was the service I was referring to.

           R. Harris: Just a comment. I think you're the last presenter from the West Kootenay group, according to my agenda. My riding is Skeena, which is northwest. I have to admit that I've been impressed with the ability of that group. They seem to have found a model outside of formal regionalization to work through and seem to be able to deliver a pretty good product to the people that live in the area. I think you should be commended for it.

           M. Oets: Thank you very much.

           I would be remiss if I didn't add that our health services society is also in favour of the West Kootenay–Boundary area becoming one region. So five out of six isn't bad.

[1530]

           V. Roddick (Chair): Well, I would like to add my compliments to you all for presenting here. Excellent presentations and very well coordinated. It's been very helpful for us.

           Now, I understand that Glen Hillson and Andrew Johnson are here. Glen Hillson will speak first for ten minutes and then Andrew Johnson for ten minutes. Then they will take questions, and they will also hand out their presentation when they are finished.

           G. Hillson: I was just going to say that I looked at the schedule and see that you're doing this from nine until nine for three days. Undoubtedly you're more aptly named the select sitting committee. Since we're only going to be speaking for ten minutes each, I wouldn't be at all offended if anybody wanted to take a minute to stand up and stretch.

           V. Roddick (Chair): We appreciate that.

           G. Hillson: Good afternoon. My name is Glen Hillson, and I am the chair of the B.C. Persons with AIDS Society which henceforth I will refer to as BCPWA. I wish to thank you for the opportunity to speak today. I am joined by Andrew Johnson, executive director of AIDS Vancouver, who is the next speaker. As we have coordinated our presentations, we wish to suggest that for greater efficiency, we will respond to your questions at the conclusion of Andrew's remarks.

           BCPWA is a provincial organization of 3,600 HIV-positive people who live throughout the province. Formed in 1986, we are the oldest and largest organization of people living with HIV/AIDS in western Canada. BCPWA's mission is to help each other become empowered through mutual support and collective action.

           Today we have come to provide you with information about the history and current state of the HIV/AIDS epidemic in Canada and, in particular, British Columbia. As well, we are here to talk about the roles of government, the community and people living with the disease in preventing and responding to the spread of HIV. In the past year a long overdue public awareness has emerged about the HIV epidemic that rages, all but unopposed, in poorer countries in the south, which account for most of the world's 40 million HIV-infected people.

           However, of late our state of collective awareness about the epidemic here at home is often misinformed by exaggerated and overly optimistic notions about the current level of scientific and medical knowledge. For example, although there has been significant progress in the development of treatments of HIV disease, AIDS is still a terminal illness. There are more than 50,000 Canadians living with HIV. There are roughly 5,000 new HIV infections in Canada each year, amounting to about 12 per day. This number of new infections is double the rate we experienced back in the early 1990s. To date, 12,000 Canadians have died of this disease. There are more than 10,000 people in British Columbia who have tested positive for HIV so far, and it is likely that many more are infected but have never been tested.

           The most recent epidemiological reports from the B.C. Centre for Disease Control show some trends that are quite alarming. Despite years of decreasing numbers of new infections in the province, it appears we may be on the cusp of an emergence of rising infection rates once again. For the first time in several years there is an increase in the number of new infections among gay men, which mirrors the experience of other large North American cities in the past year or two. Among blacks, Hispanics, Asians and heterosexuals, the numbers are also rising. Dr. Michael Reckart has said that he doubts that we even have an accurate picture of the spread of HIV amongst our aboriginal populations.

           Despite advancements in medicine, neither a cure nor a preventative vaccine is near at hand. The virus has demonstrated remarkable capacity to adapt to new drug treatments by mutating drug-resistant strains of itself. This summer, reports from the B.C. Centre for Excellence in HIV/AIDS of several cases of documented transmission of HIV strains that are resistant to all available drug treatments received worldwide news coverage. There is no certainty of how long the drug cocktails that are presently available will benefit people or if better treatments will arrive in time.

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[1535]

           In 1998 the B.C. Ministry of Health set out its goals and objectives for responding to the epidemic in its Framework for Action on HIV/AIDS which states, "In response to the seriousness of the HIV/AIDS epidemic, B.C. has developed one of the most sophisticated networks of community HIV/AIDS services and programs in Canada," and further: "The Ministry of Health recognizes that controlling the HIV/AIDS epidemic depends upon a strong partnership between people living with HIV/AIDS, their caregivers and advocates as well as committees, health authorities, other ministries, governments and agencies."

           Similar views have also been expressed by international agencies, most recently the UNAIDS report of June 2000, which said: "In retrospect, our thinking about how to tackle the epidemic was revolutionized by the community-based groups, non-governmental organizations and associations of people living with HIV that took up all or part of the challenge of care and support, and often the challenge of prevention too. Gradually it was understood not merely that these groups had become key partners in the fight against the epidemic but that their involvement would continue to be essential and needed to be strengthened."

           These acknowledgments derive from several facets of the community-based response to HIV/AIDS. We rely heavily on volunteers. For example, at BCPWA alone more than 23,000 volunteer hours were worked last year, which benefited the B.C. health system considerably. People living with the disease work more than half of those hours. Now, free labour is every employer's dream, but in the community-based HIV/AIDS movement, it is an enormous reality.

           Provincial funding contributions have a multiplier effect on the overall funding we're able to acquire for our work. At BCPWA we are able to leverage the dollars that we get from the provincial government in order to more than double those dollars through contributions from other sources, most of which are private.

           Our unique knowledge and experience, gained from working on the front lines, enables us to better understand the factors that make people vulnerable to infection. This helps to inform our prevention efforts. That knowledge is also crucial for planning and providing the most relevant, cost-effective and timely care and support for those who are afflicted. It is also important to understand the synergy between helping HIV-positive people to cope with their illness and preventing further spread of the virus. Supporting those of us who are infected empowers us to make healthy choices for ourselves and our communities.

           As well, the community-based response is not only the lowest-cost element in the entire spectrum of care, but it also aids individuals to slow the progression of their disease, enabling them to preserve their health longer. This decreases the financial burden on the costliest components of the health system, such as hospitalization and acute care.

           A recent review of the federal government's response reveals that the largely static investment through the Canadian Strategy on HIV/AIDS is neither adequate nor appropriate. Funding for the Canadian strategy has remained stable at $42.2 million per year since 1994. This amount has nowhere near kept pace with the growing number of Canadians becoming infected, the increasing number of people living with the disease, inflation or with Canada's growing population.

           Similarly, in British Columbia the $11 million allocated annually for the community-based response has remained stable since 1995. In the six years since then the number of HIV-positive people in the province has grown, and BCPWA's membership has doubled. It is crucial to the health of British Columbians as well as to our provincial economy that the government not only continue but strengthen its support for the community-based response to the epidemic. The cost of this disease in terms of human suffering is incalculable. The monetary cost of responding to the epidemic, although staggering, would be much greater if it were not for what we are able to achieve with the ongoing support of the B.C. government.

           A. Johnson: Good afternoon, and thank you very much for this opportunity to speak before you. My name is Andrew Johnson. I'm the executive director of AIDS Vancouver. Founded in 1983, AIDS Vancouver is Canada's oldest and second-largest AIDS service organization. Our mission is to alleviate individual and collective vulnerability to HIV and AIDS through care and support, education, advocacy and research.

           Since we first opened our doors, AIDS Vancouver has for most of the time enjoyed a very collaborative and productive relationship with the provincial Ministry of Health and in fact with all sectors of the provincial government. For almost two decades now we've worked together and with other groups and our partners to tackle the HIV epidemic head-on. Together, we have much to be proud of to date. Now, in a time of core services review and health reform — two processes that are critical to the vitality of the future of this province and its citizens — we want to strengthen that collaboration, and we want to do our part and work with you to find solutions for the challenges that are before us today.

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           Someone has already taken the wind out of my thunder with regard to determinants of health and population health, but I am delighted that message is coming forward, because that's the message that we want to bring forward to you today. Our experience in HIV and AIDS clearly demonstrates through research here in British Columbia and abroad that addressing the social determinants of health does have a positive impact on the HIV epidemic and on reducing health care costs.

           Research funded by the British Columbia government has demonstrated that targeting specific determinants of health decreases health care costs immediately and, more importantly, in the long term. It reduces morbidity, mortality, high-end hospital health care costs and the cost of long-term chronic care.

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           Recent research by the B.C. Centre for Excellence has demonstrated that those most marginalized in society are most at risk of providing increased health care costs to the system. In society those groups are the poor, aboriginals, injection drug users, gay men, youth and women — to mention just a few. Further research at UBC's Institute of Health Promotion Research has indicated and supported the same findings from across Canada in other jurisdictions as well. Recent studies at York University now show the same results in the context of heart and stroke as well. There is definitely a link across the board in health, not just in marginalized populations.

           Recent collaboration with our municipal, provincial and federal governments here in Vancouver around harm-reduction approaches further support this. It has demonstrated that by focusing on the social determinants of health and the underlying issues related to injection drug use, we can reduce overdoses. We can reduce the cost of expensive emergency stays in hospital, increase success with treatment, reduce crime, increase public safety and confidence, and increase the rate of entry into the workforce. Again the list goes on with opportunities for improving the health of communities and individuals and reducing cost to the health care system.

           Now, I've got a picture for you to try and demonstrate a case example of what we believe is an effective approach to population health and determination. I would like you to consider, if we begin at the top, HIV infection. Imagine that HIV infection is something that is acquired and that the risk of infection is compounded as a result of social determinants of health — reduced income, reduced social opportunities, housing, all of those factors you've heard about already. If those social determinants are not addressed, research has demonstrated that HIV infection increases. That leads to increased morbidity and increased injury. It also leads to increased mortality. Both of those together result in increased health care costs. In the context of HIV and hepatitis C, those costs are significant, and they are very high.

           The end result is that we have decreased health care resources which we can then use in prevention efforts and primary care, two critically important models that must be further addressed in health care reform. Decreased prevention and primary care efforts will lead to increased infection, and the cycle continues. If we don't intervene with appropriate care and support specific to the social determinants of health related to this particular illness and others, and if don't address prevention efforts in this same context, we will continue to have this cycle. Research supports this. I hope that this gives you an easy understanding of how all of those factors are linked together.

           There are a couple of things I would like to emphasize around the prevention component. To date, our efforts around prevention have been very, very individually focused. When you develop prevention programs that target the individual, you have a very short-term result in behaviour. But we have come to learn and the research has shown us that if we don't address the underlying social determinants of health — I keep going back to that — the poverty, the housing, the nutrition, all of those things eventually undo what we have done in prevention.

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           Our prevention efforts must be enhanced, and they must focus on those broader social issues. That's the next step we have to take in health care. We have to take prevention and primary care away from the individual. Well, we have to maintain that, but we have to move it to a societal community level. By taking care of individuals and communities as a whole, we will then improve the overall health of British Columbians. It's a very important concept that we've come to learn and understand and have had great success with in HIV and AIDS.

           Finally, I wish to leave you with one important point with regard to the experience of health care for HIV and AIDS in British Columbia at this moment. It is the issue of regionalization, and I think I would be remiss not to mention it very briefly.

           Regionalization has its merits in some areas, but in the context of HIV and AIDS it poses a serious threat to the overall health of British Columbia. HIV and AIDS remains a public health crisis in this province. Any epidemiologist, your medical officer of health, will tell you that we still have a raging epidemic. To compartmentalize the response, to regionalize the response, means you do not have a coordinated approach to addressing an epidemic, both in terms of preventing and containing infection and to responding to the overall health. I would protest that you can still deal with regionalization, but you must maintain a coordinated provincial response to HIV and AIDS. I would offer the Ontario model, where they did regionalize services but kept HIV as a coordinated response. That unit has demonstrated some of the most successful community-based academic and hospital care programs in the world. I think there is something that we can learn there. The quality of our care is just as good, if not better, but we need that kind of coordinated response.

           I wish you well in your deliberations. You have an incredible task before you. We remain at your disposal. Thank you for this opportunity.

           V. Roddick (Chair): Thank you. Thank you both for such a good presentation. I am sure there are questions from the panel.

           J. Bray: It's good to see that you've gone from the Finance Committee to this committee.

           A. Johnson: Yes, sir. Thanks for the invite. I'm here.

           J. Bray: I'm glad you're here. I have one question and one suggestion. I'll go to the suggestion first. We've heard a lot about the social determinants of health, and that's been a common theme in all parts of the province. My suggestion is that there is a Select Standing Committee on Education, and the best preventative health system we have in the province is in our public education system. So I'll urge you to make a

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presentation dovetailing into public education, much as you did at the Finance committee. That would be my suggestion.

           A. Johnson: Are you on that committee too?

           J. Bray: No, that one I'm not on.

           My question is more back to Glen. What do you think has created an upturn again in the infection rates? What is missing that maybe can be addressed in the short term that's occurring in British Columbia — Canada is probably similar, but in terms of British Columbia? Is that increase primarily in the urban centre, particularly in the downtown east side, or are you seeing a relative increase in the rural populations as well?

           G. Hillson: First of all, to comment on your suggestion, I appreciate that. I also sit on the minister's advisory committee for HIV/AIDS. At our last meeting we had a representative from the Ministry of Education. I think it's very problematic that the ministry cannot mandate curricula. They can only suggest curricula to local school boards. The consequence of that is that in many areas of the province, children are becoming adults without the information and tools they need to make informed choices about their health and their sexuality. That is leading to a constantly decreasing average age of new infections, which at last count in 1999 was 23 years of age.

           We have postulated many reasons for increases in infection rates among certain populations. What we have seen in large urban centres like New York, Chicago, L.A., Toronto, Montreal and Vancouver is increases in particular amongst gay men, which is very alarming because for several years now our prevention efforts have been successful amongst that population. That population accounts for at least two-thirds of North American infections. Condom fatigue and the fact that there is a new generation of sexually active young people who did not witness the real carnage of the disease back in the eighties are some of the things that have been put forward.

[1550]

           I think another reason is that we need to retool our prevention efforts. Largely, they have been targeted at uninfected populations. Well, every time somebody becomes infected with HIV, there's an HIV-positive person involved. I think one of the missing components of the prevention movement has been messages targeted directly at those of us who are infected around our responsibilities in curbing new infections.

           There are many others. I've only touched on a few. As far as the urban versus rural dynamic, in particular the downtown eastside — that's an easier part of your question to answer — they reached a saturation point back in about 1997 amongst the injection drug user population, as far as HIV was concerned.

           There has been a decline in the number of new infections in that population in the last two years. Mostly what we're seeing is gay men in large urban centres, who are located mostly in large urban centres. Also, although the overall numbers are small among people of colour, all those categories are showing increases — blacks, Hispanics and Asians. The numbers may be small now, but the increases, I think, are something that can't be ignored.

           A. Johnson: Can I have 15 seconds? I think one of the most important things is that the prevention message, from the stance of the provincial government, has just fallen right off the table. It has been several years since we have heard anything widespread from the province of British Columbia, officially, to the citizens that HIV remains a concern and that there is concentrated prevention effort going on. There's not even brochures or anything. We need the province to remind the province that this is an issue and a concern. Not a penny has gone into prevention for almost five years.

           R. Harris: Actually, what Jeff covered was the area I wanted to. Just to follow up a bit, you said that you may have to change your strategies in terms of where you market your campaigns on prevention. What program would you say has been your most successful, recognizing that it's a growing thing? Where are you seeing some success in terms of the delivery of some of your prevention programs? Is there any one, specifically?

           G. Hillson: Andrew could probably answer this question better than I. In my opinion, I think the greatest success over the course of the epidemic has been amongst gay male populations. That is the population which, as I mentioned, accounts for most of North American infections, and we were able to achieve many successive years of decline in the rate of infection in that population.

           I think that's where we've been most successful. I think what we've learned through the years is that it's not a one-size-fits-all dynamic here. We have different ethnic and cultural populations, and our prevention messages must be culturally sensitive. They must be targeted at people in such a way that when people hear the messages, they don't think we're talking to somebody else.

           A. Johnson: I would second what he said. I think our targeted approaches to gay men have clearly demonstrated that working with gay men in their communities and now branching out into a gay health concept — not just focusing on HIV gay men or not just about HIV; they have other health issues — working with them in a broader context, has opened a new door for us. We are now engaging in a new dialogue and a new prevention opportunity.

           The same can be said in terms of applying harm-reduction principles and working with the injection drug–using community, working with elders and community leaders in the aboriginal community. It's about focusing, spending…. There's no question: it's expensive. It's about taking care and time to work with those targeted communities as you have mentioned.

           Probably one of the most successful things — but it gets stopped by the curriculum — is the opportunity in

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the schools. One of our groups, YouthCo, does incredible work with youth in the schools, but because of the rules around curriculum and the school board's control over what happens, it is very, very difficult to reach youth in the school system. That's one of the most important places that we could look at the new generation.

           S. Brice (Deputy Chair): Andrew, you had said that you need to keep a provincial view on things. In a rural and urban British Columbia, what is the face of the AIDS support in urban B.C. for the community that needs it? For instance, down on the lower east side of Vancouver or in Vancouver generally, there are support groups and all sorts of thing. What about in rural B.C.?

[1555]

           A. Johnson: Well, I think that in many areas they are struggling to meet the demand, but they've done phenomenally well. We've just come out of our biannual PAN, the Pacific AIDS Network, meeting where all the groups in B.C. come together and share that information. One of the things we've learned, though, is that if we get compartmentalized, if we get regionalized, the opportunity to communicate through a central office and through these provincial networks really blocks us off from each other. So the collaboration between rural and urban centres has grown tremendously over the years. We have shared models; we have extended back and forth. We're learning from them as well.

           They do have support groups; they do have needle exchanges; they do have prevention programs. But I think, no matter where you are percentage-wise and in the context of the epidemic, there still just isn't enough. It's really hard to imagine if we're ever going to get a handle on quelling the epidemic and its capacity to move into all sectors of society. It's a great question. I think the face of AIDS in the rural areas remains deeply hidden.

           The health care systems of rural areas still are very nervous about HIV and AIDS. The attention to confidentiality by physicians, nurses or whatever — not pointing a finger here, but just lack of understanding and awareness — really makes it difficult for people to access and get care. That's why you see a migration into the urban centres where they can get care, the systems are in place, and we have a history of treating people confidentially and with respect. There's so much that can be done, but if we break it up, we're in big trouble.

           R. Hawes: Maybe I'm reading your HIV/AIDS statistics sheet wrong, but maybe you can just tell me. Using both British Columbia and Canada, it looks like, for HIV-positive tests, men outnumber women about seven to one. But last year, 2000, it was moving in to being close to equal. That would seem to say to me that there's a huge explosion of women, who weren't there before, testing positive for AIDS. What would be the cause of that, and is that accurate?

           A. Johnson: You just got an A-plus on your epidemiology exam.

           G. Hillson: I think it's important to recognize that throughout most of the world, first of all, HIV is sexually transmitted. The bulk of transmissions are through sex. Secondly, throughout most of the world, those transmissions are through heterosexual contact. So I think it's to some extent unexplained why the epidemic in the north has been as small as it has, relative to gay male populations. I think what that demonstrates is that those of us in the north may be moving in the direction of where the epidemic has gone in portions of the world that account for about 95 percent of infections.

           A. Johnson: As the epidemic moved into the injection drug scene and into the sex-work scene, where women are particularly vulnerable and are three times as likely to become infected in a sexual encounter with men than men are from women, the math is pretty easy to understand. That, on top of no broad-based prevention messages to the general public, means that people have virtually forgotten about HIV and AIDS, or some have developed a myth that the new drugs and cocktails are really…. Like, there's a cure out there, or we've found the answer. Indeed, we have not. In fact, those treatments are failing. So there is a really desperate need right now to get that message up and alive again in a new way to everybody.

           R. Hawes: Do you think there's still a belief with a lot of people that this is somehow more of a gay-type disease, so if you're heterosexual, you don't have to worry about it? Would that be accurate?

           G. Hillson: I think many women do not perceive that they're at risk and are not aware of the risks that they are subjected to. That has been a problem since the beginning. It's kind of what I was referring to when I talked about targeted prevention messages so that the people hearing them don't think it's somebody else that this is designed for.

           V. Roddick (Chair): I've just got a couple of questions. You said you had an all-group meeting. How many groups are there in the province? Do you have any idea?

           A. Johnson: They're not all groups, because our membership invites government programs and programs of other groups, so there were about 50 different programs, agencies. I'd say there are about 30 groups throughout the province of different sizes and then programs within other agencies, other health units or whatever. We had nurses, all kinds of people attending that meeting.

[1600]

           V. Roddick (Chair): Okay. The other thing you say is that it's going up dramatically, aside from the female aspect of it, in gay men. You've been talking

[ Page 651 ]

about lifestyle, drugs, etc. Is this where it's really mushrooming again, or is it in just the general gay population, regardless of what the income or lifestyle is?

           G. Hillson: I think there are many complicated, compounding factors which lead to vulnerability to infection. The use of recreational drugs is certainly one of those factors, as are the social determinants of health, of which many can be applied to gay men as a population to show their stigmatization and marginalization.

           I'd really like to tie into the point Andrew made earlier. I think that until gay men's health is viewed in a larger context rather than just the narrow vision of HIV/AIDS, we are going to be confronted with rising infection rates for HIV. Many of the health issues that gay men confront on a daily basis are not being addressed through the medical system and are not included in the curricula for the training of health professionals.

           A. Johnson: It's young gay men. It's the new generation of gay men who actually grew up with AIDS in their lives, who went through puberty and sexual exploration with AIDS as a reality. They've grown up with this sense of invincibility towards it all, and we need new messages. We need new prevention messages for this new generation of young gay men who've grown up believing that the cocktail is the answer. That's really sad. It's the next generation that we have to deal with.

           V. Roddick (Chair): The other thing is: what is the percentage between aboriginals and non-aboriginals in the rural areas that have AIDS? Do you have any idea?

           G. Hillson: You may find those numbers in a summary of some stats that are in your package. I don't know off the top of my head. I was joined in a media conference this summer for our AIDS walk launch by Dr. Mike Rekart, who heads up the B.C. Centre for Disease Control. One of the comments he made during that conference, which I noted in my presentation today, is that the state of testing among our aboriginal populations is such that he doubts that we actually have an accurate picture of the extent to which infection rates are rising and what percentage of people are infected and what the contributing factors and the vectors of transmission are amongst that population. It is so heavily stigmatized that it's difficult to get that information.

           A. Johnson: It's the on-off reserve issue, where one jurisdiction has authority over the other, and we have migration from on and off reserve. There's very little collaboration there, so the stats are not realistic. It's a problem. That's another challenge before us.

           V. Roddick (Chair): Thank you both very much. We really appreciate it. This is Dr. Mike Rekart?

           A. Johnson: Dr. Rekart, the director of STDs and communicable diseases, BCCDC — a fabulous guy.

           G. Hillson: I want to thank you all for your very thoughtful questions. I appreciate them indeed.

           V. Roddick (Chair): Not at all. What I'd just like to ask about this is: has he done a presentation? We wouldn't mind if you would ask him to do a written presentation. I don't think he's on the list.

           G. Hillson: I will certainly pass that along. He's in Thailand right now.

           S. Brice (Deputy Chair): I know that Dr. Perry Kendall has certainly got close contacts with him. Dr. Kendall may have material that we could table with our committee.

           V. Roddick (Chair): That would be great.

           G. Hillson: The Centre for Disease Control publishes an annual update on rates of infections, which is also cumulative. It's all there. A copy of that might suffice.

           V. Roddick (Chair): Great. Thank you very much.

           Our next presenter is George Heyman from the B.C. Government and Service Employees Union. Good afternoon, George.

[1605]

           G. Heyman: Good afternoon. First, let me thank you for the days you're spending on the road to hear from people across the province. I myself have travelled around the province to hear from people in different capacities. I know there are long days. I know it can be a tremendous strain sitting and trying to absorb and assimilate a tremendous amount of complex information. I hope I give you something to catch your attention and think about today.

           I hope your advice will help the Minister of Health Services and the Minister of Health Planning develop a health care system that reflects current social conditions and the best interests of all British Columbians. My union, the B.C. Government and Service Employees Union, represents 65,000 workers. Just under half of our membership, 32,000 workers, work directly in the provincial public service. Another 33,000 workers work in the broader public sector, which includes the community social services, community health and advanced education sectors, as well as in the private sector. Of those, 13,000 are health care workers.

           First, let me say a few words about the principles which we think any government should use in its approach to building and maintaining a health care system. One principle is to preserve public health through active measures of promotion, prevention and protection. That means making it a priority to address the determinants of health care — such things as housing, employment, income levels, education, the environment, as well as peace.

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           I would also urge your government to recognize health care as a public good in which the few should not profit at the expense of the many. From this perspective, we believe that we need a system of health care which is organized on the basis of public administration and public insurance, a system that delivers services on a public, not-for-profit basis.

           I'm concerned that although your government has publicly committed to improving health care services, it has already talked about freezing health care spending. A freeze on spending is a cut. The growth of the general population and particularly the growth of the senior population make it impossible to improve health care while freezing budgets.

           In recent weeks real cuts have already begun. The sick and elderly are now worried about proposals to cut Pharmacare. Are they doing without the drugs that they need to stay healthy and therefore out of acute care? St. Paul's Hospital in Vancouver is closing one bed in six. Eye exams are now going to be an added personal expense. Glucose-testing strips are now delisted. That means a large expense for thousands of people with diabetes. Long term care facilities have been told that patients at intermediate care level 2 will no longer be funded for care. Where will these patients go? If they could afford private care, wouldn't they be in a private facility already?

           Many recent policy decisions are also going to have a very negative effect on the determinants of health care. The poorest families in our province have been told not to expect welfare on a continuing basis. Social housing is being eliminated. The provincial child care program has been halted. I can add that the proposed public sector layoffs and the uncertainty about who will be laid off is causing stress and may ultimately cause health problems for thousands of workers.

           I recently received the quarterly Public Service Employee Relations Commission report on the employee and family assistance program. This program is open to all members of the direct government service who require assistance with work-related or other personal problems. I can tell you that utilization rates have jumped dramatically in the past three months. In fact, our contacts at the plan provider's office say that they have never seen two months like the past two. The utilization rates, which are generally around 5 percent, are now up to 8 or 9 percent. Utilization is 36 percent higher than it was during the same period last year. The biggest spike is among employees who have between two and five years of service — the most vulnerable to layoff. Their utilization rate is 9.5 percent.

           I add this evidence here to indicate that unemployment and the threat of unemployment, whether it's in the public sector or the private sector, are already causing increased stress and other related health problems in communities around B.C. Government policies, if they deliberately or inadvertently create more unemployment, will drive up costs in the short run and the long run. We cannot create a good health care system in isolation from other government decision-making.

           Health care costs impose a heavy burden on the provincial budget. There are ways to achieve cost savings that continue to be ignored and that have been ignored for many of the past years, despite study after study confirming that they are in fact extremely cost-effective. I'm talking in particular about home support programs. I want to spend some time today, during this presentation, discussing these programs where thousands of BCGEU members work.

[1610]

           In B.C. today, seniors and people with disabilities are already being denied home support services that could keep them healthy and independent. Yet the 1991 Seaton Royal Commission on Health Care and Costs report found ample evidence that community care is far less costly than crisis-oriented acute care. Home support should be a solid part of the health care system, yet it continues to be funded haphazardly at levels well below demand, and it seems to be the first service to be cut back at the regional level when the publicity around acute care needs takes precedence.

           These cheap services help maintain an elderly person's functioning and prevent his or her deterioration. Having a home support worker perform housecleaning chores as little as once a week provides stimulus and stability and acts as an early warning system for more serious health problems. The goal of home support is prevention, so cuts to basic home support means that people end up in facilities prematurely and in emergency wards unnecessarily. For many people home support is the difference between healthy and unhealthy conditions, safe or unsafe homes, health and independence or illness and institutionalization.

           Community health workers providing home support are an early warning system that can identify when a senior or a person with a disability is at risk and can deal with health risks before they become acute. A home support worker in Parksville reported that a woman receiving palliative care for a brain tumour was overdosing on her sedatives. She was taking about ten or 12 a day, when she was supposed to be taking two a day. Only intervention by the home support worker kept her safe, healthy and out of acute care.

           A Sechelt client who was blind was told that shopping was no longer covered by home support. Workers had done her shopping previously and put away her groceries so she knew what they were and where they were. There are no delivery services in Sechelt. She was told to use a taxi for pickup from the grocers. How will she know what the items are when they arrive? How will she know where to find them when she's looking for them?

           Loss of hours and loss of service are a constant in every region of the province. Let me give you a sense of how far current service levels are from filling the real and present need we have today. Between 1991 and 1999 the total number of individuals in B.C. receiving home support dropped by 19 percent. During this period the population of British Columbians 70 years and over grew by 25 percent. In Vancouver-Richmond home support hours were decreased by 5 percent, but the seniors population increased by 10 percent. In

[ Page 653 ]

South Fraser hours increased by 7 percent, but the population of 65 and over increased by 21 percent.

           Present amounts of home support fall far short of demand, and care is being rationed on the basis of budget room instead of on the basis of need. A recent study by respected UBC health researcher Marcus Hollander also showed that denying home support ends up costing the health system over the long term. Hollander looked at two similar populations in two different regions receiving home support: one where there had been deep cuts in home support services and the other where the level of home support services had been maintained.

           In the area where cuts were made, 17 percent of those who lost their home support services ended up in long term care institutions. When Hollander looked at the outcomes in the area where no home support cuts had occurred, he found that only 7 percent of clients were institutionalized over the same time frame, and — a more ominous finding — the death rate was 50 percent higher among those who lost their home support services.

           Quite apart from the difference that home support services made in these people's lives, quite apart from longevity, home support made a tremendous difference to the provincial budget. The home support services for each person cost the government about $2,500 a year. Basic institutional care costs about $42,000 a year per person.

[1615]

           Today in B.C. the minimum criterion to qualify for home support is needing help with a bath. This means if you have serious cognitive or mental health problems but can bathe yourself, you may still be disqualified. As a home support worker in Howe Sound points out, we did more essential service hours during our 1995-96 strike than we actually do now at full service.

           When home support is rationed, the strain on family members increases. It's reflected in worker absenteeism, lower productivity and a decline in their own health. The government and employers often underestimate what's involved in the care of adults. It's not like looking after children. Caring for an adult means negotiating with them, respecting their dignity and dealing with their far more volatile health needs. It's complex, and it requires skill and training.

           As one home support client puts it: "My daughter is 75. She's not doing very well herself. She takes me shopping when she can." This client is 100 years old. She also comments on the balancing act that she and many other seniors are forced to undertake. She does pay out of her own pocket now for somebody to come and clean house for her, but she had to cut out fruit from her diet because she couldn't afford it any longer.

           Many seniors simply don't have the private means to fall back on. In the absence of publicly funded home support, they simply do without. They end up choosing to eat or not to eat, whether to change dressings or not, whether to change incontinence pads or not.

           I want to point out to the committee that even in the past when the government earmarked money for health regions to be spent on home support, it was often redirected by regional health authorities to acute care or long-term care, despite the demand for more home support. I urge the government to make sure there is clear accountability for provincial moneys that are allocated by requiring dollars to be spent on the service for which they were intended by Health Planning.

           The BCGEU also continues to be concerned about the move to award home support contracts to agencies with the lowest-cost bids. What happens in practice is that large companies make artificially low bids to win local contracts. Then they increase their fees after the non-profit, community-based companies are driven out of business. This has already happened to home support in the capital health region. The result of contract changes was the movement of thousands of clients and workers. It was upsetting for everyone, including the clients. This happens when quality of home support is not part of the request-for-proposal process.

           International studies cited in Without Foundation, a study produced by us and the Hospital Employees Union that I think you've seen, show us what happens when for-profit companies deliver home support. Overall health care costs increase for the public. Private spending on health care rises. Patient outcomes are worse. Staff turnover increases. Patients and families are less satisfied. We are starting now to see some of those negative changes in British Columbia.

           Some regions in B.C. — Nanaimo, the Okanagan — have shortages of home support workers. The reasons are many: poor working conditions, hours of work, workload, lack of support, inability to make a decent living and no personal time for family or social needs. Scheduling is erratic, and the result for workers is an unreliable income. In our last round of bargaining, home support workers reported to us, their union, that they cannot get mortgages or car loans or borrow money for other household needs because their incomes are unpredictable.

           Home support workers are leaving. They are going to work in facilities where they enjoy a regular schedule, a supervisor on the floor. All of this costs in the quality and economics of care. These studies and our own experience show that we cannot afford the for-profit delivery of home support taking scarce dollars out of our public system. We can't afford contract churning. We can't afford the results of deliberately creating a system that tries to do more by paying less and depressing workers' wages.

           We have labour adjustment provisions in the collective agreement that try to mitigate against the disruption caused when contracts move from one agency to another. Workers, wage rates and working conditions follow the work. I'm very concerned at recent statements by the Minister of Labour and others that indicate the government wants to try and save money by eliminating these protections for workers in the case of contracts changing hands.

[1620]

           I think it's important to put this committee on notice, as I've put the Minister of Labour and other members of cabinet on notice. Unions will not stand by and

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watch these important provisions, these successorship provisions which we freely negotiated, simply wiped out by a stroke of a legislative pen. If people want to discuss these things, the appropriate place to do it is in collective bargaining.

           There are advantages to successorship for employers, the government and workers. Successorship provides stability. It provides continuity of service when contracts are tendered and re-tendered. It preserves a standard of living that keeps and attracts health care workers to this important and, I hope, growing field. You will not find better health care at the end of a downward spiral of health care wages and the removal of employment security that workers currently enjoy.

           User fees and delisting of services don't save us money. Both of these simply transfer the costs. They stop people from getting health care at the preventative stage. As a result, people only show up for acute care when their conditions have deteriorated to the point that they need emergency intervention. What appears to be a cost-sharing actually deters people from seeking early care. This costs the system more money overall.

           I would like to comment briefly on the proposed changes to Pharmacare. Pharmacare is an important universal program. We believe that people shouldn't have to pay for medically necessary treatment, whether it's surgery or drug treatment. The ideas being floated by the government about changes to Pharmacare aren't about cutting costs. They're merely about shifting costs. People will still need drugs. Cutting Pharmacare simply means transferring costs to individuals. Higher user fees mean that lower-income people go without necessary drugs, and this can result in the need for acute care at much higher costs. There is clear evidence that a public Pharmacare system is more equitable and more efficient. When public and private spending on drugs is combined, B.C. spends less than any other province in Canada. That should tell us that our Pharmacare system is working. Efficiencies are achieved through government bulk purchases. The best opportunity to control drug costs is through the reference drug program. Pharmacare now shops to get the best, most medically effective drug for the best cost-effective price. When scientific evidence shows us that several drugs work equally well, Pharmacare pays for the least costly one, the reference drug. This program keeps Pharmacare affordable, and it must be maintained. Your government should also look at the inappropriate prescribing of drugs. Changes in the behaviour of physicians will save the system, and the public, money, while dissolving the reference drug program will just increase our health care costs while enriching drug companies.

           In closing, let me quickly address the three questions posed by your committee. First: what is the sustainability of the health care system in its present form? The health care system is sustainable in its present form with the shifting of resources. There are some recommendations from the Closer to Home report, the Seaton Royal Commission on Health Care report, that the government should move to implement. Ensure that the Ministry of Health retains responsibility for provincewide goals, priorities, strategic plans, standards and guidelines, management information systems, health care personnel plans and regional allocations of budgets. Ensure that regional budgets are based on the needs of the population they're intended to serve. Pass legislation confirming the five founding principles of medicare.

           Your second question was: what are the immediate and medium-term solutions to better plan and manage public services, costs and funding pressures? I urge your government to regulate and monitor how private facilities spend the public dollars they now receive. You should take steps to contain the growth of for-profit health care by bolstering the public non-profit sector. Any expanding partnerships should be with the non-profit sector. Regional health boards must continue to represent and be accountable to their communities. They should continue to include labour representatives in recognition of the knowledge and commitment that health care workers bring to the system. If you are moving to downsize the number of regions, and I know this is under discussion, efficiencies must be weighed in the balance with local accessibility and representation.

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           Many of the initiatives needed to put our health care system on a sound footing can be found in the Seaton commission report. Let me call your attention to recommendations related to home support. Evaluate the levels of home support to ensure they're sufficient for independent living. Also ensure, in the case of people with disabilities, that levels of home support are flexible enough to accommodate the disabled person's education and employment. Increase home support programs in order to shift both resources and patients out of more expensive institutional settings. Redirect funds from acute care to home care. There must be clear accountability for funds provided by government for home support to the regions. Ensure that home support workers' salaries and benefits are adequate to attract and retain competent staff. I want to impress upon you that this is no less important with home care workers or other community health workers than it is with nurses or physicians.

           There are other more general recommendations which were made a decade ago by Justice Seaton that are still very sound and would lead us to a sound health care system. He recommended: support alternative health service delivery organizations that are non-profit and publicly funded; prioritize prevention programs, particularly alcohol and drug services for children and youth, aboriginal people and seniors; develop training and development programs in alcohol and drug abuse to make sure we have personnel available; provide mental health services as close as possible to the individual's home, avoiding hospitalization whenever possible and using the least restrictive and least intrusive interventions; shift funding priorities from hospital-based programs to community, residential and social support services; and develop alternative service settings for mental health treatment.

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           In addition, I urge you to open up and slow down the government's core review process. The very nature of government and the foundation of health care that provides for people is being rewritten. There's no doubt about that. Far-reaching decisions are going to be made. This is occurring behind closed doors. More extensive consultation is required than can be achieved through this set of committee hearings, notwithstanding your diligence and your hard work.

           Your committee's third question was: what are the measures to improve and renew health care in the long term to ensure sustainability, accessibility and timeliness? First, I would encourage your government to work with Ottawa to include comprehensive home support and Pharmacare under the Canada Health Act. Your government must address the determinants of health in order to decrease health spending in the long run. This includes providing adequate incomes, housing, nutrition and schooling. Social services and economic programs should be maintained at high levels, particularly during these times of economic downturn, to ensure optimum health.

           Again, the Seaton commission had some important guidance for us. In 1991 he recommended that child care programs based on the increasing social, psychological and physical functioning of children be implemented; increased welfare rates for families with children; pay equity legislation; broader participation in decision-making in health care organizations; and more support for women in the labour force, including child care.

           From our perspective, health care delivery must be based on a continuum of care, with community care being a major part of the delivery system. This includes home support, long term care facilities, mental health services and alcohol and drug counselling programs.

           Finally, let me close by saying that it's extremely important to recognize the role of all of the health care workers in the system. The compensation and working conditions of health care workers will determine whether B.C. can retain these workers. All fields of health care will be experiencing worker shortages in the coming years. Imposing contracts, legislating workers back to work as was done with paramedical professionals, driving wages down through contracting out and privatization, and the fracturing of bargaining structures will not help retain and recruit workers and will not save money in the long run.

           In the months to come I believe that your first priority and the first priority of your government must be people, not the bottom line. Don't make things worse for British Columbians by ignoring the changed conditions that we find ourselves in today. Don't make things worse for British Columbians by imposing artificial deadlines for eliminating the deficit, no matter what today's economic conditions in British Columbia and the world look like compared to what they looked like several months ago. Don't make things worse for British Columbians by cutting our health care when we most need dependable, accessible services.

           I thank you for your attention, and I wish you well in your deliberations. I'd be happy to answer any questions you have.

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           V. Roddick (Chair): Thank you very much. We appreciate your coming forward with your solutions, because that's what we're out here to glean from everybody. We've had terrific participation throughout the province.

           K. Johnston: Mr Heyman, thanks very much for your presentation. It certainly covered a lot of ground. It was well thought out. We're on the road and listening, and we are listening. We are faced with this $9.5 billion cost at this time in terms of health care. It's grown, as you probably know more than I, and it's projected to grow quite nicely, I assume, over the next five years if we don't make some adjustments in the way we deliver it. I guess that's why we're here.

           I was intrigued by your page 10. You talked about the health care system being sustainable in its present form, answering my first question, with the shifting of resources. Now, I was quite interested in that, because you did talk about acute care to home care. Is there anything else in that statement that you might want to expand on? It seems pretty relevant to this whole discussion that we're having.

           G. Heyman: Well, I hope our submission made it clear that we think an investment in home support and community health care — while maybe not having an immediate impact on the demands on the acute care system — will hopefully, in short order, decrease the demand on the acute care system as well as the costs of the acute care system.

           It was a great frustration of mine that I appeared before the previous government many times making exactly the same point. I thought I was getting a receptive ear but never really saw the changes. I think one of the reasons for that is there's a natural tendency…. Because the public and the media make the most out of crises in the acute care system and in the emergency wards, it just sucks everybody's attention in such a way that it's perhaps difficult, and it takes political courage to focus on the solutions.

           We also think that a range of community-oriented health care services focused on prevention, health promotion and encouraging people to have healthy lifestyles and to seek community intervention for certain kinds of developing health problems will all save money in the long run by keeping people, as much as possible, out of more costly acute and crisis intervention–modeled services.

           We worked with the B.C. Nurses Union and with the Hospital Employees Union on a couple of papers. One of them we cited in here: Without Foundation. Another was called Blended Care. We go into quite a bit of detail in those studies about some recommended solutions. We point to areas in both other parts of Canada and in the United States where a smoother continuum of care with a focus on community care has resulted in

[ Page 656 ]

better health outcomes for people and people being able to stay closer to their communities and their families, as well as lowered costs.

           I'm sure you can find those papers, because they were submitted to your caucus when they were produced a number of years ago. We brought them to the attention of the Health minister, and I think you'll find a number of good recommendations within those.

           K. Johnston: I appreciate what you're saying, but I guess I'm asking the question: are you suggesting a shift of costs and resources from acute to…? Because that's what this sort of says.

           G. Heyman: What we mean by this is that if we put the focus that Seaton recommended on community care now, the demand for spending at the other end of the system, in the acute system, will taper off. But it won't be immediate.

           I hesitate to use this analogy, and I want to assure you I'm not using it facetiously. But the analogy that the Finance minister used many times when he was in opposition was that if you cut taxes, eventually revenue to the province will increase. I'm sure he didn't mean it would happen the next day. Our experience shows that it doesn't. If the theory is true and the prescription works, eventually you'll catch up, and it's worth the investment. Otherwise, we'll just keep spiralling down the road we're on now with costs escalating out of control — delivering, in many ways, care at the back end when it's most desperate and in a way that nobody really wants to have to access — rather than spending less money over the long run and keeping people healthier and closer to home.

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           R. Harris: I just have one small question. On page 10, when you were talking about prescription drugs, you say that changing the behaviour of physicians will save money. Do you have any advice for us on how we may accomplish that or, in fact, what you mean by changing physicians' behaviour?

           G. Heyman: I hope my own doctor isn't listening.

           I think it's generally accepted in society that many doctors are trained to see prescriptions as the answer to almost everything. Many patients come to doctors for almost any malady, and frankly, what keeps people happy sometimes when they come in is writing them a prescription and shooting them out the door.

           I think the government needs to work cooperatively with both the public and the physicians to put the focus more on other solutions, ensuring that doctors aren't writing prescriptions when they're not really needed and educating the public to realize that it's not really in their best health or economic interests to have that happening. I don't think it will be an easy task, but I think it's a necessary one.

           V. Roddick (Chair): Thank you very much. I'd just like to say that this whole concept of the team sort of cluster group care, either home care or even with the doctors and nurses and LPNs, has been coming out all around the province. We appreciate what you've had to say.

           I'd like to make one comment on Pharmacare or the drugs. This isn't just provincial or national; it's international. We had five Washington State Senators come up here to look at our system, and they were faced with exactly the same problems. It's something that we all need to work together on to be able to solve. They say they're running into just spiralling costs, and they have the same problem with their federal government as we have our federal government sort of running the pharmaceutical show, so to speak. We need to get together and work on that, so thank you.

           G. Heyman: In terms of your comment about the cluster, the team approach, I think if you have another look at the paper that I mentioned, Blended Care, we talk about examples where that team approach extends right from the acute care facility into the community. It is a sort of seamless approach that provides follow-up care and enables people to be kept out of facilities as much as possible, but the care does continue once they're back in the community without a drop or a falloff in necessary information.

           V. Roddick (Chair): Great. Thank you so much.

           G. Heyman: You're welcome.

           V. Roddick (Chair): Our next presenter is the Registered Nurses Association of British Columbia: Bonnie Lantz and Laurel Brunke. Good afternoon.

           B. Lantz: Good afternoon. I'm Bonnie Lantz, and to my left is Laurel Brunke, the executive director of the Registered Nurses Association. Thank you for the opportunity for the Registered Nurses Association of B.C. to make this presentation.

           My goal is to provide you with the answers to the three questions you posed from the perspective of the Registered Nurses Association of British Columbia, the professional organization representing the 35,000 registered and licensed graduate nurses in this province. Our mandate is to serve and protect the public by ensuring safe and appropriate nursing practice for the people of B.C. This is achieved through regulation of nurses in the public interest by promoting good practice, by preventing poor practice and by intervening when practice is unacceptable.

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           The three messages I have for you address rising costs. They outline ways to increase efficiencies in the system. They provide ideas for protecting the delivery of the public health care services, improving overall health care outcomes and ensuring the long-term sustainability of the health care system. They are based on the principles of accountability, quality and prompt service delivery. These messages are (1) improve health care practice environments in order to retain nurses and recruit young people into the nursing profession, (2) ensure that the education of nurses will retain

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nurses within the profession and sustain the future generation of nurses vital to the system, and (3) reorient the health care system to focus on health. Promoting health and preventing disease will sustain the ability to afford to treat disease and injury.

           First I'd like to talk about practice environment. Health care practice environments must be addressed not only to recruit health care professionals but, more importantly, to retain the health care professionals we already have.

           Fifty percent of the nursing population is between the ages of 45 and 65. We could potentially lose 14,000 nurses to retirement in the next ten years. In Canada a total of 113,000 nurses could be lost to retirement. The average age of retirement for a nurse in B.C. is 58.

           Nurses have the highest illness and injury rate of all professionals. Each week in Canada 8½ percent of the nursing workforce is absent due to illness. In B.C. that's the equivalent of 2,400 nurses. Nurses in Canada lose three weeks of work to illness and injury, compared to six and a half days lost by other workers. The cost to the system of that absentee rate is huge. At even half the rate, the cost to the system would be $100,000 a week in salaries for nurses unable to work. That doesn't include the cost of replacements.

           The reasons for the high absenteeism are the heavy physical work done by nurses and the very stressful environment that nurses work in. The lack of infrastructure to support novice nurses entering the workforce places additional stress on experienced nurses. They not only carry a heavy patient assignment but also are responsible for non-nursing tasks such as delivering food trays, answering telephones and organizing staffing. To ask them, then, to assist a newly graduated nurse or student with his or her assignment is asking a lot.

           Couple this with environments that don't involve registered nurses in patient care decision-making or support them with ongoing education, and it's no wonder nurses retire early or choose to reduce their availability by working part-time or casual. This stress leads to nurses getting injured, becoming ill or leaving nursing altogether. In Canada three out of ten nurses depart the profession or the country within five years of graduation.

           There is a solution. Research demonstrates that environments characterized as magnet hospitals retain nurses, reduce turnover and decrease injury and illness. Magnet hospitals have high job satisfaction rates, yet they also decrease the mortality rate of patients by as much as 10 percent. Magnet hospitals have high ratios of registered nurse staff and almost no casual staff. Magnet hospitals encourage nurses to practise autonomously, providing highly visible and credible nurse leaders to support front-line staff.

           The provincial government must work with employers to create magnet hospital–type environments in the health care system. This means increasing the number of regular jobs for nurses. It means providing sufficient numbers of support staff so nurses can concentrate on caring for patients, and it means providing each unit with nurse leaders so that nurses, particularly novice nurses, are supported by the expert nurses in their practice setting.

           Improving working conditions for nurses is critical for the retention of our existing nursing workforce. It is our existing nurses who will encourage young people to enter the profession. Supporting novice nurses through the transition from student to practitioner will help retain our young nurses. The savings in decreased illness, injury and turnover will be huge if work environments are improved. If, by addressing these problems, the weekly absentee rate were reduced by 1,000 nurses, that would mean 1,000 more nurses available to care for patients. This is how to ensure that the health care needs of British Columbians are met.

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           The Registered Nurses Association of B.C. has a voluntary program called the agency consultation program that assists agencies to examine their practice environment and make changes consistent with the well-researched features of magnet hospitals. It provides the opportunity for employers and nurses to create workplaces that support excellent nursing practice and quality health care. Unfortunately, very few agencies take advantage of this program because it is voluntary.

           I'd now like to talk about the education of nurses. Beyond addressing the workplace, if we are to solve the problems with health care, we must also ensure that new graduate nurses entering the workplace are appropriately educated so they can practise safely, confidently and competently in the health care environment of today. The current diploma nursing education programs, which are three years in length, do not provide enough time to accommodate the breadth and depth of learning required by today's registered nurses.

           The competencies required for registered nursing practice are consistent with a four-year baccalaureate nursing education program. Across Canada baccalaureate education is becoming the standard. The schools of nursing in B.C. have planned for this change. This planning will ensure that B.C. has the same number of nursing graduates even though the program is longer. It is dangerous to think that we can provide more nurses more quickly by limiting nursing education to a three-year diploma program. Due to the current nurse shortage there are fewer experienced nurses to mentor novice nurses. This means that new graduates must obtain enough knowledge and practice experience in their educational preparation to face the current working conditions and be job-ready.

           Today's clinical practice environments, regardless of whether they are acute care hospitals, long term care, home care or the community, require nurses to provide sophisticated care that relies on complex knowledge and technology. It is essential that students be given sufficient time to learn not only what is needed to practise nursing today but also the time to apply that knowledge to the specific practice settings in which they will work.

           The last year of most degree programs enables senior students to choose an area of focus for their clinical practice experiences. This provides a sound foundation

[ Page 658 ]

for their future work and allows the development of expertise in a nursing specialty. Students can consolidate their clinical knowledge and develop the professional problem-solving and critical-thinking skills that enable them to make sound clinical judgments about the care that patients need. Innovative strategies must be developed to assist nursing students and new nursing graduates to be better able to practise in current health care environments. These include internship and cooperative education programs similar to those already in place for other practice professions such as medicine and physiotherapy.

           Far from being a solution to the nurse shortage, reducing nursing education may actually promote the loss of nurses. Education has been shown to be a significant nurse retention strategy. Last year a report by the Canadian Council on Social Development indicated that nurses with a diploma made up 34 percent of those nurses leaving the country, while their university-educated counterparts made up only 19 percent. Nurses with diplomas were also less likely to remain working in direct care and more likely to take nursing assistant–type positions.

           Implementing the baccalaureate program at the entry-level nursing program will mean the number of nurses leaving the profession within a few years of graduation will decrease, increasing our supply of nurses and saving education costs and investments. In times of such great shortage, assistance with tuition, perhaps linked to the provision of service, should be considered. This could be put in place through internship and cooperative education programs.

           The faculty in schools of nursing are also aging. A recent study by the Nursing Education Council of B.C. — appended in appendix A — showed that the average age of nursing faculty in the 15 colleges and universities is between 50 and 59 years of age. This is another reason for ensuring that nurses have access to baccalaureate education. Baccalaureate preparation enables nurses to progress to graduate education, which is needed to replenish the ranks of nurse educators and managers in the system today. Young people choose careers that will offer them advancement. A diploma program offers no career advancement. Hence, the trend is for nurses prepared with a diploma to seek a degree, and they leave the workplace to do this.

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           Finally, I'd like to talk about reorienting the health care system. If we are to provide accessible and effective health care, then we need to look beyond the recommendations I have made to address the current problems and look at the underlying foundation of the health care system.

           If we are to provide good health care for the people of B.C., we must reorient the health care system to focus on health rather than illness. Today the health care system is focused on the treatment of disease and illness. This drives the cost of health care services ever higher. There is always another disease and another new treatment. It is endless. The Ministry of Health has developed health goals for British Columbia that reflect the need to emphasize the promotion of health and the prevention of illness and injury. They provide an excellent framework for cost-effective initiatives that could be implemented at the local, regional and provincial level.

           Currently, there is little investment in the prevention and health promotion side of health care, even though prevention could provide potential savings that would allow us to sustain treatment costs. A case in point is the management of chronic illness, such as diabetes. We focus more resources on treating the complications of diabetes than on preventing these complications. Diabetes is responsible for 25 percent of all our cardiac surgery, 40 percent of end-stage renal disease and 50 percent of all non-traumatic amputations. Cardiovascular disease is two to four times more common in diabetic patients, and the incidence of stroke is two and a half times higher in this population.

           These complications are very expensive to treat. Cardiac surgery costs about $20,000 per procedure. In 1998 there were 21,000 patients in B.C. requiring dialysis. The cost of dialysis annually is $50,000 per patient. By 2005 it is predicted that 40,000 people will require dialysis. Today we are unable to meet the demand for hemodialysis within the province. What will we do in 2005?

           The health care system must focus on health. To quote Ken Fyke: "We must prevent the preventable, treat the treatable and abandon the pursuit of the unachievable." In other words, in the short term we need to focus on preventing the complications of chronic illness. For example, with diabetic patients this can be done by increasing access to diabetes education clinics and educating people with diabetes to manage their health.

           Early intervention is needed to improve outcomes with the goal of delaying disease progression. We need early screening and monitoring to control symptoms that progress to diseases like stroke, end-stage renal disease and heart attack.

           To reorient the health care system, we must address the issue of primary health care. According to the BCMA, today there are 100,000 British Columbians without a family physician. How do these people access care? It is the physician who is currently at the entry point to the health care system. Patients without family physicians must visit the emergency room or walk-in clinic. This results in episodic care. The patient is treated by different physicians in different situations, none of whom have a record of the patient's history. This can result in redundant treatment and lead to serious health problems being overlooked.

           In the medium to long term this problem can be addressed with community health centres. These centres provide access to health care through a multidisciplinary team of health care professionals. The team includes physicians, nurse practitioners, pharmacists, physiotherapists, dietitians. Care must be available 24 hours a day, seven days a week. Each health care professional needs to be utilized to their fullest capability.

           The Ministry of Health Planning hosted a conference this October to present the primary care demon-

[ Page 659 ]

stration projects occurring in the province. Feedback from the physicians and nurses in these projects demonstrate that this is an excellent way to provide health care in the future and one which will optimize the use of scarce health care professional resources.

           In his keynote address at that conference, Dr. Duncan Sinclair indicated that similar centres in Ontario have shown this approach to health care reassures the public that care is available 24 hours a day, seven days a week. It provides a continuum of care. Community health centres produce shifts in the provision of services that could have significant impacts on health costs. For example, there was a 20 percent decrease in specialist referrals, a 30 to 35 percent decrease in hospital beds and a 15 to 20 percent decrease in emergency visits.

[1655]

           The emphasis must be on having the right provider in the right place at the right time. To assume that patients must always see a physician first limits the ability to maximize scarce health human resources and restricts access to care.

           To implement community health centres, there must be political will. There is evidence that such centres are not only more cost-effective over the long term; they better utilize the scarce supply of health care providers and improve the quality of their work lives, retaining them in Canada and in their profession.

           Community health centres encourage health promotion and illness prevention. They enable nurse practitioners to treat clients who have common acute and chronic illnesses and to assist clients to learn to manage and monitor their own health. The physician is available to address those with a major illness.

           To implement community health centres, we must be able to measure, monitor and manage the health care system with information systems that are compatible with health care facilities throughout the province. The state of the information systems in B.C. is appalling. Federal moneys are available for information systems and should be invested to improve this basic business tool. Modern information systems will improve the continuity of patient care, prevent redundancies and reduce costs.

           Legislative changes and educational programs will be required to prepare nurses to become nurse practitioners — a valuable component of community health centres. Again, initial investments in education and information systems will enable the system to save money and improve health outcomes in the long term.

           In conclusion, the Registered Nurses Association of British Columbia recommends that the problem with work environments be addressed by creating workplaces with the characteristics of magnet hospitals. These will retain our existing nurses and help us recruit future nurses.

           Nursing education programs in British Columbia must be of sufficient length to adequately prepare nurses to meet the realities of clinical practice today. They must also ensure career advancement and the retention of nurses in the profession by providing basic baccalaureate education so nurses can move into advanced practice positions such as the nurse practitioner role. Also, nursing education programs must provide the beginning level of education for nursing faculty and nurse managers.

           Community health centres must be implemented with multidisciplinary teams of health care professionals to ensure the people of B.C. have access to primary health care when and where they need it.

           R. Hawes: Thank you very much for the presentation. I do have a question about your second point, education. I'd start by saying that we've heard several times in our travels around the province — and certainly I hear from nurses in my own region, the Fraser Valley health region, but I'm sure the others hear it all the time too — that the diploma program is a very valuable program. A return to that and perhaps to teaching hospitals is something a lot of nurses are saying we should do. There should then be laddering into the degree program for those who want to look for advancement. Where would you see the big problem there?

           B. Lantz: The problem we primarily see is the lack of clinical hours that the diploma programs have. The existing diploma programs are all three-year programs. There are significantly less clinical hours. The feedback we get from graduates of such programs is that they need more clinical time, which the degree program offers in the fourth year. As I said in my presentation, most of the degree programs do have their fourth year as clinical time where students can select clinical areas that they want more experience in, with the idea that they will work in that area on graduation. The key issue is that they need more clinical time to be able to apply the theory they learn in school, whether it's a diploma program or degree program.

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           R. Hawes: One of the things we're hearing, or at least I'm certainly hearing, is that a lot of these nurses are saying that if we go to the teaching hospital model, which I think was at one time in existence and certainly is in other provinces, they are getting clinical time from the first day that they go. They're living it from the first year.

           Further, I've heard several nurses now say there are graduates in the degree program who get very close, and they start going into their clinical time and then find out nursing is not for them. They carry on and get their degree, but they don't practise nursing, because they've never actually been in a hospital or clinical-type environment until they hit that last year.

           Certainly, what I'm hearing and I think others are hearing — I hope they are — from some of these nurses is that from a bedside perspective, the nurses that are providing care in hospitals from diploma programs are as effective as nurses from the degree program. But they don't have the training to go on to be nurse managers or whatever, to advance further, without laddering into the degree program.

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           B. Lantz: I'll speak as a hospital-trained graduate. I graduated from Vancouver General Hospital 36 years ago. Times are very different today in those programs. We also have to identify that the diploma nurses in practice now have probably come from those kinds of programs or have gained experience since their graduation. When you were speaking of diploma programs…. I'm speaking of them with respect to the people we're educating now for the future. They don't meet that requirement for the clinical experience within the diploma program.

           R. Hawes: But if we went back again, as I said, to the hospital training program where you combine the diploma program with in-hospital training, then they are getting that clinical time. Would that not be correct?

           B. Lantz: The other thing you'd have to take into consideration is that in those days, 80 percent of the jobs in nursing were in hospitals. Our practice environment has expanded. About 26 percent of jobs are now in long term care facilities. A hospital-based training program would provide nurses with experience to work in acute care. Similarly, 13 percent of jobs are in community care. There needs to be a broader base of experience than just the acute care hospital.

           R. Hawes: I don't dispute that at all. I'm just wondering. If nurses were able to take the diploma program in hospital, with the in-hospital training, at some early stage they could make the same kind of choices that they're making in the degree program in the fourth year as to whether they're going to specialize. Perhaps they could make the same choices and move to in-service training in long term care facilities or whatever area of specialty they decide, where they can get practical training as well as the technical training that they would get in the school setting through the diploma program.

           V. Roddick (Chair): Randy, maybe I could just interject here. I think what we've been wondering…. You say you took your nurse training in hospital. I remember, when I was at UBC, that the same thing went on with teachers. They had two years, and then they could…because there was a terrific shortage. This is what we're trying to address here. There's such a huge shortage. How do we facilitate this?

           I think they changed that at UBC. You did two years. You could then go into the junior school system teaching, and you went back every summer until you got your degree in education.

           What we're trying to look at here is whether there is any way of facilitating a diploma course or hospital training to get the student nurses up and running in the shortest space of time, and then ongoing linkages so that they end up with a proper degree — the baccalaureate that you're talking about. Is there any way you can think of that we could link those? I think that's what Randy's….

           R. Hawes: Getting closer.

           B. Lantz: We are all struggling with that. I just want to let you know that there's only an eight-month additional length of time for the baccalaureate program and the diploma program.

           Laurel wanted to make a comment as well.

           L. Brunke: To go back to one of your questions around the clinical experience for students in nursing education programs, many of our programs now are involved with what's called the University of Victoria collaborative program. Other diploma programs are working in conjunction with the other university programs.

[1705]

           In fact, the diploma students and the baccalaureate students are taking the same programs and receiving the same clinical experience for the diploma portion of the program. They're not getting clinical experience only in the fourth year or the latter stages of their program. What happens is that the diploma students are required to bridge out. In fact, we spend additional dollars on a course, to allow those individuals to bridge out, that we could be spending on continuing to support them to a degree completion, which is what the majority of students actually want.

           The issue of how we get nurses up and running more quickly is a very challenging issue. All of us want to ensure that there are enough registered nurses to meet the needs of our population. The challenge is: do you deliver a half-baked nurse who truly can't meet the needs of the population, or do you invest the additional time and resources to ensure that nurses can, in fact, meet those requirements?

           The competencies or the content that's required in the nursing education programs has been developed through a fairly rigorous process and agreed to across Canada. The diploma programs tell us that their students cannot achieve these competencies within their nursing education program. The programs are too short. The nurse educators looked at that issue, because they realized that what we need to do is not only sustain the number of graduates but, if we can, increase the number of graduates. So they're looking at innovative ways to deliver the baccalaureate education program.

           The University of British Columbia has an upper-level program, where the first part of the program can be done in another faculty or, in fact, we take graduates from another faculty, and they then complete their nursing education in the last part of the program. You're getting a baccalaureate graduate in two years.

           Some of the programs in other jurisdictions in Canada have compressed the program to a three-year period. It's a three-year continuous study. You're getting the graduate, with all of the knowledge and skill that he or she requires, in that same time period, but you've approached it in a way that is different. What the nurse educators tell us is that that's the way we need to approach this problem. It's not to try to turn nurses out faster with not enough knowledge and skill, but to look at how we deliver education in a more creative way.

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           The other comment I would make is that I, too, hear the comments about: "I was a diploma graduate; it worked for me." Those nurses have been in the system for many, many years and have acquired a great deal of knowledge and skill. Our system has changed. There are no longer the nurse managers to support the new graduate. There are no longer clinical instructors on the units or in the public health unit to support the new graduate. Those supports aren't there. Those graduates need to be able to have improved knowledge and skill in order to function in the environment that we face today.

           R. Hawes: Madam Chair, could I just add one comment to that?

           One of the nurses that did speak to us on Vancouver Island is actually a graduate from, I think she said, 1996 in the Maritimes. She went through a residential in-hospital training programs, which I think was continuous for the full two years. It was not a three-year program but a two-year program. It was residential, and so I'm assuming that the exposure and the hours were much longer.

           I'm just wondering…. Maybe that's a little different approach. It's thinking much differently than where you are today, but I don't know that 1996 is a long time ago. I would hate to think — if she's not competent — that we're hiring nurses that aren't competent and putting them in a medical…. I believe that she probably is competent. She certainly was very sincere in what she said to us and felt very strongly that nurses from that program are highly competent and are, at bedside, as competent as degree nurses.

[1710]

           L. Brunke: If I could just comment on that. The reference to the hospital-based programs has come up a few times. One of the really significant differences between the hospital-based education programs and both the diploma and the baccalaureate programs is, in fact, that students in the hospital-based programs were used for service and that the education was, in many ways, not education as we know it now. It was learning on the job rather than having supports and instructors to teach you. Nurses in hospital training programs many years ago were used to staff the hospital rather than it being an educational experience.

           I would assume that the nurse from the Maritimes is competent, or she shouldn't be registered, but she's now had six years of experience. I imagine that the world she faced in 1995 was much different. Interestingly enough, all of the maritime provinces now require baccalaureate as the entry education for registered nurses, as do two of the western provinces and Ontario.

           B. Lantz: I wonder if I could add to your question about the diploma program and trying to get people educated more quickly. One of the things we've done in partnership with….

           V. Roddick (Chair): I'm sorry. I'm not getting my point across, I guess. What I'm saying is that we're trying to get them into the system more quickly to assist the nurses that are already there and keep going at that level so that they do attain the education you're talking about. I'm not trying to suggest that they don't have the education in the end. It's just that we are faced with a huge problem right now, and we're looking for really good solutions. We need your help to try and figure out how the heck we do it.

           I was just using that example of the teachers. It was about 1960 — that's dating me — when they used that system. I was just wondering if there was a chance that we could utilize that now in the nursing program — sort of use them in the hospital and at UBC. Is there any way of doing that, or is that hopelessly unattainable?

           B. Lantz: I just wanted to make the comment that we try to do that. One of the programs that we did in collaboration with the collaborative nursing program was create a specialty program in operating room nursing. When the employers had to start doing these programs just to staff the specialty areas, the college programs essentially said: "Well, we would really like those to be accredited programs so that people who do the diploma could do those programs and still put it towards their degree." But what we're finding — and I'll speak as an employer — is that when we get the diploma graduates, they come in, are oriented and find the workload so overwhelming that they say they want to take courses or go back to school and get their degree because they can't cope with the work environment. I see this every month.

           V. Roddick (Chair): I really appreciate you being forthright on that. That's what we're trying to ascertain here.

           W. Cobb: Two questions. When we're talking about diploma versus registered, what are the numbers in the province? Roughly how many diploma and how many registered nurses do we have?

           B. Lantz: Okay. Diploma nurses are degree nurses; they're all registered nurses. Is that what you want the breakdown on?

           W. Cobb: These two different levels of education: how many are in the diploma — came from the diploma, or whatever — compared to the other?

           L. Brunke: There's a difference between nurses who have returned to complete their baccalaureate and those who graduated initially. I'm sorry that I don't have those numbers with me, but we can make them available to the committee. Certainly, the number of baccalaureate graduates is increasing, and it's well over 50 percent now in this province on an annual basis.

           W. Cobb: So normally there were more of the diploma-type entries.

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           L. Brunke: Yes, because initially there were only the diploma education programs, and what we see is more nurses either wanting to do the degree as their entry program or, as Bonnie indicated, recognizing that what they have is not sufficient and leaving the workplace — which is an issue for us when we're trying to keep nurses working — to pursue their degree.

           B. Lantz: These nurses prepared at this level are not helping the experienced nurses. That's what I was trying to say. They're a burden on them, and they burn them out. That's why I think we have to really look at what we're expecting our senior nurses to be able to support in the practice environment.

[1715]

           W. Cobb: Do we have a national registry across Canada, or is it separate from province to province — the nursing degree, the quality, the level of expertise?

           L. Brunke: The competencies, which really describe the knowledge and skill that registered nurses must have, have now been agreed on at a national level. The Canadian registered nurse examination, which is the examination that any student in Canada would sit, is based on those competencies that have been agreed on nationally.

           W. Cobb: It's different from doctors, because they're different in every province.

           L. Brunke: I can't comment on how physicians manage that.

           R. Harris: If a nurse graduates in Alberta and applies for a job in B.C., can she just come in and go straight to work, or does she still have to be registered by the RNABC?

           L. Brunke: Yes, she still needs to be registered. We need to ensure that she's a member in good standing in Alberta and that she has good employer references and no criminal convictions.

           R. Harris: Why haven't we gone to a national model of registering nurses so that there's full portability within the country?

           L. Brunke: That's a good question, and it's one that we ask. What we, the nursing regulatory bodies, have done in Canada is to sign what we call an endorsement document so that we can comply with the requirements under the agreement on internal trade. If all of her documentation is in order, we can have a nurse coming from another province and who has been registered in another province working within ten days. What we do with a nurse who has been registered in another Canadian province is fairly minimal. For example, if you were the person lying in bed, you would want us to check with the Alberta association to make sure that this is not a nurse who has a complaint against her at the present time. The B.C. government requires that we do a criminal record check. No other province in Canada requires that at this time.

           R. Harris: That would be like a standard employer check on an employee anyway. I'm thinking in terms of how we can save time and create portability. We asked the doctors the same thing, and the answer was: "We should be doing it, but we don't."

           L. Brunke: It is under discussion. I was just recently in Ottawa, and we talked about how we can move towards that.

           Can I go back to your question about how we get people working more quickly? One of the things that the association did this year was amend some of the rules under the Registered Nurses Act to allow students at certain points in their program to work in agencies as nurses, provided they can meet the requirements of the job description, which the employer reviews with the school of nursing. Currently, those students are required to be extra. There is a way, we think, in which we can provide for students to be beginning to practise parts of the profession and supporting some of the work issues. Those are some of the ways we're trying to problem-solve this one without having to take nursing education back to a place where it's not sufficient.

           V. Roddick (Chair): Thank you very much. That's really been helpful. I'm sorry; we didn't mean to grill you. We know you've got the expertise up here, so we wanted to get it out of you. Thank you so much. We are recessed till 6 o'clock.

           The committee recessed from 5:18 p.m. to 6:02 p.m.

           [S. Brice in the chair.]

           S. Brice (Deputy Chair): We'll reconvene the committee hearings. I invite all of those who are going to be making presentations to take their seats, and we'll begin. We have a full slate of presenters for tonight. You've each, I know, been advised of the time limit. We want to make sure, in fairness to everyone, that all who are scheduled to speak have an opportunity, so we'll be holding you pretty closely to that time.

           I'd like to call first Ann Moniz from the Nurse Educators Council of B.C.

           Interjection.

           S. Brice (Deputy Chair): She's not here yet. We can wait, then, for her when she comes.

           How about Dr. Jean Moore? Would you care to come forward, Dr. Moore, for the Canadian Mental Health Association? Good evening.

           J. Moore: Good evening. I want to begin by thanking you for this opportunity to speak to you. Before I go into the main part of it, though, I wanted to give a bit of background. The Canadian Mental Health Association has 22 branches and two steering committees

[ Page 663 ]

here in B.C., across the province. Our mission is to promote the mental health of people in British Columbia. We do this through an emphasis on public education and research. We have adopted the framework for support, which is a model that's used to formulate policy in the care and support of those with a mental illness. We do that through advocating and working for access to adequate housing, income, education and employment. We always want both consumers and families involved in treatment.

[1805]

           I've been a volunteer for more years than I would care to admit probably — it's 30 plus — both here and in Alberta. I've worked at the branch level, at the division or provincial level and at the national level.

           We want to acknowledge the support of the government through its commitment to fund the mental health plan. I'm sure I don't need to remind you, but it is on page 23 of the New Era document. We hold that very close to us. We also want to acknowledge the leadership and support of the Minister of State for Mental Health, the Hon. Gulzar Cheema. Of course, this is a first here and across Canada. We would also acknowledge the people with mental illness and their families for advocating for a new mental health system.

           I want to summarize our document, and I will try to do that quite briefly. I'm sure everyone will agree that mental health services have been underresourced for years, and I would emphasize that. That becomes very evident in the conditions in which people with a mental illness live and survive. There are too many of them who are still homeless, who live under a bridge, who are subject to HIV/AIDS infections and who are served by the police as a default mental health system. I suppose you can say there's zero rejection and their basic need for food and shelter is met, but that's a sorry statement.

           We are asking you not to abandon people with a mental illness or their families and to fund the mental health plan as promised. I would emphasize one more point here. The money should be new dollars for the mental health plan and not taken from other services.

           Our second policy point is to protect mental health funding. The research is clear that in many jurisdictions where there's been a significant strain on the health care system, it often seems that either the first reduction, or one close to the first, ends up being the provision of mental health services. I would say that those are among the people who are the most vulnerable. Please protect the mental health dollars that are being spent now.

           The third point that I would make is to invest in building a community system. If the community system is not in place, it does result in unnecessary costs to the health system. For example, currently — I think this is part of an example — the cost of a bed in Riverview Hospital is $390 daily. The cost of an acute care bed in a psychiatric ward is much more than that. It would be far more economical to have the services in the community first. They have to be accessible as well as appropriate, and I know that appropriate can cover a very broad definition.

           Without this investment in community care — and we all talk about community care — an individual frequently will have as many as three to six hospitalizations and police involvement more often than we would like in getting care. They'll live in substandard housing, and their community living experience will be defined by the professional relationships that they have.

[1810]

           What does work for people with a mental illness is supportive housing and service from a community mental health team. In an ideal world — and it would be ideal — the caseload would be one to ten, not one to 60 as it is in some places now. Support, also, from a peer support worker who can work with the person with the mental illness and help them to rebuild their personal network of friends and support….

           The investment in mental health has to be beyond one ministry, because it involves health, housing, employment, human resources, and I suspect we could add a couple of others as well. It's an investment in assisting the individual to rebuild and develop quality of life again.

           Lastly, I have to mention systemic advocacy and to say that we were disappointed with the decision to close the office of the provincial mental health advocate. Today in B.C. only one in three people who need care accesses it from the formal system. If you think about that, that's an awful lot who don't access it. We see this as justification in itself for the need for such an office to report independently to the government. Thank you.

           S. Brice (Deputy Chair): Are there any questions of Dr. Moore? No questions. Thank you very much for coming in and presenting to the committee, and thank you for your many years of volunteer work. Terrific.

           Have we seen the Nurse Educators Council of B.C. come yet this evening? No, we have not. We'll move, then, and see if Iris Reamsbottom is here. She hasn't checked in? We are a little bit ahead of schedule. Has Ann Moniz not checked in? Is Joanne Foote here? No. Do we have anyone in the audience who is scheduled this evening? No.

           Then we'll take a five-minute recess and reconvene when we have something to deliberate on.

           The committee recessed from 6:12 p.m. to 6:24 p.m.

           [S. Brice in the chair.]

           S. Brice (Deputy Chair): If you'd like to come forward, Iris. We've taken a brief recess, and I know we're a few minutes before your official time to present. But if you're ready, we are.

           I. Reamsbottom: Yes. I don't mind doing that. I just wanted to make sure you had a bit of a break. I notice your schedule is really quite full, so you don't have much of a break.

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[1825]

           Good evening. My name is Iris Reamsbottom. I'm a resident of Maple Ridge, and I do work in the health care field at the Ridge Meadows Hospital. I'm in the X-ray department as clerical staff.

           The Canada Health Act's five principles state that the provinces must provide health care that is accessible, universally available, comprehensive in coverage, portable across the country and publicly administered. Despite the huge budgetary surpluses that the federal government has registered over the past few years, Ottawa has not restored the funding cuts that were made to health care in 1995. The federal government has committed, at least in principle, to build in health care and social transfer escalators for Canada's economy, population growth and an aging population.

           Our health care is in a fragile state due to pressures from for-profit interests entering the health care field, provincial plans for large-scale privatization and the fact that the Canadian federal government has put health care on the international table. The international agreements of the North American Free Trade Agreement, the General Agreement on Trade in Services and the free trade area of the Americas are currently in place and under negotiation and could have massive and irreversible effects on our health care system. These agreements have specific language that will reduce the role of government and extend that of private commercial activity in all sectors, including health care.

           Once trade in services is negotiated at the World Trade Organization, it could mean the death of our health care system. If only one province allows private hospitals, then the WTO could demand the same thing for all provinces. "Why could they?" you ask. Prohibiting private hospitals would then be seen as unfair restrictions on corporations.

           I would like to draw your attention to a couple of WTO rulings that Canada has lost. In the dairy industry Canada has a marketing board which manages production and prices for milk and dairy products. The U.S.A. complained that these marketing boards restricted imports to Canada and promoted Canadian exports. The WTO decided that Canada must cut back the power of the dairy marketing boards. In the auto industry, the Auto Pact was crucial in making Canada's auto industry the most successful in the world. It encouraged automakers to set up shop in Canada in return for free access to Canadian consumers. The complaint was that there should be no obligations for car companies wanting free access to Canada's market. The WTO decided that Canada must get rid of the Auto Pact.

           High-quality public health care services that meet all patients' needs where they live and when they need it is a message from the New Era for British Columbia document. To me, that means the recognition of all health care workers for their skill and experience and for their valued contribution to society and patient care, whether that worker is a care aide, unit clerk, laboratory technician, registered nurse, laundry worker, mechanic or janitor. Health care workers are subjected to a work environment where there are high levels of infection, violence, workload and stress. They deserve to receive appropriate remuneration.

           To provide high-quality public health care also means supporting the existence of single bargaining units that cross the facilities and communities line for (1) the registered nurses, (2) the paramedical professionals and (3) the services and support workers. A single agreement for each bargaining unit covering the entire continuum of care strengthens the ability of health authorities to coordinate care delivery and to shift resources between different care settings. Patients can move between hospital, long-term care and home care without disruption of their health care.

           Taxpayers expect and deserve decent standards of care in government-funded hospitals, long term care facilities and home care. Working conditions with the highest regard for health and safety of the workers as well as patients must be observed at all times. Time and money invested in education and training staff to operate ergonomically designed safety equipment will pay big dividends in the end. There will be fewer injuries to both the worker and the patient, while creating a happier working and living environment.

[1830]

           As B.C.'s population ages, the demands of our health care system increase. There is pressure to replace in-hospital care with both out-patient treatments and recovery at home with care. The shift from hospital to home puts greater demand on the Pharmacare program, as patients must then pay for the drugs. They turn to Pharmacare to meet these costs. The largest group receiving benefits under Pharmacare is the elderly, who often require multiple prescriptions. I say: do not decrease the B.C. Pharmacare program funds. We owe it to our seniors to provide them with a healthy, normal life.

           Of course, I take issue with the pharmaceutical companies, who are driving up the costs of prescription drugs. A ruling from the WTO stated that Canada must lengthen patent protection for brand-name drug makers. The Mulroney Conservative government's extension of the patent protection on new drugs for 20 years has driven up the cost of all drugs and put a greater burden on provincial public Pharmacare budgets. These same drug companies are also aggressively marketing drugs to both patients and doctors.

           It is true that B.C.'s public drug plan covers a larger share of drug costs than other provinces. But what is also true and has to be mentioned at the same time is that the overall per-capita drug expenditures are lower in B.C. than in any other province. How are we able to achieve these savings? By B.C. approving low-cost generic drugs more quickly than other provinces and controlling costs through reference-based pricing which requires doctors to prescribe the lowest-cost alternative drugs.

           I would like to share some suggestions: (1) that the B.C. government work with the federal government to restore funding to Canada's health and social transfer payments; (2) that the B.C. government's budget process for health care services must build in escalators for population growth and aging; (3) that administrative

[ Page 665 ]

efficiencies can continue to be established through the support of the single facilities community bargaining units for each of the following health care unions: the service and support workers, the registered nurses and the paramedical professionals; (4) that the B.C. government continue to fund and support the Occupational Health and Safety Agency for Healthcare for the ongoing education of staff, the purchase of required safety equipment and the monitoring of worksite equipment; (5) control the cost of the Pharmacare budget through bulk purchasing of drugs and reduce the overprescription of drugs by doctors to patients; (6) support and encourage healthy lifestyles; (7) that the B.C. government lobby the federal government to oppose the WTO negotiating health care into the trade in services agreement.

           Public health care is a fundamental right. Medicare cuts hurt everyone. For me, my health is the most precious possession. Thank you for your time and attention.

           S. Brice (Deputy Chair): Thank you for your presentation. Are there questions? Thank you very much. We appreciate you coming.

           Joanne Foote. You start whenever you're comfortable.

           J. Foote: Good evening. My name is Joanne Foote. I'm an Ojibwa of the first nations. My band is known as the Chippewas of Mnjikaning nation in Orillia, Ontario. I've been out here in B.C. now for 20-some-odd years. I'm also a wife, a mother and a health care worker.

           You'll see that I've given you long-term and short-term goals. If you don't mind, I'll just go through them: utilize skills of workers to their full scope; support current staff by upgrading their skills; get rid of all private contractors — costs are much greater than in-house. "Get rid" really doesn't sound like a good word, but at the time it did.

           S. Brice (Deputy Chair): We get the point.

[1835]

           J. Foote: Get rid of private clinics and labs and reinvest the money back into the public purse; cut out middle management; recruit workers in specific occupations and provide them with appropriate training.

           Regionalize the services. An example is lower cuts than private contractors. Vancouver General electricians could do the work at Arbutus Manor, for example, which does not have electricians, as it's a small facility. Private contractors' costs would be much greater than in-house or regional electricians.

           The last one is to have necessary equipment available to workers to provide service efficiencies.

           My long-term were: no tax shelters for private corporations, and funnel the money back into the public purse; open up seats in colleges and universities for students graduating and planning on entering the medical field; direct public money to the community to ensure a continuum of service to the clients, thereby freeing up beds in acute care hospitals.

           Put doctors on salaries. The example I want to give you here is just recent. Last week I had to go see my doctor, and I told him I wanted to go see a podiatrist. He said to me: "I'll make your appointment." I said to him: "Can you not just go in to a podiatrist anymore?" He said: "Don't worry. I'll make the appointment."

           His office called me back and said: "Okay, we have an appointment for you at the podiatrist next week." I called the podiatrist myself that afternoon and got in that afternoon instead of waiting a week. I thought that obviously there must be some little thing, that a doctor might get a referral, whereas people should be doing this on their own.

           Utilize your skilled people — an example is care aides — to free some of the RNs in jobs that they're in and the shortage of RNs. We can use people as care aides in the acute facilities. They can be doing an awful lot of the work, and that would free the nurses. Care aides are very skilled doing the ADLs in the daily living of residents in a long term care facility. They can do the very same — the washing and cleaning and feeding and assisting — in acute care, and this would release a lot of the RN duties and duties that are not RN duties.

           I'd like to see us support our country's credentials. Doctors, nurses, other professionals such as physiotherapists and rehabs have tickets, but the province of B.C. does not allow them to work at those jobs until they rewrite. This is something that we have to look at very seriously as well.

           I don't feel that anyone should be making a profit on health care. As Tommy Douglas said, and as you can see, civilized life is part of medicare. I have also worked in acute care, and I have been in health care for about 25 years. I work at a private, for-profit, government-funded facility in Maple Ridge.

           I don't have a problem with people making money. Everybody understands that shareholders are the reason we have profit, but I don't even know if shareholders would be happy to see, for example, that I am the only full-time recreation aide in a 125-bed facility.

           There's no possible way I can give my undivided attention and proper care to residents living there when there's only one full-time person. I don't know if you're familiar with the recreation activities that we do with our seniors. My time is very precious in my job. I don't have a lot of time for a senior who's crying or having a bad day or sad or lonely, because we don't have that time.

           In private for-profit, we never have enough supplies to work with. Every day our care aides come on the floor — and these seniors are the ones that fought for our country, gave us our medicare — and they don't have