INTRODUCTION

In February 2014, the House of Commons Standing Committee on Health (Committee) agreed to

undertake a study of up to 10 meetings of best practices and federal barriers related to the scope of practice and skills training of healthcare professionals, provided that this study will focus on 3 areas: (a) the federal role in the scope of practice of Canadian healthcare professionals; (b) highlight best practices on the use of scope of practice, both in Canada and internationally; and (c) federal role and support for skills training and curriculum development.[1]

Four meetings were held in March and April 2014 on this study.

On 24 February 2015, the Committee passed a motion to “have only two additional meetings with witnesses Tuesday, March 10, and Thursday, March 12, and that, tentatively, the Committee consider a draft report of its findings on Tuesday, April 21, 2015.”[2]

The Committee heard from a total of 39 witnesses representing 29 organizations, drawn from a wide range of health-related professions, and received 16 briefs. This report is based on the testimony of those witnesses and the content of those briefs.

DEFINING SCOPES OF PRACTICE

Witnesses, noting that there is no formal consensus as to the definition of “scope of practice,”[3] provided their views of what “scope of practice” entails.[4] Taken together, witnesses suggested that it was defined by a combination of legislation identifying the extent and limits of activities permitted for any given profession or occupation, preparation provided by educational programs and institutions, and certification by a regulatory body overseeing that profession.

Other witnesses, including two government officials,[5] pointed out that scope of practice is also determined, to some extent, by the employment situation in which a healthcare professional is working. Witnesses described how a scope of practice may be inconsistent with the “scope of employment,”[6] that scopes of practice change in response to shortages of healthcare professionals and other factors,[7] and the need for common skill sets for each profession across jurisdictions.[8]

These themes – the roles and responsibilities of educators, legislators, regulators, employers and practitioners – recur throughout sections of this report. The next major section of the report focusses on the federal role with respect to the scope of practice of healthcare professionals, followed by an overview of “best practices” identified in testimony and briefs, and a further section on less direct federal support for curriculum development and skills training in the health and allied professions.

THE FEDERAL ROLE IN THE SCOPE OF PRACTICE OF CANADIAN HEALTHCARE PROFESSIONALS

As noted in a brief to the Committee, “[s]copes of practice are determined largely by provincial and territorial governments, and each jurisdiction has developed its own regulations regarding what health professional groups may do and under what circumstances.”[9] However, there are particular responsibilities that implicate the federal government more directly in the definition and administration of scopes of practice for healthcare and allied professionals.

While describing multiple players in the definition of scopes of practice at both the national and provincial levels,[10] a Health Canada official told the Committee that provincial governments are responsible “for health professional legislation and regulation, payment mechanisms, education, and health human resources planning, all of which impact scopes of practice.”[11]

She described the federal government role as “supportive,”[12] with roles in “research, health human resources programming, related regulatory responsibilities, and working within established scopes of practice for the delivery of care to federal populations.”[13] In particular, the next sections of this report focus on health services to federal populations and some of the federal regulatory framework that has a direct impact on scopes of practice for health and allied professionals, including the federal/provincial/territorial Agreement on Internal Trade, the Controlled Drug and Substances Act, and extended health benefits for federal employees. Discussions of federal initiatives with respect to health human resources planning and coordination are described in a later section devoted to the federal role in health human resources planning and development.

A. HEALTHCARE SERVICES TO FEDERAL POPULATIONS

The federal government is directly responsible for healthcare services provided to particular populations, including: members of the Armed Forces, veterans of those Forces, people in federal corrections facilities, and First Nations and Inuit. As noted by one federal official, “[A]s a provider of services to federal populations … the federal government has a direct role to play in championing novel approaches to healthcare delivery, including with respect to scopes of practice.”[14]

Occupation-specific recommendations with respect to services to federal populations called for the inclusion of “pharmacist-provided medication management services”[15] and the inclusion of chiropractors in “team-based models that would enhance federal programs – better care at a lower cost.”[16]

More generally, a witness representing the Canadian Physiotherapy Association described the value of the Federal Healthcare Partnership[17] in bringing interdepartmental coordination to such issues. The Committee recommends:

RECOMMENDATION 1

That the federal health care partnership engage with all interested stakeholders to ensure their full participation in ongoing efforts to facilitate strategic partnerships in support of better programs, interdisciplinary care and evidence-based policy.

1. Armed Forces and Veterans’ Affairs

The Deputy Surgeon General of the Canadian Forces, Colonel Hugh MacKay, in his presentation to the Committee, indicated that the Surgeon General of the Canadian Forces “controls … all clinical matters, including scopes of practice, distribution of occupations, health education and training, allocation of clinical resources, etc.”[18] He identified a challenge in operating across provincial and territorial jurisdictions.[19]

Other witnesses identified mental health, particularly post-traumatic stress disorder, as a significant challenge for meeting the health needs of active members of the Canadian Forces.[20] While Colonel MacKay told the Committee that care is provided in these cases “as close to home as possible and as close to their family support system as possible,”[21] another witness identified the need to extend services beyond the member of the Forces to his or her family and other supports.[22]

Colonel MacKay told the Committee that the Canadian Forces “have both uniformed and civilian psychiatrists who work in our mental health clinics or who work in our operational trauma support centres.”[23] A witness representing the Canadian Psychological Association identified the value in including clinical psychologists in healthcare teams serving the Department of National Defence (DND).[24] The Committee recommends:

RECOMMENDATION 2

That the Department of National Defence consider reviewing the make-up of their intercollaborative mental healthcare teams, which include psychologists, psychiatrists, mental health workers, and social workers, to ensure that service delivery on the front lines and at home continue to meet the needs of our forces.

A witness representing the Canadian Chiropractic Association told the Committee that “our soldiers have less access to chiropractic care than other federal employees,” and that “[t]hese injured soldiers go on to become veterans.”[25] Another witness said that Veterans Affairs “prohibit[s] dental hygienists from practising to their full scope by permitting only the most basic level of dental hygiene services for veterans.”[26]

2. Correctional Service of Canada

The Assistant Commissioner of Health Services at the Correctional Service of Canada (CSC) told the Committee that the agency “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.”[27] Like DND, CSC operates across provincial jurisdictions, and faces “barriers to optimizing efficient delivery of healthcare.”[28].The witness from CSC told the Committee that the absence of easy interprovincial transfers for health “significantly limits the mobility of registered professional staff across Canada, thereby limiting matching staff availability to the geographic area of need.”[29] As this issue was raised by a wide range of witnesses and organizations submitting briefs, recommendations are included in the later section of the report entitled “Pan-Canadian Coordination of Professional Scopes of Practice.”

Other witnesses identified challenges within CSC, particularly with respect to the provision of mental health services. A witness representing the Canadian Psychological Association told the Committee that CSC is the largest employer of psychologists in Canada.[30] In addition, witnesses representing the Canadian Nurses Association[31] and the Canadian Council of Registered Nurse Regulators[32] both described the particular challenges facing nurses in prison settings in responding to the mental healthcare needs of patients. A representative of the Canadian Association of Occupational Therapists suggested that members of that profession could be helpful in meeting those mental health needs.[33]

3. First Nations and Inuit

An official from Health Canada described the role of the federal government with respect to the provision of health services to First Nations and Inuit:

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.[34]

a. Rural and Remote Communities

While not all remote and isolated communities are Aboriginal communities, many are. A Health Canada official identified the specific challenges of providing health services in these communities, and how they often required the provision of primary care in the absence of physicians.[35]

Similarly, a witness representing the Canadian Association of Midwives described situations in remote communities where “midwives work to an expanded scope and provide a broader range of services to meet the needs of the population.”[36] At the same time, the Association described the demonstrated need for services of midwives in Aboriginal communities, but identified a barrier to their being hired by First Nation communities, because they are not “listed as a recognized profession under the Health Occupational Group Structure within the Treasury Board of Canada.”[37] As proposed by the Association, the Committee recommends:

RECOMMENDATION 3

That Treasury Board review its Health Services Occupational Group to consider how midwives may be included.

Many of these challenges in meeting the needs of rural and remote communities, including First Nation and Inuit communities, relate to recruitment and retention of health and allied professionals in such communities.[38] A Health Canada official noted that there is “on average, around a 30% vacancy rate of nurses in remote and isolated communities,”[39] forcing the department to rely on contract agencies. A number of witnesses suggested that recruitment within these communities, particularly First Nation and Inuit communities, would contribute to the retention of healthcare professionals and could contribute to a more stable supply of healthcare professionals in those communities.[40]

A witness from the Canadian Association of Schools of Nursing told the Committee that special efforts were being made to provide schools of nursing in remote areas, including the Northwest Territories and Nunavut, “to improve the recruitment and retention of Aboriginal nursing students.”[41] Some suggestions for the recruitment of Aboriginal students and others from rural and remote communities related to specific occupations, including dietitians[42] and mental health practitioners.[43]

Representatives of the College of Family Physicians of Canada[44] and the Canadian Dental Hygienists Association[45] suggested that particular efforts must be made to ensure access to healthcare services in rural and remote communities. As a means to achieving such access, HealthCareCAN called on the federal government to “[e]nsure broadband access for rural and remote communities to expand the telehealth models which have proven to increase general accessibility.”[46]

b. Non-Insured Health Benefits Program

As described in an internal audit report by Health Canada:

To support First Nations people and Inuit in reaching an overall health status that is comparable with other Canadians, Health Canada's Non-Insured Health Benefits (NIHB) Program provides coverage for a specified range of drugs, dental care, vision care, medical supplies and equipment, short-term crisis intervention mental health counselling, and medical transportation for approximately 926,000 eligible First Nations people and recognized Inuit.[47]

The Health Canada official described a recent review of scopes of practice within the NIHB program and their alignment with provincially mandated scopes of practice. As a result, changes

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.[48]

The Committee also heard that specific professions are not able to operate within their full scopes of practice under the terms of the NIHB. These included dental hygienists,[49] occupational therapists,[50] physiotherapists[51] and midwives.[52] The Committee also heard that the Minister of Health had undertaken a review of the NIHB in 2014.[53]

The Canadian Dental Hygienists Association “urged the federal government to move quickly to ensure that all NIHB program recipients have the same access to oral health services across the country,”[54] and the Canadian Physiotherapy Association called on the federal government “to actually look at how to maximize scopes of practice within federal programs, such as the NIHB program, and invest in interdisciplinary models of care that truly reflect these models.”[55]

The Committee recommends:

RECOMMENDATION 4

That Health Canada review the roles of dental hygienists, occupational therapists, physiotherapists and midwives within the Non-Insured Health Benefits program to improve its ability to provide needed health services in rural and remote communities as part of a healthcare team.

B. AGREEMENT ON INTERNAL TRADE

According to a federal government document in 2014,

Signed in 1994, the Agreement on Internal Trade (AIT) governs the movement of people, goods, services and investments within Canada. It is a political accord that creates a framework for the reduction of barriers to trade within specific economic sectors. Its creation followed the signing of the North American Free Trade Agreement (NAFTA) and was supported broadly by Canada’s business community.[56]

The seventh chapter of the Agreement is entitled “Labour Mobility,” whose stated purpose is

to eliminate or reduce measures adopted or maintained by the Parties that restrict or impair labour mobility in Canada and, in particular, to enable any worker certified for an occupation by a regulatory authority of one Party to be recognized as qualified for that occupation by all other Parties.[57]

The chapter of the Agreement “applies to measures adopted or maintained by a Party relating to…. [c]ertification requirements, other than residency requirements, for workers in order to practice an occupation or use a particular occupational title, and occupational standards.”[58] Exceptions allowing parties to require additional education or training can be sought when:

• a)     there is a material difference between the scope of practice of the occupation for which the worker is seeking to be certified in its territory and the scope of practice of the occupation for which the worker has been certified by the regulatory authority of another Party; and
• b)    as a result of that difference, the worker lacks a critical skill, area of knowledge or ability required to perform the scope of practice of the occupation for which the worker seeks to be certified.[59]

Health Canada, in a submission that followed up on testimony by its officials before the Committee, reported:

With the recent implementation of the Agreement on Internal Trade (AIT), Chapter 7 on Labour Mobility, there will be increased consistency in scopes of practice across jurisdictions to allow for the freer movement of workers…. It is expected that this will result in greater efficiency and productivity, as provinces and territories will recognize each other’s qualified workers without requiring reassessment, retraining or retesting, unless this requirement is based on a legitimate objective such as health, safety or consumer protection grounds.[60]

Witnesses involved in the regulation of doctors,[61] nurses[62] and dentists[63] described progress in meeting the terms of the AIT. However, of the 14 “approved exceptions by occupation,” 9 are health or related occupations, including paramedics, psychologists, midwives and dental hygienists.[64]

For example, a witness from the Canadian Psychological Association told the Committee that mobility for psychologists under the AIT is based on the “least rigorous” of standards that vary across the country, and not on the” very robust standards for training in psychology established and maintained by the Canadian and American Psychological Associations …that define training in psychology across North America.”[65] The Committee recommends:

RECOMMENDATION 5

That the federal government work with the provinces and territories to review the provisions of the Agreement on Internal Trade to ensure the harmonization of certification requirements for psychologists while maintaining requirements to ensure these professionals have training required for their work.

HealthCareCAN called for a federal coordinating role to improve the impact of the AIT, suggesting that Health Canada could work with them and others “... to further harmonize legislation and regulations across the country,” adding that “[t]his would also support the Agreement on Internal Trade (AIT) which was intended to break down interprovincial barriers enabling the free flow of health and other workers, increasing overall efficiency in labour markets.”[66]

Representatives of some of the “approved exception” occupational groups described greater challenges in achieving mobility. Several of these challenges are related to differing scopes of practice, and are addressed in a later section of the report entitled “Pan-Canadian Coordination of Professional Scopes of Practice.”

C. Controlled Drug and Substances Act and regulations

The Committee heard from a Health Canada official that the federal government’s Controlled Drug and Substances Act (the Act) “supports health professions to practice to their full scopes as set out in provincial or territorial legislation,”[67] referring specifically to 2012 regulatory changes under the Act as examples of that support.[68]

The New Classes of Practitioners Regulations[69] of the Act allow midwives, nurse practitioners and podiatrists to prescribe certain controlled substances if these practitioners are already authorized to do so by the province in which they practice.

The regulations were deemed to be necessary because, while a number of provinces had recognized an expanded scope of practice for these groups in legislation which included prescribing certain controlled substances, the Act authorized only persons registered to practice medicine, veterinarians and dentists to conduct activities with controlled substances.[70] Midwives, nurse practitioners and podiatrists were therefore unable to prescribe narcotics until authorized by the Act to do so.

In testimony before the Committee, a witness from the Canadian Pharmacists Association noted that this authority was not extended to pharmacists, and suggested that pharmacists should have similar authority under these regulations.[71]

While praising the work of Health Canada in achieving these changes to the legislation, one witness pointed out

[T]hat work stops short of brokering a collaboration across the country whereby those changes could be more immediately implemented into practice. What is happening as we speak is that approximately half the country has now reached the ability, under provincial or territorial legislation, to enact those provisions. The other half of the country is still working to do that … If there were such a table as a federal-provincial-territorial table that looked at harmonizing those at the point of brokering them, we believe there would be more immediate uptake.[72]

The Canadian Medical Association, in its brief to the Committee, Identified other examples of expansions of scopes of practice in various professions that remain uneven across the country.[73] In support of the solution suggested by this Association, the Committee recommends:

RECOMMENDATION 6

That the federal government work with provincial/territorial governments and with health professional associations to promote a consistent pan-Canadian approach to scope-of-practice expansions.

A further discussion of how the federal government could encourage more consistency in scopes of practice across provinces and territories is included in the section entitled “Pan-Canadian coordination of professional scopes of practice”.

Another witness pointed out that the legislation does not have a “monitoring and surveillance side,” and recommended that “a national monitoring vehicle” be added to the Act to address the interprovincial mobility of professionals.[74]

D. EXTENDED HEALTH BENEFITS FOR FEDERAL EMPLOYEES

Witnesses identified other administrative obstacles in federal programs that may limit the ability of health and allied professionals to provide optimal service to eligible patients. A witness representing occupational therapists suggested that the Public Service Health Care Plan[75] be expanded to include that profession in the plan.[76] A similar recommendation was made with respect to dietitians.[77]

Other witnesses pointed to more general obstacles in the plan and other federally (and privately) administered health programs:

There are a lot of things within the [extended health benefits for public servants] program that actually don't make sense because they are delaying the access to treatment and access to professionals...[78]

In particular, several witnesses suggested that the requirement for a doctor’s referral to an allied health professional imposed a restriction on the scope of practice that is not otherwise imposed by regulation or legislation.[79] A witness representing physiotherapists cited a study that found “that insurance companies use that doctor's note, the referral or the prescription for physiotherapy, occupational therapy, and other services as a cost containment measure,” but added “they are delaying the access to treatment and access to professionals.”[80] The Committee recommends:

RECOMMENDATION 7

That the federal government review the requirement for physician referrals to health services under the Public Service Health Care Plan, in order to assure that access to care remains appropriate.

Similarly, a representative of the Canadian Nurses Association questioned whether physicians should be required to sign forms required for access to federally administered programs including the disability tax credit certificate, [Canada Pension Plan] CPP disability benefits, employment insurance benefits, and benefits under the Public Service Superannuation Act.[81] The Committee recommends:

RECOMMENDATION 8

That the federal government review the ability of nurse practitioners to be included as signatories in federal tax and benefit programs, with a view to facilitating access for Canadians to timely benefits that affect their health.

BEST PRACTICES ON THE USE OF SCOPE OF PRACTICE

A. INTERPROFESSIONAL TEAMS

The Association of Faculties of Medicine of Canada described a project which “set out to conduct a thorough review of medical doctor (MD) education in Canada, assess current and future societal needs, and identify the changes needed to better align the two.”[82] One of the resulting recommendations called for advancement of “inter- and intra-professional practice.”[83] Many witnesses spoke positively about such practices, also called “team” practices, citing their capacity to better meet the needs of patients,[84] and identifying initiatives to provide training and competency in this approach.[85]

Other witnesses described challenges in identifying and regulating scopes of practice in multidisciplinary teams. For example, a representative of the Royal College of Physicians and Surgeons of Canada told the Committee of ongoing efforts to establish a framework for interprofessional regulation.[86] Other testimony highlighted the challenge of team-based approaches when health practitioners are each compensated per service provided to an individual patient,[87] and some health and allied professions are not covered by provincial health plans and rely on patient payment.[88] Another witness noted the impact the model may have on human resources requirements in the health sector,[89] addressed in greater detail in a later section entitled “Health Human Resources Planning.”

Testimony and briefs supported a federal role in supporting such practices,[90] including through funding research and evaluation of this approach.[91]The Committee therefore recommends:

RECOMMENDATION 9

That the federal government, through Health Canada, work with provincial and territorial governments to support the development, implementation and evaluation of interprofessional team approaches to the provision of primary healthcare and that it support research in this direction.

B. PAN-CANADIAN COORDINATION OF PROFESSIONAL SCOPES OF PRACTICE

The Committee heard from most witnesses that differing scopes of practice across provinces and territories relate to curriculum differences, accreditation requirements and regulatory requirements, particularly with respect to the range of competencies required by each profession. As noted above, the interprofessional team approach being introduced in many healthcare settings makes the role of each team member subject to change.

Witnesses and submissions described the variations in scopes of practice across Canada.[92] The national associations of educators, practitioners and regulators both acknowledged the primary role of provincial and territorial governments in establishing scopes of practice and called for continuing federal support of efforts in the development and harmonization of scopes of practice across Canada.[93]

In addition, witnesses representing federal organizations responsible for healthcare services also identified the value in greater “standardization” of scopes of practice.[94]

In support of suggestions by witnesses, the Committee therefore recommends:

RECOMMENDATION 10

That the federal government, in collaboration with provincial and territorial governments, encourage pan-Canadian harmonization of scopes of practice.

The Committee heard that new communication technologies could support more mobility for Canadians and professionals alike through the development and implementation of electronic health records, allowing professionals across the provinces and territories to share the same information.

A witness from DND told the Committee that fully functional electronic medical records already exist for members of the Canadian Forces, and that their experience is being shared with others within the federal government.[95] Witnesses from other organizations described the importance of the implementation of electronic health records in their own work.[96] The Committee therefore recommends:

RECOMMENDATION 11

That the federal government continue its work with provincial and territorial governments and other stakeholders to support the implementation of electronic health records across Canada.

Other witnesses described the application of new communication technologies to expand the reach of their services.[97]

C. RECOGNITION AND USE OF ALTERNATIVE HEALTHCARE DELIVERY

The Committee heard from witnesses who identified alternative healthcare delivery approaches and occupations. One witness described what she saw as the limitations of the mainstream approaches:

The focus of our current system is on how to diagnose and treat disease, and few resources are given to prevention. In fact, as physicians and other allied healthcare providers, we are left to mop up when patients, who perhaps haven't learned how to take care of themselves properly or optimally, develop significant and chronic diseases.[98]

A witness representing the Royal College of Physicians and Surgeons of Canada described the increasing collaboration between practitioners of new approaches and of more conventional ones, “especially when we are dealing with populations who are either indigenous or in rural remote communities.”[99] Another witness suggested that without regulation, “there is a significant variety in the quality of care provided” by alternative health practitioners and added that there is a federal role in determining whether or not an occupation is regulated, which has an impact on the respect it is given.[100]

The Committee also heard from two witnesses providing alternative models of healthcare, each of which include both conventional and alternative approaches and practitioners. Dr. John Cline proposed the introduction and implementation of “functional medicine in health care professions' curricula and practices throughout Canada.”[101] He told the Committee that “Functional medicine addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership.”[102]

The Committee also heard from Pure North S’Energy, which described the considerable savings to the healthcare system resulting from its program, which featured “simple and effective prevention-focused clinical interventions.”[103] These interventions included “vitamin D3 and high-quality multivitamin and mineral supplementation, health education, and the safe removal of mercury amalgam fillings.”[104]

FEDERAL ROLE IN HEALTH HUMAN RESOURCES PLANNING AND DEVELOPMENT

One witness described the pace of recent changes that affect human health resources and its impact on the need for greater planning:

There has been relatively little attention paid to the impact of system and organizational change on health human resources in comparison to the extent to which such changes have occurred during the past decade.[105]

In a brief that followed the appearance of its officials before the Committee, Health Canada described two components – a Pan-Canadian Health Human Resources Strategy and an Internationally Educated Health Professionals Initiative – of a major funding program, pointing out that they both support activities in the health human resources area.[106] These are two of the specific topics addressed in greater detail in the next sections of the report.

A. HEALTH HUMAN RESOURCES PLANNING

Witnesses described human resources planning initiatives in which the federal government is a key player, including the federal-provincial-territorial advisory committee on health delivery and human resources[107] and the Physician Resource Planning Task Force.[108] Recommendations from several witnesses called for federal “leadership” in health human resources information gathering and planning,[109] while others proposed federal involvement in and support for such initiatives.[110] In particular, a witness representing the Royal College of Physicians and Surgeons of Canada identified the potential for “a pan-Canadian or a national human resources for health institute or agency…to garner the benefits and strengths of the learnings, evidence, and experiences from provinces, territories, professional agencies, and researchers.”[111]

In support of these witness suggestions, the Committee recommends:

RECOMMENDATION 12

That the federal government work with provincial and territorial governments and other interested stakeholders to assess health human resources planning challenges, particularly in rural and remote areas, and to facilitate the sharing of best practices and planning data.

B. INTEGRATION OF INTERNATIONALLY EDUCATED HEALTH PROFESSIONALS

A witness from Health Canada told the Committee that the department’s work on the integration of foreign-trained nurses and physicians has involved

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.[112]

In a follow-up to its appearance before the Committee, Health Canada described broader efforts through its Internationally Educated Health Professionals Initiative (IEHPI), which was “established in 2005–2006 to increase the supply of health professionals in Canada by promoting the integration of internationally educated health professionals into the Canadian health workforce.”[113] The document outlined the seven priority occupations under the initiative: physicians, nurses, physiotherapists, pharmacists, occupational therapists, medical radiation technologists and medical laboratory technologists, with additional investments “in additional occupations, such as midwives.”[114]

A related initiative by the Medical Council of Canada, described to the Committee, “is developing pan-Canadian standards to assess international medical graduates who may qualify to practise in Canada without further training, for those who are not seeking to enter postgraduate training or residency.”[115] Health Canada reported that “[b]etween January 2012 and December 2013, over 2,100 international medical graduates have been assessed using the tool, with over 1,020 international medical graduates entering residency training.”[116] Health Canada described a similar initiative with respect to internationally educated nurses.[117]

Health Canada also reported that a Saskatchewan project

promotes and supports the retention of internationally educated health professionals in Saskatchewan, providing career planning, referrals to training, mentorship and peer networking opportunities with the goal of improving the skills necessary to attain professional licensure and to better integrate into the Province’s health workforce,[118]

and that services have been provided to 442 internationally educated health professionals.[119]

The Committee also heard testimony about initiatives by specific organizations, including the Canadian Association of Occupational Therapists[120] and the Federation of Medical Regulatory Authorities of Canada.[121] Occupation-specific recommendations came from the Dietitians of Canada for continuing federal support for “bridging programs for internationally educated health professionals including dietitians,”[122] and from the Association of Faculties of Pharmacy of Canada for a resetting of “immigration quotas for internationally trained pharmacists,” pending “a comprehensive assessment of current and future pharmacist manpower.”[123]

C. SKILLS DEVELOPMENT AND RETENTION

Witnesses testified with respect to both initial training and continuing education of healthcare professionals, and identified current federal roles. These roles include “some targeted funding and initiatives in the area of rural and remote training”[124] and an on-line training program focussed on patient care for pharmacists.[125]

Witnesses saw opportunities for the federal government, particularly in its role as an employer, to contribute to the training of healthcare professionals, including nurses[126] and psychologists.[127] The Committee recommends:

RECOMMENDATION 13

That the federal government review existing internship or student programs, such as the Federal Student Work Experience Program and Health Canada’s Student Bridging Inventory, to consider training opportunities for healthcare professionals.

Some witnesses also called for a federal role in supporting ongoing training for healthcare professionals, particularly physicians, though the development of “a national consultation on continuing professional development,”[128] signalling the federal government’s support for “the maintenance and enhancement of physician competence and performance by supporting credentialing bodies.”[129] Other witnesses called for the establishment of “a standard that allows people to work to their full and optimal scopes of practice by helping to establish standards for practicums and residencies that foster interprofessional competencies” and the encouragement of “post-licensure credentialing work.”[130]

Other profession-specific suggestions included federal government support for “a national framework to guide the future of nursing education based on an examination of the scopes of practice of nurse practitioners, registered nurses, and practical nurses, as well as intraprofessional and interprofessional collaboration as part of this framework,”[131] for “Improve[d] access to medical education for individuals from socio-economically diverse backgrounds,”[132] and for incentive programs to attract youth to train for high-demand jobs and to encourage the recruitment and retention of counsellors/psychotherapists across Canada.[133]

D. CANADA STUDENT LOANS

A federal government website describes the Canada Student Loan Forgiveness program for “family doctors, residents in family medicine, nurse practitioners, and nurses who work in rural or remote communities.”[134] This program specifies that loan forgiveness could reach $40,000 for doctors and residents in family medicine ($8,000 per year for up to 5 years), and up to $20,000 for nurses and nurse practitioners ($3,000 per year for up to 5 years). Eligible practitioners must have been employed for a full year (12 consecutive months) and have provided a minimum of 400 hours (or 50 days) in-person service in designated communities.

According to a witness representing the Canadian Federation of Medical Students, “As of November 2013, this program had enabled more than 1,150 family doctors and nurses to receive some loan forgiveness.”[135] However, the same witness described what the Federation sees as the limitations of the program, as it requires beneficiaries of loan forgiveness to have outstanding student loans:

The barrier to maximizing the number of new family doctors taking advantage of the program lies in ensuring that they have outstanding federal government loans when they are in a position to take advantage of the program… Most medical residents choose at the start of their residency training to consolidate their Canada student loans to a line of credit from their financial institution. This shift of debt significantly reduces the incentive that has been created to draw new doctors to rural and remote communities.[136]

The Dietitians of Canada identified specific circumstances that, in its opinion, result in “federal policy with regard to Student Loan Assistance and Interest-Free status [continuing] to hamper efforts of post-degree programs to provide practicum training.”[137] Their brief points out that repayment must begin 6 months after graduation, but “[d]ietetic internships (about 40 weeks) do not provide a stipend for living expenses and there may be a registration fee.”[138]

The group concluded that “[f]or some dietetic interns, the repayment requirements (with no option for delay or continuation of interest-free status) combined with lack of income for living expenses (no access to student loans) becomes a barrier to completing their studies.”[139] The Committee recommends:

RECOMMENDATION 14

That the federal government review repayment requirements under the Canada Student Loan Program to ensure that health professions are treated fairly, and do not face unreasonable barriers to completion of their education.

In its discussion of the student loan forgiveness initiative, a witness representing the Royal College of Family Physicians of Canada told the Committee that “We do hear of rural communities being able to recruit but having great difficulties with retention,”[140] and therefore encourages the measurement of the impact of incentives in the Student Loan program on retention of health professionals.[141]

E. SUPPORT FOR RESEARCH

The Committee heard that the federal government is a major funder of health research.[142] For example, witnesses explained that federally funded research supported the expansion of pharmacists’ scope of practice[143] and the Canadian Collaborative Mental Health Initiative.[144]

Witnesses identified further research initiatives that could support the maximization of scopes of practice and the optimal performance of the healthcare system. A witness from the UBC Centre for Health Services and Policy Research called on the federal government to

invest in an infrastructure to measure and monitor scopes of practice of Canadian healthcare professionals linked to appropriate dimensions of care. A federal role is needed to implement systematic monitoring and evaluation, with a specific focus on inputs and outputs, to estimate costs incurred for introducing change and the long-term return on investments.[145]

The witness further recommended that the federal government “earmark research funds to address gaps in the literature and our knowledge in a number of areas. (e.g., payment models and electronic medical records).”[146] Finally, she recommended that the federal government

fund research to assess the impacts of selected key health system innovations on health human resources in both urban and rural settings; to develop a national framework for guidelines and quality standards for optimal, expanded, and overlapping scopes of practice; and then to promote best practices and facilitate subsequent scale-up and sustainability of initiatives across the country.[147]

In a written submission to the Committee, HealthCareCAN wrote that

[the Canadian Institutes for Health Research] CIHR could contribute research funding to address evidence gaps in the current literature – such as cost-benefit analyses and [return on investment] ROI relative to different models of care and scopes of practice, and the impact of changes on patient outcomes.[148]

A witness representing the Canadian Psychiatric Association also identified a “need [for federal funding] to support demonstration projects on how collaborative care can help address common problems faced by healthcare systems, particularly with reference to underserved populations, such as the Aboriginal, homeless, rural, and isolated communities.”[149]