Health — Issue No. 29 — Friday, July 8, 2016 (HTML)

320 Strategy Room, Morris J. Wosk Centre for Dialogue
580 West Hastings Street, Vancouver, B.C.

Present: Linda Larson, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Donna Barnett, MLA; Dr. Doug Bing, MLA; Marc Dalton, MLA; Sue Hammell, MLA; Dr. Darryl Plecas, MLA; Selina Robinson, MLA; Dr. Jane Jae Kyung Shin, MLA; Sam Sullivan, MLA

3. The following witnesses appeared before the Committee and answered questions:

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


CONTENTS
Page
Presentations	533
S. Mathias
P. Liversidge
M. McGregor
S. Troesch
D. Fontaine
A. Ruddiman
J. Coward
K. Shojania
D. Cochrane
C. Krause
G. Trépanier

L. Larson (Chair): Good morning, everyone. My name is Linda Larson. I’m the MLA for Boundary-Similkameen and the Chair of the Select Standing Committee on Health, an all-party parliamentary committee of the Legislative Assembly of British Columbia.

As part of its mandate to identify potential strategies to maintain a sustainable health care system for British Columbians, the committee undertook a public consultation in 2014-2015. This summer we launched an additional call for submissions, and we are looking for new or updated information.

As part of its consultation, the committee has held public hearings in Victoria, Prince George, Kamloops and Vancouver. British Columbians are also invited to participate by sending a written, audio or video submission. The deadline for submissions is Friday, July 29, 2016. All the input we receive will be carefully considered by the committee as it prepares its final report to the Legislative Assembly.

Today’s meeting format consists of 15-minute presentations followed by 15 minutes of questions from the committee. Please note that our meeting is being recorded and transcribed by Hansard Services, and a complete transcript of the proceeding will be posted to the committee’s website. All of the meetings are also broadcast as live audio via our website.

I’ll now ask the members of the committee to introduce themselves, starting with our Deputy Chair.

J. Darcy (Deputy Chair): Hi. I’m Judy Darcy, Deputy Chair of the committee, MLA for New Westminster and NDP spokesperson on Health.

S. Hammell: Hello. I’m Sue Hammell, MLA for Surrey–Green Timbers and critic for mental health and addictions.

S. Robinson: I’m Selina Robinson, MLA, Coquitlam-Maillardville and the opposition spokesperson for local government, sport and seniors.

D. Barnett: Donna Barnett, MLA for Cariboo-Chilcotin and Parliamentary Secretary for Rural Development.

L. Larson (Chair): Assisting the committee today are Susan and Stephanie from the Parliamentary Committees Office. Ian and Alexandrea from Hansard Services are here recording the proceedings.

With that, I’ll turn the floor over to our first presenter. Welcome, Dr. Mathias. If you would introduce yourself and who you have with you, and then leap in.

S. Mathias: Absolutely. Thank you very much. I’m Dr. Steve Mathias. I’m a child and adolescent psychiatrist as well as a psychiatrist trained in addiction medicine. I’m here as the executive director of the B.C. Integrated Youth Services Initiative, a new initiative here in our province. I’m accompanied by Pamela Liversidge, who’s our director of policy and partnerships.

S. Mathias: Okay. She’s actually a director from the organization. Thank you very much.

We’re here today to talk about young people in our province. I understand that we’re looking at ways of investing our hard-earned health dollars in this province. I want to bring this population up for your attention but also mention a project or an initiative that has had considerable investment already in our province. I hope that we can continue to invest in this initiative.

The reason why we’re concerned about our young people…. Half of all lifetime cases of mental health disorders begin by the age of 14, and 75 percent begin by the age of 24. Severe mental illnesses typically will present late in teenage years. From our own government data, 130,000 young people in any given year will actually attempt to get help. That does not include, likely, another 130,000 young people who didn’t try to get help or who don’t know where to get help. That’s something that has played out in research over the years.

There has been an increase in our emergency rooms, so there’s a cost associated with this population: an 85 percent increase in ER visits over the last five years for youth aged 15 to 19. We have to also highlight that nearly three times more young people will die of suicide than from cancer in any given year.

Youth mental health and substance use presentations are also the second most expensive population in acute care settings, which is something that might surprise people. The lifetime economic burden of childhood-onset mental disorders is large. Adjusted for population in British Columbia, the cost is $26 billion. Despite that,
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the return on investment for mental health treatment and best-practice intervention is clear and certainly something worth considering.

The other thing to think about, because there is a strong economic argument…. There are more folks aged 60 to 65 in our province than there are 16 to 20 — and by a long shot. If we need this group to be productive, we need to invest more than the half-penny per health dollar that we currently spend on youth mental health and substance use in our province.

I don’t want to beat up on this province, because if you look nationally, we are probably one of the most progressive provinces if not the most progressive province in this domain in the country, which may come as a surprise to folks. We are being viewed as a leader in this area now. In the past year, we really have made some significant inroads. But that said, we are not alone when we say that we underinvest in the care that young people need.

I’ve come here, really, to address this issue. How can we create a cost-effective system of primary community care built around interdisciplinary teams? But this also touches on the first and third issues that you’ve raised as part of the committee.

Who are the B.C. Integrated Youth Services Initiative funders? We are governed by two ministries currently — Ministry of Health and Ministry of Children and Families. We also have four foundations that have come to the table with sizable investments: the Graham Boeckh Foundation, which is a national foundation interested in mental health; the InnerChange Foundation; St. Paul’s Foundation; as well as the Michael Smith Foundation for Health Research. All told, in the first three years of this initiative, which we’ll discuss in a second, these partners have committed over $16 million to getting five sites off the ground.

Our vision, quite simply, is to improve mental health, substance use and primary care access for youth and young adults — aged 12 to 24 — in communities across B.C. We intend to do this by establishing youth-friendly branded storefronts — in fact, we’ll be doing five in the next year; integrating and augmenting existing services with a common communication and branding strategy; and also providing, either directly or through our partnerships, e-services such as web-based virtual clinics and phone help lines.

We will be enhancing provincial efforts to ensure that young people have access to the services they need by partnering with philanthropic communities, interministerial partners, research-granting agencies and community organizations.

We’ve been doing this in alignment with provincial policy. We’ve looked at the Ministry of Health drafts on primary care homes. We’ve examined the strategic policy framework. We’ve worked with the deputy ministers on this issue at both ministries — the Ministries of Health, and Children and Families — and our project and our initiative aligns with policy.

In 2015, we opened a prototype for this model called the Granville Youth Health Centre. That’s on 1260 Granville Street — just at the corner, between Drake and Davie on the east side. Basically, our vision was to create a multidisciplinary, multilevel, multisector, multi-linkage approach that is anchored in the local community and, as this quote states, is “the hallmark of a sustainable and comprehensive community mental health care system.” This initiative, quite simply, is about partnerships.

The Granville Youth Health Centre was designed and co-created by young people. Our graphic work, the location and the layout were things that were informed by the population that we wanted to serve. In fact, it’s quite different than anything you’ve ever been to if you’ve tried to access health care in a community setting.

We have principles that go along with our services. The first is that a comprehensive system of care insures not only health promotion, prevention and early intervention but other core components.

We also have a principle that services need to be timely, accessible and developmentally appropriate. As part of this initiative, we’ve established and adopted national benchmarks for service access. In other words, any young person who calls one of our centres will be seen within 72 hours. Anyone who needs a crisis intervention will be seen within 72 hours. And anyone who has a care plan designed for them will have that care plan initiated within 30 days.

We also are committed to having services that are both youth- and family-centred, collaborative and empowering to both. This is the waiting room of the Granville Youth Health Centre. As you can see, it looks very different than most waiting rooms of child and youth mental health services.

We also have a principle of integrating services and that these services should be integrated through intentional partnerships. In other words, we should have collaborative intersectoral working relationships, with special attention on the actual process of integration.

At the Granville Youth Health Centre, we offer more than just primary care. We offer more than just mental health. We have walk-in counselling every day of the week. We have substance-use services. We have peer support. We have rehab support, income assistance, housing and supportive employment. And we’ll have a developmental disabilities navigator starting with us in the next month.

In other words, we’ve taken all of the best services that we offer in this province, and we’ve put them under one roof. For a young person, it means that they come through one door, they let the person at the front desk know what service they need, and they’re directed to meet with that person.
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It works incredibly well, and I have to say, it’s not rocket science. But for young people, it’s what they need and what they’re looking for.

In order to scale up beyond the Granville Youth Health Centre, we created a backbone organization, and Pam is part of that group. We have 12 individuals on the team, and we’ll be growing to 13 very soon.

Most of the clinics that are out there right now trying to serve youth are doing it on a shoestring budget, and they really struggle to do certain things, like research and evaluation, like knowledge exchange, having a communications strategy, developing their own funds, having policies in place. It’s all stuff that’s done off the side of the desk of a manager working way too many hours.

What we said was: why don’t we create a backbone organization that basically takes up all of those responsibilities and supports all the centres in the network? This is, in fact, what we’ve done in the last year. We’ve had a group of highly trained and highly educated individuals working on this project.

In December, what we did is we launched a provincial expression of interest asking communities across this province — this was last December: “What is your community’s vision for integrated youth services?”

We were overwhelmed by the level of community interest. We had 25 communities answer the call. We shortlisted 13 of them, and they went through what was called a convening phase, which is really creating a business plan for what their partnerships would look like, what their staffing level would look like, and they created partnership tables. In some communities, they had 16 organizations and ministries come together to say, “Okay, we want to work together under one roof,” instead of having services basically in all four corners of the town.

We had incredible community involvement. Families and youth engaged in the process. What we really found was that the outcomes far outstripped what we expected. This is a picture off our website, and really, the “Together we can make this happen” is what we believe is the future of health care for young people in this province.

The first outcome that we found was that resources were mobilized and funds were leveraged locally. You had these foundations and government ministries that put $16 million on the table over the first three years of this project. What we found was that philanthropy came to the table, research came to the table, government came to the table. Then locally, we had non-profit and other government agencies commit over $36 million to this project.

In other words, it wasn’t like there weren’t services on the ground. A lot of the services just weren’t linked up. They weren’t integrated. They weren’t working together. In some cases, they were competing with each other for the same funds in their local community. They certainly hadn’t identified the gaps that were missing for young people. They hadn’t identified that they were missing counselling services or primary care because they hadn’t been able to do an inventory. This process brought all these partners together.

We also found that local philanthropy was interested, and they started kicking in money to open the sites. We found that there was a tremendous amount of interministerial interest that was expressed. We’ve been working with several branches of the Ministry of Health, including the First Nations Health Authority, who are committed to this initiative and really believe that this is the way to work with urban youth in this province.

We’ve also have had the Ministry of Children and Families, as mentioned, and we’ve got several branches of that ministry. The Ministry of Social Development and Social Innovation. B.C. Housing has been working with us — and several other ministries, including Education. I know several of you are educators. Education has been working with us to look at how we can in-reach into the work that they do. And the Ministry of Justice, obviously, has a stake in the game here.

The third outcome was that for the five sites that were announced June 17, over 70 partners came to the table to work on this initiative. This is unprecedented in this province, especially around a population like young people. We really have a broad spectrum of services working on this initiative.

The announcement was made June 17, although it was the worst-kept secret in the province: six sites, the Vancouver site being the first. Five more were named. This was done by an independent panel. Campbell River on the Island was selected, as well as the North Shore, Kelowna, Prince George and Abbotsford. There was one site in each health authority.

This was chosen by a panel of youth, families, a Mental Health Commission of Canada representative, as well as clinicians, reviewing what were 70- and 100-page documents to really drill down and choose what they felt were the best sites and the sites that were the most likely to succeed in this proof-of-concept phase.

Kelowna, for instance, has a lead agency, and the lead agency is the Canadian Mental Health Association. Each site has its own lead agency. In Campbell River, it’s the John Howard Society. In Prince George, it’s the YMCA. In Kelowna, it’s the Canadian Mental Health Association. Each site has a lead agency taking on the role of leading the initiative.

These are the partners that the Canadian Mental Health Association brought to the table when they put their submission in. It’s a broad group. As you can see, there’s an incredible representation of various interests, and this group is going to be working together in their site.

We believe that this approach applies to e-health as well. We are now working with the PHSA to work alongside them, as well as other on-line services, to create a
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web portal that will hopefully simplify the youth experience when seeking services.

All of these services will be branded under a new umbrella. All our organizations have agreed to go through a co-branding process. This time next year, we will have a word or a phrase in this province that families and young people can use to basically tell their youth where to go for help when they need it.

No more will it be: “Well, you know, you go to that place around the corner. We’re not quite sure what it’s called. It’s going to be a different service in each town.” Now we’re going to have one name that will be co-branded, and all our partners have agreed to this co-branding process.

Why I’m here today is because I think that this is worth investing in. We’re proposing 25 to 30 of these centres across the province, in addition to the five that we’re opening up in the next year. We believe that this is what really represents an equitable shift in terms of access to services for our young people. The total anticipated cost is $20 million to $25 million for capital investment — basically, one time for each site.

It’s funny. I was driving home from the Okanagan along the Coquihalla, and I saw that we got a $40 million pullout that we’re investing in for highways. I thought: “Oh, that’s interesting.” I wonder what we could do with $40 million in terms of creating spaces for young people to get the help that they need so that they can work at building the pullout.

We are asking for $15 million per annum to operate 30 sites, in addition to what we believe will be 2-to-1 matching resources from health authorities, interministerial partners and community agencies. We’ve already shown that that can happen with the first five sites.

We’re asking for $2 million per annum for e-health services, so that rural and remote young people can actually get the help they need without having to drive six hours to a site. And we’re asking for $1.5 million per annum for the backbone organization.

The $500,000 annualized funding per site is to really support the operations and the clinical services that are lacking in each community, services and gaps that communities have identified. This is a scale-up that we would propose over the next five years. We feel that the amount of money asked for in terms of e-health response would easily be a return in investment in terms of decreased emergency room visits.

If you look at emergency room visits in our province, the vast majority happen between 4 p.m. and 11 p.m. It just so happens to be a time when no services are open. We really need to rethink that when it comes to young people.

Finally, we envision a province where the wellness of our young people is a priority.

With this model, we believe that 35,000 to 50,000 individual youth per year would receive in-person services at these sites; that 6,000 individual youth per month would receive e-health services from the new e-health team and partners; that we would create a strong brand recognition linked to quality youth-friendly services — in fact, we would become a national leader in this area; and that we would have thriving young British Columbians able to access health services when needed so they can support, in an productive way, the aging population that we have in this province.

L. Larson (Chair): Thank you very much. Wonderful work you’re doing, without a doubt.

L. Larson (Chair): And the age range that we’re targeting most with these centres is…?

S. Mathias: It’s 15 to 17. It’s 12 to 24. But if you look at the group of kids that are most likely to use these centres, it’s going to be in the 15-to-17 age range, which is really that group that’s coming into their mental health issues, their substance use issues, and are less likely to access Ministry of Children and Family services.

J. Darcy (Deputy Chair): Thank you so much. It sounds like a wonderful initiative.

I wonder if you can talk about who the team is that provides these services. How many health care providers or other providers? You also talked about social agencies that deal with other needs that you have. Can you talk about what the team looks like and how the referrals happen to other agencies?

S. Mathias: This is a process where, basically, kids can walk in off the street. Internal referrals are made, either through an introduction or through a piece of paper that allows that young person to have an appointment set up in the same space, typically within a week.

S. Mathias: They can self-refer. So they can either be self-referred or…. Deputy Minister Brown’s vision is that the primary care homes that are going to be rolled out around the province would be able to refer young people to these sites if they were unattached or if they needed more specialized youth services or if the youth didn’t want to come to a walk-in clinic or a primary care home where they didn’t feel comfortable.

Within each site, we’re really building off the strengths of the communities and what services they have on the ground, but what it really looks like is the that health au-
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thority has come together with the local lead agency and the social services they provide, with child and youth mental health and some of the clinical services they provide and maybe the guardianship services they provide. So all those services will be working together. Effectively, we’re creating new teams of folks coming from different organizations to work together on site.

M. Dalton: Thank you very much. It’s a very exciting project that’s happening. I know that there’s great need out there in the province. I know that Maple Ridge, which I represent — and also Doug — is very keen, and we’re disappointed about not being one of the first five.

The way the centres are chosen. Is that primarily because you want to make sure you get it done right or funding or a combination of factors? I know that, for example, our community is interested in even a scaled-down version, even just to get the foot in the door. There’s a lot of community interest and, as you mentioned, from other sectors from the population at large and non-government agencies that want to get involved too. So it’s very, very exciting.

S. Mathias: The selection process was really one that was through an independent panel. We were told that we had, basically, effectively two years to prove this could work, and so we had to mitigate risk along with balancing what were strong applications. In some cases, many of these sites chosen have been doing some of this work over the years, and we’re looking at broadening their scope. The funding allowed for partners to come to the table who wouldn’t have come to the table otherwise.

We believe in the competitive process, quite frankly. We understand that lots of communities are working towards this model. But the competitive process allowed for a really strong base to come forward and, quite frankly, forced certain services and certain ministries, I think, to come to the table when they wouldn’t have, had it not been competitive.

P. Liversidge: Just quickly to add to that, the Fraser Valley…. We knew that we wanted to select one per regional health authority. In the Fraser region, of course, the youth population, proportionally, is significant, and so there was a lot more competition in your health region.

S. Mathias: We had eight applicants from the health authority and Fraser Health.

D. Barnett: Thank you very much. This is wonderful to see, and it deserves all the support that we can give it.

I see the sites, naturally, are in the regional centres for health and other things that we have across this province. Of course, I come from rural British Columbia, and we have a huge population of First Nations youth. So my question is: how are we going to integrate rural British Columbia communities? These people are not going to go to Kelowna. They’re not going to go to Prince George. How can we get this out there where the need is so great?

S. Mathias: I totally agree. One of the things we’re really clear on is that this model is not a provincial with only five sites. That’s one. The second is that we really envision having large sites but also smaller sites, potentially, maybe open two or three days a week, maybe in a much smaller space. Some of these sites are going to be 9,000 square feet. These are going to be big sites with 25, 30, 35 staff on board, but in a lot of spaces we may only need four or five, with someone providing primary care a couple of afternoons a week. That may be enough.

What we envision for our rural and remote communities is a hub-and-spoke model, where we can identify clinicians on the ground who feel like they’re linked in to something bigger and where we can use telepsychiatry, which is through our partnership with the PHSA, to reach out to those young people and also give them an opportunity for after-hours access to care and services.

This is a project that really would take five to seven years to transform the service delivery in this province, but we feel that that’s likely the model that we need to go after, given how rare it is to find a qualified mental health clinician in some of these remote communities.

J. Shin: Thank you. I think some of the answers that you’ve provided actually gave me the clarification that I was seeking. We do know that the empirically tested youth interventions do work, and they’re important work for the services that we hope to provide for our youth.

I’m just curious to find out if this particular program does anything in the way of identifying effective programs for the broadened array of complex issues that our youth face today. Do we have a chance to examine the intricacies or sensitivities around ethnicity and the diversity of our population that we’re serving in British Columbia? Do you have a chance to clarify the conditions in which some of our existing programs do or don’t work? Even if you have a fantastic program, if they are not in the right conditions to cultivate success, then it may not work.

It sounds like what this program is, is creating a hub that’s accessible for youth to be able to find help, and you play the middle person to be able to effectively make referrals to the right agencies. I’m curious to find out if you are involved in the research side of things to qualify or quantify the outcomes. I’m curious to find out if, over the past few years…. I wasn’t able to find when this initiative started and when the Vancouver site was first opened. But since then, have you had the chance to analyze it and look at some of the outcomes to see if there were any palpable improvements through your services?
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S. Mathias: Yeah, and I’m happy to have an off-line conversation if that would help.

S. Mathias: The evaluation process. We’re linked into a national research network now, funded to the tune of $25 million. We’ve also been co-applicants in a national centre of excellence for knowledge exchange. As I said, I think we really have an opportunity to be leaders here in the work we’re doing. We are establishing a robust data collection system and a stepped-care model of care, where we will be able to track young people along the pathways that they go and also monitor them to see how they do.

What we’re really interested in is breaking away from the traditional medical sorts of scales that are used to see how someone is doing and really shift into quality-of-life measures, following up with young people and using technology. We have the technology now to do this, to follow up with young people and see whether or not their quality of life has improved and, if it’s not improved, intervening based on quality of life, not based on illness.

That’s really sort of the tack that we’re taking. By having youth and families as part of our backbone organization, part of our team, they’re holding our feet to the fire. So we have a parent and a young person who are in all our meetings, and they’re basically telling us: “Listen. That scale is irrelevant to us. We don’t care if you’re using the PHQ-9 or the GAD-7. We want to know whether our quality of life is improving.” That’s where the shift of our focus has become.

L. Larson (Chair): Thank you very much. We’ve less than three minutes. Selina and Sue, you’ve got the last two questions. It’s not so much the questions; it depends on how long your answers are, or I’m going to have to cut one of them off, okay?

S. Robinson: I’ll try to be quick. I’ve pulled it up on the website, just to get a real sense for who’s on your team. I’m just reading about Granville. It sounds like there’s a number of case managers and psychiatrists and doctors. I’m assuming it’s integrated, multidisciplinary care. I’m trying to figure out where the social service agencies fit in. Are they doing part of the care model, are they sitting around the table, or are they just referring in?

S. Mathias: Well, our income assistance worker, for instance, has a caseload of 120 youth, and she works in an office space right next to mine. If she’s concerned about a mental health concern, she’ll just walk over and ask me to see a young person. She’s part of our casework. We have a housing worker and three housing support workers from the PCRS, which is another non-profit organization working on site, seeing youth there. We have recreational support as well.

S. Robinson: And sharing information back and forth, you’ve been able to find a way to make that all work? We’ve been hearing some challenges about that.

S. Mathias: Yes, absolutely. That’s right. We sit down with our youth, and we explain the need to share information. We couch it, basically, by saying; “Listen, you don’t want to tell your story more than once.” You know, this is what we’re trying to cut down, and they get it. It’s been about seven years that we’ve been doing this now, and we’ve really broken away from youth coming back and saying: “I didn’t want you to talk about this.” We’ve really managed to overcome those hurdles.

S. Hammell: A number of my questions have been asked, and I was particularly interested in the cultural diversity piece. I’ll just make a comment. I just think this is very, very exciting.

Constantly, in the mental health community that I work with and talk with, there’s always a concern about people being able to identify where to go to get help. It’s not only in the youth. It’s in the larger community as well, so this is a great initiative.

One quick question. Is there a core set of services that are provided and then add-ons, depending on the community?

S. Hammell: You talk about a backbone organization. Is the supervision done, then, by the backbone organization?

S. Hammell: And the other people that are in there from other non-profits…. I mean, there’s some kind of…. I see it’s complex.

S. Mathias: It is complex. What we realized was that we weren’t going to come in with a new service in each community. We wanted to help the communities do what they’ve always wanted to do, which is work together and provide seamless care.

For whatever reason, the way things have been structured in this province — and, quite frankly, across the
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country — is that everybody works in pockets. When you recognize that there’s a greater need at the community level and that there’s money for the community, not just for your agency, all of a sudden it brings people together.

For us, really, the supervision that we’re providing is project management. Opening one of these suckers up takes a lot of work and a lot of energy and a lot of understanding around floor plans, program plans, etc. So we’ve got project management helping lead the way. We’ve got partnerships that can be recreated at each centre. It doesn’t have to be one-off partners, so we’re working at the ministry for that. There are all kinds of functions that the backbone organization does, but ultimately, the lead agency is responsible for what happens on the ground.

And the core services, to your question — primary care, mental health, substance use, youth and family navigation and support, and then social services.

L. Larson (Chair): Thank you so much. Fabulous work that you’re doing. Keep doing it. We will certainly capture your message in our report.

L. Larson (Chair): Quick turnaround here. I’ll ask the next presenters to move up to the table as quickly as possible. All right, we will move ahead here. I want to assure everyone that presents that you get your full 15 minutes to present. They just don’t get as much time to ask questions.

To the University of British Columbia, department of family practice: welcome. I’m not sure who’s taking the lead, but I’ll ask you to introduce yourselves and then move right into your presentation.

M. McGregor: Thank you. My name is Dr. Margaret McGregor, and this is my colleague, Susan Troesch. Actually, we both have affiliations with many different professional organizations and academic groups, but we’re speaking to today as clinicians trying to share our experience. We’re not representing any of those august bodies at this moment but ourselves and our somewhat extensive experience, at this point, in the trenches.

This next slide is the venue that informs our narrative today. I believe you heard from some patients yesterday also about the same site.

This is the outline of our presentation. We’re going to talk about who we are, very shortly, and we’re going to outline the question, because that’s how we’re taught to do good PowerPoint presentations.

I’m going to very quickly get us to step back and look at the overall current system of primary care and the big picture of how it’s funded and delivered. Then we’re going to get into the meat, which is the history of team-based primary care at Mid-Main Community Health Centre, what we’ve learnt and our recommendations.

Who are we? We’re clinicians who’ve experienced, really, the power of building and working on interdisciplinary teams in a primary care practice. We’re also clinicians who’ve experienced that there are barriers to providing patient-centred, cost-effective, interdisciplinary care after transitioning from a salaried to a fee-for-service family practice environment. We’ve lived the experience, and we have some insights in that capacity.

The question is: how can we create a cost-effective system of primary and community care built around interdisciplinary teams?

Just stepping back a bit, I think it would be good to look at the big picture, which is that primary medical care, at least, is publicly funded yet it’s privately delivered. Physicians are self-employed small business people that provide their service as independent contractors rather than as employees. It’s an open system, where we have the freedom to practise where and how we wish, as long as we have a billing number that’s valid and are accredited by our colleges.

This system really has been in existence since the early ’60s, when medicare was first enacted. The business side of service provision is balanced with professionalism, and the system is, really, largely based on trust. From a broad government perspective, it’s a challenge. The public purse is delivering a service that actually can be quite chaotic. Things pop up everywhere, and there’s very little ability to incent a cohesive system, which you’re learning about in these last two days.

Fee-for-service has been the predominant form of remuneration, despite some movement in different provinces to blended funding. Just to review what fee-for-service is, it’s really remuneration by the act. Acts that are covered, and well covered, tend to get done a lot. Acts that aren’t covered or are poorly covered tend to not get done. Sometimes, if they’re not covered at all, patients are charged for them. You may have all had experiences where a doctor said: “You’re going to have to pay for that note because it’s not covered by the health plan” or “You’re going to have to pay to get your records transferred.” That very much shapes how work is done and how the services are delivered.

I’m going to hand it over to Susan now, just to talk about interdisciplinary care.

S. Troesch: I’m a pharmacist, and I’ve been around since the ’70s. I was a dispensing pharmacist for 28 years.

In 1997, I got a phone call from the team members at Mid-Main — it was a smaller team then — inviting me to come and talk to them about joining their team. Imagine my surprise and excitement. When I got there, they were really looking for a cheap dispensary for cheap drugs for their patients. There wasn’t funding for us to easily get
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that funded to start. I said: “What else can I do?” They gave me the look. You know the look.

I decided that I had time to volunteer, so I made a commitment to volunteer for four hours a week for the next year to see what working together might look like. We had just started talking about pharmaceutical care a few years before, and we knew the power of having all the team members working together and the patient in the centre.

After about six months, I think we got the sense that this was a great way to provide care, and we started looking for funding. At the end of the year, there was no funding, despite our multiple attempts to find some. So I went away, saying: “Call me when you get some money.”

I got a call in 1999. I started working part-time at Mid-Main. That was facilitated by some negotiation by the physicians, who really transitioned to a salaried practice, under an alternative branch, and freed up a little bit of funding for me. I think the physicians, motivated by that experience, started looking for other members of the team.

We’ve been through a lot of transitions since then. Recently, because of a reorganization of Vancouver Coastal’s primary care funding and an earlier transition of our funding into that pocket — they had five primary care practices — there was a decision made to get out of doing that interdisciplinary work. Those practices, except for Raven Song, were closed.

In the past, as we learned to work together…. It takes a while for providers to learn to work together and for patients to recognize the benefit of having a pharmacist. “I thought you only counted, poured and stuck on labels.”

Lots of the services that I historically began to provide through…. When I first got there, they said: “I don’t know what you can do. Oh, you can do the medication refills. Oh, it would be helpful if you’d see patients who need to quit smoking. I don’t have time in my appointments to really focus on that.” So lots of learnings for me and us together and then a growing of the role.

Early on the provincial government was looking at throwing some money at chronic disease management because we recognize there’s lots of cost involved with patients with chronic disease who are poorly supported. We were involved in some of those early initiatives and were encouraged to use a web-based toolkit to keep track of at least the number of patients we had — because we had no electronic record — and to do some support for patients using evidence-based flow sheets and some group care. That’s how we became the group care gurus — through experience.

I think one of my roles has been shared care in the fact that often…. None of our physicians work full-time. The nurse practitioner and I would kind of fill in the blanks. The patients knew us as part of their team, and they could call on us if their family doc wasn’t available.

One of the primary…. Home visits for frail elders I’m not able to do under the new system, and it’s very frustrating. You know how we’re all aging, and we can make a difference.

What we’ve learned is that the interdisciplinary care…. Once you’ve been in a face-to-face environment with clinicians — this is different from the pharmacist and the physician working over the telephone or by fax — it’s really difficult to go back. You see the power of that interdisciplinary care, and the patients learn to value it and benefit from it. It really makes a difference if you have the opportunity to work face to face, and it does take some focused time and energy on learning to work as a team.

When the transition fund was going on, there was a group sent out from Ottawa to look at interdisciplinary care. Was there evidence for it? Yes, there was. Then how do we figure out how to promote that? A toolkit was developed. Mid-Main was one of the five sites where they came to see what might work to build team.

Continuous quality improvement is one of the things that team can focus on, and that helps with improvement in patient care. Without the team, often the most appropriate provider is not having to deal with the issue. Like, I’m the med expert.

The physician has ten minutes now to see a patient, and the patient has 20 meds. What we’ve learned is that when we transitioned to fee-for-service, the salaries for the non-physician providers have disappeared. How do we allow us to continue to be on site? There’s overhead involved. There are patient visits. We have to build the team to allow for a sharing of payments to allow us to stay. If that doesn’t happen, then those non-physician team members are down the road. Right now there are very few delegated authorities that myself or the NP can do in a fee-for-service environment.

I have a great group of physicians. What happens is I’ll see a patient for 20 minutes. I go knock on the physician’s door, who’s in seeing a patient. They pop over. The patient and I tell the physician what we’ve talked about, what our plan is. There’s documentation signed, if needed. Then they do the billing, and part of that billing fee supports the role. That’s how it works, but there are lots of things we can’t do.

In the current fee-for system, that provides a barrier to opportunistic care. Because the patient has already seen the doctor, and they’re going to bill $35 or whatever, they can now not see me. They’re going to have to come back to see me. If I’m starting someone on insulin, that’s not something that happens in 20 minutes. But they don’t want to go to a teaching centre. They want the care from the people they know. Then it’s going to take several visits for me to be able to get that patient ready to start that activity.

We don’t have a hierarchy with a physician in our team, but there’s a potential for that to happen. I think you may
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have talked to a physician yesterday, where the tone was more in that direction. The physician should be in charge, and they would get the other professionals to come in and help where they saw fit. So that’s a worry.

As well, we’re under lots of pressure to do lots of extra jobs to make the billing happen. I’m copying appointments here and there. It just is very labour-intensive. We’re still all there. Well, most of us are all there. Margaret has left the practice. But there are some days when we just wonder: are we going to be able to continue to do this?

I can’t take the time to do an intensive medication or chart review when I get a drug information question. At most, I could call the patient and get some information from them. That would generate $15 for a delegated phone call, and that would have to be shared.

M. McGregor: Our recommendations are, first of all, to introduce diversity of forms of payment for physician remuneration in this province. Particularly, the next generation is very, very interested in not being small business people that have to depend on generating a fixed number of acts that are billable at a certain amount to build and take care of people. They’re not trained in medical school to be business people. They don’t do it well.

There needs to be choice of how one is paid. It should be revenue-neutral. There shouldn’t be much difference between the salary made by someone on salary or the number of patients cared for. There needs to be some equity of responsibilities, but generally, there needs to be choice in how people are paid.

We need to study difference. Actually, B.C. has quite a history of pockets of different ways people have been paid, such as Mid-Main, such as…. I’m not sure if you’re going to hear about the Langley model, where they use population funding.

There are still some models here in the city where a different funding formula is used, yet we’ve not done any very good research evaluating how they’re different from the usual care, whether they cost more, looking at all the downstream and upstream costs and, also, this interdisciplinary piece. We need to study that — not just looking back but also going forward. If we introduce this diversity, we need to study it prospectively.

We need to ensure, as we train, that doctors get posted at home and community care health units and understand the world of home and community care because these are the people that we need to be working with. Likewise, nurses need to be trained in what the typical doctor office looks like, what that world is about. Right now none of that is done. Pharmacists too. We need to start getting training together about our worlds.

Finally — and this is a bit of a ringer — we need to ensure 24-7 access to primary care and home care. It needs to be a standard of care. Unless it is, there’s no way we can develop high-functioning, integrated primary care in this province.

I wonder if you could expand a little on some of the care that you were able to provide previously — the visits to the frail elderly, the involvement of the team in doing that. Nurse practitioners, I believe, and pharmacists sometimes were involved in that. As well — it was in your presentation — some of the group education programs, like the diabetes and so on.

I wonder if you could talk some more about both of those. They were touched on yesterday by the patient group that presented, but I think it would help to give us a bigger picture of what was in place and what we can aspire to.

M. McGregor: A typical scenario, in terms of home visits for elders, would be that…. We had a roster of people that we would visit who were unable to access us in an ambulatory way. That was fine. The doctors would sometimes do those visits. We’d sometimes share the visits with, particularly, Susan but also the nurse practitioner.

The most relevant, though, is when something happens — and something always happens on a busy day — where that person needs service immediately. Having the capacity of a team to drop things and go and respond to a situation was particularly important and helpful in providing good access to care when it’s needed. So that’s one example.

Another example is what Susan described as the opportunistic visit. Someone hasn’t been in for a long time. They’re diabetic. They haven’t had or they maybe have just had their blood work. They’re only booked for a standard 15-minute visit, and they come in with a crisis. The only reason they’ve come in…. They haven’t come in to talk about their diabetes at all. That’s the last thing on their mind.

So there’s the issue of dealing with the thing that they want dealt with, but they’re there anyway, and it’s a wonderful opportunity to also start talking to them about the diabetes. That’s where having a tag team of one or two other disciplines, with some flexibility to be fluid in how the day works, is a wonderful situation both for the patients and for the clinicians. You don’t feel like, “Oh, I missed that opportunity, and I’m going to have to make them come back,” and you know they probably won’t. And the patient knows they can get a bunch of stuff dealt with at the same time.

I’m going to turn it over to you for the groups, because you’re the group guru.

S. Troesch: We just have our eighth physician joining us now. Six of our physicians have regular quarterly dia-
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betes group visits, and then we have some pre-diabetes group visits regularly. One of our clinicians has a hypertension group visit. We’d love to expand all the groups.

We’ve, in the past, done some health promotion groups. We build a calendar once a year. You can go to our website and have a look at it. There is room in the fee-for-service environment to do some of that stuff, but it’s labour-intensive — the preparation, the calling the patients and advertising. Right now we’re not able to use electronics — emailing, for instance, or texting — just because of confidentiality issues, in our practice anyway. So it’s a barrier to communicating with patients.

What happens is it’s an hour-and-a-half session. A group of patients come each session. It’s usually facilitated by myself, but we have a new nurse practitioner, so we’re hoping she’s going to help.

I get started. We have volunteers, who are patients who we have trained, to help us with this now, because we couldn’t do it in fee-for-service otherwise. We actually get releases from patients to allow our POMMs, we call them — pals of Mid-Main — to sign….We get their phone number and name only, and then they call them and remind them about group.

They’re there to do blood pressure, height and weight. These people have all had police background checks and have signed confidentiality agreements, and they just come and set up the room for me. I give them the worksheets. They get everything ready. They meet, greet, weigh and measure, and then I come in and we have the group.

Our clinician joins us now at the end of the group, whereas before, they used to attend the whole session. They see the patients one-to-one.

D. Plecas: Thank you for your presentation. You implied that the notion of moving from fee-for-service to salaried positions — and, presumably, there could be a salary scale for both of you — would be cost-neutral. That’s exciting. Did I interpret that correctly?

What percentage of doctors and pharmacists do you think would opt to have the salary model?

M. McGregor: Well, I’ve got to say that I did a study with new graduates from UBC, in family medicine, and something like 75 percent said they did not want to work under fee-for-service. I think it depends on the demographics of who you’re asking, but I think there’s a very big appetite out there on the part of younger physicians to have a more salaried, predictable income — possibly less, making less, in exchange for working with a team and not having to run the business side of things.

There would be trade-offs, for sure. But certainly, in all the interviews and questioning I’ve done of the next generation…. I think people are interested in that trade-off — at least some people.

The fact is now there’s just no diversity; there’s nothing. They graduate with all the values that they’ve learned — of good chronic disease management, of patient-centred care — and then they’re spat out into the ten-minute visit, high volume, I-do-everything model. It’s pretty discouraging. That’s why a lot of them go to walk-in clinics, to be quite honest. We really are bleeding that generation of very highly trained providers into walk-in clinics.

S. Troesch: The faculty of pharmacy at UBC, I hope you know, has just changed to entry-level pharmD program, which is an extra year of study. So pharmacists coming out should be competent and ready to start stepping into my shoes or working in sites like this. They’re pounding down my doors and wanting to come and see what I do and saying: “How can I get a job, like you?”

They’re not able to practise this scope in their current plug-and-crank environment. Sadly, the pharmacies now don’t have to be owned by pharmacists, so pharmacists are employees that have a lot of pressure from above to plug and crank, work fast to make money. There’s no satisfaction in that. Definitely, I think we could….

You know, you should look at the Sweden model. It remains part of CACHC, the Canadian Association of Community Health Centres. When I was in Montreal, a Swedish anaesthesiologist came to talk to us about the Swedish model. They had transitioned all of Sweden over to an interdisciplinary community health centre model. The physicians were just told: “You have to do it.” They used one electronic record, and there were incentives for good care. They said the physicians loved it, the teams…. The quality of care improved, and everything was great.

D. Bing: Sure. I’ve worked in both systems. When I graduated from dental school, I worked for the REACH Community Health Centre on Commercial Drive. I did that for two years. It was a very nice environment, and for a new graduate it was great. We didn’t have to worry about the number of patients we had to see and this sort of thing, and getting a practice started. The patients were there and everything.

Just to defend fee-for-service practice, I was in private practice for 35 years as well. You had an opportunity to set your own hours and to be your own boss. That is an attraction for a lot of clinicians. At REACH, our hours were set. It was nine to five, Monday to Friday. When I
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was in practice, I could determine the hours I wanted, the days I worked and when I took my holidays.

There are advantages to both, and it appeals to different people, I’m sure, at different phases of their careers. I just wanted to mention that.

M. McGregor: Yeah, I think that’s a very good point, that one size probably doesn’t fit all. But at this point, in this province, there is only one size, except for the tiny little things like REACH or in Mid-Main, where a few people might hear of it and go. There really isn’t that availability of diversity. But you’re absolutely right. It’s not for everyone and at every point in their lives.

L. Larson (Chair): We have heard compelling stories from lots of people regarding how the fee schedule could be improved to provide better health care for British Columbians. Thank you very much for taking the time to be here this morning. We really appreciate it, and we will capture your comments in our report.

I’d like to welcome the B.C. Care Providers Association — Daniel Fontaine and Michael Kary. Daniel, of course…. Both myself and Darryl, having a seniors portfolio for a while, are very familiar with what you do. Please, 15 minutes. Go right ahead.

D. Fontaine: Good. I’ll try to keep on time. I noticed my predecessor was able to do that. But first, I want to thank the committee for inviting us to come in and to present. It’s the first time I’ve had the opportunity to do that, so I do appreciate the invitation and the tremendous work that you do.

For those of you who aren’t familiar with us, I’ll just let you know that the B.C. Care Providers Association has just over 300 members. A significant number of those are service providers, and they represent both residential care, the long-term care, as well as home care. Our association is the largest and the leading association representing the continuing care sector in the province.

We have roughly 23,000 individuals that are receiving care every day, and they’re not all seniors. A vast majority are, but we do have younger adults that have an acquired brain injury, so I want to make sure that that’s covered as well.

Today I’m going to talk about two of the three areas that you’d like us to come and speak to you about. The two focus areas we’re going to look at are how to improve health and health care services in rural B.C., as well as, secondly, looking at creating a cost-effective system for primary and community care built around interdisciplinary teams. Those are the two areas we’re going to focus in on.

On the first area of focus, I’m going to talk about improving health in rural British Columbia as well as addressing the issues of recruitment and retention. There are a number of challenges. I probably could have had about 20 slides, but we decided to just pick a few to cover off for you so that you’re aware of some of the challenges.

In residential care and home care, right now there are some significant health human resource challenges. Some of those challenges relate to a number of different factors, including things like high worker burnout, workplace injury rates. I often tell people that…. I have a little quiz where I say, you know: “Fireman. Miner.” I list all these occupations, and then I say: “Care aide.” I say: “Which one has the highest injury rate?” Very few guess that it’s a care aide.

We have significant issues. We are working as a sector to address that through SafeCare B.C. We’ve done that. There’s also the issue of new graduates being job-ready — definitely an issue.

The lack of geriatricians. Dr. Sinha, who just spoke at our conference, mentioned…. I think, Michael, the number was 260 geriatricians across the country. You compare that to pediatricians, and it just is phenomenal how few people are actually in that area of practice. Also a lack of geriatrics training, including violence prevention in dementia care.

I’m here to give you a little bit of a warning. There is a decreased capacity now. In particular, we’ve been getting anecdotal information around the reduction in the number of training spots. People are not going into the training so that the colleges and other organizations providing training are closing down classrooms, in particular in rural B.C. That’s definitely a canary in the coal mine for us.

Solutions and strategies. You may or may not be familiar, but a number of years ago, back in 2008, the government partnered with B.C. Care Providers Association and about 20 colleges across the province because, lo and behold, we had a health human resource issue, and we also had an economy that was going in the other direction than where it is today.

We were able to work collaboratively to actually fill up, almost to 100 percent capacity, these spaces so that we were starting to produce an increased supply of the type of personnel that we’re going to need. Unfortunately, the program ended in 2012. We thought we had solved the problem by 2012.

It was not an issue of lack of funding; just that industry and government and the colleges thought we were doing well because we had everyone signed up 100 percent. Unfortunately, over the last three or four years, we’ve gone back into a position now where we’ve got some significant shortages on the human resource side.

In terms of the burnout and high injury rates, as I indicated, some of the solutions include things like introducing SafeCare B.C., which we’ve done. SafeCare B.C. is a non-profit that we spun out from B.C. Care Providers Association. It’s self-funded, so we tax ourselves. We impose a seven cents levy per $100 payroll. That funding
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goes back. The society, SafeCare B.C., does nothing but injury prevention in long-term care. We’re looking to expand that into home care next January.

That is an area that we are doing ourselves and taking control of, but there are other programs, like PIECES and GPA and others, that can assist in terms of some of the issues around burnout.

We would highly recommend that you look at expanding the number of nurse practitioners and also consider the introduction of physician assistants in the province of B.C. We’ve taken that position and have been advocating that for a while. That’s something we think could be a potential strategy for a solution for you.

Lastly, increased funding for care providers to ensure that they actually have the funding they need to hire the front-line staff and to provide the direct care hours that seniors are asking for across the province.

On the second area, focus No. 2: create a cost-effective system of primary and community care built around interdisciplinary teams. There are several challenges we’ll highlight for you.

The current model of residential care in B.C. really does not support interdisciplinary teams. There’s a very limited set and scope of activity that takes place in — and I’ll put it in quotes — a “typical nursing home.” We don’t call them nursing homes anymore. But there’s a limited set there, so that’s a big challenge.

The health care professionals, including the physicians, are often very poorly integrated into the residential care setting. In fact, in many cases, there just is no integration at all. So you find people going to emergency rooms and coming back, and the staff at the care home have no idea what happened at the ER. You can’t get the electronic files transferred. There’s no discussion between the two sites. To describe it as chaotic might not be overstating it. There’s a lot of work to be done in terms of integrating those care teams.

The funding models are also not responsive to the acuity of residents nor the health care services being provided to seniors. Again, a one-size-fits-all funding model does not necessarily support the fact that somebody might have a higher level of acuity. Their funding isn’t attached to that. That’s a challenge.

Many seniors that are living at home and in residential care communities experience unnecessary hospitalizations. I’m sure you’re all very familiar with that, and that’s definitely a challenge.

On the next slide, in terms of the solution, it’s something we’ve proposed in a white paper that we released about a year ago. It’s been included. We have provided to all of you two white papers that we just released last month. It incorporates the concept of the continuing care hub.

If you walked into a typical care home today — if you look on the left-hand side — they would have a limited array of health and clinical services, global budgeting, very unresponsive to the needs, and it severely limits the ability to innovate.

We’re not utilizing staff to the full scope of practice. I’m sure you’ve heard that before, many times — very minimal integration of health care professionals. Information flow is restricted between the acute site and the care homes, and unnecessary visits to emergency rooms still exist. That is even more so in a home care situation — so a little bit less in residential care but definitely high on home care.

On the right hand side, with the blue box, is what we’re proposing that British Columbia look more into. It’s something I’ve talked about with Dr. Plecas.

I just had the opportunity to visit a place called Niverville, Manitoba. I don’t know how many of you have ever visited Niverville, Manitoba. It’s where I was from, born in that general area. It’s a community of 4,500 people.

They actually have got this hub going. I was absolutely astounded by it. I was saying to Dr. Plecas that I wish all of you could go there. Anybody want to go to Niverville, Manitoba? I’ll tour you around.

What I liked about it is that it’s in Canada. It’s in Manitoba. You don’t have to go to Sweden or Finland to go see it. There are a lot of innovations happening right here in our country, right here in western Canada.

We had actually proposed this model before I actually visited Niverville. On this model — a little bit different than what’s currently happening — the funding is actually linked to innovation and actual service delivery. So what you’re doing, you’re getting funded for, and I said here “i.e., outcomes.”

Increased on-site subacute services. There’s an array of services that are actually available at the care campus compared to what we offer now. That’s something that we’ve heard from the ministry that they want to look at. Can we utilize care homes in a different way than we have in the past?

That’s something that we’ve put in a policy paper. We’ve listed off an array of services that we could offer if the funding were there to provide it.

The continuing care hubs tend to and should be utilizing staff to their full scope of practice. Health care professionals are definitely working in multidisciplinary teams, so there’s more discussion and flow, integration between acute and the care homes.

Effective use of information technology and patient records. I can’t imagine you haven’t heard that before, a few hundred times. The patient information flow is really in dire need of some reform. Anyways, I won’t say more on that.
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It provides more services in communities. The care hubs themselves can become centres where people can actually, if they’re living at home in a home care setting, come to the care hub, integrate, reduce the social isolation, have opportunities for adult day programming and access to RTs, OTs, all on that site, without having to go into an acute care centre.

They end up producing some pretty amazing results in terms of reducing the number of unnecessary emergency room visits and also will reduce the ALC days as well. People can be discharged from an acute setting and brought into more of that sub-acute setting a lot earlier, so they don’t have to be costing the system $1,800 a day versus $200 to $300. That’s the continuing care hub model, one of the solutions that we’ve proposed.

The last slide, in terms of some of the planned outcomes…. Assuming that you move down this model, what we would hope is that the expanded services will keep seniors living in their preferred location longer. So if they want to stay in their apartment or their home or wherever, they can age in place. That’s the ultimate goal. We would hope that there’d be an increased supply of labour, that we actually have enough care aides.

I can’t emphasize to you enough that the time for studies and the time for reports and the time for more analysis is over. I describe it as like a rising tide. A lot of people think that…. They call it the silver tsunami. You’ve all heard about the silver tsunami. It’s not a tsunami. Tsunamis you don’t know are going to come. They’re destructive. You can’t prepare for them. What we’ve got is a rising tide. It’s a tide that’s been rising for a long time. The water is now reaching a point where, when you look back at the beach, it’s now about a kilometre away from you.

We need to act. We have to stop talking and stop reviewing and analyzing and actually move towards action. Otherwise, we’re going to be in a pretty serious crisis.

We were talking about physical location of acute and sub-acute services. We talked about that. It would be one of the outcomes. We’re hoping for new rules for health care aides and integration of physicians, nurse practitioners, physician assistants — creating those interdisciplinary teams.

Lastly, that that alternate funding model and reimbursement methods would be there to help increase innovation, help support that.

For more information, we’ve left this with you, but as I indicated, Michael has done an amazing amount of work in the two policy papers that he did. I think there’s like 170 pages over the course of two papers, and they cover off a lot of innovation, a lot of ideas that we’ve put out to the public. We’re actually consulting with them over the course of the summer. We’ll be back here at the Wosk Centre for Dialogue on September 20 to culminate that discussion.

L. Larson (Chair): Thank you very much, Daniel. One of my daughters is a care aide, so I understand that.

L. Larson (Chair): You mentioned the community in Manitoba that only has 4,500 people. I mean, my community has about 5,000, but there’s one private facility that would not be suitable for this hub, and the others are all under the health authority. So how does that work if the only residential — that type of care — you have is in a health authority?

D. Fontaine: First of all, it’s a challenge. I would say that rural British Columbia is more challenging to produce these than urban areas. Where they have been tried and where they have been implemented have been mainly in the urban centres. That’s why I point out Niverville, because Niverville is 4,500 people. One of the challenges they had was that the seniors that were within their communities were having to leave. They had to leave to get care.

The community essentially banded together and said: “We’re done. We’re tired of shipping our seniors off to other communities.” What they did was set up a non-profit society. There was a care home already there as a nucleus, the centre for that — so that private residence could be, potentially, the nucleus for that. Then they, essentially, built around it. They now have life lease on there. They have AL. They have a complex care special dementia unit. All the services on there.

But here’s what’s exciting to me: they have a fully serviced, licenced restaurant. They have a pub. They have a banquet hall. That place is now the centre of the community. The community comes there for weddings. When you drive up to it, you don’t feel like you’re going to a care home. You feel like you’re going into the centre of the community. It’s completely turned around the way that people perceive seniors care in that community. So it can happen.

L. Larson (Chair): Do they have enough spaces for the people that they need to serve?

D. Fontaine: They do now. Absolutely. What’s they’ve done is actually become a hub where people are now…. It’s been the reverse brain drain, where people are now coming in and moving into Niverville.

You know, it’s funny, because I joked with the executive director. I said: “How did you do all this? Because it just is so innovative and so amazing that you were able to pull this all together.” Before he said anything else, he said: “Just so you know, I broke every rule. We had to literally break every rule to get this to happen. Now look at it. It’s now the poster child, and everyone’s looking at how it should be done.”
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I don’t want to encourage rule-breaking, but there definitely is some merit in thinking out of the box and being innovative on some of this stuff.

D. Barnett: That’s very interesting. My question is: how is it funded? The seniors that go in there…. Is it all private funding? Is it funded by the public system?

D. Fontaine: It’s very similar to British Columbia in that it’s a mix. So there are private. For example, the life leases would all be private. It’s kind of similar to our independent living. A number of the other beds are funded like they are in British Columbia. Although it’s a non-profit, private site, the beds are actually contracted and funded by the health authority. Very similar to us. There’s no difference in that model. They do have some private components in terms of IL, independent living, and they have the publicly funded residential care as well.

D. Fontaine: Absolutely. In the model that they’ve built, it’s every dollar that they get in revenue from, say, their restaurant and their banquet hall rentals…. They’ve got a daycare on site so that the workers actually can bring their kids and have them right at the daycare. Then the rest of the community can use the daycare as well. So they built the daycare right on site.

All the revenue from that goes right back into care. It goes right back into the centre. It circulates within the site. They call it social entrepreneurism. I think that’s how they termed it. I didn’t get into the books in terms of how much money they generate, but they said it was significant enough that it helped them to enhance the quality of life for seniors. They were able to do things for them that they might not have otherwise been able to do simply with the public funding.

You’ve talked about an expanded role for physicians and nurse practitioners, more care hours for nurses and care aides as well as physician assistants. I wonder if you can talk about how, in the hub model that you’re talking about…. Who are they employed by? How does the funding work for that in what you’re proposing? I know that there is certainly a move towards having more physicians who are not employed by but attached to it as part of the practise of residential care in British Columbia. Who pays for that team? How does that work? How does the attachment happen?

D. Fontaine: We actually do have, thankfully, a good example of it here, in the Metro area. In Surrey, for example, we have Elim Village. Elim Village is not quite at the level of complexity of this campus, but it’s getting there. It has independent living. It has a pharmacy now on site. It has complex care. It has that whole campus right on site. It’s a mixture, again, of…. It’s funded through the health authority. The funding for the beds is provided by the health authority. They also have the independent side, which is funded privately by individuals. They can access care, if they need it, from the site, from the care campus.

It’s not like we’re asking for a revolutionary model in how it’s funded. There’s still the public funding component of it. It’s more about how you build the physical infrastructure and then how you integrate the team so that they’re actually on site. The key is, ultimately, that if somebody is living in an independent living setting there, they can retain their friends and their community and not have to be moved out and shipped out somewhere else when they need that advanced level of care.

J. Darcy (Deputy Chair): Not quite. That deals with the funding source, perhaps, broadly speaking. Nurse practitioners are not widely used in residential care, and physician assistants are not. You’re proposing that they could be and should be. So how does the funding…? We’ve heard a lot about funding models for nurse practitioners, for example, and the need to expand. How would that work in this model, and who would pay them?

D. Fontaine: They’re not privately paid, if you’re asking whether or not it’s going to come from the private sector. It would come from, I’m assuming, the Ministry of Health. It would be funded by the government of British Columbia. We wouldn’t be proposing a private system subset where people would have private hospitals and that type of thing. It would be something similar to what we would have now in terms of how the nurses are funded — or LPNs or other members of the clinical team.

S. Sullivan: I’m on the freedom-of-information and privacy protection committee. I’ve actually heard more from this committee about the issue of privacy issues and how it affects our medical system. I know our workhorse…. The tools that we allow our medical people to use are fax machines and pagers. We do allow them to use automobiles. We’re not making them use horses and wagons. At least, in that area…. It is quite remarkable.

You referenced how that has affected your care and your ability to…. Could you elaborate on that?
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D. Fontaine: As I indicated, the issue of information transfer and…. We are still using fax machines. I haven’t seen a fax machine in probably five years, but apparently they still exist in doctors’ offices. It’s a terrible system.

You might become ill in the middle of the night in a care home. You might go into an emergency room. You might be gone for eight, ten, 12 hours and then come back into a care setting, and there is absolutely no ability for us to find out what happened. It might take days, hours, to be able to determine what’s happened with the clinics at the acute care centre. Most of that relates to technology, and it relates to privacy.

I’ll give you the best example I can give you. I have probably 50 apps on my phone, and every single one of those apps asks me for access to my phone, my this, my that. I click yes. I don’t even care because I want the access to that app. Why can’t patients and why can’t the public opt for that, if they want?

For example, Mr. Sullivan, if an individual, who is the patient, and the care home agree that they want to share that information, that flexibility isn’t even there. So even if you want to give your information, you can’t, and the systems are definitely not there to do it.

I’m sure you’ve heard this in the broader perspective, but when it comes to the frail elderly, it’s very important — I mean, I’m sure it is for everyone — to get that information as soon as possible and to find out what happened on site. Oftentimes, it can take a while for faxes to come in, etc.

When you talk about continuing care hubs, I know you’re thinking of those as being placed in a community. But one could also think of those as being placed right within a residential care centre. What would be the number of units you would have to have, generally speaking, before that begins to be workable?

D. Fontaine: Well, it’s almost…. You could see it as…. I’ve watched them evolve. They started with a core of one care home, and then maybe an AL unit’s been built on, and then there’s been some independent living built on. So the campuses have been somewhat organic. They haven’t…. Nobody’s come out and said, “We’re building a care campus,” which would actually be quite innovative. But nobody’s come out and said: “This is what we’re purposely going to do.” The care campuses have evolved over time.

In terms of the number of care campuses, I don’t have an exact number for you. But I would tell you that if you’re looking at the image that I’ve put onto the slide there…. It’s part of another presentation I give. That was an old school on the west side of Vancouver that had…. The actual enrolment had gone down, so the school board was looking to repurpose it.

They had a declining student population and an inverse ratio of people getting older. Everybody in the community was looking at each other, going: “We have to go out to places like Abbotsford to get our seniors care. Why can’t we stay within the community?” So in this model, the community got together and said: “You know what? Let’s repurpose an older school, and let’s turn it into a care campus.” And then the land costs are really low, because the government owns the land already. Involve the private sector in that to build a care campus, build the child care, build the things you need for that site.

Something like that on the west side of Vancouver would probably have several hundred — I would assume several hundred — beds and units of AL. It would be a real hub, for sure.

I think that when you hear things like schools that are underutilized and schools that are not being properly used to their maximum capacity, I can assure you that there are a lot of seniors who would love to see that unused land converted into a place for them to live closer to where their current single-family home is, rather than having to be forced…. I won’t say forced out to places like Surrey, because they’re beautiful places. I live in New Westminster. But you should….

D. Fontaine: I love New West, and Coquitlam’s nice too. But people should be able to live….

D. Fontaine: And Surrey. I know. We’ve got the whole gamut. That’s why I knew I was going into a landmine. I was going: “I’m from New West. I live in the suburbs.”

But people, if they do live in an area, should have the…. Especially in places like Burnaby, Vancouver, Richmond, West Van, where the land costs are so high and there is underutilized land, I think the provincial government could work with the cities and with the Ministry of Education and the private sector to look at this campus model as something that it may want to pilot.

L. Larson (Chair): Interesting concept, for sure. It’s the costs of the land and the building itself that are usually so high that you can’t create these care places in the middle of the cities — because of that, right?

D. Fontaine: I’ll give you my last…. I’m running out of time. If you look at the O’Keefe properties…. I think Sam would be very familiar with that; he probably sat in many public hearings. When they were looking to redevelop the O’Keefe, I remember there were so many complaints about the density and people were saying:
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“Oh my God. We don’t want this. We don’t want this built in our neighbourhood.”

Interestingly enough, if you actually look at who purchased in those places, it’s all people who have sold their single-family homes and retired and moved…

D. Fontaine: Yeah. They didn’t want the density, and now they’re actually living in these places.

So I think we can do it. I think if the model is sold properly — a lot of people have a fundamental philosophical issue around removing land from the public purse, moving it away from that and selling it — perhaps there’s another model that could be used, which could actually repurpose the land and help a different population.

L. Larson (Chair): Interesting idea. Good. Thank you very much. Thanks for your presentation and for all the good work that you do. Like you say, most of us are well familiar with the B.C. Care Providers and all of the good work that you do. Thank you for being here.

Good morning to Dr. Ruddiman, who is here representing the Doctors of British Columbia — the president or chair or however that works.

Just so you all know, he comes from my community, Oliver. Just letting you know that rural British Columbia has good representation with the Doctors of B.C.

A. Ruddiman: Madam Chair, thank you for that, and a warm welcome to all of you as well. It’s a pleasure to be here with you today.

As Linda has correctly alluded to, I’m Dr. Alan Ruddiman. I’m a rural generalist physician. I’ve practised in Oliver, in the Interior of British Columbia, for the last 20 years as a generalist. We’ll get into that a bit later on.

I’m here today in front of you as the president of Doctors of B.C. Some of you may have followed the rather public election we had last year. I’m very, very happy to be in the role that I have today. Just as a reminder, our organization serves about 14,000 doctors at all levels of their careers in this province.

I also co-chair the Joint Standing Committee on Rural Issues. Donna and I, the rural caucus — we’ve had, certainly, time to interact in the past in that regard as well. There’s lots of good work that needs to be done.

I should probably let you know that Doctors of B.C. remains very committed to making a meaningful difference in improving the health care of patients and residents across British Columbia. We want to work alongside, certainly, our physician members — the 14,000 doctors that we represent — but, more importantly, with our provincial partners. It truly is about partnership in achieving what I believe is a high standard of quality care in this province. That’s the motivation that drives us all.

For our organization, we rebranded a couple of years ago. We used to be the BCMA, and we were misassociated with a number of groups, the B.C. meat-packers association being one of them. We rebranded as Doctors of B.C. I think it better and more generously describes who we are.

Our tag line is “Better together.” That “better together” piece is really, really important as we look to how we plan for health care in this province moving forward. We’re better together as an organized group of knowledge workers. But I believe we’re also better together when we reach out and talk to the partners that are responsible to help guide the ship that is health care in our province.

Through the joint collaborative programs that we have in our province — these are collaborative programs where there’s a partnership between the Ministry of Health, the health authorities and Doctors of B.C. — we’re funded through the physician master agreement. That comes up for renegotiation every so many years. But we’re partnered in a lasting relationship now with the provincial government. We’re very fortunate to have the health authorities as partners in that relationship as well.

We’re really focused on benefiting, first and foremost, patients. This is about caring for patients in their communities. It’s also about the clinical care we as doctors deliver and, certainly, the services that are driven around access. We’re very aware that access deserves critical attention in this province.

Today I hope to have a very open and frank conversation with you. I do realize I’m the only person that stands between you and your lunch hour, so I’ll try my best to keep on task here.

I want to talk on two areas that are of interest to you. One is primary care, and the second is rural care in our more remote and isolated communities. Both of these actually do fall into my area of expertise, being a rural generalist physician for the last 25 years in Canada now.

Firstly, I want to talk very briefly on the really, really big picture about health care and just take an international optic on that. In 2014, the Commonwealth Fund, if any of you are familiar with that…. The Commonwealth Fund is an organization in the United States. It writes broadly about what’s occurring not just in the U.S. in their health care but in other jurisdictions in the world. It does comparators. It looks at the performance of health care systems.

In 2014, they looked at 11 developed nations around the world, and they included Canada in that. Canada
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scored ten out of 11 on the scorecard. That was really, I think, for Doctors of B.C. and for people in health care leadership…. That was a little bit confronting not just to the province but to Canada as a whole. The only nation that scored worse than us was the United States, and for them, they scored worse at twice the per-capita cost that we’re spending on health care in Canada.

The study focused on four key areas of quality of care. They were: effective care; safe care; the coordination of care, which the previous discussion was just talking about; and then patient-centred care, which really is the foundation of the doctor-patient relationship.

In assigning the rankings, if you dig deeper into that quality report, they also looked at other key measures. These were, first and foremost, the issues surrounding access — and I think that’s a big issue for us in British Columbia — efficiency of care, equity of care, healthy lives for patients and communities, and then the per-capita health care expenditures that we absorb as a province and the transfer payments from the federal government.

I bring this up early on not to be demoralizing as we sit and have these conversations. I do that to highlight and suggest to you today that simple tweaks and nuances that we think we can add to improve our health care system are probably no longer prominent in addressing health care in 2016. We’re sitting with a health care system that was designed in the 1960s, and no longer can we address the quality-of-care issues around the design system of those 1960s tenets that we were proposed to have.

We’re faced now, I believe, all of us — governments, health authorities, doctors and other care providers — with a very unique opportunity to truly update and redesign both our provincial and our national health care systems, not on four- or five-year cycles anymore but looking forward to generations of care. That opportunity sits in front of us today.

I point that out because we in the province are responsible for delivering the care to the citizens of our province. The feds do have their footprint, but we’re different, when you cross the Rocky Mountains, and I think we need to think about producing B.C.-specific solutions to the health care needs of our populations and our citizens.

I think we need to stop picking away at these small pieces that I’ve alluded to. We talked very briefly, just before I started, about pilot projects. Those are picking away at small pieces. We really need to come up with a defined vision for what health care service delivery looks like in British Columbia.

I also think we need to try and get to a place where we stop thinking about the political cycle in four-year cycles and the medical cycle as to the length of years of service that doctors and nurses have, because clearly there’s not alignment there. If we make this all about the political need, I think we’re missing the better objectives about what our citizens and our patients require in our communities.

Let’s get on to one of the two issues you’re interested in hearing on, and this is the primary care piece. It brings me to a very important place. I pride myself on my 20 years of service in Oliver, Linda, as a primary care physician and as a generalist. We’ll talk a little bit more about generalism in a minute.

But we’re very, very pleased, as Doctors of B.C., to see that in the government’s policy papers, government clearly has produced, through the ministry, a very real attempt to now deal with the broad-based care challenges that are facing us in health care. Not just in terms of strategy, but government is now talking about holistic care, and I think that shows significant movement in position from where we’ve been before.

It’s an incredibly big job, and physicians, I think, want to continue to be active partners in the true sense of the word but also managers — which we really haven’t been given access to, to this point — through the health authorities and the other areas where our footprint could be absorbed and meaningful information extracted from what doctors and nurses and other health care providers see every day as areas of inefficiency, ineffective care and, where cost savings can be derived, for the government and the ministry to reinvest in more appropriate strategies.

Our interest, first and foremost, is really about quality patient care. It really is the fundamental principle of that doctor-patient relationship. Patients need to have their voice heard, and we need to embrace the virtues of what being a patient, and a vulnerable patient, means in British Columbia in 2016.

The challenges in the health care system. You’ve probably heard this from many previous delegations, and you’re well aware of this, but I’d just like to highlight a few important issues that face us.

One of those is we’re seeing a rapidly aging population, and in the area that Linda and I live in, it’s more prominent than most areas. I think we are the litmus test, like Victoria and Sidney are, for the rest of the province. If you want to know what’s going to happen in your community, come and talk to us, because we’re already living and breathing and servicing that population’s needs.

The average patient in my medical practice is a 76-year-old woman. That’s my average patient. I have patients in their late 90s still driving to my office to have conversations around health care with me.

The second is that the population numbers continue to grow in this province. British Columbia is a desirable place in Canada, and we’re incredibly desirable as a province in the eyes of the world to come and settle and do business and live and raise families. We need to bear that in mind.

We’re also — and this is where I’m really perplexed — actually on the cusp right now of having probably the largest proportion of doctors register their intent to retire than we’ve ever had to embrace and address. The aver-
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age family doctor in this province is 54 years old, and 25 percent of all family doctors in this province have told us that in the next five years, they have registered the intention, if the economics hold out, that they probably would like to transition to some form of retirement in their professional lives.

Our younger doctors — who are just as hard-working, just as motivated and just as dedicated — are, however, less willing to work the gruelling hours that I and my colleagues and peers have committed over the last 25 or 30 years. I think we need to pay attention to that. They’re not less committed to providing quality health care, but they do want to have a balanced life so they can be healthy to look after their loved ones, to interact with their families, to commune with their community, but also to be healthy enough to look after the patients that they want to serve for the next 30 and 40 years.

How do we, as a province, meet those challenges? I’d like to consider physicians as team players, but beyond the traditional model of how we see playing in the sandbox. Doctors really want to embrace and reach out to a team-based care model, working with allied health care providers in our communities and across the province. The thinking is that in combining physicians’ practices with the networks of other health care providers, such as nurses and others — and I heard about nurse practitioners just a little while ago — more patients will be able to gain access to continuous care provision, maybe not from a doctor all of the time.

I don’t see doctors necessarily wanting to protect that turf any longer. Yes, we have. We’ve sat on that, and we’ve said that really is the foundation. But I think doctors are becoming wiser at understanding and appreciating that patients don’t always deserve a doctor for every interaction they need on the health care team.

At the same time, though, in order to do this effectively…. This, I think, is a really important piece for me and for all of my colleagues: data and the coordination of electronic information within this province. We really need to invest more time and more energy and be more resourceful in the way in which we instruct the data providers, the vendors and, more importantly, get physicians and other providers to embrace health care technology as a way of being able to support patients in navigating their health care information through the health care system.

In this way, I think we can best use the time of physicians and other health care providers, because what would occur is the patient’s electronic record would always be dynamic. It would be occurring in time as the patient encounters care. There would be no gaps. There would be no errors in the way in which that information is captured. The patient would be the custodian of that electronic health record, and it could serve patients well, not just in our province.

If I was king for the day, I would see that health record become a national standard. No matter where in Canada you present as a patient, as part of our health care system, we know that the information is accurate and up-to-date and captures the type of care that is being delivered to you.

In visioning, we did consultation through the GP Services Committee, that tripartite relationship between government, the health authorities and Doctors of B.C. We did visioning exercises with about 3,000 family doctors in this province. The majority of doctors have registered that they view this concept of team-based care in a very, very favourable light. That’s a strong message I need you to take back to government.

I should note that the foundation of this model really did start with something government invested in with doctors, which was the GP for Me initiative. I know that the media has been really hard on government in saying, “You haven’t delivered a family doctor to every patient in this province,” but that never was the focus of the GP initiative to begin with. It was to identify high-needs and vulnerable patients and connect them to primary care providers, primarily family physicians, to make sure that their complex care needs and their chronic disease managements could be enrolled in longitudinal provision of care.

I’ll give you a couple of examples of what’s occurring right now. We’ve talked about pilot projects, and these would be worth highlighting. On the Sunshine Coast and in the Kootenays, GPs are now working together with patient navigators and social workers to help marginalized patients in those geographical communities.

This is where we’re shifting away from the traditional model of care. We’re thinking about the social determinants of health. Putting shoes on the feet of patients with diabetes keeps them out of the emergency department — not giving them more antibiotics for their recurring foot ulcers. Having a social worker that’s willing to listen to somebody whose family is falling apart rather than admit these patients to a psychiatric unit because they’re in distress — these are the kinds of issues we need to be embracing if society truly is to move ahead in British Columbia.

At a new wellness centre in Nanaimo’s John Barsby Community School, students that are now in grades 8 to 12 don’t even have to leave the school grounds to interact with a doctor or a social worker. They’re embedded into the school footprint, so that these children and these young minds are now given an opportunity to come forward as young-occurring adults and actually embrace health care on their own and have some very private conversations with providers — conversations they otherwise would not have with traditional physicians and providers in their community. So they’re being given the space to have those conversations.

In the New Canadian Clinic and the Global Family Care Clinic in Burnaby, government-sponsored refugees have now been given nurse practitioners as their primary resource to interact, to understand their language, their
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culture, their skill set. When these people are then transitioned to the community, the division of family practice in that community, in Burnaby, is now creating the space to absorb the capacity of these people who have now been acculturated to Canadian medicine through the nurse practitioner so that their complex care and chronic needs can be addressed as well. I think it’s a wonderful initiative.

The Burnaby Division of Family Practice really knows they were given a huge opportunity to interact in a meaningful way with the health care system that was a non-traditional approach to solving problems that governments had.

We know that the models can work. There really are four key areas that I want to talk to you about in the domain of primary care that I think you should help me understand and appreciate and that we should pay attention to together.

The first key area is actually, for me, in advocating for doctors: what is the role of the physician in that team-based care? Doctors are listening, and they’re going to take some advice on the leadership of government in terms of where doctors fit in the team. But they have a strong message to send as well, so I think we should pay attention to that.

Physicians have always had a very respected role in the team-based care that we interact in. A large part of that occurs to some degree with our community staff that we interact with — the nurses, the other care providers, the allied health care professionals, dentists, social workers. But really, the best place to watch that interaction is in the emergency departments and the acute care facilities, particularly in the rural areas, because we’re under-resourced. So we’re encouraged, and we’re essentially forced into a situation where we need to play together well.

I encourage all the students and residents that I have come through my practice. I say to them before we even step foot in the hospital: “What’s the most important thing you need to do if you are to survive the next eight weeks here?” The answers that I hear are never the answer that I want to hear, so I lay the ground for them. “Pay attention to what the nurses have to tell you. The nurses will save your life, and by doing so, they will save the lives of patients. These are smart, in-tune and very, very well-informed allied health care professionals.” The students and residents come out on the other side, and they become immersed in that culture, and this is the way they want to deliver care in the business of health care.

Within these well-organized teams, we also respect the fact that doctors are the trained medical experts. When a crisis erupts or there’s a major catastrophe for a patient, all members of the team tend to look to the physicians to say: “Well, what do we do next?” So we need to protect that medical expert role and not dilute the social equity that doctors have in our province.

Again, I turn this around. The 3,000 doctors in that cohort study said: “Please tell us what the future could look like. We really want to be in a team-based care setting and providing care.”

Doctors do take their role in health care leadership very, very seriously. Yet we don’t want to see patients jeopardized and compromised, so we know that access is important, and we’d like to work with other allied health care professionals to deliver the access piece of the equation.

We also recognize — I know this word has been overused, and maybe we need to find a new word to replace it — that collaboration truly is key. When I think of collaboration, I think of synergy. I think about my patient with a revolving team of providers around them. From time to time, those providers reach out to me or I reach out to the patient, and that synergy produces a better quality of life for the patients that we’re interacting with. I simply believe we have to protect that physician voice in the team-based care model.

The second piece that I’d like to speak to — I’ve talked on this very briefly — are the issues surrounding data, electronic medical records and the electronic health records that now are permeating health care. There’s a lot of pressure from external vendors and providers and third parties to say: “We are the best tool around. Please use us.”

How do we effectively and efficiently do this? A comprehensive and integrated approach to electronic health records is critically essential to the success as we move forward. EMRs are critically important to coordinated and timely care and access provision to patients in our health care system. I truly believe that we need to have a universally accessible IT system. Maybe this is where you folks can drag the federal government into the conversation. It needs to allow for seamless sharing of information and access points that are critically important to patients as they move through the system.

I would tell you, if you ask patients and doctors around the issues surrounding security, that I think security is becoming less of an issue when patients want to sign off so that they know they can get access at the time of day and night when they think it’s critically important. Yes, security is really important, but I think it’s not the top of the list for where patients would like to place it.

We need to think about how we appreciate risk in society, because risk is iterative throughout all levels of society and not just in health care. Big business has embraced risk. They’ve moved ahead. We’re lagging when it comes to how we incorporate information management.

Doctors and other health care professionals need to be a key part in developing the systems that we roll out. It’s no longer important for vendors to tell you what doctors and nurses need. We need a tool that is a servant to us. We don’t want to be a servant to the tools that are put in front of us. It’s producing significant inefficiency.

To this very day, we’ve embraced this in the South Okanagan. We have an excellent EHR system, but I’m still
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15 percent to 20 percent less productive and efficient than I ever used to be. I’m not a data entry clerk, but that’s the kind of work that I’m doing for about 15 percent to 20 percent of my day right now.

Systems need to be designed and devised so that they’re legitimate, that they’re tools that all levels of your health care provider team can sign off on. Only then should you be in a place to deploy a tool that says: “This will serve patients well.”

The other thing I think we should be aware of, and this is the third key point, is flexibility in our health care system. We have a lot of pilot projects that are out there, and they’re working very, very well. I think what pilot projects are telling us is that we need to embrace flexibility — no one-size-fits-all for our communities and for patients.

In team-based care, we’re going to see solutions that may be very applicable in the East Kootenays not be applicable at all on the North Shore, or a program that’s designed for Fort St. John as a service delivery model may have no application in South Surrey.

On a broader scale, the GP Services Committee, with its membership from Doctors of B.C., the Ministry of Health and the health authorities, I think is very, very well positioned right now to be provincially available and responsible for the co-design of the patient medical home and the primary care home. I hear these being used synonymously, but they’re a little bit different.

Physicians want to be central to how that conversation occurs around the patient care home. The fundamental relationship that we’re taught about all the way through medical school and into our residency and that we embrace for the rest of our professional lives is that doctor-patient relationship. It really is sacred.

It’s the one bit of space where patients can be given the independence and the freedom to truly act with the professional without fear of reprisal. It’s a very safe and protected area. If we break that down and we lose that sacred tenet of medicine, I think fundamentally we’re going to struggle to regain the trust and the relationship.

I don’t think any one model can be imposed, but we need to think about what these models could look like.

The fourth key area that I want you to appreciate — this is an area that we’re struggling in a lot — is the area around the relationship between health authorities and physicians and vice versa, because it is a relationship, and it takes two to tango.

We recently surveyed physicians as we try to understand and appreciate what we are struggling with most, and we were very alarmed to hear that it’s the relationship between the health authorities and doctors that appears to be struggling — so much so that for me as a health care provider in 2016, I really find it disappointing.

Many physicians, especially specialists and the facility-based physicians, many of whom in the rural communities are actually GPs and family physicians, have identified that they feel there’s a lack of respect from the levels of administration that we have created within our health authorities. Being able to embrace the physician voice or the clinical voice — and when I say “the clinical voice,” I include the nurses and the allied health care professionals — in offering opportunities for change that could exist within the health authorities. But there’s no formal place to register that voice of dissent.

What ends up happening, unfortunately, is health authorities go ahead and develop policies called the disruptive physician or disruptive provider policy, and they hold that policy up and say: “You can’t have your voice because you’re being disruptive.” I think that shuts down a conversation, and it shuts down the ability to embrace diverse thought. It’s the very diverse thought that is looking forward to come up with meaningful solutions for how we can change health care in this province.

The physician voice and the voice of other providers, I think, deserve greater authority, greater influence and greater representation. We’re not asking to take control, but we’re asking to be partners in finding meaningful solutions for helping fix what is not right in us ranking ten out of 11.

We do need to see scenarios change in order to move forward effectively, and we’re asking physicians and health authorities to work to resolve this. We’ve actually created that very opportunity through the last physician master agreement. They’re called medical staff associations.

Government and Doctors of B.C. have agreed to divert $65 million worth of money that would have gone into targeted fees for physicians to create these medical staff associations within the facilities to give the grassroots physicians and providers in the hospitals the opportunity to both dialogue directly with the health authority and to exercise the influence that we don’t currently have occurring. When I say that, the team-based voice in our local facilities can be conduited through the medical staff associations as well.

I actually say, as a physician, even though I find it very confronting and disappointing to say that it’s not occurring, I find it a very exciting time because we can open up at a grassroots level, particularly for the rural and remote communities, a place to have meaningful say and influence back in our health care system again.

Let’s move on, then. The second piece was what you’re interested in hearing about, which is rural care and rural health.

Rural medicine clearly is a topic very close to my heart. I’m a trained rural physician. I’ve been a rural physician for 27 years — 25 years in Canada and 20 of those years in the South Okanagan — so I think that I can speak with some authority here today when I try and bring the rural voice, just as I have to the rural caucus in the past.

Rural medicine is very dear to me. One of the things we seem to get right in rural that we maybe struggle with in the urban and metropolitan areas: we’ve still em-
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braced generalist medicine as being a meaningful and cost-effective solution for how we deliver care. And when I say “generalist,” I’m not just talking about family physicians. I’m talking about how we deploy our specialists in this province as well.

So internal medicine specialists, obstetricians, orthopedic surgeons, anaesthesiology — we embrace these in rural, but they are practised to the depth and the breadth of their training. Sometimes they’re practised beyond that by gaining additional skills to resource our communities, our hospitals and our emergency departments in providing very effective, very efficient and very timely health care to our citizens, who we shouldn’t be moving around the province to receive their care.

We have to think about holistic risk. Doctors and nurses and ambulance crews die every month of every year in our province because we move people around unnecessarily.

In B.C., the number of practising physicians in rural communities is seen to be growing, and we appreciate that it’s growing, but we still haven’t addressed the inequity that exists. So 25 percent of all of B.C.’s residents live and work in our very productive, rurally rich and resource rich rural communities, but only 11 to 14 percent of the doctors in this province live and work there. So there is an inequity. We constantly are clamouring to try and correct that inequity.

We’re overworking the doctors and nurses in those rural communities that are generalists. These are the doctors and nurses that, historically, were working 80 to 90 hours a week, and the younger doctors, again, are telling us: “We simply cannot embrace that as a way of being healthy in our communities.”

I’d like to share with you a quote from one of my rural colleagues, Dr. Peter Newbury, from Hazleton, B.C. This is a quote that originated from Dr. Newbury as recently as last week. He’s an Order of Canada recipient, so there’s something right about the way this guy thinks and works. This is what he said. He said: “For rural, remote and isolated communities, the presence of a family doctor who makes a commitment to the community contributes not only to individual patient wellness and care but, just as importantly, to how the community thinks and feels about itself.”

I know we’ve seen this very, very often when we hear about vulnerable communities become communities in duress, and they become communities in crisis. I don’t think, in this day and age, we should ever be talking about communities in crisis in rural British Columbia.

To move forward, I think we need to think back to that big picture that I alluded to earlier. Where are we not scoring well on the scorecard, and can we actually have a very frank and honest conversation about improving our scorecard in British Columbia? We lead in many, many areas of rural health care provision. We lead across the country. Other provinces stare at us and say: “How did you develop these rich and generous programs to recognize the uniqueness of generalism in rural medicine?”

We’ve got it right, but we can do better. The joint standing committee does amazing work, and the Rural Coordination Centre of British Columbia is probably the critical think tank on rural health right now that understands networks, understands the value of your communities that you advocate for every day.

We need to support the growth of these vibrant communities. These are where the resources are. They’re being mined, and they’re supporting the general coffers in this province, but they’re not necessarily coming back to us in the health human resources numbers, which I think we need to see to support maintaining the vibrant-community status of rural Canada and rural British Columbia.

On the issue of health human resources, then, I’d like to make the following comments. In this respect, if we are truly to pay attention to the alert of the Commonwealth Fund, the area that we need to focus on, I ask you to really try and bring back a strong message surrounding generalism through your themes. We need to rural-proof British Columbia.

Rural British Columbia is not asking to be better off in dispensation than the rest of B.C. We simply want to have equity in that conversation so that we know we can produce a very balanced type of service that we deliver to families and patients and communities.

We shouldn’t destabilize core and critical generalist services, because if you remove an anaesthesiologist from a small rural hospital, we know that you can compromise the emergency departments, you compromise obstetrical care, and, before you know it, you compromise the very existence of a community hospital. We have to think about the trickle-down and the ripple effect. When you touch something here in the Jell-O, what wobbles on the other side?

In generalism in family medicine and those core specialties, we need to really have the physicians’ voice and Doctors of B.C. voice permeate through the HHR planning piece. I think it’s critically important. We don’t want to be the only voice at the table. If we’re going to have these collaborative teams, I think we need to incorporate all of those health care providers in that.

Let me conclude, then. One of the things we need to think about is the entrants to medical school and how we train and retain our own physicians. I sit here today in front of you as somebody that still has a foreign accent, but I’m very, very proud to call myself Canadian. There are doctors that come from overseas every day that we plug in as international medical graduates, and we’re plugging in Canadians that have gone overseas and come back as international medical graduates. I think we need to work with our university and train our own talent in our own province to meet the future needs.

I’ve provided my thoughts to you as a committee, and you’ve been very generous in listening thoughtfully, but I’d
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like to turn it over to you by thanking you for, first of all, creating this conduit. Doctors of B.C. and the 14,000 doctors that are committing to supporting health care in this province have a very strong and very authoritative voice.

I say the authoritative voice, but I’m suggesting we need to listen more broadly to the profession. Women now outrank men by over 50 percent when they enter general practice. Women think differently about how medicine should be addressed, and I think we need to expand that in our boardroom at our committees at Doctors of B.C. I bring my voice to say that I’m going to do better in that regard. But I look at your committee today, and I say I think you’ve got the balance right.

L. Larson (Chair): Actually, Alan, we don’t have time for questions. We have another presenter who will be here in 25 minutes. We have to break and shut down on air here.

Anyone and everyone is more than welcome to send Alan questions. He will answer them, I guarantee you, if you’ve got any. I have a few myself. I may be able to catch him on the plane, but nonetheless, please email him your questions. He will get back to you right away and certainly hit those topics that we know we have heard all week that we don’t have a chance to ask about right now.

A. Ruddiman: Thank you all for your time and attention. From Doctors of B.C., we truly want to thank the provincial government for partnering with us. That partnership becomes critically important as we move forward.

L. Larson (Chair): You have 15 minutes to do your presentation, and then, hopefully, we’ll be able to ask you some questions. I’d like you to introduce yourself and your background, where you’re coming from.

J. Coward: Okay. I’m Jel Coward. I’m just a simple country doctor, somebody could say. I’m a rural physician and have been practising in Pemberton for the last 15 years or so and previously from the U.K. I worked in urban and rural practice there and then came across to Canada in 2001.

I do some rural support work with the Rural Coordination Centre of B.C. I also sit on the board of the Rural and Remote Division of Family Practice, and I’m one of the founders and directors of the CARE course, which is an interprofessional emergency medicine course that visits rural communities and teaches emergency care skills to nurses, physicians and paramedics in interprofessional teams within their own facilities. We’ve been doing that since 2010 and have done that 58 times, or something like that, now.

Thank you for inviting me this afternoon. It’s the first time I’ve spoken to a government committee, so please forgive me if I sound a little bit nervous.

There were two questions that really piqued my interest and made me respond. One was particularly around improving the health care services and, particularly, retention and recruitment to rural areas. The other was the interprofessional or interdisciplinary question.

I don’t have any slides for you. These are really thoughts and ideas that come from my head, I guess from my experience over years, working rurally, doing full-service family practice, and also with the CARE course, visiting many communities around B.C. and, of course, with the Rural Coordination Centre of B.C.

Retention and recruitment is a problem in rural areas. I think we’d all agree. It always strikes me that a good question is: why? It’s a fantastic career. It’s a fantastic way to practise medicine. It’s a fantastic way to be of service, which is a great thing for us as humans — the diversity, etc. Having come from the U.K., it struck me that practising rural medicine here is just much broader and more rewarding than it is in the U.K. and that Canada has something to be very proud of in its rural medicine and rural generalism.

Why do we struggle? Well, I don’t quite have an answer to that question now, but that is what I would like to say. I think there’s so much going for it. What can we do to leverage the things that would attract and keep people in rural areas?

I’ll offer a thought that I think…. People often say recruitment and retention. I think that’s the wrong way around. If we’re going to start to improve this, we need to focus on retention. Then our recruitment becomes worth doing. Unless we look at the factors that will retain people, then we’re kind of wasting our time with recruitment.

I think one place we have to go…. I think the Rural Coordination Centre has done a good job of this, and there are great things happening with government and
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with Doctors of B.C. around this. That’s something around — let’s put it in inverted commas — the “rural identity.”

I think there’s something very important about saying: “Hey, you’re a rural physician in British Columbia, in Canada. Let’s have a look around the world and see where people are practising generalist medicine in the same way that you will.” You don’t find many places, right? You find Australia. You find, maybe, some of the Eastern bloc.

But you don’t find many places where that career is on offer or where people could feel so proud about delivering, really, some birth-to-death care, from family practice right through to the most intensive critical care in the emergency department — and performing that care often on your friends and neighbours, because you live in the community.

If we can build that identity and pride in that role, then I think it sells itself very much. Certainly, supporting generalism is at the centre of that. We do have a bit of a tendency to send slightly negative messages about generalism sometimes. I think some of that is spoken to by some of the recent privileging project things. Generalist medicine is fantastic and, I think, delivers very high-quality care. We need to really keep sending that message — that patients benefit from having generalists. We need to be careful with our language and our positioning of how we talk about the care that’s delivered.

Education and support for physicians that want to work rurally, I think, are also absolutely central, and that’s rurally appropriate education. Again, to come back to this, have an identity. Have some pride in what you do. If you’re forced to go and learn, say, your trauma care from the surgeon in the city because they’re the only people that could really know, that’s great. You’ll probably get a great education. But there is a little bit of negative messaging in there.

Certainly, one of the things we have noticed through the CARE course is that people really appreciate education from their peers and interprofessional education from their peers. It’s palpable amongst the groups that we’ve been able to visit, that they think: “Now we feel empowered. We really can deliver that critical care. We really can put a tube in that chest if we have to. These other people do it.” I think that’s an important part — making sure the education is rurally appropriate.

I know I only have 15 minutes. My wife says I never say anything in 15 minutes. I’ll try and move on a bit.

J. Coward: I couldn’t hear you. I’m on the Bluetooth in my vehicle. Maybe that’s why. As long as it’s coming across okay, I’ll continue, shall I?

J. Coward: Pay. People always talk about pay and incentives. The rural incentives are very, very important and, I think, very powerful. Certainly, again, as physicians, these incentives reward you for being that generalist, for doing 24-7 care, for cradle to grave, for being prepared to do and meet whatever need comes in the door. I think that’s a good way to position them.

Sometimes they feel like they’re a little bit positioned around remoteness. “That must be a terrible place to work. Therefore, we’ll give you lots of money.” The negative message does come through, though. Even though people appreciate the money, I’m not sure always that the pull of the money is enough to outweigh that slightly negative messaging. That’s just my thought around how we position those rural incentives. Their rewards for providing great, great care in sometimes difficult circumstances, I feel, is a good way to do that.

The incentives definitely are appreciated by rural physicians — there is no doubt about that — and I think are very necessary. Practising medicine in a rural community takes more time, there is no doubt. You see everything that comes in the door. If it comes to emerg, it’ll come to your door.

It’s very different from, often, the sort of self-triaged patients that might present to a walk-in clinic somewhere, who you know, when they come in the door, that chances are this is something fairly minor; whereas, everything you see in rural medicine, you have no idea, because it always, always comes to you. Rewarding that time input is important.

Also the cultural piece. Many of our First Nations people live rurally and need excellent physicians. I’m privileged to look after a good number of First Nations communities. That care and that cultural competency takes more time. There have been some things written on this saying maybe two to three times the time for an average visit. Those incentives help reward and compensate for that, although I would say that work — caring for First Nations — is very rewarding in its own right.

Another point about some of the negative messaging. I’ve heard it from many other people — that getting people to go and work in rural communities is a very negative thing. It’s very negative for them, and it’s actually quite negative for the communities — sometimes in a number of different ways.

Really what I’m talking to here is the way we insist that international medical graduates do return of service in remote communities. That kind of labels the community as somewhere you get sent to because no one will work there. Even worse, I think there’s a little bit of being sent away to the colonies, as if you were a criminal from the past. There’s a feeling of that to it.

Some of those IMGs stick, but many don’t, and they’ll come and go within their two to three years return of service and leave the community without. It really takes our
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minds off the important issues of recruiting long term to those communities. If it was a vehicle for having these docs stay long term, it would be great, but — I don’t know the statistics, so I could be wrong — most people don’t feel that’s a way to do that.

It really allows us, perhaps, to say: “Well, we needn’t worry about community X because there are two docs there.” But the doctors are going to stay two years, but one builds the relationships that they need to provide group quality family practice in that time, etc. It’s kind of papering over the cracks a little bit and distracts us a bit. I would say, if someone asked me what is one change I would like to see, I think I would like to see the end of that practice.

I think it’s also very disruptive for some of the IMGs coming from very different cultures. They’re working very rurally and isolated from people they know from their communities, etc. I think that’s great hardship for them as well. I know they have the great benefit of coming to this fantastic country, but I’m still not sure it’s the most positive thing for them or for us. I wanted to share that thought.

Briefly on telehealth. E-health, I think, really can help us with retention and recruitment but positioned in a way that it supports local structures. There is a little bit of a tendency to see telehealth as being able to replace some physical, face-to-face care, and it can in some regards, but only really, in my view, in a structure of you know who your physician is. You have a physician who’s here. There is a physician in the emergency department if you need them.

I worry a bit that some of the telehealth, in different ways, might decrease the on-the-ground care in the long term and might also send a little bit of a message that: “Hey, as a rural generalist, you’re not good enough.”

Again, if it’s positioned well, if I have a cardiologist link up with me and we deal with a patient together and help them and support them together, that looks great. If it’s seen that I can’t look after their hypertension, and you have to go and see the telehealth cardiologist, that perhaps doesn’t look and feel so great. I think just how we position telehealth is very, very important.

Lastly, on my little list there, I have strengthening communities. I think that’s what it’s about. If we strengthen rural communities, physicians and nurses and probably the paramedics, the ambulance service…. People will stay because they’ll feel that identity with them.

Certainly, through the CARE course thing, that’s at the centre of what we do. We go into communities. We’re extremely positive. It’s a very different style to some of the more traditional, negative style of medical education. Really, our agenda — although we don’t tell anybody — is to strengthen their community, improve their interpersonal skills, improve their teamworking. We joke a little bit that if we advertised it as such, no one would come. So it’s a full-on busy emergency care course, which it absolutely is. It delivers a lot of emergency education. But we really want to strengthen communities.

L. Larson (Chair): Well, not if you want us to ask you questions. If we are going to ask you questions, then I need you to wrap up within a minute.

Interprofessional care, I think, is absolutely key. We have a nurse practitioner who works with us in our practice and has been fantastic to our team. I come from the U.K., where everybody has a practice nurse. We have health visitors. Always work in teams.

It’s a shame that we are not at that point in Canada yet. It’s a shame, even, that there seems to be a debate and discussion that it’s going to be a difficult thing to achieve. I think we should keep running at it hard, because interprofessional care, to me, and interprofessional education make my day so much better and make me feel that I deliver much better patient care.

One of the key things is, I think, to ensure that we communicate well that practising interprofessionally doesn’t threaten autonomy or doesn’t threaten anyone’s roles. I think that’s probably at the centre of it, and that’s probably around relationships and just getting on and starting doing it in a successful way.

L. Larson (Chair): Thank you very much. We have heard the recruitment and retention issue as it relates to the doctors coming in internationally, that generally they don’t stay more than the year or two. Again, a lot of it is a cultural issue. You’ve hit that right on the head.

J. Coward: Well, I think of agencies, bodies that exist. I think a conversation with the Rural Coordination Centre of B.C. would be absolutely at the centre of that and, of course, the Joint Standing Committee on Rural Issues. It would be interesting to do a clean-white-sheet-of-paper exercise with people saying: “Hey, what do we think this looks like?” Let’s take some of the things off the table and just say: “How do we think we could design this to become successful?” Ignoring any constraints, and then work out where the constraints fit into that.

L. Larson (Chair): Okay. Thank you. The CARE course that you talked about. Who funds that?

J. Coward: That’s funded…. The communities pay for it, usually by reverted CME, the continuing medical education money that the community has. But the CARE
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course is also supported, in terms of administration and lots of the things that it takes to run, through the Joint Standing Committee, through the Rural Coordination Centre of B.C.

D. Barnett: Thank you very much for your presentation. I find it very interesting that you came in 2000 — was it? — to Pemberton.

D. Barnett: 2001. What encouraged you to go to a rural community in British Columbia to practise?

J. Coward: Well that’s an interesting question, because my answer is: I was forced to because of the requirements, both the immigration and licensing requirements. So I would have to work in an area of physician need, I think it was known as. But having said that, I came from rural practice in north Wales in the U.K., and I only ever considered working rurally.

I had some friends who had worked, not in medicine, but around Whistler and in the Sea to Sky corridor, so I was kind of drawn here and started looking around, and there was a need in Pemberton. To this day, I cannot believe my luck. It’s a fantastic community.

D. Barnett: Well, thank you. I don’t really consider Pemberton as rural British Columbia because of how close you are to North Vancouver, West Vancouver. I mean, it’s still far. But the rural communities that I am concerned about are the ones that have 1,000 people, 300 people. The only access is maybe by an airplane. Places like that.

How would you suggest that we advertise or promote those areas to practitioners from outside of Canada, to come here?

J. Coward: Well, if I may come to the second bit of your question in a second. I just want to come to your first bit about Pemberton.

Pemberton has a population, I think, of 2,000 now — maybe 2,500 — but serves maybe 6,000 to 8,000, of which there are many numbers of remote reserves. Well, five remote reserves, maybe six. I fly to three of them once a week, because they have no Internet access, they have no cell phone coverage, and they have no land lines. It might seem that given the proximity, 2½ hours to Vancouver…. It serves many remote people.

How would I attract people to places other than Pemberton? Because I think Pemberton is easy to attract to. There are some important things. It’s feeling you’re joining a strong medical community. It’s feeling you’re joining something very important — rural generalism. It’s feeling that you’ll be supported in your rural generalism, not frowned at by specialists, and that you’ll be supported in your crediting process around that.

Then there’s some family things, and the family things are key. Education is a big issue. What do you do when your kids hit high school age? And actually addressing that explicitly with people, saying: “What does this look like to you?” I mean, B.C. has the great on-line program EBUS, and our children have used EBUS. But making sure that that support for families, spouses and children is in place.

Part of that, sometimes, is recognizing the life cycle of the rural physician — that, hey, maybe you won’t be in that community during the high school years and that maybe you’ll return afterwards, and that’s okay. I think being very explicit about that is important.

S. Robinson: I have the benefit, of course, of Google and googled you and came up with Vancouver Coastal Health news. So congratulations on your award of excellence in rural medicine.

S. Robinson: One of the quotes that they have here from you that’s caught my attention, and I would like to get your perspective on it, has to do with your perspective on how you’ve worked together with a whole bunch of other people in providing rural medicine.

You talked about…. You had high praise for all the Pemberton interprofessional health team, from lab to mental health to X-ray to public health to home care nursing to administrative staff — recognizing that there are a whole lot of other people that are part of the health care network.

Can you speak a little bit about how those relationships can be enhanced to provide health care to rural and remote communities?

Well, I have some thoughts. I think that if people can…. Unfortunately, physicians and certainly the structure of medicine here is often: “I’m a physician. I have my patients. And you’re a physician, and you have your patients.” Quite a lot of separateness is felt. Trying to bring togetherness, I think, will help.

I think the GP for Me project was great, but it actually worked a little bit in the wrong direction to some extent, because it was: “I have one physician.”

So encouraging people that working in a team is good and helping them see that benefit. One of the methods
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we use around the CARE course is, we say, in emergency medicine, when you’re doing a difficult resuscitation, in that resuscitation room, if the physician asks themselves, “How do I make this team work well?” — so not a clinical question about the patient at all; how do I make this team work well while I’m here? — then the patients automatically do a lot better.

Having people focus on and value their teams…. And maybe have some education around teamworking and how to make that function and physically see and feel the benefits of it.

L. Larson (Chair): Thank you so much, Dr. Coward. I think we are out of questions for you, so we will take you off line. Thank you so much for sharing with us and, obviously, congratulations on your recognition. I hope you’re going to keep doing what you’re doing for many years to come.

J. Coward: I’m going to try to. Actually, part of my life cycle is going to involve a little bit of time in North Vancouver. My eldest daughter is in high school right now. That’s part of my life cycle, and I will return.

Our next presenter is from the University of British Columbia division of rheumatology. I invite you to introduce yourself and go into your presentation. We have 15 minutes for you to make a presentation and, hopefully, 15 minutes for us to ask you questions.

K. Shojania: My name is Kam Shojania. I’m a rheumatologist, which means that I did internal medicine first and then a subspecialty in rheumatology. I’ve been in practice for 20 years in B.C., where I see patients with various rheumatic diseases, and I also am involved in teaching, research and administration. Just most recently I have taken over as director of the Mary Pack arthritis program, which is our provincial arthritis program. It’s a provincial program, yet it is run through Vancouver Coastal Health, like other provincial programs are run through other regional health areas.

What I would like to talk to you about today is an idea that we had. We have already spoken with stakeholders, and we have broad support for this idea.

The problem is that there are long waits to see arthritis specialists. That’s the big issue. People are waiting up to year. We would like to produce a way that high-priority patients are seen quickly, but all cases are assessed. Those that are not high priority with urgent medical issues can be also treated quickly but locally and without needing specialist care.

The benefit would be shorter wait times, better access to care, reduced drug costs — and I’ll explain why this would actually reduce drug costs — better use of health professionals and better rural access.

The relevant stakeholders have been consulted and are all supportive. The team to get this going has included people from the Arthritis Society, which is the patient advocacy group, the rheumatologists of B.C., the Mary Pack arthritis program, UBC, Vancouver Coastal and even some industry partners.

One of them, AbbVie, for example, has been helping move this forward. They have the most to lose in terms of…. We’re going to use less of their expensive drug. I don’t know if they know that yet, but….

I’d like to just tell you a little bit about arthritis. A lot of people think that arthritis is just aches and pains, but there are very severe forms. When you listen to what I’m saying about this, you could, in fact, substitute diabetes, chronic lung disease or other chronic conditions. When I presented this to the heads of the other programs, they, in fact, put in their conditions and said: “This could work for us too.”

I’m going to talk to you a little bit about arthritis — osteoarthritis versus rheumatoid arthritis — a little bit about this on-line triage tool, the benefits, what else would be needed and the next steps.

The average age in my practice is 46, because we have patients with lupus who are younger, people with a condition called ankylosing spondylitis. Rheumatoid arthritis typically affects 50-year-olds, on average. Some osteoarthritis gets worse as we get older.

Arthritis is one the top three chronic conditions in B.C., affecting more than 600,000 people. It affects more adults than cancer, heart disease, respiratory conditions and spinal cord trauma combined.

Left untreated, one of the types of arthritis, like rheumatoid arthritis, can cause devastating disability and even earlier death. One of our researchers, Dr. Lacaille, has shown that people with rheumatoid arthritis have a shorter life expectancy than people without rheumatoid arthritis. We can improve that with treatment.

The other problem is there are only 64 rheumatologists in B.C. and long wait times to access us, often up to a year. And there is a lack of coverage in rural B.C.

This picture I have shows the people waiting in line for the GP and then people waiting in line for the specialists. The people in red would be someone with rheumatoid arthritis. In my line, I have more rheumatoid arthritis patients as opposed to osteoarthritis. In the GP line, there’s a lot more osteoarthritis, which is more common.

The thing about osteoarthritis is that medications actually don’t help. They can reduce symptoms but don’t
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prevent damage or progression or disability. The most important thing for osteoarthritis is lifestyle measures: weight loss, exercise, function and ways to improve their function, like using the skills of an occupational therapist.

Weight management is very interesting. Our society is getting more obese, and obesity is a very significant cause of knee and hip osteoarthritis. That’s one simple thing. If we could actually…. A very small amount of weight loss can reduce the need for knee and hip replacements down the line — another way to save money.

That’s osteoarthritis. It’s very common. We say that 50 percent of us over 50 have a little bit of osteoarthritis. Rheumatoid arthritis is the more rare type, and it’s about one in 100 people, one in 100 meaning you probably know someone with rheumatoid arthritis.

The thing about that is that’s where medications really help, but the faster we use the medications and get them into remission, the less likely they’re going to get a disability later. We just published a study right now this month in the CMAJ showing that three of our cheapest medicines, used early, are just as good as those expensive biologics. But we’ve got to get them in early. If they’re waiting a year to see me, that’s not early. Early is within six months.

If we can get them on those three cheap medicines, we have also shown that, using B.C. data, the chance of them needing one of those biologics is 50 percent less — just by getting on those three cheaper medications. We call that triple therapy.

I wanted to use two examples. I’ve mixed up names and everything. This is James Smith, a 55-year-old plumber from Vanderhoof. He has had knee pain with stairs and walking. His body mass index is 31, so getting into the heavier side of things. He’s taking anti-inflammatories, but he has high blood pressure, so that means that anti-inflammatories can make that worse. He was told to lose weight and exercise, and he kind of knows that already, but it’s easier said than done. He’s trying some alternative remedies. Okay, so that’s one person in Vanderhoof.

The next one is Teresa Jones. She is a 45-year-old car dealer in Duncan. She was actually perfectly well until she developed very recent pain in the wrists, fingers, ankles, toes — super stiff in the morning, barely can move, barely could even clean herself; fatigue; and suddenly was very limited in activities. She has tried anti-inflammatories, acetaminophen. Because she’s from B.C., she’s tried cannabis. She’s gone to a chiropractor. She went to her GP, but the GP is retired, so she’s using walk-in clinics.

She has rheumatoid arthritis. James has osteoarthritis. They’re in different towns. Where do they go? How do they map? How do they want to figure things out? What would you do? You would go on line. You’d talk to some friends. You’d try to get in to your family doctor.

Within the Mary Pack arthritis program, we have about 7,000 patient visits per year in British Columbia. However, I’ve told you we have 600,000 people with various types of arthritis — some of it milder osteoarthritis, some of it rheumatoid. How do we reach all these people? If we’re going to multiply the 7,000 we see by a factor of a hundred, can we afford to get…? Multiply the number of rheumatologists, therapists, nurses. It’s not going to work.

We proposed this electronic arthritis triage strategy. This is a qualified on-line tool, similar to a web portal, that will evaluate patients using best practice and make an initial determination of the type and severity of this disease. We already have the questions. We know that we can split apart the osteoarthritis versus the inflammatory arthritis and the lupus. We have these questions. In fact, we made a phone app that helps GPs ask those questions.

Those high-priority patients, those who red flag for rheumatoid arthritis, etc., would be assessed by a local physiotherapist, in Vanderhoof, who has been trained at the Mary Pack — arthritis-aware physiotherapists — to do a brief 15-minute exam and finish the triage process. If that patient has osteoarthritis or other conditions, that can be managed by the family physician there or an arthritis-aware health practitioner and doesn’t need to come and see me. That person will be immediately put into that system.

Teresa in Duncan, with the rheumatoid arthritis, would have a lot of red flags put on that system, where she would answer those questions. If I just take a step back, we already have a little bit….

We kind of have this through the 811 program. I’m sure you know the 811 program, and if you had kids, you called about your kids. I have. You call, and you have to give them your name. You get a registered nurse. You give them your name, your PHN, your date of birth, your phone number, and then you tell them your problem. They have a phone triage method to tell you whether you should take your kid into emerg or what you can do at home.

This would be exactly the same thing — an on-line tool asking those questions. I’d like to also have a process where people don’t — like your last speaker was saying — have Internet access. Well, most people have phones. If we can incorporate the 811 system into this and just simply give those nurses the same questions, they would be able to also triage the patients so we’re not losing people who don’t have Internet access or — like my in-laws — don’t really know how to use a computer.

The benefits would be: high-priority patients would be fast-tracked — rheumatoid arthritis, lupus, psoriatic arthritis — directly to us. We would be monitoring this system through the Mary Pack and red flag those people. I would either see them….

We would arrange for them to see the rheumatologist closest to them. They might have to come down, or we could do a video conference locally.

The best use of other health professionals…. I was looking through the transcripts previously. For example, massage therapists and physiotherapists — we would
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like to expand their scope of practice. I think expanding scope of practice is a good idea in B.C. I think we need it. Here I would use the physiotherapists expanded scope of practice to help with managing people with osteoarthritis. They don’t need medications. They don’t need to see me. Then getting those other people with inflammatory arthritis in quickly to see a rheumatologist. We’ll be able to get them on the right medications fast and prevent the need for the expensive therapies, prevent disability.

Teresa, in Duncan, would be…. There are no rheumatologists in Duncan. Right now I’m arranging a rheumatologist in Victoria to go to Duncan regularly to do clinics. That should start up soon. But in the meantime, she would have to go to Nanaimo — there are three very good rheumatologists — or I could even do a video conference, or another person could do a video conference with her, get her going on the right medicine until she sees someone in person.

I expect this would be better access for those in remote communities because of this. They could feel like they’re connected through on line or through the telephone or through video conferencing.

When we presented this to our partners…. Arthritis consumer experts and the Arthritis Society are on board. The arthritis research centre, which is an amazing, large musculoskeletal research centre in B.C., is behind it. The B.C. Society of Rheumatologists is behind it, even though they admit that something like this would make their job harder, because you don’t see all the easy osteoarthritis patients. You’re going to see more difficult patients. You have to see them faster. I mean, you have to incorporate yourself into a system. But they all realize that this is, I think, the way to go for the future.

I can talk about costs. We had a couple of technology companies put some ideas forward on how much this would cost. You have the slides, so I don’t have to go through them in detail. Mostly, it is the decision support program and the technology. When I’ve spoken with people in the Ministry of Health, who have been very excited about this, they thought that the privacy issues could be managed, with the data.

The other costs — I’m not sure. We would need a little bit more help from the health regions to increase the number of FTEs for physiotherapists to help screen some people. But I think the majority of the physiotherapy help will be in group visits with exercises. That may be able to be done through the private physiotherapy system.

Do you know that when you have a knee replacement, you get a few chits for physiotherapy afterwards to go through? If there’s no public physiotherapist nearby, you can go privately. I was hoping, and the ministry thought it was a good idea, that we could allow people who access the system a few chits for physiotherapy to be done in their local community so they don’t have to come in.

Pharmacists are a big part of this. I think what else would be needed would be to integrate the pharmacists into the system so that when people come and talk to their pharmacist, they could direct them towards this triage. Public awareness — we’d be assisted by the Arthritis Society in patient advocacy.

J. Shin: Thank you so much for your presentation. The empirical studies on the lifestyle modifications that we can do for both the prevention, upstream intervention, as well as the fact that we have what’s not even advanced technology anymore — rudimentary technology for us to better manage the flow, the access of information for their patient data. All of these are in place — and the cost to the on-line triage tool that you’ve mentioned. We’re not looking at huge, huge costs attached to these items here.

So what’s stopping us from not moving ahead with this already? I’m curious to find out if you had the chance with the health authorities, the ministry — to see how long you’ve been advocating for this and what really are the barriers that we can start helping remove so that we can get these going.

K. Shojania: You know, there’s been a lot of enthusiasm. When I spoke with the ministry, the ADMs were enthusiastic about it. They directed me to PHSA. I had a conference call with PHSA, and the plan was to get to more of the meat of it. How is this going to work? When I met with Vivian Eliopoulos from Vancouver Coastal — she’s the COO of Vancouver Coastal — she was “110 percent behind this,” and she was excited about it. We had a conference call with Vancouver Coastal and PHSA.

I can see it’s hard. There are a lot of pieces to pull together. I think the slowdown is to try to figure out where to start. There was the idea to start, perhaps, with one region, and Vancouver Coastal suggested we could use them.

K. Shojania: This January. It’s not five years. It’s not a long time. It’s been recent. What we need to move forward is someone who is better at numbers and administration than I am to help me, with a team of people — just to see where we can start and pull in the team that’s going to work this.
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D. Plecas: Another great idea from the University of British Columbia. Fantastic. Three cheers to you. It’s such a fantastic idea.

The only thing I noticed in your presentation that was a little troubling was that even if we did what you’re proposing, we’re still only 1/20 of where we need to be — doing the numbers as you’ve presented them. I mean, it’s just fantastic, and no wonder your colleagues and other disciplines within medicine have said: “Gee, we could do this too.” Absolutely fantastic.

But I’m noticing that we’re still short. I did the math, and you’re at 50,000, and you say we need 700,000.

K. Shojania: Ideally, I’d like to be able to…. The vast majority of that 700,000 only need a little bit of direction. I’m hoping that we can have some….

For example, osteoarthritis of the knees. If James in Vanderhoof goes on line, we triage him to osteoarthritis of the knees, which he has. We can get the dietitian through 1-800 Dial-a-Dietitian, call him, get him a program. We can get him to see just one individual physiotherapy session plus an exercise program, with a bunch of other people, to carry on.

Then the other thing is we don’t let James go. Whenever we start some sort of lifestyle intervention, we fall off right away. We get discouraged. We would connect with James in a month, and then in three months and then maybe in six months. “Where are you? Here are your pain scores. Here’s your function. Here’s your weight. How are you doing? How can we help?”

I don’t see that being a lot of person power and dollars in doing that. I think we can reach more than the 50,000. I suspect we’re going to be able to get into the hundreds of thousands of people — maybe not 700,000, but getting up there.

D. Bing: I appreciated your point about seeing more high-priority patients rather than the osteoarthritis ones. What percentage of your patients would be osteoarthritis versus the rheumatoid, etc.?

K. Shojania: I triage all my referrals that come into my practice. When I see that it’s obviously osteoarthritis, we will say: “This patient has osteoarthritis.” We will actually not see that person. We’ll say: “Here’s what you should do for this person.” My secretary has a form that we send out. “Try this first. If that doesn’t work — physiotherapy. If that doesn’t work, there’s something else going on, and I’m happy to see you.”

If I take all comers, it would be about 50-50. And it’s also referral. They know me, and the referring doctors know that I often see mostly inflammatory arthritis and connective tissue diseases, so they may not refer to me the osteoarthritis. But as it is now, it’s about 50-50 — 50 percent of my patients could be removed from my….

D. Bing: Do they refer to you because they aren’t sure whether it’s rheumatoid or osteo?

If you have osteoarthritis, does it increase over time as an absolute, or are there methods of containing it at a lower level? I assume that would be part of the process that you would engage people in doing and that people would have to come back. One of the best things that you’ve proposed is that the person isn’t just let go, that there’s some sort of accountability, not only for the person but for the system that’s looking after that person.

I guess my question, really, is: is the osteo bound to increase over time, or can you actually prevent it by doing the right thing?

K. Shojania: In all the osteoarthritis studies that we review in terms of lifestyle, exercise and weight management are key and slow down the progression of osteoarthritis and improve function. Of course, there are different types. There’s the type of osteoarthritis that affects the base of the thumb and the fingers. Of course, we don’t walk on our hands, so weight loss often, you don’t think, helps that type of arthritis.

The interesting thing is that it’s a little more complicated than that. The fat cells actually do increase certain types of osteoarthritis symptoms in the hands. Lifestyle measures do help that, but also other ways of doing activities, gripping and…. You know, so many things can be taught to improve function that don’t necessarily change the underlying disease, but people function better and have less pain, and that’s the most important thing.

L. Larson (Chair): No, that’s quite all right. You see, I sit on my hands for that very reason. I don’t put polish on my fingernails because I have all of these horrible lumps and bumps. But just as you’ve said, I make sure I use them, use my hands. You have tools that are larger, so you don’t have to grip tight, a steering wheel cover that’s fat, so you don’t have to grip your…. There are all kinds of wonderful tools out there that the societies have come up with. So thank you.

Not seeing any more questions, we thank you very much for being here and for all the good work. This is a wonderful tool, so I hope that it’s something that is picked up and becomes a norm throughout the province.
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L. Larson (Chair): We’ll just do a quick changeover here, and we’ll start right away.

I’d like to welcome to the committee today the B.C. Patient Safety and Quality Council. If you would please introduce yourselves and move into your presentation. You have 15 minutes for your presentation, and then we’ll pepper you with questions.

D. Cochrane: Madam Chair, thank you for the opportunity to present to the committee. I’m Doug Cochrane, and I chair the B.C. Patient Safety and Quality Council. I’m joined by Christina Krause, the executive director of our organization.

We do acknowledge that we’re presenting today on the traditional territories of the Coast Salish, the Tsleil-Waututh and Squamish Nations, and we’re honoured to do so.

Today we’d like to speak to you about an opportunity that we as the council seek in the provision of care for citizens here in British Columbia, specifically those living in rural and remote areas of our province; those who need care and support for mental health and substance use; and in our health system safety net, primary care.

To set the context, I’ll speak briefly to the role of the council and then focus on principles of redesign that we know underpin successful change, change that is sustained and the change that becomes enduring because it’s incorporated throughout the system in the way we do our work. The principles that I’ll speak to you about in more detail include the provision of quality care, care that is measured in terms of quality; care that is designed in communities, by those in the communities; and the care that is based on collaborative practice of needed providers.

In 2008, the British Columbia Patient Safety and Quality Council was created by the provincial government to enhance patient safety, reduce errors, promote transparency and identify best practices to improve patient care. Now, eight years later, our mandate is to provide systemwide leadership on quality and collaboration with stakeholders, to encourage patients and caregivers and the public as partners in their own care, and to build capacity for health care system transformation and improvement — all the while doing that, working to improve specific areas in the quality of care delivered to British Columbians.

In areas being considered by this committee — primary care, rural care and addictions recovery — the ministry and many partners have a number of action strategies that, if they were implemented and sustained, would result in improved care for British Columbians. For such change to be successful, however, our own experience and the research of others shows that the care in these areas needs to meet a number of criteria.

It needs to be community-based. It needs to be designed and implemented with and by the patients it’s intended to serve. Because these areas are actually the most complex areas that we have in our health system, we need to have care that is delivered by those individuals whose group experience can address all issues. And of course, this care, as we heard from the last speaker, can be integrated across the continuum, geographic or illness, by a technology where that is relevant.

As a result, system change and redesign in these areas is largely founded on these principles. And based on our experience, they’re critical to achieving the more specific goals of improved health care — in the example here, better triaging of rheumatic patients and those with osteoarthritis.

The principles that we’re talking about are seen nationally and internationally as other systems use them to improve global health around the world. So today we’d like to leave you with four fundamental points, if I may.

It’s about defining quality and using that as the measure by which system transformation in these areas is to be measured. Any solution that is proposed needs to reflect the needs and the values of the community in which it is to be implemented. The care, generally, in these areas, because of complexity, needs to be team-based. And it requires co-creation — co-creation with the individuals in the community to which the care is to be provided and served.

What, then, is high-quality care? The B.C. Patient Safety and Quality Council, at its inception, defined what quality care is. What you’ll see on the slide are multiple dimensions.

Care is quality care when it is acceptable to patients and families. It meets their preferences, needs and values, and it’s culturally sensitive. It is appropriate, care that is based on evidence. It’s specific to each of the individuals’ clinical needs. It is, of course, accessible to them, and it is delivered in a way that allows them to be safe from harm. And it’s effective. The care provides the outcome that we anticipate and need for patients.

Now, that’s the care for the patients. The system, actually, delivers this in a way that is equitable and efficient.

Care, for any of the system transformations you’re considering or that you’re seeing, should address all of these issues.

The next slide, though, does speak to the fact that these dimensions of quality are all interdependent. If we focus on one to the exclusion of others, we will not ever sustain improved care for patients, nor will we avoid unintended consequences that have always been a surprise.

If we look at health care evolution here in Canada, in British Columbia and elsewhere, when the focus has been on one dimension — whether it be access or safety or even appropriateness, if someone’s done that — to the exclusion of others, the system actually is not sustain-
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able. So any model that you’re looking at should really be examined across all of these dimensions. Certainly, the implementation needs to be.

The solutions that you may hear about need to work at a community level for the areas under consideration by your committee. This is because various needs differ across our province. They differ with respect to the community needs. They differ with respect to the capacity of a community to actually provide care in the areas of primary care, substance use and rural and remote care. The needs, for example, in an addiction program would be very different in downtown Vancouver than they might be in Quesnel.

If we look at an example — it’s a hypothetical example, but it’s one that I think is absolutely relevant to health care in Canada generally — let’s consider a youth indigenous addiction treatment program in rural communities in the north, and let’s compare that with Oak Bay. Both programs would need to demonstrate cultural humility and provide cultural safety for the individuals involved. They need to be designed to reflect these cultural values and the needs and, in fact, the preferences of those individuals. However, the local community will determine, by virtue of its unique strengths and resources, how a program might play out.

Therefore, a standardized approach as to how a program will work across the province will probably not be successful. A program will actually need to be unique to a community and unique to the needs and the resources and the capabilities of that community. Ensuring the principles of high-quality care — care that is effective and appropriate; accessible; safe; and perhaps most importantly, acceptable to cultural values and preferences — is key, no matter where you are in British Columbia.

The care that we’re talking about is for really complicated problems. This is not as simple as some of the sophisticated operations that you know about occurring in acute care. These are difficult problems. These are people problems. They’re social problems. The ability of an individual provider — nurse practitioner, physician, physiotherapist — to actually know how to address all aspects of this problem…. It just doesn’t happen. We don’t train people that way; they don’t work that way.

The foundation for care in these complicated environments relies on the knowledge, the competence, the skills of many individuals brought together. It’s really around teams. You’ve heard much, I’m sure, about team-based care, but the purpose, of course, is to create joint care planning — to deal with issues of language and coordination, to take the patient out of the role of being the glue between the doctor, the nurse, the physiotherapist and others who might be involved in the care and putting the patient at the centre of that activity.

There is no doubt, I think, that — for primary care, for mental health care and for rural care — this is all about co-creation. The community has resources, but the community is made of people. It’s the co-creation with the people who need care; know care; and know what the solutions, in most part, for care are that allows a system change to be sustainable. We’ve had many system changes over the years here in British Columbia. Some have stuck and some have not. The ones that have stuck have been built with the people who needed the care to be delivered.

In the past, improvement efforts have been led by health care leaders, such as myself and others, who are familiar with the service. They’re not often led by individuals who are expert by experience.

As health and health care systems strive to become patient-centred — and that’s a focus of the areas under review here — patients and families, who are the experts by experience, need to be true partners in care and in the design of that care. The key to this change is that it requires time and a focus on relationships and the development of trust.

As Don Berwick has said, for change to be delivered at the pace of human learning and at the pace at which government can help by willingly removing barriers and obstacles, it’s important to be realistic. You can’t move an organic process, a process about trust and relationships, faster than nature allows.

We’ve talked this afternoon about the criteria, I guess, or the characteristics of successful implementation. We haven’t actually talked about a program or an app or a how-to-do or a what-to-do kind of thing. We’re talking about how to do it in order that it may be made successful.

We require quality to be measured in all of its dimensions. One is insufficient. Useful models and solutions must be community-based in primary care, rural care, remote care and for those suffering from mental illness and addictions. And it must suit the local context.

The approach to change is probably as important, or more important actually, than the model that we wish to implement, and that process must be developed with those who do the work and will receive the care and proceed at their own pace.

I notice in your matrix there, which looked pretty impressive…. What about the matter of evaluating the outcomes of that? I guess I would wonder…. I suspect there hasn’t been an evaluation, to date. But it seems to me that it’s an essential component to have the evaluation, because what doesn’t get measured doesn’t get done.

The second part of that is: how do we think about it all within the context of available resources? It seems to me you’re talking about what we ought to do, when some of us would say: “There’s lots that we’re doing that we shouldn’t do.”
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D. Cochrane: Well, I would certainly agree with the latter comment. As you probably may be aware, there are initiatives, nationally, receiving some traction here in British Columbia regarding choices and choosing wisely the examples of what doesn’t need to be done.

The approach that we have used is to try and take…. Because it’s a multidimensional definition of quality, it becomes the framework for measurement. If we look at a hip and knee program, we can actually measure it in all of these dimensions.

The one that’s weakest, unfortunately, is the appropriateness. This is: how does it relate to people’s values and needs? How to measure that and to respond to it is an evolving work, but there’s no doubt in my mind that this is the only way that makes sense.

We’ve tried to deal with issues of access, for example. We make assumptions about the quality with regard to safety, the effectiveness and so on, but actually, we don’t always measure that, and we certainly don’t measure the appropriateness. These are things that actually can occur without incremental cost.

J. Darcy (Deputy Chair): Thank you very much for your presentation. It kind of takes us to a different level of thinking about all of this. I think that’s very helpful.

You referred to cultural humility. Yesterday we had a presentation from the First Nations Health Authority, who described some of their mandate and their programs. We’ve heard about some very specific ones in communities. I think we were all very…. We all learned a lot and were quite moved by what we heard — in particular, about what it means to provide services in a way that is culturally safe and that recognizes the legacy of residential schools, for instance, and what that means about people’s understandable fear about traditional institutions.

I just did a quick scan of who’s part of the council. I don’t see the First Nations Health Authority, although I know they’re quite a new entity. I wondered what your relationship is with them. It seems to me so much of what you talked about are areas where there is so much mutual learning that could go on. We heard about some amazing health centres, in particular, that were practising very much what you’re talking about.

D. Cochrane: We’ve been blessed, actually, with the opportunity to work very closely with the First Nations Health Authority.

C. Krause: Actually, we have been working with them on the cultural humility and safety campaign. It’s something that all of you can go to.

J. Darcy (Deputy Chair): Okay. Oh yes. I saw your photo on line. You’re on Twitter, holding up the sign.

C. Krause: My own pledge around what I can do, which is really around how I can listen and truly listen. I think that’s a lot of what it’s about. We have a big obligation around cultural humility and safety for indigenous people, I think, in this province. It really is about…. When we relate cultural humility and safety to the quality matrix, it’s about acceptability of care. It’s about care that is based on an individual’s cultural values and needs and preferences, and that takes listening.

That’s why…. The opportunity that we now have as an organization — through supporting the Patient Voices Network, which is a network of patients around the province — to help ensure that their voice is heard in the redesign and in improvement initiatives in B.C. is really key. That patient voice in the co-design and co-creation is something we talk a lot about.

It does mean that change takes time. We often talk about going slow to go fast. If you move too quickly in implementation and do a traditional top-down approach too much, you lose a core part of the change process, which is around engagement and relationships and designing together. When you ask us about why things don’t sustain over time and why we fall back to the old practice, quite often it’s because we’ve bypassed the people behaviour–based part of the change and focused just on structures and processes. How many FTEs do we need, and what is the model? Really, it’s how you do the change that will lead to a lot of that success.

That’s one thing we’re paying a lot of attention to and trying to support leaders to do — to demand that to happen.

J. Darcy (Deputy Chair): Just on the Patient Voices Network. I’m certainly familiar with some of the history and some of the…. Anyway, we won’t revisit that. Are they now…? There was discussion about them being housed within…. The Patient Safety and Quality Council was one of the options that was being looked at rather than…. They were taken temporarily into the Ministry of Health after…. Anyway, you know — after that bit of a shemozzle.

C. Krause: The patients themselves actually came up with the idea and approached us and approached the ministry around the quality council taking them on and supporting them. So we have done that. We have an oversight and an advisory committee that has all of the key health partner stakeholders but also equal numbers of patients at the table to design for themselves what the network looks like. That’s been, in our first six months, a lot of fun.
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With that said, though, I have a comment, which is that one of the things that stood out for me is the fact that, as far as access to the 811 service goes, you provide the health information in over 130 languages. I find that a lot of the government services as well as other programs that are available within our community….

We sometimes, by the limitations of our resources, do cater to the majority of the minority communities — some of the bigger communities. Often I usually see them translated in two to three languages, but we do have a very diverse population, and sometimes it’s that very small pocket of a minority group that is most marginalized in every sense. I just really appreciate the sensitivity and the thoughtfulness that’s demonstrated in this matrix and for the work that you do. I just wanted to say thank you for that.

L. Larson (Chair): Seeing no further questions, thank you for participating today and telling us what you’re doing — certainly, how it really is an overarching set of policy or moral, with the way we’re looking when we look at community health care, especially in the rural communities. We know every one of those is different, but the common ground is that the community has to participate and be part of this whole solution. Thank you very much.

L. Larson (Chair): Okay, we’ll go off line for a few minutes. Thank you. We’ll take a temporary recess.

L. Larson (Chair): We’re going to move ahead with our next presenter. I’d like to welcome Gabrielle from the Sunny Hill Health Centre for Children.

G. Trépanier: I am not speaking on behalf of Sunny Hill. I want to make that clear.

L. Larson (Chair): Of course. Anyway, I will let you introduce yourself properly. You have 15 minutes to talk to us about whatever it is you would like to talk to us about.

I would like to thank the committee for allowing me to speak today and for allowing British Columbians to take stands on very acute problematics in our health care system.

I would like to make it clear and unambiguous that I am today presenting my opinions and ideas as an informed citizen. My statement is in no way representing values or ideas of my current or previous employers, and I wish to make sure that is part of the public record.

My name is Gabrielle Trépanier. I am a pediatric occupational therapist. Right now, I offer specialized service to children that would fall within tier 3 or 4 of service as described in the documents that were submitted to your committee in 2014 by Child Health B.C.

I graduated from McGill University in 2008, and I have worked as an OT in Quebec, in the Yukon and in B.C. I’ve been working in B.C. for almost six years.

I wanted to participate in the public hearing today because the topics at hand have been on my mind for many years, either working in my current capacity or when I worked in the schools of the Yukon, which is my rural experience. I would find myself thinking about these topics after having encountered true challenges to find rural OTs for my patients and have also run into the inefficiencies of our always-evolving, albeit one of the best, health care systems out there.

Today I present my ideas as an informed user, an informed citizen who spent time thinking about these issues as they pertain to children’s services. I do not claim that my ideas are realistic or feasible. They’re ideas, and I hope they help offer insight and potential solutions.

I wanted to ensure that my contributions today were meaningful and well informed and would add to what the committee has already heard rather than repeat information or recommendations from previous contributions. To do this, I reviewed previous submissions from the October 2014 call for statements. Not many were directly related to children. You will hear me refer to the Child Health B.C. submission mostly. That did a really detailed report on services.

Outside of these records, other documents exist outlining health services for children. The most up-to-date one gathered information from three ministries — the Ministry of Children and Family Development, the Ministry of Health and the Ministry of Education. It’s called the early years report, from 2013 and 2015.

I think that in understanding the context of families and children’s services, these two documents are important to review.

With all of this in mind, I decided to address two of your questions. The first one: how we can improve health and health care services in rural British Columbia; in particular, how long-term solutions can address the challenges of recruitment and retention of health care professionals in rural B.C.

Rural health care, obviously, is a unique practice context for all professionals serving all age groups. With children, there are unique challenges and risks. In an-
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swering this question, I would like to share my reflections and ideas for a solution that addresses the element of job satisfaction and stressors that come with practising in rural areas, mostly for allied health professionals — so occupational therapists, physiotherapists and speech-language pathologists.

I will also outline an idea with regards to creative funding, or a different way to think about acuity of care in rural areas.

My first recommendation is increasing the sense of therapeutic community by finding ways to have centralized or generalist-based pediatric rural teams.

In thinking about staff retention, the first thing that comes to my mind is job satisfaction and mitigating the stressors. What satisfies me in my work in an urban area as an allied health professional is to be surrounded by a multitude of disciplines and to have colleagues in my own profession to go to for support and questions.

In smaller communities, allied health professionals are often working in isolation. They are either the only allied health professional in their community or the only member in their profession on their team. Children’s services tend to be compartmentalized, also, by age group, so rural teams by age groups form really small teams. If you divide the teams into zero to three, three to five and then school age, you end up with really compartmentalized teams.

Some places have already combined services for infant development and child development to try to pool resources. The funding comes from the same ministry. But it’s harder sometimes to pool two ministries together. The Ministry of Education funds school services. It’s sometimes harder to get that funding together.

I think that if we were able to pool those services and then have access to more full-time-equivalent or more people in the same centre, we could build a community of therapists in smaller places that could offer support to each other. That’s my first point, I think.

Then, also, in considering that — I know it’s a bit stating the obvious — rural care does demand more travelling for the health professional because services are often provided at home. For the same child or a similar child in a rural area, for the same face-to-face time, you need more travelling time. So overall in your day, you’re spending more time for that child than in urban areas.

That means that if funding is solely based on population or how many cases you have on your caseload, you will run out of time at the end of the day and feel like you haven’t been able to address everything. This is stressful for anyone. We’re all professionals. We all want to feel like we did our best. So that causes stress, for sure.

The other part that would be addressed by, hopefully, creating a bigger team where there would be less transition is that we would avoid those transitions that happen every three years for children. After three years old, they switch to the child development centre.

In looking at efficiency and time management, that therapist has spent time creating rapport with that family, getting to know them, and then they have to prepare transition papers for the next service — and then the next service needs to build rapport again. That process happens three times before the child is 19. By having a bigger team where maybe professionals could be with a child long term, that might be saving some time and resources.

I’m going to jump to recommendation 2. Actually, I was going to skip that one and just give it to you guys in writing. Sorry about that.

Recommendation 3. To me, it’s quite important. I know that Child Health B.C. has given you guys the tiers of service. It’s a very good way to look at things. I don’t know exactly how it works at the government level, how funding gets allocated, but to me, there needs to be an element of distance when considering acuity of care.

When I worked in the Yukon, one had to travel really far to see a patient, and oftentimes you would spend a long time between visits. A child with a nondescript feeding difficulty, for example, in Vancouver would probably get seen by their therapist a little bit more frequently. Also, if a problem emerged in between visits or if a problem was identified at a visit, the access to specialized services is faster. It’s just because of distance.

I think we need to consider that as in inherent risk of rural areas. As such, a similar problem is of higher acuity. It’s more emergent than in an urban area. It’s a different way to think about health, because we tend to think about it as: “Well, they have the same function; they need the same funding.” But actually, I think there is a greater risk for children in rural areas with similar functional deficits. So my recommendation is to revise funding to add the element of distance as a tier of service or a level of acuity of certain functional deficits.

I’m going to skip to question 2, because I don’t know how much time I have left.

G. Trépanier: Okay. That’s good. How can we create cost-effective systems of primary and community care built around interdisciplinary teams? It’s the big question. I decided to give two recommendations in that regard.

The first one is to build a comprehensive e-charting system that can be accessed and receive a contribution from non–health authority centres — for example, the IDPs. As a health care professional in 2016, I think it’s fair to say that I’ve kind of had it with paper charts. Especially after trying — back in 2007, during an internship — an e-chart system that was local, in a little long-term-care facility, but that worked so well. It was really easy to access and saved a lot of time. Right now, I find myself rooting through handwritten notes, I need to go see the e-chart, and there are often conversations that resemble:
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“Oh, have you read about this, about this patient?” “Well, actually, what chart was that on?” There’s a lot confusion. It’s very cumbersome.

I know that you guys know about this, because I know there is something out there that wants to bring all health authorities together and have everything over e-charts, and I think this is great. Today I’m going to ask you to not stop there.

I start from the assumption that everyone’s time is important, because everyone’s time is money in the health care system. By this, I want to bring your attention to the time that I will still need to spend, or a clerk will need to spend, looking for IDP reports, OT reports from the child development centre, looking for consent, because the consent isn’t inherent in those other health authorities. This is, actually, probably where I’ve spent most of my time right now.

This won’t be solved by the interauthority e-charting system. I know it’s a…. You know, I’m not an informatician or a computer person, but I know…. I don’t know what’s possible. I think that right now, it’s really easy to scan anything, and it would be interesting to have a system where IDPs, CDCs, even schools — obviously, with parents’ express consent — would be able to scan documents into the e-health system. Then if parents want their IDP/OT to have access to their health records, for that to be possible.

My last point, in terms of building cost-efficient interdisciplinary teams, is to look at the funding structure for children — again, I’m speaking about children — and to look at a funding system that is entirely function based and not diagnoses based. There is a system that already exists: the At Home program, where children receive what they need depending on their level of function.

For children that cannot access the At Home program — so that, thankfully, are doing better — it is more difficult to get funding, typically. Some families have access to the autism funding, but if a child has Down syndrome, they often don’t get as many services even though their needs, albeit different, might be just as great. Children with autism obviously need the services that they are receiving, and I want to make clear that I do not think that these services should be stopped. I simply would like the committee to consider that, right now, the services are provided, at some level, on a diagnoses basis and not always on a functional basis.

This lack of specificity defies cost-effectiveness as it does not evaluate each individual need, and it just puts a blanket solution on everything. My last recommendation would be for children to receive funding depending on their level of function and their needs, as evaluated by the capable professionals that we have out there.

L. Larson (Chair): Thank you. Excellent. Obviously, as you know, others have presented about the accessibility to people’s records, charts, etc., crossing all levels of professionals, non-professionals, care in general and ready access. So one would only hope that it wasn’t just…. If and when we get to the point where we’ve done it efficiently, that it does not just be health authority to health authority, but also social service levels and all of those things would be part of it. You certainly have touched on one of the issues that’s facing us right now very clearly, so thank you very much.

J. Shin: I will cede my opportunity to Darryl first, since I went first last time.

D. Plecas: I just want to first thank you for your great presentation and your handout. We’re so lucky to have you here.

My question relates to your last recommendation. I’m just not fully understanding what you mean by the difference between a diagnostic funding and functional funding. Can you just say a bit more about that?

G. Trépanier: For example, it is known that children with autism will sometimes have difficulties with food aversion or being quite specific about the food that they want to eat. The same problems could be seen in a child that would have been premature or had delayed access to food — for a heart condition reason, where they were tube fed and things like that.

For a child with autism who needs intensive therapy to expand their diet and have a fulfilling life with good nutrition and everything like that, that’s funded right now by the autism funding, which is really needed and is really important. But the other child who has the same issue — the parents will have to put that money forward for the therapy.

So there is an inequity in access to services right now for problems like this that are not significant enough to fall under the At Home program but are creating inequalities between similar functional deficits in two families that would benefit from the same service.

J. Shin: I just wanted to say thank you, because you’re not only an informed citizen but a very caring one, so thank you for demonstrating the kind of passion and commitment that I can see so clearly.

With the thanks, I also just want to reassure you. I think this is day 5 of the Health Committee, and as great as our challenges are, when we see the kind of talent that’s come through the door, and the ideas, I think our prospects are very hopeful. So you’re definitely not alone in your disappointments and frustration but also with your hope and vision for the health care that we envision for our province that we all so love.
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My question for you is…. There are a number of initiatives that are pilot and some that have been proven to be successful and ongoing. There are too many things that often come with a big price tag, but there are a few things that I think we can manoeuver fairly quickly, given there’s consensus. Are there any sorts of continuing education efforts that you’ve seen that you would like us to continue to do or do more of? There is a recommendation that you’ve put forward, but I’m just wondering if there is any specific program that you know of that we can continue to advocate for.

G. Trépanier: There’s a lot of outreach education that is happening right now, and for sure these are, I think, really welcomed and needed. I think that part of funding for outreach services from specialized centres outward…. There is an element of education that’s always a part of it, but there’s also an element of having sufficient patients to see — when you travel to Quesnel or you travel to Terrace — and sometimes there just isn’t enough to justify, so we don’t get to go. Then that education happens over the phone or through telehealth, which is a good medium too.

But sometimes hands-on — you know, be there; do it — are just opportunities that rural therapists don’t get. Where I worked, I really quickly had a wealth of experiences that I’m sure others would love to have too. They just don’t get access to them.

D. Barnett: Thank you very much for your presentation. In your comments here about building a generalist centralized team utilizing the Ministry of Children and Family Development and the Ministry of Education…. Are there any models there — that they actually do work together — that you have found?

G. Trépanier: I think — don’t quote me on this — that they’ve had to adapt sometimes because of having difficulty finding therapists to work up north. I’m thinking about up north in particular, where I believe that some therapists just found themselves being the sole provider in the whole town, so they end up working with all ages. They’ve likely adapted their funding structure. But I don’t know that there’s been an effort to say: “Okay, we’ll have a centre with three OTs, three speech paths, three physios, and it’s going to be zero to 19.”

G. Trépanier: Yeah, funded together, all in the same centre, able to build their own expertise within their teams and get a social worker, a nurse, and have not just them but the community feel like any door is the right door. So they’ll see many therapists, and issues are likely to get addressed faster.

M. Dalton: Merci beaucoup pour votre présentation, Gabrielle. C’était excellent. You put a lot of time into it, and thought. Your voice is important. You do have a lot of experience in many respects, and to be able to add to that…. And you do a lot of research also. So thank you for that.

Just to give you an opportunity…. Maybe one take-away. I know you’ve already expressed…. When you worked up north, for what you saw, maybe just one thing that you felt worked really well that you think might be beneficial for us here.

G. Trépanier: It’s not an experience that I’ve had. It’s a comment that I’ve had from a colleague. It’s just a difference between having externally hired therapists coming to a town rather than the contract being owned by the town or even by the band council or something like that. It’s the difference that it makes for families to receive a phone call from someone from their town to make appointments — I’m talking about outreach services — versus receiving a phone call from someone in Vancouver, saying: “Oh, our therapist is coming up. When are you available?”

Therapists that have shared with me say that the difference can be from having a 50 percent no-show to having 100 percent showing. I think that communities are also looking for that sense that services are coming from within.

J. Darcy (Deputy Chair): Thank you so much for your presentation. We had a presentation sometime earlier this week from the Association of Occupational Therapists where we also heard a lot about the relatively low number of occupational therapists in proportion to the population compared to other provinces, for instance. But the major focus in our conversation there certainly was on the impact that it has on seniors and mobility and function and quality of life and so on.

I wonder if you can just talk to us a little bit about what it means for a child. What kinds of things do you do with a child? What does it mean for a child not to have access to occupational therapy if the child needs it?

G. Trépanier: I think we need not to just talk about the child but the family, because all services that are not provided by a therapist really fall on the family — caring for them for various things. I know that the less you’ll see a child, the more you try to impart your knowledge on that parent and get them to understand what the exercises are and why they’re important. Overall, it just becomes a burden on the parent to do that therapy, really, with their child. They’re meant to have a parent relationship, not a therapeutic relationship.

The consultative model works. I think that it’s a great model. It’s proven to be cost-effective for a lot of things. I think that, for a child, there needs to be thought into
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how often we see those children to avoid that burden on the parents. Because it’s consultation if you see them every month, but if you see them twice a year, you’re just jumping into that family’s life for an hour, trying to give them your best thoughts of the day. How meaningful is it to them? Do they even remember you?

We all know family life is extremely busy. Raising children, you have a million different theories out there of how it should be done. So to offer meaningful services to those families and to help those children grow into productive adults, you need the services to be there.

D. Bing: I just wanted to echo my colleagues’ thanks and appreciation for coming and for your efforts. I would like to mention one of my pet peeves though.

As professionals, we tend to use a lot of jargon and acronyms. It’s a little difficult for us, sometimes, to be confronted with SLP and CDC and IDP and so….

D. Bing: So if you could just remember that the next time you present, we’d appreciate it.

G. Trépanier: IDP means infant development centre, and it serves children from zero to three years old. CDC is child development centre, three to five. And then SLP, speech-language pathologist. OT, occupational therapist.

L. Larson (Chair): We can never remember all of that anyway. We need it written down for us.

Thank you so much for coming and for your well-written presentation. We really appreciate you took the time out of your busy life to be here today to talk to us. We will certainly capture your comments in our report.

L. Larson (Chair): Thank you very much to the committee. We are finished our presenters for today. I’ll ask for a motion to adjourn.

Access to on-line versions of the report of proceedings (Hansard)
and webcasts of committee proceedings is available on the Internet.

5) Dr. Jel Coward
6) University of British Columbia, Division of Rheumatology	Dr. Kam Shojania
7) BC Patient Safety and Quality Council	Dr. Douglas Cochrane
	Christina Krause

Chair:	Linda Larson (Boundary-Similkameen BC Liberal)
Deputy Chair:	Judy Darcy (New Westminster NDP)
Members:	Donna Barnett (Cariboo-Chilcotin BC Liberal)
	Dr. Doug Bing (Maple Ridge–Pitt Meadows BC Liberal)
	Marc Dalton (Maple Ridge–Mission BC Liberal)
	Sue Hammell (Surrey–Green Timbers NDP)
	Dr. Darryl Plecas (Abbotsford South BC Liberal)
	Selina Robinson (Coquitlam-Maillardville NDP)
	Dr. Jane Jae Kyung Shin (Burnaby-Lougheed NDP)
	Sam Sullivan (Vancouver–False Creek BC Liberal)
Clerk:	Susan Sourial

1) BC Integrated Youth Services Initiative	Dr. Steve Mathias
	Pamela Liversidge
2) University of British Columbia, Department of Family Practice	Dr. Margaret McGregor
	Susan Troesch
3) BC Care Providers Association	Michael Kary
	Daniel Fontaine
4) Doctors of British Columbia	Dr. Alan Ruddiman

REPORT OF PROCEEDINGS(Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH