HEAL Committee Meeting

37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Wednesday, October 1, 2003

·

1320

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

Mr. Ray Joubert (Registrar, Saskatchewan College of Pharmacists)

Mr. Randy Wiser (President, Saskatchewan College of Pharmacists)

·

1325

The Chair

Ms. Rosalee Longmoore (President, Saskatchewan Union of Nurses)

·

1330

The Chair

Mr. Brett Filson (Executive Director, Representative Board of Saskatchewan Pharmacists)

·

1335

The Chair

Dr. John Bury (As Individual Presentation)

·

1340

The Chair

Mrs. Marianne Greer (Director, Saskatchewan Drug Research Institute)

·

1345

·

1350

The Chair

Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)

·

1355

Dr. John Bury

Mr. Réal Ménard

Mr. Randy Wiser

¸

1400

Mr. Réal Ménard

Mr. Randy Wiser

Mr. Guy Nobert (Vice-Chair, Representative Board of Saskatchewan Pharmacists)

The Chair

Mr. Greg Thompson (New Brunswick Southwest, PC)

The Chair

Mr. Greg Thompson

¸

1405

Mr. Ray Joubert

Mr. Greg Thompson

Dr. John Bury

Mr. Greg Thompson

Dr. John Bury

Mr. Greg Thompson

Mrs. Marianne Greer

¸

1410

Mr. Greg Thompson

Mrs. Marianne Greer

Mr. Greg Thompson

Mrs. Marianne Greer

Mr. Greg Thompson

Mrs. Marianne Greer

Mr. Greg Thompson

The Vice-Chair (Mr. Réal Ménard)

Mr. Greg Thompson

Dr. John Bury

Ms. Carolyn Bennett (St. Paul's, Lib.)

Dr. John Bury

Ms. Carolyn Bennett

Mr. Greg Thompson

Dr. John Bury

Mr. Greg Thompson

Dr. John Bury

Mr. Greg Thompson

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

Mr. Guy Nobert

¸

1415

Ms. Carolyn Bennett

Mr. Guy Nobert

Ms. Carolyn Bennett

Mr. Brett Filson

Ms. Carolyn Bennett

Mr. Brett Filson

Ms. Carolyn Bennett

Mrs. Marianne Greer

Ms. Carolyn Bennett

¸

1420

Mrs. Marianne Greer

Ms. Carolyn Bennett

Mrs. Marianne Greer

Ms. Carolyn Bennett

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

Mr. Ray Joubert

Ms. Carolyn Bennett

Dr. John Bury

¸

1425

Ms. Carolyn Bennett

Dr. John Bury

Mr. Guy Nobert

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

Mr. Ray Joubert

The Vice-Chair (Mr. Réal Ménard)

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

¸

1430

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

¸

1435

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

Mrs. Marianne Greer

Ms. Bonnie Brown

The Vice-Chair (Mr. Réal Ménard)

Mr. Greg Thompson

Dr. John Bury

¸

1440

Mr. Greg Thompson

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett

Mr. Ray Joubert

Ms. Carolyn Bennett

¸

1445

Mr. Ray Joubert

Mr. Guy Nobert

The Vice-Chair (Mr. Réal Ménard)

---

CANADA

Standing Committee on Health

---

NUMBER 054

l

2nd SESSION

l

37th PARLIAMENT

---

EVIDENCE

Wednesday, October 1, 2003

[Recorded by Electronic Apparatus]

·  (1320)  

[English]

    The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good afternoon, ladies and gentlemen. I'd like to welcome you to this meeting of the Standing Committee on Health, as we pursue our study on prescription drugs.

    I'd like to ask the witnesses from the Saskatchewan College of Pharmacists, the Saskatchewan Union of Nurses, the Representative Board of Saskatchewan Pharmacists, and the Saskatchewan Drug Research Institute to please come to the table—and Mr. Bury as well.

    We'll begin this afternoon with the Saskatchewan College of Pharmacists. Representing that body we have Mr. Randy Wiser, the president, and Mr. Ray Joubert, the registrar.

    Mr. Wiser, or whichever one of you is prepared to go first, please begin.

    Mr. Ray Joubert (Registrar, Saskatchewan College of Pharmacists): Thank you.

    My name is Ray Joubert. I'm the registrar with the Saskatchewan College of Pharmacists, and on behalf of the pharmacists of Saskatchewan and the public we serve, welcome to Saskatchewan. We're delighted to have this opportunity.

    Under authority of the Pharmacy Act, 1996, of the Province of Saskatchewan, our college exists as the governing body for the profession. In administering this piece of legislation, we govern pharmacists, pharmacies, and the conditions of sale of drugs, so we exist in the public interest so that there will be quality pharmacy care in Saskatchewan.

    This mission includes a number of goals around public safety, standardized pharmacy services, self-regulation of the profession, a positive professional image, and optimum public use of pharmacy services. Therefore, this presentation is made in the context of our regulatory and public protective role.

    Our message is quite simple. We believe that efforts should be targeted towards optimizing the use of pharmaceuticals rather than directed specifically at the drugs themselves. That's because one of our fundamental beliefs is that optimal drug use is the most common effective therapeutic intervention. So to that end, we are more interested in improving how drugs are used and how strategies are coordinated to ensure optimum drug use.

    In June 1999, we released a discussion paper entitled, “A Framework for a Comprehensive and Integrated Drug Use Management Strategy for Saskatchewan”, which is attached to our presentation for your interest.

    To summarize, we observed in that discussion paper that a number of drug use management strategies existed in Saskatchewan. Those included: pharmacists conducting drug utilization reviews in hospitals and community settings; initiatives such as the Saskatchewan Drug Information Service; the Saskatchewan adverse drug reaction reporting program; the triplicate prescription program; and drug benefit coverages under the Saskatchewan prescription drug plan and other third-party insurers, including Health Canada; and prescription monitoring programs under those insurance programs, and so on. The list is quite long.

    We observed that because those drug use management initiatives are the responsibility of various stakeholders, they need to be more integrated and coordinated so that they work together to achieve optimum drug use.

    Mr. Randy Wiser (President, Saskatchewan College of Pharmacists): My name is Randy Wiser. I'm president of the Saskatchewan College of Pharmacists. While many organizations cooperate in the delivery of these initiatives, they're fragmented at best. Duplication exists, for example, with some health districts maintaining drug information services while similar initiatives exist at the provincial level.

    Therefore, we propose that these strategies be integrated under the authority of a governing structure. To that end, we suggest that governments fund a drug use management centre to manage, coordinate, and integrate these strategies. One option might be to give this governing responsibility to the newly established Health Quality Council. Based on determinants, indicators, and measurements established by the council, the centre could use these appropriate methods to monitor and promote healthy outcomes from drug therapy.

    Some examples of initiatives might include the following. The centre could access drug use databases, such as the drug plan, to identify quality care issues. Then strategies could be coordinated with our drug information services and continuing education resources to inform and educate providers. Alternatively, the centre could direct academic detailing, where pharmacists could provide objective non-biased information—which is very important—to physicians on drug therapies of choice. The centre could also use the data to develop and evaluate prescribing guidelines based on best practices, thus payers can be assured of the value of funds spent on drug therapy.

    Making complete drug utilization databases available online in real time to physicians and pharmacists would assist them in making drug therapy decisions. A more complete drug use profile on the patient would aid in assessing such factors as compliance and compatibility with concurrent therapies. While progress is occurring, the centre could play a leading role in this area.

    In conclusion, while examining the factors that influence the costs of drugs is useful, promoting optimal drug use provides Canadians with access to cost-effective therapy. Better coordination of the current drug use management strategies can achieve this goal. As pharmacists are integrally involved in these strategies, coordination and integration also respond to the recommendations from the recent commissions of inquiry into the health care system, which were directed toward a more active role for the pharmacist in the drug therapy management process.

    Pharmacists have five years of university and have taken a lot of courses in drugs and drug therapy, but are far too underutilized in the public field where they could be more effective in making these medications work better.

    Thank you for our opportunity to submit this.

·  (1325)  

    The Chair: Thank you, Mr. Wiser and Mr. Joubert.

    Our next speaker will be from the Saskatchewan Union of Nurses, its president, Ms. Rosalee Longmoore.

    Ms. Longmoore.

    Ms. Rosalee Longmoore (President, Saskatchewan Union of Nurses): Thank you.

    On behalf on the Saskatchewan Union of Nurses, I would like to thank the committee for the opportunity to share our views on this urgent and important issue. We know that the rapidly escalating cost of prescription drugs in Saskatchewan cannot be sustained. There are many other pressures that are competing for our health dollars. We must begin to invest in prevention and in much needed equipment that will help to prevent costs in areas of injury and absenteeism.

    From 1999 to 2002, Saskatchewan drug plan expenditures grew by approximately 16% annually. In 2000, drug costs for Saskatchewan citizens averaged $423 per person, representing 13.9% of total health spending. But these averages do not reflect the reality that it is Saskatchewan's seniors who are most affected by the tremendous rise in drug prices.

    Large numbers of workers in Saskatchewan are unionized employees, and they have negotiated extended health benefits for their members. So while these costs remain a cost to the taxpayers, they are not impacting these persons as workers.

    Saskatchewan seniors, while representing only 15.6% of the eligible population for the province's drug plan, receive 46.7% of all prescriptions. In fact, the province's health services and utilization review committee found that in 1998, on average, each senior received 23 prescriptions. Although Saskatchewan's elderly receive nearly half of all the prescriptions, only 20.8% of them are drug plan beneficiaries. This means that 80% of seniors are paying for their own drug costs without financial assistance. There are many stories told about people not taking their drugs as prescribed. For example, they'll take them twice a day instead of three times a day, to make their prescriptions last longer.

    Nurses know that many of these prescriptions are for brand-name drugs that are no more effective than their generic equivalents. Nurses also know that many prescriptions are simply inappropriate. The health services and utilization review committee reports that some 10% to 25% of all prescriptions are inappropriate. In 1991, the Canadian study of health and aging found that 23% of elderly people in Manitoba, Saskatchewan, and Alberta were taking one or more inappropriate medications.

    The escalation in cost is the result of both adding new therapies, particularly expensive new medications for previously untreatable conditions, such as multiple sclerosis or Alzheimer's, and the higher volume of drug use. The challenge is to maintain the cost of the drug plan while continuing to support those people who need assistance. Saskatchewan offers a special support program. As of February 28, 2002, 40,174 families, 70% of them seniors, were approved for special support.

    We believe the solution is that Canada must implement a comprehensive, universal, publicly funded prescription drug plan with first-dollar coverage, as recommended by the National Forum on Health. We should develop a national formulary to encourage the cost-effective use of drugs, relying on a formulary to promote appropriate prescribing and incorporate evidence-based decision-making.

    We understand this may require the federal government to review the Patent Act and its relationship to the World Trade Organization's trade-related intellectual property rights agreement and take steps to reduce their negative effects on generic drug substitution. We must remove any other barriers to early market entry of lower-cost generic drugs.

    Health Canada should be given the mandate and resources to independently verify the drug industry's research data. Health Canada should also require clinical trials to take into account the different effects of a drug on the elderly, on women, and on children. A prohibition on direct-to-consumer advertising of prescription drugs should be strictly enforced.

    Thank you.

·  (1330)  

    The Chair: Thank you very much, Ms. Longmoore.

    From the Representative Board of Saskatchewan Pharmacists we have Mr. Brett Filson, the executive director.

    Mr. Brett Filson (Executive Director, Representative Board of Saskatchewan Pharmacists): Good afternoon. Welcome to Saskatchewan, and specifically to Saskatoon.

    The Representative Board of Saskatchewan Pharmacists is a membership advocacy organization that represents 1,159 pharmacists within this province.

    The focus of the standing committee, as I understand it, is to evaluate the cost and use or abuse of medications in the health care system in Canada. Although this is the strict focus, my remarks will be more general in nature, relating more to services provided by pharmacists than to drug costs. In the process, I will address several of your interests, or attempt to.

    Medication costs are known to be on the rise in Canada, some say at the rate of 14% to 16%, as Rosalee alluded to. The rate of increased spending is in part related to the general aging of the Canadian population, as baby boomers are now reaching an age where medication is needed to maintain and improve general health.

    Pharmacists have a role to play in that process, as they advise their clients/patients on the appropriate use of medications and potential drug interactions with medications purchased from the same pharmacy or in some cases the same pharmacy chain.

    The provision of medication management, in order to be effective, requires that pharmacists have access to health information: the lab results, physician diagnosis, complete list of medications, and diagnostic imaging. With this array of medical information, the pharmacist can more accurately provide medication advice to the patient.

    Medication management is a tool for ensuring the patients have a reduced risk of adverse drug reactions. Their advice and guidance, when followed by the patient, reduces morbidity and mortality that could result from inappropriate drug therapy. The best way to ensure the advice is correct is to ensure that the complete database of patient information is completely accessible to the pharmacist.

    To achieve this, Health Canada and the provincial departments of health have to ensure that the application of the Personal Information Protection and Electronic Documents Act does not unnecessarily impede the sharing of health information within the circle of care, in which I would include the pharmacist.

    They have to ensure there's a central and reliable base of information on all patients that can be shared amongst health professionals. Pharmacists must be included in the circle of care, necessitating recognition in Canada under the tax law as medical professionals. Payment for pharmacist professional services must be established.

    Monitoring systems for adverse effects are already in place, as pharmacists provide information on the medications and potential side effects each time they provide the service of dispensing. They're also available to patients to discuss side effects if and when they occur, reassuring patients when appropriate, and referring them back to their doctors when necessary. Pharmacists also intervene when there is a concern or a question about medication prescribed. Often pharmacists contact physicians to verify the type and dosage of medication prescribed to reduce the risk of adverse reactions.

    Pharmacists feel very strongly that each health care professional has a role to play in patient care. Doctors provide diagnosis following defined protocols to determine disease state. They are experts in this area. Similarly, pharmacists use their training and experience when it comes to simple to complex medications.

    The process of pharmaceuticals being distributed to patients by doctors undermines this system, as pharmacists no longer have the chance to assist the patients in appropriate medication management. Our organization believes that the process of providing drug samples should be left in the hands of the professional trained to deal with them--the pharmacist.

    Hopefully, through this short presentation you've gained some perspective on the drug situation. RBSP and its members believe that the effective use of the skilled professionals in our field will go a long way in controlling the cost of prescription drugs and the potential abuse, through a better communications system.

    Thank you.

·  (1335)  

    The Chair: Thank you, Mr. Filson.

    Our next speaker will be Mr. John Bury, who comes to us as an individual citizen.

    Dr. John Bury (As Individual Presentation): I'm actually Dr. John Bury. I don't like to push my title, but I'm a physician and that's why I'm here.

    I started practice here 40 years ago, and I quit 15 years ago. On July 3, 1963, the fourth patient I saw had a severe purulent pharyngitis. I wrote a prescription for penicillin. He said to me, I'm sorry, I can't afford to pay for that.

    I'd never had this experience before because I had practised in the national health service since the day of its inception in 1948. This was an Alice in Wonderland situation. We could have examination and diagnosis, but we couldn't have treatment under an insured medicare plan.

    Fortunately, I worked in a community clinic, and after this sort of hearkening, we studied the prescribing habits of the eight family physicians and five specialists. Out of the over 3,000 items available, we devised a formulary of 100 items, which covered 95% of all prescriptions written by the group. By the use of generics and stocking only one brand of any one drug, we were able to demonstrate a 30% reduction in the average cost of a prescription.

    That was partly because--and Mr. Filson just talked about this--of our use of the pharmacist. No detail person—they used to be called “detail men” then, but I have to say “detail person” now, I think—was allowed to see a physician. They had to bring their pitch to the pharmacist, who was a member of the formulary committee. And because of his expertise, we were able to keep a careful check on the efficacy and sorts of prescriptions that got into the formulary.

    Of course, the Saskatchewan prescription drug plan, started in 1975, used the same principles, but with much too large a formulary, in my opinion. By offering standing offer contracts for six months for the sole purchase of drugs, I managed to get good prices, but only from the generic companies. During the course of the plan, the price of generics went up relatively slowly--and I'm talking now of a study I did of the plan from 1975 to 1992, which is referred to in my brief.

    In those first years we kept control of the price quite well. In the first five years in fact the cost of the pharmaceutical in the average prescription went up about 7.6%. By that time, 50% of the prescription drug plan prescriptions were filled by generics, despite Saskatchewan having the highest proportion of no substitution prescriptions written by physicians. For some reason the physicians seemed to want to scrap with the plan.

    In the five years preceding the free trade agreement, 1982 to 1986, the pharmaceutical cost of the plan rose by 94% or by 18.8% per year. In the next five years, after the free trade agreement, the average cost went up 60%, or about 12% a year.

    The importance of that...and I expect you've already received evidence from--I hope you will--Dr. Elgie from the Patented Medicine Prices Review Board, who will tell you that drug prices go up at much the same rate as the cost of living index. My evidence shows they started on a very high base year. For those five years before the patent protection was extended to 20 years, there was a very rapid rise in the price of drugs.

    I would like to remind you, members of Parliament, of the honourable thing your predecessors did in 1966-67. Have you read this book? It's called the Special Committee on Drug Costs and Prices - Second and Final Report. Talk about déjà vu. This all came about after Senator Carey Estes Kefauver in the United States started a Senate inquiry into the price of drugs in the States. This was chaired by Mr. Harry Harley, a Liberal member of Parliament. They had evidence from over two years; the stack of evidence was this high.

    What did they say? They said that the price of drugs in Canada was at least higher than it should be.

·  (1340)  

    They also showed that 23% of manufacturers' sales dollars went to promotion directly to physicians; 6.5% was directed at pharmacists; and only 7% was directed to research.

    They also noted that there were too many pharmacists for too few people. We have 63 pharmacies in this city at the present moment.

    They also recommended, of course, compulsory licensing, after the expiration of the 10-year patent protection.

    Now, they also suggested the industry should voluntarily reduce its volume of promotion to physicians and pharmacists, and from my point of view, there is no evidence this has been done.

    It's important to note, however, that despite that 10-year restriction on their patents, they were making very considerable profits. In fact, they were making profits the committee estimated to be at least two to three times higher than the average industrial product, however you wanted to calculate it. On income, on capital expenditure, or any other way you'd like to add it, they made about two to three times as much.

    Now drug prices, as everyone is telling you, are going up faster than anything else, and most of the recommendations of the Harley committee were rubbished when we introduced Bill C-22 and extended the patent by some 20 years. And what's happened is where we are.

    According to Fortune magazine--unfortunately the only magazine I could get information from--the profit of the pharmaceutical industry is still reckoned to be three or four times higher than the average. Five percent is the return on the automobile industry. It's 18% to 25%, depending on which year you look at, for profits calculated on the pharmaceutical industry.

    So what I would like to do is ask your committee to re-examine the sales and profits of the industry, not only the brand names, but the generic industry, because I don't think all of the things we've talked about so far this afternoon--more rational prescribing by physicians, less demand from patients, reducing promotions--are going to help much as long as this incredibly powerful industry can continue to make a huge profit, way out of proportion to what I think...they justly deserve profits, but not that much.

    It's very depressing for someone my age, just pushing 80, to see the things we worked so hard for 40 years ago having gone down the drain. We're back to where I started, when my fourth patient couldn't afford his prescription.

    The Chair: Thank you very much, Dr. Bury. You're showing us there's nothing new under the sun, because much of what you've reported from that earlier report is exactly the issues we're thinking about and looking at today.

    From the Saskatchewan Drug Research Institute we have Ms. Marianne Greer, director.

    Ms. Greer.

    Mrs. Marianne Greer (Director, Saskatchewan Drug Research Institute): Thank you.

    Thank you also for the opportunity to present before your committee today. I have to echo what was said earlier. I'm really pleased that you came to our city of Saskatoon, even though I understand that Air Canada isn't always being cooperative.

    This presentation focuses on an important aspect of prescription drugs, and that is the value and importance of clinical pharmaceutical research. No surprise given who I am and what I do.

    In 1993, the University of Saskatchewan established the Saskatchewan Drug Research Institute, which I will refer to as SDRI, to forge links between Saskatchewan researchers and research sponsors in order to enhance both the quality and the quantity of clinical research conducted in our province. As a not-for-profit unit of the University of Saskatchewan, SDRI provides site management, or administrative support, services to Saskatchewan clinical researchers, whether they're affiliated with our university or not. SDRI is currently the only organization in Saskatchewan to provide site management services to any and all Saskatchewan clinical pharmaceutical researchers who request them.

    SDRI has been recognized as a centre of excellence within Canada for supporting the conduct of clinical pharmaceutical research. As one of the oldest such organizations in Canada, SDRI has served as a template for the creation of similar organizations both in Winnipeg and in the Maritimes.

    Over the 10 years since its inception, SDRI has provided services for over 600 clinical trials, conducted at over 770 sites, with a total contract value of nearly $40 million here in Saskatchewan. For the 2000-2001 fiscal year, the total contract value of the research serviced by SDRI represented over 9% of the total sponsored research conducted at the University of Saskatchewan.

    SDRI's position is that clinical pharmaceutical research, as the cornerstone of the drug approval process, requires participation of a broad geographical distribution of researchers and patient subjects in order to adequately inform therapeutic evaluation of drug products relevant to the local clinical practice as well as to inform decisions regarding provincial reimbursement policies.

    Despite anticipated continued double-digit percentage growth in clinical research globally, it must be remembered that pharmaceutical research by its nature is subject to volatility and is impacted by general economic factors. In order for Canada to remain a player in this variable research environment, it is important that Canadian researchers continue to conduct clinical research in a wide range of therapeutic areas. The clinical research conducted in Saskatchewan provides both provincial and national benefits. Every region in Canada that contributes to the conduct of quality cost-effective clinical pharmaceutical research contributes to Canada's overall capacity, reputation, and competitiveness.

    The clinical trial process for a new prescription drug is based on a series of studies, each building upon what has been learned in prior studies. It is an incremental process. It is designed to evaluate potential new therapies and provide evidence of their value. While any given single clinical trial may not in and of itself result in an improved therapy, all clinical trials conducted with potential new pharmaceuticals contribute to our collective knowledge of medical conditions and their treatments, and ultimately to improved future therapies.

    Clinical data collected according to Canadian and international requirements are essential to the approval of new drug therapies for use in our country and around the world. Clinical data collected in Canada provide the added benefits that, one, Canadian researchers get first-hand experience with new therapies under investigation; and two, Canadian study participants have the opportunity to be treated with a new, potentially improved therapy at little or no cost to them or to those who usually pay for their treatment.

    Clinical research contributes to the health of the people of Canada by providing the opportunity to be treated with a therapy that is hypothesized to be an improvement over existing therapies or to represent a therapy where none was available before. The clinical trial process is highly regulated and controlled to ensure the scientific validity of the research as well as to protect the safety of the participants. Typically the care provided under study conditions is paid for by the study sponsor.

·  (1345)  

    In addition, sponsors of clinical research often continue to provide study treatment to participants free of charge for the period between the end of the clinical trial and when the product is available on the market. This means that for those Canadians who participate in clinical research, they, their provincial health plans, or their health insurers are relieved of some of the burden of the cost of their care.

    Clinical research is often conducted at the crossroads of the jurisdictions of universities, health regions, and sufficient researchers. As such, it contributes to the development of more effective and efficient working relationships among these players. This in turn can have a positive effect on both the training of health care professionals and the delivery of health care. In order to gain the full benefit of clinical pharmaceutical research, it must be valued, supported, and conducted in a way that complements quality patient care.

    For many physicians, clinical research contributes to an exciting work environment, which helps keep them at the top of their health care service performance. Therefore, supporting and encouraging the conducts of clinical research in Canada's provinces contributes to attracting, training, and retaining top-calibre physicians and medical faculty to our universities.

    Physician researchers often participate in company-sponsored clinical trials for two reasons: one, to learn how to conduct clinical research in accordance with federal and international guidelines; and two, to be able to conduct their own studies, designed to address issues identified in their practices or to provide evidence to support local health care policies. Researchers' fees from sponsored clinical trials often are used to fund physician-initiated studies or to purchase research or diagnostic equipment.

    For universities, supporting the conduct of clinical research contributes to research-intensive environments by recruiting and retaining research-oriented faculty, enabling clinical faculty to be actively involved in the research endeavour, and providing opportunities for undergraduate and graduate students to be exposed to a full range of research types. There is no doubt that success breeds success. Excellence in clinical pharmaceutical research raises the competitiveness among all health research conducted.

    From an economic perspective, clinical research provides an important and growing source of revenue, whether through overhead charges at universities, fees for administrative and health care services rendered during clinical trials in health regions, or through employment opportunities for clinical research coordinators, study nurses, and research support personnel. Indirect economic benefits, as I've mentioned earlier, can come in the form of sponsor-paid patient treatment.

    In conclusion, the Saskatchewan Drug Research Institute contends that it is important for Canada to remain actively involved in the conduct of clinical pharmaceutical research in order to ensure that Canadian clinical pharmaceutical researchers and potential study participants retain the opportunity to participate in this research endeavour and reap its benefits.

    Further, the Saskatchewan Drug Research Institute, as a unit of the University of Saskatchewan, urges this committee, in its deliberations regarding the many relevant aspects of prescription drugs and their use in Canada, to remember the value and importance of clinical pharmaceutical research and the potential impact on its conduct of any actions the committee may recommend.

    Thank you.

·  (1350)  

    The Chair: Thank you, Ms. Greer.

    We'll move now to part two of our meeting, which begins with questioning by the members of Parliament, and we'll ask Mr. Ménard to lead off, please.

[Translation]

    Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ): Thank you, Madam Chair.

    When as a parliamentary committee we accepted the mandate to do this study, our chairperson told us that this was to be a long-term study. The more witnesses we hear, the more we realize how right she was. Theoretically, we had planned to review the Patent Act, which worries me greatly in light of the fact that that act and its attendant regulation, ever since it was introduced by the Conservatives, was always dealt with by the industry committee. The Ministers of Health appeared before that committee, because of the aspects that involve Health Canada.

    But from the beginning of our work, I have noted that several witnesses felt that the solution consists in reviewing the Patent Act and in reducing the extent of the protection period. I do not know where all of this is leading us. When I began my work here as a member of Parliament, on the committee, I met officials from International Trade; perhaps they will come and speak to us. I was told that Canada is bound by certain international obligations, including agreements on the trade-related aspects of intellectual property rights, the TRIPs, as well as by other agreements, and that it would be difficult to reduce the scope of the Patent Act.

    That being said, one responsibility which clearly lies with Health Canada is issuing notices of compliance. As you may know, in the case of investigational drugs, clinical monographs must be submitted and then Health Canada issues a notice of compliance. Now, the Patented Medicine Prices Review Board tells us that out of 70 new drugs for which a notice of compliance is issued for human use—I am not talking about veterinary drugs—about 10% improve the health of the patient.

    Do you not think that this should be our primary concern and that we should recommend that Health Canada ensure that notices of compliance are issued for drugs that really have some new therapeutic value? Should that figure not be 30, 40 or 50 per cent? We have to give this some thought, in my opinion.

    I was very surprised when officials from Health Canada told me that when a clinical monograph is assessed, the therapeutic value of the drug is not taken into account. So, this is my first question: what do you think about the idea that the committee ask Health Canada to tighten up the issuance of notices of compliance, and to apply a criterion, expressed as a percentage, regarding the new therapeutic effect of drugs that are approved? That is my first question, and I have two other ones.

    I do not know who would like to answer.

·  (1355)  

    Dr. John Bury: Excuse me, I do not speak French.

[English]

    It was so nice to hear you translated with a Scots accent.

    Some hon. members: Oh, oh!

    Dr. John Bury: I think that's a very good idea. I'm sure PMPRB told you about the conference it had in Ottawa last fall, when the Australian and British people came and said they only introduced into their formularies drugs that either are more effective, are cheaper, or have less side effects. They are quite rigid about that, so they have kept a constraint. I think that's certainly one of what I would call the minor things to do.

    I'm sorry you're trying to sweep the Patent Act under your carpet, because it's your carpet, quite frankly. Industry has an objective of promoting industry. You in your committee have an objective of promoting health, and I don't think those things are necessarily parallel.

    You talked about TRIPS, and we know how the major drug companies are dealing with TRIPS: Doha. It looked as though TRIPS was going to be of value to the developing world, but despite Mr. Bill Graham's hard work, it doesn't seem to be happening. They're still delaying any implementation of those recommendations, as far as I can understand from reading the news media, and it's because they are frightened that we in the west might find out how cheap the drugs really are. The fact that you can take a drug the brand names sell for a hundred or so dollars and sell it for $5 and still make a profit...and you tell me the generic industry is making a big profit. The drug companies don't want to hear that. Everybody in Canada needs to hear that, and it is your duty to see that it happens.

[Translation]

    Mr. Réal Ménard: Would anyone like to add any comments in this regard?

    I will ask my second question, in that case. My colleagues and I want to go as far as possible with the tools we have at our disposal. For my part, I believe—and I am convinced that this is what my colleagues also think—that if it proves necessary to examine the patent issue, we will do so, even if in principle, this involves Industry Canada and not Health Canada. There are certainly links that exist, and with regard to these issues, as parliamentarians, we are not naive.

    Several witnesses have spoken to us about a type of pressure that pharmaceutical companies bring to bear. Studies reveal that those companies invest $20, 000  per physician to promote certain products, which certainly gives rise to some ethical concerns. Pharmaceutical companies say that between the moment when they isolate a research molecule and the time when a product can be put on the market, there is an investment cycle of some 800 million dollars. Of course, we are not talking about community groups here; neither the political parties, nor the governments who invest these sums are community groups. The reality is somewhere between the two. Indeed, on this tropic, pharmacists might be in the best position to answer this question.

    In your opinion, what type of guidelines should we propose for the marketing of promotional products? Pressure is brought to bear on health professionals, physicians and pharmacists, and to some degree, nurses, to promote certain products.

    Have you experienced this type of situation, and according to you, what type of guideline should the committee propose?

[English]

    Mr. Randy Wiser: I have a couple of comments here. There are companies out there that are gleaning information from the marketplace and finding out directly or indirectly what the prescribing habits are. Then they'll go back to a physician, and if he's not prescribing this certain drug, they'll be able to see it as an opportunity and visit him.

    In terms of the samples, I deal very closely with a couple of groups of physicians, and I continually see how the physician will use maybe 20% to 30% of the samples that are brought in--that's an estimate--because they kind of relate to his practice. He likes the medication. Now, the rest of the samples that arrive on his desk sit on a shelf, expire, and get thrown in the garbage. This is what I've seen in practice anyway.

¸  (1400)  

[Translation]

    Mr. Réal Ménard: Do I have time to ask one last question?

    This is a somewhat indiscreet question, which may appear a bit petty, but I am going to take it upon myself to ask it. Human beings can be noble, but they can also be petty on occasion; they can display either characteristic.

    What is the profit margin pharmacists make, on average, on the sale of prescription products? The Kirby report, the Clair Commission and the Romanow Commission all mentioned the fact that the cost of medication was increasing, but when the time comes to determine the responsibility of all of the parties involved, everyone blames everyone else. Be that as it may, the fact is that the cost of drugs is increasing.

    For instance, what is the profit margin pharmacists make on prescription drugs? How would you express it as a percentage? This is a nosy question, but everything that is said will remain here.

[English]

    Mr. Randy Wiser: Well, one of the paradoxes that we as pharmacists are in is that we receive reimbursement from a dispensing fee. To me, when you're talking about the health of people, receiving a reimbursement for dispensing a prescription doesn't make sense. In practice, the more prescriptions we dispense, the more money we make--if you want to look at it that way.

    However, this is not what we're talking about or advocating in our paper here. We're asking if there's a way we can find a way to reduce the cost of therapy, either through the elimination of drugs or the substitution of a lower-cost alternative. Hydrochlorothiazide is a perfect example, a drug from twenty or thirty years ago. We're getting these high-cost blood pressure medications pushed on us, yet this is one of the more effective drugs.

    It doesn't make sense that we would get reimbursed for dispensing more prescriptions. It would make more sense if we got reimbursed for providing a service that's beneficial to the public.

    Mr. Guy Nobert (Vice-Chair, Representative Board of Saskatchewan Pharmacists): If I may, keep in mind that this cost is the same regardless of whether a medicine costs $500 or $2. The way to look at it is that your “upcharge” is the same, whether you're buying a car or a peanut. So that's an interesting dilemma we have as pharmacists, in that, as Randy says, we're providing a service, and that is what we are upcharging on; it's not the product.

    The Chair: Thank you.

    Thank you, Mr. Ménard.

    We'll proceed to Mr. Thompson.

    Mr. Greg Thompson (New Brunswick Southwest, PC): Perhaps I'll just follow up on Mr. Ménard...and I don't want to get ranting on this, as I did yesterday, with regard to pharmacists and their profitability on drugs and dispensing fees.

    I see a few grins around the table. I think they were forewarned by the meeting yesterday that this might be coming. Is that true? No?

    Well, there you go. They're just in a good mood, Madam Chairman.

    The Chair: I'm expecting you to keep them in that mood, Mr. Thompson.

    Mr. Greg Thompson: Okay.

    Now, I think there's not a critical level of honesty in terms of the pharmacists. I have great respect for what you do, and the good work, but when we get into the profit, you always get kind of squirmy in your chairs as we do when we're uncomfortable as witnesses when testifying. Every doctor I've talked to, and everyone in the industry, tells me of the so-called kickbacks from the generics to the pharmacists in terms of trips and reduced prices on the product--nothing to do with dispensing fees, but the price you pay for the product.

    We've heard here this morning that the product, especially generic drugs, is 21% to 50% higher in Canada than in the United States. And the only reason you get away with that higher price is that it's lower than the patent drugs, but the truth is that they should be much lower. So it's a bullet that you'd like to duck, but again, you can't talk to a doctor in this country who doesn't understand that's happening. I mean, you deny it, and you'll sit here today and deny it, but it is happening.

    At one point will you step up and say, yes, we do get a favoured treatment on generics, and yes, we're getting a huge profit margin on generics? Could you address that?

    I'm not sure if I should start with you, Randy, or Guy, or it could be Ray, or whoever.

¸  (1405)  

    Mr. Ray Joubert: From the perspective of the Saskatchewan College of Pharmacists, your question is very timely. Our council, which is our governing body, examined this issue briefly on September 24, but agreed that the issue around kickbacks might require further study and examination by our organization.

    As a second point, that decision was made because of reports in the professional and public media around the kickbacks that pharmacists and pharmacies were receiving.

    Third, the situation in Saskatchewan might be a little different from any other jurisdiction in Canada because of the unique nature of the Saskatchewan prescription drug plan, which basically says, as one of the rules, that any kickback must be passed on to the patient through what's called “actual acquisition costs”. So the pharmacist must impute into the cost of the drug that is sold to the consumer any kickbacks that would be provided--if I understand properly your definition of the term “kickback”.

    Mr. Greg Thompson: I know we do use the term loosely, and then it becomes a bookkeeping arrangement in terms of the costs of the pharmacy versus a new.... There are a lot of things.

    We'll leave it at that. I'm satisfied you're taking a look at it.

    Dr. John Bury: I'll answer that question for you, sir.

    Mr. Greg Thompson: Dr. Bury, I have another question for you specifically. Maybe the next member can get into that.

    By the way, I just want to put it on the record that I was really impressed with your presentation. Much of it I agree totally with.

    One of the things I wanted to mention to you, Dr. Bury--again, I was impressed with your presentation--is that after listening to Marianne Greer on behalf of the Saskatchewan Drug Research Institute, it brings to my mind a question that you didn't address in your paper, and I don't think Ms. Greer did either. This is with regard to the terms of a clinical trial registry.

    I'll tell you what brings me to that, Dr. Bury. Looking at your paper, you talk about the multitude of drugs that comes on the market.You talk about hypertension and some of the drugs on the market that cost 100 times as much as some of the first-line drugs that have been out there for 10, 15, or 20 years. They cost 100 times as much but typically have no overall benefits.

    I'm just wondering, Doctor, with your experience, how you think a clinical trial registry could figure into this so that we could be more informed in terms of some of those new drugs coming online, some of the past experiences, good or bad and so on. Is that something you've considered, Dr. Bury?

    Dr. John Bury: I'm afraid I'm not going to be able to answer this very well, because I've been out of the loop for the last 15 years. But it seems to me that research when new drugs are assessed and followed is often problematical. One of the things we've not talked about today, it seems, is the long-term effects of drugs. That's very badly monitored in this country. Side effects are not properly acknowledged.

    Mr. Greg Thompson: I hate to cut you off--I'm not the chairman--but through the chairman I want to put the same question to Ms. Greer in terms of a clinical trial registry.

    Now, that idea was floated here this morning by the Minister of Health for the Province of Saskatchewan, which I find very intriguing. We had some presentations here too. In fact our other member, Carolyn Bennett, had some very specific questions on clinical trials.

    In your experience, Ms. Greer, would a clinical trial registry be a helpful thing?

    Mrs. Marianne Greer: I do think it would be worthwhile to have a clinical trial registry. Certainly the FDA has instituted one. There are some difficulties in terms of how much information you can actually share. Certainly you can share that this study was done, that it compared this and that, and that this was the result. But you may not hear about all trials. There are some trials that are conducted that aren't part of a registration package. They may be conducted in a country outside of this one.

    So unless you can somehow enforce that all trials actually conducted are included in the registry, you're going to be looking at a portion only.

¸  (1410)  

    Mr. Greg Thompson: So it's sort of an international problem.

    Mrs. Marianne Greer: It is an international problem.

    Mr. Greg Thompson: It's something for the World Health Organization or whatever.

    Mrs. Marianne Greer: Clinical research is global, definitely.

    Mr. Greg Thompson: Then you can tweak it to those other considerations, which we might not have stumbled upon, but I guess with your experience you'd say it would be helpful--

    Mrs. Marianne Greer: I think it would be helpful, but there would be some stumbling blocks to make it everything you would like it to be.

    Mr. Greg Thompson: Right.

    This is a fascinating panel, Mr. Chairman. I'd love to spend the rest of the afternoon getting informed. Have I any time left?

    The Vice-Chair (Mr. Réal Ménard): I'm open to giving you four more minutes. I'm a generous man.

    Mr. Greg Thompson: There you go. You heard it here in Saskatchewan.

    Thank you, Mr. Chairman.

    Again, Dr. Bury, I've been shuffling through some of what you had to say here. You talk about the lessons learned--this would be on page 2 of your presentation--from the Saskatchewan prescription drug plan. You talk about a restricted formulary, which fits into some of the previous arguments in your paper, and about generic drugs significantly reducing the cost of many prescriptions.

    I'm back onto my favourite hobby horse here, which I guess Dr. Bennett got me on, if you will. Now she's going to have to take the blame for my ranting.

    Don't you think the generic drug companies are getting more credit than they deserve? I go back to this apparent price difference between generic drugs in Canada and in the United States, our nearest neighbour. It appears our patent drug legislation and review process works where we've driven down the cost of patent drugs, but we're out of sync when it comes to generic drugs.

    When you're doing a paper like this, or when any of us are making a presentation, we can always talk about the significant savings on generic drugs. But what I guess I'm suggesting is that these savings could be greater, because these people are basically taking advantage of the Canadian marketplace. My understanding is that there are only two major generic manufacturers in the country. They basically have a captive market and are taking full advantage of that marketplace. So we can stand up and say that there are some savings, but the savings could be greater.

    I'll leave it at that and look for your comments.

    Dr. John Bury: It's interesting that the complaint against the generic companies increasing their prices is fairly recent. My own study went to 1992. I noticed at the PMPRB conference that it was definitely a discussion point, that the generic prices are going up.

    You will remember in my evidence to you today that I suggested you look to the profit margins of both the brand name and the generic companies. I very strongly think you should do that.

    Ms. Carolyn Bennett (St. Paul's, Lib.): The generics are all private companies. You can't see their profits.

    Dr. John Bury: Well, that's the trouble, isn't it?

    Ms. Carolyn Bennett: Seeing as it's being paid with public dollars, yes.

    Mr. Greg Thompson: Doctor, I'll just throw this one out quickly before the chairman runs out of patience with me.

    We have the review agency structure for patent drugs. Should we perhaps take a look at doing it for generics?

    Dr. John Bury: Why not?

    Mr. Greg Thompson: That's a good question. Why not?

    Dr. John Bury: Anything that would watch over the pharmaceutical industry more closely would please me.

    Mr. Greg Thompson: Thank you very much.

    Thank you, Mr. Chair.

    The Vice-Chair (Mr. Réal Ménard): Merci, monsieur Thompson.

    We have two more speakers, Madame Bennett and Madame Brown.

    Ms. Carolyn Bennett: Thanks very much.

    My initial interest was in Mr. Filson of the Representative Board of Saskatchewan Pharmacists. I just want to know the history of that or the genesis. Where did that come from? It's not something we've seen in other provinces.

    Mr. Guy Nobert: Essentially, our organization grew from the parent organization with which Ray has been associated for years.

    I'm not sure, Ray, if you want to be the one to address this as far as the genesis goes. Certainly I can address it.

    What it came down to was that because the Saskatchewan College of Pharmacists represents the public, it found that it could not also adequately represent the needs of the pharmacists. As a result, the Representative Board of Saskatchewan Pharmacists was created, at that time an offshoot and now an independent organization, to address the needs of the pharmacist group more adequately.

¸  (1415)  

    Ms. Carolyn Bennett: My understanding of the College of Physicians is that it's to guide the profession and protect the public. Are you saying that can't be done in the same organization?

    Mr. Guy Nobert: We found that when you were negotiating with government, very often a lot of the issues that we had could not be considered to be--

    Ms. Carolyn Bennett: So this is the difference between, say, the college of nurses and the nurses' association.

    Mr. Brett Filson: I think you'll find, Madam Bennett, that in all the provinces in Canada there are two organizations representing most of the medical community. There is the college here in Saskatchewan, the College of Pharmacists, just as there is the College of Physicians and Surgeons, just as there is the Saskatchewan Registered Nurses Association and the Registered Psychiatric Nurses Association.

    The other side, or the advocate side, is represented, in our case, by the Representative Board of Saskatchewan Pharmacists; for the nurses, it's the Saskatchewan Union of Nurses; and for the doctors, the Saskatchewan Medical Association.

    There is the advocate voice and the regulatory voice.

    Ms. Carolyn Bennett: Within your organization, is there a bifurcation between the pharmacists who are on salary in hospitals--and I don't know if you have any pharmacists on salary in community clinics or whatever--and the pharmacists who rely on a profit prescribing fee? Wouldn't their interests be different?

    Mr. Brett Filson: No, we don't find their interests substantially different. In fact, a lot of the work we do here in Saskatchewan, through the Representative Board of Saskatchewan Pharmacists, we do in cooperation with the Canadian Society of Hospital Pharmacists, Saskatchewan branch.

    We represent the interests of both the owner pharmacists as well as the staff pharmacists and the hospital pharmacists.

    Ms. Carolyn Bennett: Okay.

    We've been interested in Roy Romanow's recommendation of a drug agency that would actually look at some sort of collaborative model of common drug review, post-market surveillance, or whatever else we could do. I'm interested in the idea of the clinical trial registry as well. Certainly from what we heard this morning from the Canadian Arthritis Patient Alliance and others, shouldn't there be some ability for patients who are about to be enrolled in a trial to have an objective view of that trial in a way that isn't flavoured by anybody who has some benefit from the trial?

    Mrs. Marianne Greer: Certainly that's the goal of the informed consent process. The whole idea is to lay out for the potential subject in the study what the benefits and risks are and what their options are if they are not to enroll in the study. So that is the goal of the informed consent process.

    For the most part, that goal is met, although there may be cases where someone wants to have someone else enrolled in the study and they're pushing a little bit harder. There is that possibility.

    Ms. Carolyn Bennett: There's a serious power differential in the relationship between the physician and his or her patient.

¸  (1420)  

    Mrs. Marianne Greer: It's also important to recognize that it's not always the physician who's doing the informed consent process. It's often the study nurse.

    Ms. Carolyn Bennett: Yes, but in my practice I think the nurse had greater bonding than some of the physicians.

    If we move to a new approach, if CIHR gets its way and we move to a phase two where we would have centres of clinical excellence funded in terms of clinical research, they wouldn't necessarily be funded by pharmaceutical companies, but you would be looking at best practices in congestive heart failure or anything else you want to name.

    What would happen to your institute in those sorts of trials, or would those trials be done with mainly just teaching hospitals and you'd be out of the loop? A relationship with pharmaceutical companies is very much part of your mandate,right?

    Mrs. Marianne Greer: We get funded out of the university's overhead, and the university charges overhead on company-sponsored trials. But we also help faculty members on campus when they are making applications for CIHR or NIH grants. We have no way of getting paid for that, but as a not-for-profit unit of the University of Saskatchewan, obviously we do our very best to support those types of research as well.

    I would hope that the University of Saskatchewan would see the value in the services we provide and support us so that we could continue to provide that service regardless of the funding agency.

    Ms. Carolyn Bennett: Okay.

    Going back over the last couple of days, one of the things that seems clear is that physicians' behaviour is pretty difficult in terms of their power differential. I think that probably any pharmacist who has ever been at the other end of a phone when trying to persuade a physician that maybe they don't need to use this drug any more....

    I was interested that in Quebec they began.... Obviously, you don't get a dispensing fee for not filling a prescription, which I would say would be a good thing for a minister of health to do. You should get the prescription fee for refusing to fill the prescription. There's a saying in management, “the folly of rewarding A while hoping for B”. We seem to reward bad behaviour all the time.

    I know that in Quebec they tried giving the pharmacists a fee for calling the doctor and telling them to change their minds. Does anybody know how that worked, or whether it didn't work? Maybe we should ask that in Quebec.

    The Vice-Chair (Mr. Réal Ménard): It's because Quebec is a distinct society.

    Ms. Carolyn Bennett: Well, they have good ideas and nice people like you. That's why we need them in Canada, sir. My Canada includes Quebec.

    The Vice-Chair (Mr. Réal Ménard): Would you like to add...?

    Ms. Carolyn Bennett: The pharmacists also know who the bad doctors are. What line does somebody have to cross for your guys to call the College of Physicians and Surgeons to say, “We've got Dr. Nick here prescribing 500 of this and 3,000 of that and we don't think he should do this any more”?

    Mr. Ray Joubert: Madam Bennett, I'd like to address your first question, if I may, by indicating that when the system in Quebec was studied, particularly the refusal to fill fees, it demonstrated positive outcomes in the sense that it was achieving the purpose for which it was implemented. What hasn't been studied very clearly is why there hasn't been a more extensive uptake of the concept across Canada, or why there have not been higher volumes of refusals to dispense compensated by this type of fee.

    So I would encourage you to continue to ask the question whether or not there is any evidence out there that would conclusively demonstrate that alternative reimbursement for pharmacists in that way is the approach that needs to be taken.

    In Saskatchewan many years ago we began the process of looking at alternative reimbursement schemes for pharmacists, and there are funds of money available out there that are now under review. I don't know if our colleagues from the Representative Board of Saskatchewan Pharmacists can elaborate on the progress, but those funds are sitting there for the purpose of reimbursing pharmacists differently, in other words, for incentivizing the pharmacists to provide service on the basis of outcome rather than volume.

    Ms. Carolyn Bennett: Dr. Bury, do you have any comment?

    Dr. John Bury: Well, you mentioned Roy Romanow's report.... Primary health centres are part of the answer, where in fact the pharmacist becomes part of the team. In the early days of the clinic, for about the first 20 years, this was the case in Saskatoon. It makes a huge difference, because they know a lot more about drugs than physicians do; they spend five years training on drugs and we spend a few months. So I think that's one of the roads we should go down. If that happened, I think it would be much better.

¸  (1425)  

    Ms. Carolyn Bennett: We did hear this morning from the Saskatoon Community Clinic. I think they had some data showing that prescribing was 20% less in a clinic such as theirs, compared to solo practitioners and fee for service. It's certainly what my instinct would be, that if you can prescribe a social worker, the patient is probably a bit better off—or maybe with both.

    Dr. John Bury: That's what we did.

    Mr. Guy Nobert: If I may, as well, please keep in mind when it comes to refusal to fill, although it's a great program in Quebec, the amount of refusals to fill that occur are based on what kind of information you have. When we have prescriptions that are saying “take as directed” with an unlimited quantity, that is very difficult really to make any decision on. I just wanted to point that out.

    The Vice-Chair (Mr. Réal Ménard): Last question.

    Ms. Carolyn Bennett: Yes, last question. On the IT system that's being developed here, obviously for people like me this is a huge priority for the country, to actually have an IT backbone where we could do all of this and learn from one another. Some of those problems would disappear. You couldn't really do as directed on this if you're prescribing on a drop-down menu. Who is developing the software that would help you do your jobs better? Are you involved in what's being sorted out at Infoway and everywhere else and with your new thing here?

    Mr. Ray Joubert: Yes, we are involved, and there are two critical issues. One is, how do these technological solutions provide pharmacists and other health care providers with the information they need to make good decisions? I think the answer to that is that it's possible.

    The other issue is, to what extent do these technological solutions facilitate communications amongst these providers so that they can function in a true team environment, and in that context we wholeheartedly support what Dr. Bury said, because pharmacists value highly the relationship they have with physicians and patients. You ask where that line is crossed. It takes a lot of disparaging behaviour for a pharmacist to actually report a physician.

    What happens in a good teamwork environment is that where there are differences, those differences are worked out between the pharmacist, the physician, and the patient. That requires communication. That requires support. That requires the building and maintenance of healthy relationships. If you're examining a recommendation around a national pharmacare program, I hope this will encompass a technological solution that fosters (a) critical decision-making information and (b) the ability to communicate and maintain the teamwork atmosphere.

    The Vice-Chair (Mr. Réal Ménard): Thank you.

    I think we will have more time for a second round, but I would like to give time to Mrs. Brown.

    Ms. Bonnie Brown: Thank you, Mr. Chair.

    I'm a little bit confused about the Saskatchewan Drug Research Institute, which you claim is at arm's length from the university and not for profit. Is that correct?

    Mrs. Marianne Greer: We are a unit of the university.

    Ms. Bonnie Brown: But when you claim to be not for profit, it suggests to me you keep your own books.

    Mrs. Marianne Greer: Yes, we do, and we provide an annual report to the board of governors of the university.

    Ms. Bonnie Brown: Okay. You also mentioned that the 600 clinical trials conducted in Saskatchewan meant $40 million.

    Mrs. Marianne Greer: Of total contract value, not money to us.

    Ms. Bonnie Brown: No, but how much of that goes to the university?

    Mrs. Marianne Greer: The university charges a minimum of 20% overhead on what money is actually received. The thing about clinical trials is that you might have a total contract value of $200,000 based on an anticipated number of patients, not only enrolled but staying throughout the whole trial. Quite often that target is not met for various reasons—either because it's competitive enrolment and our sites are getting up and starting slower than other sites, or maybe we just don't have enough patients to hit that target in that particular therapeutic area.

¸  (1430)  

    Ms. Bonnie Brown: Do you administer these contracts?

    Mrs. Marianne Greer: The University of Saskatchewan accounting department administers the inflow and payment out on the contracts. The University of Saskatchewan contract officers are the ones who actually sign the contracts.

    Ms. Bonnie Brown: I guess what I'm trying to get at is how much of the $40 million stays in the treasury of the university. In other words, is it a net gain for them to have your unit working in this field? I assume it is, or they wouldn't bother.

    Mrs. Marianne Greer: It is a net gain, but it's much smaller than it might seem when you see $40 million.

    Ms. Bonnie Brown: But do you know what it is?

    Mrs. Marianne Greer: No, I don't. At a rough guess, of that $40 million, probably about 60% actually is realized, and then if you take 20% of that over the ten years, that's what the University of Saskatchewan would have seen.

    Ms. Bonnie Brown: Okay. Now, do you recruit the doctors who are part of the clinical trials? Is that part of your work?

    Mrs. Marianne Greer: We can play a role in identifying physicians who do research in a specific area, but it's not up to us to decide who will get a site or conduct a trial. That's usually up to the sponsor to make that decision.

    Ms. Bonnie Brown: By the sponsor you mean the pharmaceutical company?

    Mrs. Marianne Greer: Whoever is paying for the trial, yes.

    Ms. Bonnie Brown: So they find their own doctors, is what you're telling me.

    Mrs. Marianne Greer: They often do, but they sometimes come to us and ask us whether we know a physician who has an interest in this therapeutic area who might have patients who would fit the requirements of this study.

    Ms. Bonnie Brown: I want you to think about an occasion when you helped to recruit some doctors. Are you aware if any of those doctors had to sign confidentiality agreements?

    Mrs. Marianne Greer: They all must. We do too.

    Ms. Bonnie Brown: Okay. Are you aware of any of them, say, refusing to sign on for the second round with a certain pharmaceutical company because of their own discomfort?

    Mrs. Marianne Greer: Yes.

    Ms. Bonnie Brown: Yes. Could I assume from that that what they found was perhaps adverse effects on their human subjects but were unable to report that, except to the sponsoring company?

    Mrs. Marianne Greer: I am not privy to that information. The one case that immediately comes to mind had more to do with the physician's concern about what was actually stated in the confidentiality agreement, in terms of what his responsibilities were to the company. It wasn't specific about adverse effects.

    Ms. Bonnie Brown: We had a very compelling presentation this morning about the fact that from the business perspective, and probably even from the scientific research perspective, we look at the words “clinical trials” in a positive light, because hopefully it expands the body of knowledge. This presenter pointed out that every single time there's a clinical trial, there are human subjects. I'm wondering whether we are being rather overly optimistic looking at these clinical trials in such a favourable light, if in fact there are human subjects who may suffer adverse effects, or, as it was suggested in one case, that after the trial was over the human subjects who had become healthier on a very good pharmaceutical product were essentially abandoned and had to do without it.

    Do you have any power over the pharmaceutical companies to make sure they will not abandon their subjects? There's usually a period of time between the end of the clinical trial and the full approval and marketing of the drug.

    Mrs. Marianne Greer: I do not have any power. However, I have observed that a large number of the clinical trials by a wide range of sponsors do try to make sure that the patient has access to that product until such time as it's on the market. But then there's another hurdle. It may be on the market, but it might not be reimbursed at the provincial level.

    Ms. Bonnie Brown: It might not be on the formulary.

    Mrs. Marianne Greer: So the rate of abandonment of that patient may be at more than one gate. We have a lot of patients here in Saskatchewan who were on clinical trials. The trial has ended and they're continuing to receive that therapy. My father is one of them.

    Ms. Bonnie Brown: We talked about the clinical trials registry, and you seemed to be feeling positive about that possibility. Would you be as positive if we had a law that said you had to register your clinical trial? Our problem is that it has been reported to us that we don't hear about all the clinical trials where the results show failure, because naturally a pharmaceutical company does not want to have its name attached to something they have cancelled partway through because of adverse effects or lack of efficacy of the product or some such thing.

¸  (1435)  

    Mrs. Marianne Greer: I think the idea of a registry is a good one. One of the points I made was it may be difficult to have the registry do everything you want it to do, because it might be difficult to require people to register all of their clinical trials.

    Ms. Bonnie Brown: But what if that is the law?

    Mrs. Marianne Greer: Well, a clinical trial could be done in India.

    Ms. Bonnie Brown: Yes, but our responsibility right here is for Canadian citizens who might become the human subjects and in some way to protect them. If every clinical trial had to be registered, and then the people conducting it had to report back as to whether they cancelled it halfway through, or whether it was completed, at least we would have an idea as to the possible impact on those human subjects.

    Mrs. Marianne Greer: Well, some of that actually is done by Health Canada already, because in order to get a product on the market here in Canada, the trials do have to be reviewed by TPD. They have a list of the clinical trials--

    Ms. Bonnie Brown: That's for the successful ones.

    Mrs. Marianne Greer: Well, no, because you don't know ahead of time if a trial is going to be successful, do you? I've seen trials that have been really well designed; you're going for a hypothesis, you've thought of all the consequences, and you try to set up the trial, but you don't know beforehand whether or not it's going to be successful. And all of those trials, if they're part of the registration package, I understand, have to be submitted, regardless of their outcome.

    Ms. Bonnie Brown: Thank you, Mr. Chair.

[Translation]

    The Vice-Chair (Mr. Réal Ménard): I see.

[English]

    Thank you very much.

    We have 10 more minutes. I don't know if any colleagues want to raise other questions.

    Mr. Thompson, you can share the time with Madam Bennett.

    Mr. Greg Thompson: Thank you.

    I'm going back to Dr. Bury's presentation here. I'm still impressed with your presentation, Doctor. You're using plain language, which most of us who aren't pharmacists and doctors appreciate. You remind me of Harry Truman, who was just slightly older than you are when he was President. Remember, he was a great believer in plain speaking.

    On page 3 of your brief--and I'm just saying this because it reinforces what Dr. Bennett was saying and what was reinforced by the pharmacists--you talk about this team approach. Again, this is just old-fashioned common sense, but it's something any layperson can.... And you've itemized what the reasons are for the high cost of drug programs, and one of them is irresponsible prescribing, which speaks for itself, and we've spoken of that.

    Second is inefficient dispensing. I just want to read this into the record, if you don't mind:

The present system of dispensing using highly trained pharmacists to spend most of their time recognizing names on bottles, counting, filling in labels and making out invoices is a gross waste of their skills. This function should be reserved to dispensing clerks while pharmacists should join physicians in a therapeutic team.

    That's the team approach that has been talked about by Dr. Bennett and the pharmacists:

This is well argued by Evans and Williamson [4], who estimate that a more rational system of dispensing could save between 11.4 and 16.7 % of prescription costs.

    I think it's important that you maybe talk on that some more, because it fits in well with your idea that unless we get costs under control, forget about a national drug program. I know the representative who's with us today from the nurses' union has suggested--and I don't think any of us disagree with the idea--of a national program, but until costs are under control, maybe that's a street we shouldn't go down.

    Dr. John Bury: If any of you have been to Sweden, you'll notice that the term for pharmacist is “apotek”, and that's all they do. They sell and dispense drugs and they spend a lot of their time talking to patients about them.

    When we introduced the drug plan in 1975, some of us in the bureaucracy--because I was in the bureaucracy at the time--wondered whether we really needed all those pharmacists. We thought at one time that Saskatoon, which then had a population of about 130,000, could have done with the three hospital dispensaries and perhaps four or five more.

    But we didn't do that because politically it would have been a disaster, because every small community out there in Saskatchewan needed four things. It needed an elevator, it needed a hospital, it needed a doctor, and it needed a pharmacy. Because the pharmacy was such an important store in most of those towns, as it didn't sell only drugs but everything else, and because Saskatchewan had one of the largest colleges of pharmacy in the country and we exported not only wheat but pharmacists from here, the government decided it would be a political disaster if we reduced the number of pharmacists, so they chickened out.

    I would love to go back to having pharmacists behave like professionals. I really do object to having to wade through the bra counter, the razor blade counter, some boots, and some groceries to get to the pharmacy at the back of a superstore. It's an awful way for pharmacists to have to behave, and I'm sure we can manage with much fewer and then have them just dispensing. Where they were, they would have dispensaries, and I would prefer them to be very close to physicians.

¸  (1440)  

    Mr. Greg Thompson: There's something about the counting out of those little pills too, and I agree totally with you. That just spells it right out, and I think that with the education and the ability these people have, they are being underutilized. Maybe that team approach is something we'll have to take a look at, Mr. Chairman.

    Thank you very much.

[Translation]

    The Vice-Chair (Mr. Réal Ménard): Thank you.

[English]

    Ms. Bennett, do you have more questions?

    Ms. Carolyn Bennett: Yes.

    If we are moving to a more professional world for pharmacists, obviously the pharmacy assistant could be doing some things. I want to know, could not some of that be helped by an IT system that would have some checks and balances in quantity repeats, depending on what drug it was? Are there people working on programs that would spit back anything that was for 500 of anything or that was asking for 24 repeats? That's obviously a professional call now.

    Also, in terms of drugs we now consider old-fashioned, ones you really shouldn't be using any more, or drugs that are new-fashioned, ones you shouldn't be using unless you've tried three other things and have finally reached the climax of this big sort of expensive thing, is that something that could be helped with the technology? If those guidelines were out there for patients, there wouldn't be that sort of pushing by patients because the patients would know what their roles were and that you couldn't go and expect to get truckloads of stuff.

    I think we're still finding in almost every panel that there are some prescription drugs trickling out into our society that are really problematic in a lot of the communities. What could we do to tighten that up?

    Mr. Ray Joubert: Perhaps I could answer that. I think the answer to both your questions is yes. Technology will help, and yes, work is being done, but it's painfully slow. Progress has really yet to come, as one person put it, and the limiting factor is resources.

    I just attended a meeting yesterday on a progress report on this type of system you're alluding to. I don't know if you asked the same question of our Minister of Health or what his response was, but at the end of the day what I heard was not anywhere close to my expectations. Clearly, the limiting factor is a lack of resources, money and people in particular. The technology is there, but we need money and people.

    Ms. Carolyn Bennett: As a physician, I know we use pharmacists and nurses quite differently in the hospital. We would say, call the doctor if blood pressure is over 100. With patients having their own cuffs and given the ability to fax or e-mail your results for the last month into the pharmacy, do you ever foresee, in terms of the role of pharmacies, that the pharmacist could fill the prescription if the blood pressure was fine for the month but call the doctor if it started creeping up? We do that in the hospital; I don't know why we don't do it in the community.

¸  (1445)  

    Mr. Ray Joubert: Your question is very timely, and I'm delighted to report that as of September 1, qualified pharmacists in Saskatchewan have the ability to prescribe, and our first initiative was emergency contraception.

    We at the Saskatchewan College of Pharmacists plan to expand that, the next steps embodying the kind of idea you're describing, where a pharmacist would work as a member of a team with a physician to have prescriptive authority under a protocol. The physician and the pharmacist would decide between themselves under what circumstances the pharmacist could independently prescribe medicines. This is a very real method of engaging the pharmacist in a more effective role, one very well documented in the literature.

    Mr. Guy Nobert: It is a step-by-step process. We have had discussions with our colleagues in the medical community about doing exactly that, and we have taken the first steps towards that.

    The Vice-Chair (Mr. Réal Ménard): Thank you, Ms. Bennett.

    I would like to thank each of you for coming and sharing your views with us.

    Tomorrow we have a meeting in Winnipeg.

    I adjourn the meeting.