:
Good morning, everybody.
Mr. Chairman and members of the committee, I'm very pleased to have the opportunity to appear before you today to provide an overview of the provision of health services to Canadian Armed Forces' members and respond to your questions pertaining to the scopes of practice of Canadian Forces Health Services Group clinicians.
The Canadian Forces Health Services Group is Canada's 14th health care system, providing high quality care to Canadian Armed Forces personnel wherever they serve. The system comprises an integrated team of military and civilian health professionals, which offers a patient-focused comprehensive spectrum of care in evidence-based health services.
While making use of provincial and territorial health resources within Canada, it is unique among jurisdictions in its integration under a single command of almost all elements of a comprehensive health system, including: education; training; research; occupational health; public health; professional regulation; clinical services, including medical, dental, pharmaceutical, emergency medical services, etc.; and supportive aids and benefits, such as home aids, return to work programs, and peer and family support. It also must uniquely maintain mobile and medical defensive capabilities to deal with hostile and environmental hazards that are generally not encountered in Canada.
The health needs of Canadian Armed Forces personnel is a top priority for the Department of National Defence as they must be employable and deployable at all times. The Canadian Forces Health Services Group is obligated to provide health services in order for Canadian Armed Forces personnel to maintain and improve their health and mental well-being; to prevent disease; to diagnose and treat illness, injury, or disability; and to facilitate return to operational readiness as quickly as possible. With the closure of our static hospitals in the 1990s, we've become far more dependent on the civilian health sector for domestic in-patient care and now access a significant amount of specialist and hospital care through provincial and territorial health systems.
The Canadian Forces Health Services Group comprises approximately 6,300 regular force, reserve force, and civilian personnel. Our mandate is based on three tenets: one, to deliver health services; two, to provide a deployable health services capability for operations; and three, to provide health advice to the chain of command.
The Canadian Forces Health Services Group provides health services to Canadian Armed Forces personnel in two distinct environments: in garrison and on deployment. In Canada, the primary health services system is based on a standardized approach through the primary care clinic model. The nucleus of this system is the care delivery unit, which consists of a primary health care team comprised of a medical administrative clerk, medical technicians, a physician assistant, a primary care nurse, a nurse practitioner, and a family physician, all operating within established scopes of practice. The CDU team works collaboratively with patients to assess their needs and to provide and coordinate their care.
Additionally, physiotherapists, pharmacists, and a variety of mental health professionals provide care in collaboration with the team or through direct intervention. In support of patient care, the Canadian Forces Health Services Group has implemented a pan-Canadian electronic health record system, a robust quality assurance program, a performance measurement platform, and a comprehensive health promotion and public and occupational health protection system.
We must also provide full-spectrum health services anywhere in the world that the Canadian Armed Forces elements deploy, whether on land, in the air, at sea, or under the sea. We must therefore be able to rapidly deploy and sustain medical, surgical, and preventive health capabilities, including tertiary care hospitals, anywhere for humanitarian or military missions without supporting local infrastructure.
In addition to being broadly clinically skilled, our staff must be trained to survive in hostile environments, deal with diseases, exposures, mass trauma, and other health threats that are generally not encountered in Canada. They must also be able to provide superb care with limited resources and intercontinental medical evacuation and supply chains in extremely dangerous and austere conditions.
Such circumstances require that the military health system be structured in a manner that makes the most efficient use of all health resources and occupations. This is facilitated by the military culture's prioritization of mission first, welfare of subordinates second, and personal interest last, as well as by the surgeon general's control of all clinical matters, including scopes of practice, distribution of occupations, health education and training, allocation of clinical resources, etc. During Afghanistan operations, we would not have achieved history's highest war casualty survival rate without the subordination of individual and professional interests to the mission, nor without expanded training and scopes of practice under physician supervision for certain occupations like physician assistants and medical technicians.
The health team in the Canadian Armed Forces is composed of both military and civilian personnel from over 45 occupations and specialties. Many of these occupations are regulated by professional bodies and have mandated scopes of practice, which, when necessitated by unique military operational exigencies, may be modified by the surgeon general. Health professionals are expected to register with their respective regulatory body. For example, in order for a military physician to practise within the Canadian Armed Forces, like their civilian colleagues, they must be registered with a provincial or territorial professional regulatory authority such as the College of Physicians and Surgeons of Ontario.
Given that we span the country we face challenges with respect to scopes of practice for some regulated professionals as they are not consistent across provincial jurisdictions. There may thus be differences for some occupations in some of our clinics. Additionally, we have an internal credentialing process and a practice review board to address issues with respect to registration and clinical practice. Our professional culture is based on a patient-centred philosophy that strives to provide access to the right care at the right time by competent caregivers. This philosophy is supported by a multi-interdisciplinary collaborative care model hinged on a high availability of caregivers and referral of care, as necessary. The clinicians' achievement of optimal professional practice is supported through a robust maintenance of clinical readiness program, coupled with access to a variety of continuing professional education and recertification opportunities.
At one time, the Canadian Armed Forces were the sole national jurisdiction that trained, educated, and employed two unregulated health occupations: medical technicians and physician assistants. With the rising national demand for allied health professionals to extend physician services, civilian physician assistants are now produced by select Canadian universities and employed in several provinces. The Canadian Forces Health Services Group was instrumental in the establishment of the Canadian Association of Physician Assistants, which certifies physician assistants through an examination and ongoing, annual continuing professional education requirements. Our medical technician training includes certification as a primary care paramedic through external civilian programs, community colleges, and internal guidance for ongoing maintenance of clinical readiness. Canadian Armed Forces medical technicians can also obtain registration from a provincial or territorial regulatory authority. They receive more advanced clinical training to have the skills necessary to deal with the urgent needs of deployed Canadian Armed Forces personnel in austere, hostile, and geographically dispersed environments.
In closing, like many other health jurisdictions, the Canadian Armed Forces are very committed to providing the right care to the right person by the right caregiver to optimize care and resource utilization. The Canadian Forces Health Services Group is broadly engaged with national professional authorities and organizations to contribute to the dialogue and to keep abreast of new initiatives that may benefit the Canadian Armed Forces.
Thank you once again for the opportunity to be with you here today.
:
Good morning, Mr. Chair and members of the committee. My name is Michele Brenning, Assistant Commissioner, Health Services, Correctional Service of Canada. With me is Henry de Souza, Director General of Clinical Services and Public Health.
I would like to thank the committee for the opportunity to comment and provide input on the federal role in the scopes of practice of Canadian healthcare professionals.
[English]
The Correctional Service of Canada, or CSC, is mandated under the Corrections and Conditional Release Act to provide every inmate with essential health care and reasonable access to non-essential mental health care. Moreover, the act stipulates that the provision of health care shall conform to professionally accepted standards.
To accomplish our mandate, CSC relies on approximately 1,250 health staff, as well as contractors, who work in interdisciplinary teams and include nurses, psychologists, social workers, occupational therapists, general practice physicians, psychiatrists, and pharmacists. In addition CSC is looking to diversify our staff mix to include nurse practitioners and physician assistants, as well as non-regulated health professionals such as personal support workers.
On a typical day there are 15,000 offenders in federal institutions across Canada. CSC's institutions are divided into five regions: Atlantic, Quebec, Ontario, prairie, and Pacific.
To support professional competencies, CSC provides ongoing training in a variety of areas within the streams of mental health, public health, and primary health care.
Along with adherence to professional standards of practice as articulated by the relevant professional colleges, CSC's national essential health services framework, the national drug formulary, and active quality improvement processes are key tools used to promote consistent, safe, and effective delivery of health services to our clientele.
Health care is costly, and human resources are a significant cost driver. As a provider of health care to a challenging clientele, understanding the scope of practice of various disciplines and finding the right staff mix are critical in our efforts to maximize effective and efficient service delivery.
Although there is no consensus definition, the key element of scope of practice can be identified in the Canadian Nurses Association definition:
A profession’s scope of practice encompasses the activities its practitioners are educated and authorized to perform. The overall scope of practice for the profession sets the outer limits of practice for all practitioners. The actual scope of practice of individual practitioners is influenced by the settings in which they practice, the requirements of the employer and the needs of their patients or clients.
Achieving the optimal staff mix requires leveraging the flexibility within overlapping scopes of practice, while at the same time valuing and strategically utilizing the specialized expertise. For example, in the field of mental health there is overlap within the professions such that the mental health counselling can be carried out by the disciplines of social work, nursing, psychology, general medicine, psychiatry, or occupational therapy.
On the other hand, there are activities where the expertise resides exclusively or primarily within the discipline. For example, a multidisciplinary team will rely on a psychologist to conduct a psychological assessment. Similarly, general practitioners providing primary mental health care may rely on a psychiatrist for more complex or tertiary level psychiatric interventions.
As a federal government department operating within several provincial jurisdictions, and therefore several provincial colleges, there are barriers to optimizing efficient delivery of health care. For example, there is no automatic interprovincial transfer of licensure for professionals. This significantly limits the mobility of registered professional staff across Canada, thereby limiting matching staff availability to the geographic area of need.
Telemedicine and telehealth are recognized as being both effective by providing access to specialists who might not otherwise be possible, and efficient by reducing travel costs and enhancing the ability to see more patients. However, there is still no consensus on liability with respect to providing treatment across provincial jurisdictions.
Although the scope of practice may allow certain activities by a professional, training may be required to ensure competency in unfamiliar areas of practice.
As a result of these observations, we would offer a few recommendations to improve the ability of health care professionals working with CSC to better respond to our evolving needs. These include a national standardization that allows interprovincial mobility, and flexible scopes of practice that allow, in collaboration with the relevant college, the option to train to an accredited standard beyond the scope of practice in order to address needs in rural and remote areas where recruitment is difficult.
[Translation]
I believe that CSC is well placed to offer an opinion on the practice and training of healthcare professionals on the federal level in direct relevance to this committee study.
Although considerations for time prevent me from providing more specific details. In my opening remarks, I would be pleased to answer any questions this committee may have.
Thank you once again for the opportunity to appear before you today.
:
Thank you, Mr. Chair and members of the committee.
I am here this morning to provide you with an overview of Health Canada's role and work on the subject of scope of practice for health professionals. I'd like to begin by stating that scope of practice is defined in many ways by different players in the health care system, both at the national and provincial levels, including ministries of health and education, regulatory bodies, credentialing bodies, national and provincial professional associations, education bodies, and employers.
Broadly speaking, “scope of practice” refers to the roles, functions, tasks and activities, professional competencies, and standards of practice that licensed health care professionals are authorized to perform in a specific field. By this I mean that each regulated health profession has a scope of practice statement that describes in a general way what the profession does and the methods that it uses.
The scope of practice statement is not protected in the sense that it does not prevent others from performing the same activities. Rather, it acknowledges the overlapping scope of practice of the health professions, and therein is the challenge, because health professions often practise as a team. The result is that the scope of practice for each health professional is enacted according to the needs of the patient and the practice environment in which he or she works. Consequently, the actual scope of practice—that is, what happens in day-to-day practice—may vary substantially across health care settings and sectors as well as according to the patient population being served.
The provinces and territories play a major role in scopes of practice. They make the decisions about how best to optimize the scopes of practice of health professionals working within their jurisdictions. They are responsible for health professional legislation and regulation, payment mechanisms, education, and health human resources planning, all of which impact scopes of practice.
The federal government plays a supportive role in this area through research, health human resources programming, related regulatory responsibilities, and working within established scopes of practice for the delivery of care to federal populations. The federal government is committed to ensuring a health system that is responsive to the needs of Canadians and that Canadians have access to the care they need. To this end, we support efforts in health human resources management that allow professions to work to their optimal scopes of practice in a number of ways.
Firstly, the federal government is responsible for national enabling legislation such as the Controlled Drugs and Substances Act, which supports health professions to practice to their full scopes as set out in provincial or territorial legislation. Specifically, Health Canada introduced the new classes of practitioners' regulations that came into force on November 1, 2012. These regulations authorize midwives, nurse practitioners, and podiatrists to prescribe, administer, and provide controlled substances, with some exceptions, provided they are already authorized to do so under provincial or territorial legislation.
Secondly, Health Canada facilitates the advancement of optimal scopes of practice in collaboration with provinces, territories, and key stakeholders in various ways including, for example, by providing $24 million in funding to advance the adoption of team-based care through initiatives such as the Canadian Interprofessional Health Collaborative; by providing $6.5 million in funding to McMaster University to evaluate team-based approaches to health care delivery; by providing advice to deputy ministers of health on the planning, organization, and delivery of health services through the federal-provincial-territorial committee on health workforce; and by partnering with the Canadian Institutes of Health Research to support a best brains exchange on March 14 of this year on optimal scopes of practice.
Thirdly, as a provider of services to federal populations, including to first nations and Inuit, federal inmates, and the Canadian Forces—as you have heard—the federal government has a direct role to play in championing novel approaches to health care delivery, including with respect to scopes of practice. Given this, I will now turn specifically to Health Canada's role in first nation communities.
Working to improve the health outcomes of aboriginal peoples is a shared undertaking among federal, provincial, territorial governments, and aboriginal partners. Health Canada's role involves supplementing and supporting provincial and territorial health services to provide culturally appropriate health programs and services that work to improve the health status of first nations and Inuit communities. To fulfill this role, Health Canada funds or directly provides public health, health promotion and disease prevention, addiction and mental health, and home and community care on all first nation communities, and primary care services in 85 remote and isolated communities.
Regulated health professionals and unregulated health workers make up the almost 10,000 strong workforce. Regulated professionals include registered nurses, nurse practitioners, licensed practical nurses, dentists, dental hygienists, dental therapists, nutritionists, pharmacists, physicians, and environmental health officers. Health Canada requires its health professionals who provide direct services in first nation communities to be licensed in the province or territory in which they work and to maintain good standing with the regulatory body.
However, in remote and isolated first nation communities with limited direct access to physician or even nurse practitioner support, registered nurses delivering direct primary care services often provide a broader range of health services and functions than would be authorized by provincial legislation on scope of practice .
The need to address the legislated scope of practice of registered nurses working in these remote communities, while ensuring safe care and protecting the licences of nurses, is addressed in various ways across Health Canada's regions. For example, the Province of British Columbia has introduced a certified RN designation that defines additional education requirements and broadens the scope of practice for isolated and remote communities, and we require nurses to obtain that certification.
Saskatchewan has introduced new nursing standards specifically addressing primary care service delivery in northern communities that will authorize RNs to take on additional functions.
In Alberta first nation communities, a collaborative and consultative practice model, accessed on site or via telehealth, between nurse practitioners and registered nurses has permitted the safe, timely, and high-quality delivery of primary care services that align with provincial nursing scope of practice legislation.
In Quebec, provincial legislation has been introduced to delegate or transfer authority for RNs to provide primary care. Working with provincial partners, Health Canada has introduced practice directives or ordonnances collectives that align with the legislation.
In Manitoba and Ontario, a provincially recognized delegation process permits the alignment of Health Canada's employment functions of RNs with the provincially defined scope of practice.
To mitigate the risk of nurses working outside their scope of practice, Health Canada has recently reviewed its nursing delegation tools, specifically the first nations and Inuit health branch's clinical guidelines for nurses in primary care and the nursing station formulary and drug classification system. This review identified a need to revisit and update these tools to ensure alignment with provincial frameworks, and we are in the process of doing so.
Further, Health Canada provides education and training to all nurses working in primary care to ensure they have the skills and necessary certifications to provide safe care. All nurses are required to take, within a period of time after joining the federal government, a primary skills training course covering the expanded care needs. Health Canada also makes sure that nursing staff in remote and isolated locations have direct phone or video access to a physician at all times to discuss diagnosis and treatment, and to authorize treatment such as prescription medications.
We are also implementing the recommendations from an internal study on health service delivery models in remote and isolated first nation communities, which will further support an alignment with the provincial scope of practice legislation for health care providers in primary care services. The measures being implemented include the introduction of collaborative and interdisciplinary teams; the introduction of providers not currently included in primary teams, such as X-ray technicians and pharmacy technicians; the increased presence of nurse practitioners; and the increased use of e-health services.
In closing, Health Canada will continue to undertake activities to address scope of practice issues to support improved health care in first nation communities. In terms of Health Canada's broader role, I would emphasize that we will continue to collaborate with the provinces and territories and to facilitate the sharing of knowledge and best practices in support of their efforts to optimize the scopes of practice of health care professionals.
Thank you very much.
:
Thank you very much, Chairperson, and welcome to our presenters today.
As you've heard, we're just beginning our study about best practices, scopes of practice, health human resources, and so on. It's a bit of a mouthful, and we're just beginning to get familiar with the topic and how we need to address it. So maybe our questions will be a bit general today.
Listening to what you each had to say, I have two questions. First of all, I have to say I was a bit surprised that none of you mentioned Health Canada's pan-Canadian health human resources strategy, which we understand from the background work that we had prepared is sort of the document or strategy that's overseeing a commitment that was made—I think it was made in 2005. That strategy outlines five areas, one of which is health human resource planning and forecasting, so that takes us directly into the issue of where there are shortages, how they're regionally based or within remote communities.
I guess my question is this. Who's doing that? Who's overseeing the planning and the forecasting? I can tell you that when we, and I assume this is for all members of the committee, meet with various professional associations, whether it's the nurses, or psychologists, or occupational therapists, or whoever it might be, this issue of disparity and shortages, depending on where you are, but particularly in remote communities, northern communities, comes up again and again. It certainly was a major issue identified in the 2004 health accord. My first question is whether the various departments that you work in federally are aware of this strategy. Does your department collaborate with other departments? It's meant to also be a provincial and territorial thing, not just a federal role. I'd just like to know, do you know who's responsible for it? Do you work with those people? That's one question that you could all address.
The second question, if I could just be quick about it, is this. Ms. Brenning, I really appreciated your presentation. There was one paragraph that you actually didn't read out, and I don't know whether you skipped over it or whether you didn't want to say it, but I thought it was good. It said health care needs to exist on a broad continuum ranging from addressing activities of daily living and emotional support to more complex medical interventions. It's at the top of page 6. We've heard previously that 80% of inmates have substance use issues. That's obviously a major concern. I wanted to ask you whether or not Corrections Canada uses a harm reduction approach—for example, needle exchanges, methadone—in looking at the issue of substance use from a multidisciplinary perspective and actually reducing the risk and the harm of inmates who may be involved, particularly with drug use. If you could address that, it would be very helpful.
Those are my two questions. Sorry to take so long.
:
I'll start with your first question, which Health Canada also answered. Certainly we rely on the leadership of Health Canada, but from a very operational perspective, we're a fairly small employer of about 2,400 health professionals.
We do very detailed operational planning. Each of our five regions has an operational plan for where the hiring needs to happen. We know that we have a continuous need for intake of nurses in the prairie region. We have an open process where we're always evaluating nurses who would be willing to come and work for Correctional Service of Canada. The prairies is one area where we do see a shortage of nurses.
We do have some needs, depending on how remote some of our institutions are. For example, Grande Cache is an area where we typically have challenges recruiting health professionals. There are some gaps with psychologists, but overall we have fairly good success in recruiting health professionals.
To answer your second question, yes, thank you for pointing that out. That really was a paragraph that talked about the overlapping scopes of practice. We did address that earlier, but to answer your question very specifically, we do have harm reduction programs. It includes the use of bleach kits and other types of measures such as that. We do not do needle exchange.
With regard to a methadone program, we have a very rigorous methadone program. It's an interdisciplinary team approach. Essentially you have an aspect where the physician, the nurse, and counselling will be provided, and there's ongoing, very regular routine monitoring of that particular program.
So yes, we do have that program in place.
Thanks to the witnesses for being here today as we get started on this important study on scope of practice. We're wanting to get an update on where Health Canada is at in terms of managing the processes in evaluating human health resources for federal institutions and so on.
Colonel MacKay, you described the primary care model that DND uses. You described the primary health care team as being regulated and non-regulated persons, and others at the table here described a very comprehensive list of professionals. It strikes me a little odd, if I come back to the military first, that our third-largest primary contact profession is not represented in any of your teams that you discussed today. I'm curious about that.
We have about 75,000 medical doctors in Canada. There are about 19,000 dentists who are primary contact. There are 8,400 chiropractors in Canada; that's a very large and regulated profession across the country. It strikes me odd, when we're talking about human resource shortages, that the third-largest primary contact profession is not represented.
Colonel MacKay, I know that chiropractors made a presentation not too long ago to the Standing Committee on National Defence about representation in the military. We know that amongst their areas of expertise for low back pain it's well established that chiropractors give far more cost-effective and effective care delivery. Chiropractors are working with the U.S. on 51 bases as part of the integrated health care team.
Is there a barrier to chiropractors participating in the primary care delivery, at least as part of the integrated team, to manage musculoskeletal issues on bases? I understand that 53% of your medical releases are actually related to musculoskeletal problems.
Could you respond to that?
:
Thanks, Chair. Thanks to the witnesses for coming today.
I think I'll take a little different light at it.
Colonel, my son's in the military, and was deployed over to Afghanistan and has come back. I'm retired from the RCMP so you will have to mind my answer to him when he came back. He came back and complained of some lower back pain. I basically told him to “suck it up, buttercup”, but I recognize it's more than that from the perspective that I don't think we recognize from time to time what our soldiers are doing overseas and the heavy load they do carry.
I wanted to carry on with the questions from Dr. Lunney who had been speaking about the chiropractic care, and it seems like it would be of benefit to the forces to look down that road. It certainly has helped many people.
From the perspective of that, and because you had mentioned in your opening remarks that you follow the primary care clinic model, that would mean to me anyway, coming from a community that follows the primary care model, that there is the potential to enlist those types of medicines that are not normally found within what we'll call the traditional model.
In terms of my question—and I know you can't answer it here today—but I believe there's some opportunity for the armed forces to consider such roles that are not normally found within the health care model. Could you speak to it a little more, especially certainly to those injuries that are not normally looked at from the perspective of chronic pain. When we look at back pain, we look at it from the perspective of a temporary issue as opposed to a long-term issue.
I know that's a difficult way of looking at it, but I guess the way I'm looking at it is from the perspective of primary health care. In my community all of the medical services are provided through one roof, through one funnel, and one of those is chiropractic. If that is the case is there the potential for the armed forces to do that as well?
I'm very glad that my colleague raised the question of midwifery and what's going on there. I'd like to come back to that question, Ms. Gillis, and question it a little more closely, given that we have some additional time for questions.
First, there's no question that primary health services to first nations, Inuit, and Métis communities is a federal responsibility, constitutionally. There's a lot of evidence to show that midwifery does improve the health outcomes in aboriginal communities. To be quite honest I don't feel very satisfied by the answer you gave. To me, this is a key example of scope of practice where we could be doing something that is practical, effective, cost-effective, and has good health outcomes.
There's an association that's ready to go. They want to do this. As you say, it's a profession that's being more and more recognized. For you to tell us, you're focusing on nurse practitioners...by the way, I understand how important that is as well. Surely the federal government has the capacity to advance two job classification requests to Treasury Board. Are we waiting until the nurse practitioners are done and then maybe the midwives will come forward? There has to be a better answer to that. There's a lot of interest on this committee because it is so basic. It's something that would really qualitatively change health outcomes in northern and remote communities.
Please tell us if Health Canada has recommended to Treasury Board to look at this classification. Are you monitoring it? How long will it take? When do you expect to see a resolution?
My understanding is that what we're trying to do with this study is to see how the federal government, through its foothold in health care.... We always assume that it's entirely a provincial matter, but in fact the federal government has an important role to play by virtue of its work and its jurisdiction over aboriginal communities, the military, and the penitentiary system. So we're trying to see how we can be the leaders in terms of breaking down barriers in the medical professions in such a way that someone could practise anywhere in the country really. That seems to be my understanding of what we're aiming for here.
I'm just wondering, for example, what the Department of National Defence is doing in the area of telehealth. Are you doing that in complete isolation, the digitization of health records, and so on, for easy access? Are there any bridges with, for example, Quebec? Are they looking at your example? Are you looking at what they're doing? Because I know they're quite active in the area of telehealth. Is there some synergy here? That's the one question.
The other is this. Do you find—maybe Ms. Gillis would want to answer this—that through the examples and the standards that your department is setting, provinces that might not have the same standards and necessarily all the occupations are bringing their standards up? For example, just by way of analogy, in terms of drinking water quality, the idea is to set federal standards so that provinces that maybe don't meet those standards then have something to aim for. Do you find that you're accomplishing that?
Also, we know that through the immigration system we're trying to make it easier for newcomers to Canada to integrate into the medical profession. Are you interfacing with Citizenship and Immigration on issues of certification?
Maybe we can start with Colonel MacKay.
We have been working very closely with, in particular, provinces in which first nations live, and are finding significant success in working very closely with them in a number of different areas and breaking down some of those barriers between the first nation communities and the provincial health system. In fact, the more recent and very successful example is that last year in October, through many years of work with the Province of British Columbia, the first nations in British Columbia, Health Canada, and the federal government of Canada, we have transferred all health services to the First Nations Health Authority in British Columbia, which is working very closely with the province. But you see lots of examples of that happening right now in many different ways.
In terms of standards, and you mentioned specifically water, there are Canadian drinking water quality standards, absolutely, but they are developed in a collaborative manner with the provinces and territories. So while they are Canadian drinking water standards, they are...so for the most part provinces adopt these but they may make some minor modifications depending upon their situation.
In terms of work with foreign-trained physicians and nurses, this is some work that Health Canada has been involved in for quite some years, working with Citizenship and Immigration Canada, with Employment and Social Development Canada, with the medical and nursing colleges, and education boards. We have been working very closely over a number of years to break down some of those barriers, but ensuring that foreign-trained health workers are meeting the same standards that all physicians or nurses or others in Canada must meet.
Thanks to all of our witnesses for your participation in this study. It is, of course, one of the purposes of this study to examine barriers to effective teamwork and collaboration.
The challenge I want to throw out to each one of you is, when you hear those packages put together of collaborative interdisciplinary approaches, and the third-largest primary care provider in Canada—that would be chiropractors—is not included, there is a gap there. When you're talking about bringing in and training other people to fill gaps as medical technicians, it's past time for that to be remedied. You're going to find that there are tremendous opportunities for more cost-effective care.
Colonel and Dr. MacKay, it was 1985 when a medical champion—if you will—in Saskatoon, Dr. Kirkaldy-Willis, published the first study on spinal manipulation and low back pain along with a chiropractor. It was the first time a chiropractor's credentials were recognized in a Canadian medical journal. The evidence has been there for 30 years, so it's time that we find better ways of collaborating.
I put that on the table as a challenge to everyone at the table here, not just for chiropractors but for naturopaths, because there are more promising avenues and more effective opportunities there that are being missed.
Now back to Ms. Gillis.
You're talking about the north here. “Health Canada funds or directly provides public health, health promotion and disease prevention, addiction and mental health, and home and community care on all first nation communities, and primary care services in 85 remote and isolated communities.”
I wonder if you have heard of a program based in Alberta called Pure North S'Energy. Pure North S'Energy started with an oil company executive's own foundation treating his oil workers with EDTA chelation therapy to take the heavy metals they're exposed to in that environment out of their systems. They also provide vitamins and minerals. They have maybe 100 health professionals working with them: doctors, nurses, and naturopaths. They'll do an analysis to determine what nutrients they're short of, he will provide the nutrients to these people in that remote northern environment—he's working with Inuit communities—and they will send the nutrients to them for life as long as they agree to a blood test a couple of times a year to monitor their progress.
It's been going on for almost 10 years now and they're accumulating—last time I talked to them—17,000 people on the program with amazing results. One of their primary strategies is to get vitamin D levels up. They're not getting vitamin D in the north; they're clothed all the time. Naked at noon is the buzzword for vitamin D, 20 minutes when the sun's high in the sky. It's not happening for most Canadians, especially in the north. Anyway, stay tuned; we hope to have them here as witnesses in this committee.
There are opportunities, and one last one would be preventing fetal alcohol spectrum disorder; it's a huge issue in the north. There's compelling evidence now that trace amounts of methanol in alcohol is what crosses the placenta and does this devastation to the developing nervous system. A simple folic acid supplement—a penny a day for the average person at risk—would mitigate that risk. Isn't it time we looked at measures like those that could be implemented in the north? There are promising models out there, and that's a challenge for all of us to move ahead.