HESA Committee Report

A. Wait Times

Under the 10-Year Plan, governments committed to establish evidence-based benchmarks for medically acceptable wait times in five priority areas: cancer, heart, diagnostic imaging, joint replacement and sight restoration. In December 2005, jurisdictions announced that they had fulfilled their commitment with respect to setting benchmarks, except those for diagnostic imaging. To date, there are still no benchmarks for diagnostic imaging. Given that many diagnoses are dependent on imaging, some witnesses questioned whether the lack of benchmarks in this area has reduced the usefulness of benchmarks for the other priority areas of treatment.

Another wait time commitment was to establish, by 31 December 2007, multi-year targets for achieving the benchmarks announced in December 2005. This deadline passed with only a few provinces setting timetables to achieve some of the wait time benchmarks. For this reason, most jurisdictions cannot report annually on progress in meeting these multi-year targets as required under the plan.

According to the Health Council, the Wait Time Reduction Fund has helped jurisdictions to move forward on wait times; jurisdictions have used the funds to build capacity and address wait-list backlogs. In particular, they have invested in equipment, human resources, training/education of professionals, technology and information systems. The Council also noted that many jurisdictions have created websites where patients can view wait times for a variety of procedures. In its view, these websites are a good first step to providing patients access to more information on wait times and rebuilding confidence in the system.

The 10-Year Plan mandated CIHI to report on the progress on wait times across all jurisdictions. CIHI has fully complied and produced four reports on wait times since 2004. CIHI’s latest data show that the volume of surgeries in the priority areas increased by 13% in Canada (excluding Quebec) between 2004-05 and 2006-07. Over the same period, the amount of diagnostic imaging equipment increased by 27% for MRI scanners and 12% for CT scanners and the number of exams performed went up even more. Despite the increase in surgical volumes and the additional diagnostic equipment in use, CIHI representatives told the Committee that they cannot conclude that this has led to meaningful reductions in wait times.

A major barrier to assessing progress on wait times is the fact that CIHI uses data and information on provincial websites and that this information remains limited. For example, only five provinces are reporting wait times for the five priority areas; the others are reporting wait times for only four priority areas. Similarly, only three provinces are reporting the percentage of procedures completed within national benchmarks or province-specific targets for radiation therapy. A further challenge faced by CIHI is that provincial data is reported in diverse ways, such as using different measures, and this makes it difficult to compare and evaluate progress on wait time reductions from a pan-Canadian perspective. For example, CIHI was able to compare only three provinces in terms of their wait-time performance on joint replacements and four provinces for cataract surgeries. Moreover, trend data are not available across the board; they are only beginning to emerge for some jurisdictions.

The report cards by the Wait Time Alliance showed that some jurisdictions made some progress in reducing wait times in the five priority areas but noted that, on the whole, governments were not fully living up to the commitment they made under the 10-Year Plan. Like CIHI, the Alliance stressed that a lack of comparable data was undermining efforts in assessing progress.

A number of witnesses raised the concern that efforts to shorten wait times for the priority areas may have had the unintended consequences of lengthening wait times for other procedures. This issue highlights the need to measure, monitor and manage wait times for all, or at least more, procedures. Witnesses indicated that the establishment of wait time benchmarks in five key areas serves as a good first step but that efforts cannot end there. The Wait Time Alliance reported that it had developed benchmarks for seven additional specialty procedures and encouraged governments to use them to establish multi-year targets.

B. Health Human Resources

The 10-Year Plan committed governments to increase the supply of health professionals based on an assessment of the gaps, including targets for the training, recruitment and retention of professionals by 31 December 2005. All governments committed to making their plans public and to report regularly on progress. The Health Council reported that most jurisdictions submitted reports on their health human resource action plans; however, these reports often lack detail. Only four include population health needs; some do not have targets; and only four link their targets to the Pan-Canadian Health Human Resource Planning Framework. This F/P/T framework is intended to facilitate planning and management of health human resources, but it is not receiving the attention and support from all stakeholders that it must have to succeed.

The Health Council also told the Committee that jurisdictions have increased enrolment in professional schools and initiated new recruitment and retention strategies in order to address shortages in health human resources. Nonetheless, a number of witnesses indicated that there are still not a sufficient number of seats in health education programs to produce enough new graduates to replace those who will leave the workforce. In fact, the Committee heard repeatedly that there is a nationwide shortage of health human resources. Information on the extent of these gaps suggests that Canada may even be on the brink of a “crisis” in health human resources.

Currently, much of the data on health professionals relate to physicians and nurses, with little information on other health professions. CIHI data show that the number of physicians and nurses increased only slightly between 2004 and 2006; an insignificant increase given the growth in population during this period. CIHI is currently developing five new databases on: occupational therapists, pharmacists, physiotherapists, medical laboratory technologists and medical radiation technologists. This improved data is expected to measure the current supply of professionals, discern the appropriate mix and distribution, and forecast future requirements. This, in turn, will help inform policy and planning decisions in health human resources.

Witnesses told the Committee that some jurisdictions lose their graduates to other provinces as they compete for the same doctors, nurses and other health professionals. While a number of provinces are working together to plan and manage their health human resources more effectively, the nationwide collaboration envisioned in the 10-Year Plan has not yet resulted in coordinated planning. Again, witnesses suggested that this should be addressed under the Pan-Canadian Health Human Resource Planning Framework.

Witnesses also pointed out that the shortage of health human resources is international in scope and, accordingly, they expressed concerns about the increased recruitment of internationally trained health professionals. In their view, Canadian employers are “poaching” workers from developing countries. Rather than encouraging the immigration of internationally educated health professionals, they suggested that governments support the upgrading, language training, and credential recognition for internationally-educated health care workers already in Canada and employed in health care.

As part of the 10-Year Plan, the federal government committed $100 million to increase the number of Aboriginal health care professionals. In 2005, it launched an Aboriginal Health Human Resources Initiative, a five-year program. Health Canada told the Committee that approximately $36 million had flowed to this initiative before the end of March 2008. The Health Council reported that the Initiative appears to be on track to meet or surpass a number of goals. It noted, for example, that the number of bursaries and scholarships available to Aboriginal health care students has tripled since the Initiative was launched. The federal government plans to release a detailed report on the progress achieved under this initiative by the end of this fiscal year.

C. Home Care

Under the 10-Year Plan, First Ministers agreed to provide first dollar coverage for certain home care services, based on assessed need, by 2006. The specific services included short-term acute home care, short-term community mental health care and end-of-life care; “short term” refers to two weeks of services. Health Ministers were to report to First Ministers on a staged implementation of the home care commitment by December 31, 2006. The Committee was told, however, that this report is not yet available.

Witnesses who discussed the home care commitment pointed to the limited scope of services covered under the 10-Year Plan. While they agreed that it is a positive start, they felt that this was a narrow and unrealistic view of home care. They stressed that the plan did not include other important home support services such as housework and meal preparation. Nor did the plan address the issue of long term facility care. They advocated for programs to provide both acute care replacement services and long-term (or continuing) home care.

Other witnesses noted that home care services continue to be poorly integrated with primary health care in many parts of the country. In their view, no matter where people live, home care services should be seamlessly coordinated with other aspects of primary health care.

For its part, the Health Council of Canada noted that there are insufficient efforts to monitor and publicly report on the progress of home care renewal. CIHI built a home care reporting system, but only a few jurisdictions participate. As a result, there is not a clear picture of the state of home care across Canada.

D. Primary Health Care, Electronic Health Records and Telehealth

With respect to primary health care, governments committed to meet the objective of 50 percent of Canadians having 24/7 access to multidisciplinary teams by 2011. They also agreed to establish a best practices network to share information on primary care reform and to regularly report on the progress of reform.

The Health Council told the Committee that some parts of the country are on track to meet the goal set in the 10-Year Plan of having 50% of people served by teams by 2011. Progress, however, is uneven and often difficult to measure. As a matter of fact, few governments have set targets or have implemented strategies for measuring, monitoring and reporting on progress. The difficulty in assessing and reporting on progress in primary health care reform is in part attributable to the lack of consensus on the definition of the term “multidisciplinary teams” envisioned under the 10-Year Plan. In some jurisdictions, it simply refers to a nurse working alongside a family doctor; in others, it strictly means a group of physicians; and in a few jurisdictions, it includes a wider range of health professionals. There is also conflicting information on the number and types of patients enrolled or registered in these teams. In its 2007 report, the Council stressed the need to develop common definitions or parameters of measurement and appropriate data and indicators to track progress in primary health care reform.

As promised in the 10-Year Plan, governments established the Best Practices Network to help health care professionals and managers share information and solve problems in their efforts to reform primary health care. However, after conducting a series of activities in 2005 and 2006, the network was dissolved due to a lack of targeted funding.

Under the 10-Year Plan, First Ministers recognized the significant investment that has been made in Electronic Health Records (EHRs) to enable health system renewal and agreed to accelerate its development and implementation. They declared that 50% of Canadians would have an interoperable EHR by 2010. They also asked for acceleration of efforts on telehealth to improve access for remote and rural communities

Some witnesses told the Committee that an EHR is pivotal for moving forward on health care renewal initiatives. Improved access to care, quality of service, patient safety, and efficiency and effectiveness are some of the positive outcomes linked to the use of EHRs. Other witnesses stressed that not only can EHRs improve the efficient exchange of patient information, minimize the duplication of diagnostic tests, improve health outcomes and patient safety, they can also be a significant driver of how health professionals organize themselves and work together to provide care. The Committee learned that Canada Health Infoway investments now total $1.6 billion, with an estimated return on investment of 8 to 1.

Despite recent investments through Infoway, governments have been slow to make progress in the implementation of EHRs. Estimates by the Health Council show that only 7% of Canadians had an electronic health record as of March 2008. As a result, governments are not on track to meet the goal of 50% of Canadians having a secure EHR linked to other aspects of health care delivery by 2010 – a goal that the Health Council had said was too modest from the start. Slow progress in this area is attributable to the lack of matched funding by P/T governments. According to the Council, public support for these investments is strong and, accordingly, governments must find ways to fund and accelerate this essential part of health care renewal. Some witnesses recommended that Infoway funding be increased and accelerated to realize the First Ministers’ vision of the EHRs.

With respect to telehealth, some witnesses noted that the technology has been particularly helpful in jurisdictions that face the challenge of delivering primary health care in remote areas. It is also used to monitor people with health problems in their own homes through data collection and to send information about patients electronically to distant health care providers for assessment. Despite demonstrable benefits, the use of telehealth to improve quality of care and collaboration among health professionals separated by distance still has not reached its full potential.

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E. Access to Care in the North and Aboriginal Health

In the 10-Year Plan, the federal government made two commitments to improve access to health care in Northern communities. First, it proposed to establish a Territorial Health Access Fund to provide $150 million over five years in additional funding to the Territories to facilitate long-term health reforms and enhance direct funding for medical transportation costs. Second, it agreed to develop a joint vision for the North in collaboration with the Territories.

The Committee did not receive any evidence during its hearings on the Territorial Health Access Fund. It is unclear whether the Fund has been established and, if so, which initiatives have been developed to facilitate long-term reforms and provide additional support for medical transportation costs. Similarly, the Committee did not obtain any information on the development of a joint vision for health in the North.

Although the 10-Year Plan had a few specifics about Aboriginal peoples, First Ministers and national Aboriginal Leaders agreed to work together to develop a blueprint to improve the health status of Aboriginal peoples and enhance access to health services. The Blueprint on Aboriginal Health was considered by the First Ministers and Aboriginal Leaders at their meeting in Kelowna, British Columbia, in November 2005. At the time, the federal government committed $1.3 billion over five years: $870 million to stabilize the First Nation and Inuit Health System; and $445 million to promote transformation and to build capacity. The Blueprint also called for implementation of the Aboriginal Health Reporting Framework to report on progress towards key health outcomes. This framework was to be completed by 2007 with actual reporting to begin by 2010-11.

Aboriginal organizations told the Committee that relatively little funding has flowed from the 2005 Kelowna communiqué and the Blueprint. This was confirmed by the Health Council which also noted that some provinces are working closely with Aboriginal communities and the federal government to improve health care and living conditions on a regional basis, but developments are on a much smaller scale than initially envisioned.

Recognizing some of the urgent needs of Aboriginal populations, the federal government announced a series of pilot projects in 2007 to establish patient wait time guarantees in the delivery of prenatal and diabetes care in First Nations communities. In addition, the Aboriginal Health Transition Fund ($200 million over 2005-2010 period) is supporting over 100 projects to integrate health services for Aboriginal peoples, improve access to services, and increase local participation in the design, delivery and evaluation of health programs and services.

F. National Pharmaceuticals Strategy

As part of the 10-Year Plan, First Ministers directed Health Ministers to establish a ministerial task force to develop and implement a National Pharmaceuticals Strategy (NPS) and to report on progress by June 30, 2006. The strategy was to include a series of actions in the following areas: catastrophic drug coverage; national drug formulary; improvements to the drug approval process; evaluation of real-world drug safety and effectiveness; purchasing strategies for drugs and vaccines; prescribing behaviour; e-prescribing; access to and international parity on prices of non-patented drugs; cost drivers and best practices. The F/P/T Ministerial Task Force on the NPS was established in October 2004 and released a progress report in June 2006.

Several witnesses told the Committee that progress on the various elements of the NPS has been slow to date and there has been a relative lack of progress as well on an overall pan-Canadian strategy. In their view, the process has not been very transparent, consultation with stakeholders took place relatively late in the process and still not much is known about what is happening in many of the key areas (e.g. expensive drugs for rare diseases).

Similarly, the 2008 Health Council report stated that governments have not made acceptable progress in creating the NPS that was promised in 2004. It noted, for example, that progress on catastrophic drug cost coverage has stalled and that Canadians still do not have a common drug formulary. Some witnesses raised the concern that, in the absence of federal leadership and an active F/P/T working group, many of the issues identified as priorities under the NPS are still being addressed in isolation. The Health Council will report later this year on the progress of this strategy.

G. Prevention, Promotion and Public Health

Under the 10-Year Plan, governments agreed to collaborate in the development of coordinated responses to infectious disease outbreaks and other public health emergencies through the new Public Health Network. They also committed to establish a pan-Canadian public health strategy and work collaboratively in developing health goals and targets in addition to fostering intersectoral work, building on initiatives such as Healthy Schools. For its part, the federal government committed to provide ongoing investments for needed vaccines through the National Immunization Strategy. The Strategy will provide new immunization coverage for Canadian children.

Witnesses told the Committee that the federal government is making progress in the area of public health and disease prevention. The government has invested $1 billion over five years for pandemic influenza preparedness at the federal level and is supporting the F/P/T National Immunization Strategy. In addition, it has launched the first national cancer control strategy, supported the development of the Canadian Heart Health Strategy, and established the Mental Health Commission.

Despite these developments, in its 2008 report the Health Council expressed concern that the idea of an integrated pan-Canadian healthy living strategy that cuts across specific diseases seems to have been shelved. Overall, public spending to foster healthy living still represents only a fraction of what Canada spends on treating preventable illness and injury.

H. Health Innovation

The 10-Year Plan committed the federal government to continue investing in health science, technology and research. Government representatives told the Committee that significant investments in health research have been made by the federal government over the last four years, including $440 million in new funding for health specific innovation. Several witnesses stressed that sustained investment is needed in order to attract and retain world-class researchers, make advances in discovery and innovation and benefit from health research findings.

I. Accountability and Reporting

The 10-Year Plan includes three different types of reporting provisions. First, and as noted in the previous sections, several reports are required from each jurisdiction for specific components of the plan (e.g. wait times, health human resources, home care, primary care reform); some of these reports have specific deadlines, while others must be produced annually or regularly. It should be noted that some components have no required reports from the federal, provincial or territorial governments (e.g. access to care in the North, prevention, promotion and public health, health innovation, dispute avoidance and resolution).

Second, the 10-Year Plan stipulates that: “All funding arrangements require that jurisdictions comply with the reporting provisions of this communiqué.” For some witnesses, this meant that all jurisdictions were expected to report in order to get the funding provided under the plan. Funding arrangements and reporting compliance were endorsed by First Ministers in 2004.

And third, the 10-Year Plan mandated the Health Council of Canada to report annually on the health status of Canadians and health outcomes as well as to report on progress on all the components in the plan. The plan also gave CIHI the specific task of reporting on progress in reducing wait times across all jurisdictions. To ensure accountability to Canadians on health care renewal, the federal government financially supports the Health Council and CIHI. Since 2004, the Health Council has released four annual reports, as well as some reports on various components of the plan, while CIHI has published four annual reports on wait times. (See Appendix A for links to these reports.)

The reports required from the jurisdictions on the plan components and on the funding arrangements can be useful tools in assisting the Health Council and CIHI to fulfill their reporting mandates. However, not all jurisdictions report on progress as required under the plan and when reports are available, they do not always provide comprehensive or comparable information. In addition, some witnesses argued that Alberta and Quebec do not participate in the Health Council, leaving two provinces entirely outside the 10-Year Plan reporting mechanism. Moreover, it is difficult to monitor the progress of the components of the plan that are not subject to any reporting requirements.

The lack of standardized, uniform, comparable health data and information was noted as a serious barrier to monitoring and reporting on the implementation of the 10-Year Plan. The Committee was told that an F/P/T advisory committee was set up to develop common performance indicators to report on health care renewal, but it was disbanded after a year. Although that committee developed 18 indicators, witnesses stated that some are not useful for reporting on the components of the 10-Year Plan, while those with value are not widely used for public reporting. Without more standardized and collaborative reporting by all governments, Canadians cannot be confident that the new money and new practices intended to improve health care are making a difference.

Government officials who appeared before the Committee did not indicate whether the federal government has reported or will report on the components of the 10-Year Plan. The Health Council reports provided information on federal activities in the areas of home care and health human resources in 2005 as well as on wait times, pharmaceutical management, home care and primary health care in 2006. The 2007 report did not contain any federal information in its comparative jurisdictional tables, while the 2008 report did not include any comparative F/P/T tables at all. As such, to date there is little information on progress achieved under the 10-Year Plan by the federal government.

With respect to provincial and territorial accountability, some witnesses were concerned that the federal government placed few conditions on the transfer payments provided under the 10-Year Plan. Similarly, the 2007 Health Council report noted: “We are unable to specify where the provinces and territories are investing funds from the federal health care agreements because no financial breakdowns are provided.” The reporting provisions as stated in the 10-Year Plan were not included in the Federal-Provincial Fiscal Arrangements Act. It must be acknowledged, however, that most of the 10-Year Plan funding is provided under the CHT and, as such, falls under the purview of the Canada Health Act and its reporting requirements. The targeted funds for wait time reduction and medical equipment are easier to identify than those for the CHT. Nonetheless, most jurisdictions are not living up to their commitment to provide annual public reports on any of the funding elements in the 10-Year Plan.

Since jurisdiction over health care delivery is primarily a provincial/territorial responsibility, some witnesses argued that the federal government should only provide the funding, without linking it to conditions or objectives. Others, however, stressed that the federal government has a constitutional right – or duty – to use its spending power to achieve health objectives for the good of all Canadians. In their view, leadership by the federal government is required to maintain the integrity of the Canada Health Act and any withdrawal of leadership will result in a system that is increasingly fragmented. In addition, as the fifth largest provider of health services to meet the needs of its client groups, the federal government has a role as a direct participant.

The Committee was told that the F/P/T Advisory Committee on Governance and Accountability was a key partner for the Health Council as it would share information on how governments spend the funds provided under the 10-Year Plan. However, this intergovernmental committee has been disbanded and information on funding is not easily accessible or, in most cases, not available at all.

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J. Dispute Avoidance and Resolution

Under the 10-Year Plan, First Ministers formally agreed to the Canada Health Act Dispute Avoidance and Resolution (DAR) process that was outlined in a 2002 letter of the Federal Health Minister

The DAR process itself was not discussed during the Committee’s hearings on the 10-Year Plan. Nonetheless, a number of witnesses raised the concern that the annual reports on the Canada Health Act do not provide sufficient information on matters concerning compliance (or lack thereof) under the legislation. They suggested that Health Canada use its discretionary powers to enforce the principles of the Canada Health Act with respect to transfer payments and report back to Parliament. Others recommended that the Auditor General of Canada perform an audit on the federal funds transferred to the provinces in support of health care delivery.