Health — Issue No. 28 — Thursday, July 7, 2016 (HTML) (2024)

2016 Legislative Session: Fifth Session, 40th Parliament

SELECT STANDING COMMITTEE ON HEALTH

MINUTES AND HANSARD

MINUTES SELECT STANDING COMMITTEE ON HEALTH

Thursday, July 7, 2016

9:30 a.m.

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

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

1. The Chair called the Committee to order at 9:32 a.m.

2. Opening remarks by Linda Larson, MLA, Chair.

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

4. The Committee recessed from 12:04 p.m. to 12:58 p.m.

5. The Committee recessed from 2:50 p.m. to 3:01 p.m.

6. The Committee adjourned to the call of the Chair at 5:33 p.m.

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH

THURSDAY, JULY 7, 2016

Issue No. 28

ISSN 1499-4224 (Print)
ISSN 1499-4232 (Online)

THURSDAY, JULY 7, 2016

The committee met at 9:32 a.m.

[L Larson in the chair.]

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

As part of its mandate to identify potential strategies to maintain a sustainable health care system for British Columbians, the committee undertook a public consultation in 2014-2015.

This summer, we launched an additional call for submissions, and we are looking for new or updated information. As part of its consultation, the committee is holding public hearings in Victoria, Prince George, Kamloops and Vancouver.

British Columbians are also invited to participate by sending a written, audio or video submission. The deadline for submissions is Friday, July 29, 2016. All the input we receive will be carefully considered by the committee as it prepares its final report to the Legislative Assembly.

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

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

J. Darcy (Deputy Chair): Judy Darcy, Deputy Chair, MLA for New Westminster and NDP spokesperson on Health.

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

S. Sullivan: Sam Sullivan, MLA, Vancouver–False Creek.

D. Plecas: Hi. Darryl Plecas, MLA, Abbotsford South.

M. Dalton: Marc Dalton, MLA, Maple Ridge–Mission.

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

L. Larson (Chair): Also assisting the committee today are Susan and Stephanie from the Parliamentary Committees Office, who we couldn’t do without. Ian and Alexandrea from Hansard Services are also here to record the proceedings.

With that, I’ll turn the floor over to our first presenters. Welcome, Brenda. Nice to see you again — and Gordon and Bodhi. I will give you your full 15 minutes regardless of when we started, so please leap right in.

Presentations

B. Locke: Thank you, Madam Chair and Members, for giving us the opportunity to present to you today.

[0935]

I’m going to start off by introducing those that are with me. Gordon MacDonald is the associate director for our association, Bodhi Haraldsson is the director of research, and Anne Horng, over there, is our president. Anyway, we appreciate this opportunity.

The registered massage therapists represents about 3,400, give or take. Registered massage therapists in British Columbia — there are about 3,800 RMTs in B.C. That is now more than there are physiotherapists, so we are growing very rapidly. We’ve probably increased our numbers at least by a third in ten years. It’s a large-growth industry, and many, many British Columbians, upwards of 500,000, see an RMT sometime in a year.

RMTs are trained in the assessment and the diagnosis of the soft tissue joints of the body and the treatment and prevention of injury, pain and physical disorders, and RMTs are dedicated to treating symptoms of pain dysfunction, including the underlying causes.

As I said, we represent a good deal of health care practitioners in British Columbia, and we truly believe that RMTs can assist the province in addressing and diverting some of those health care challenges that currently exist, especially and specifically around musculoskeletal disabilities, which are a huge cost not only to government, but to business.

I’m just going to read you a quick quote by Dr. Karim Khan, who is the professor of the department of family practice at UBC. Dr. Khan said: “Massage therapists provide a special dimension of health care to help some patients in ways that no other discipline can match. Massage therapists are an essential element of world-class treatment and prevention of acute and chronically painful conditions. If I were setting up a clinic in Vancouver, I would certainly seek to partner with a registered massage therapist.”

With that, I’m going to turn it over to Gordon to carry on.

G. MacDonald: Thank you, Brenda, and thank you, Madam Chair and committee members.

One of the things that was identified in the government’s 2014 health care priority document, setting priorities for B.C., was the whole issue of interdisciplinary approaches. We, as an association, strongly support that
[ Page 468 ]
move on behalf of government. We believe that the future sustainability of the health care sector depends on all health professionals working collaboratively to develop interdisciplinary teams which provide appropriate patient-centred care to residents across the province.

Of course, for health care to be patient-centred and integrated and comprehensive, we have to build a system that’s collaborative and inclusive. In order to improve the system, that requires all health stakeholders to be included. That includes ourselves.

Registered massage therapists are a key member of many interdisciplinary teams. In fact, at the 2010 Winter Olympics in Vancouver, they formed part of the partnership, amongst others — physiotherapists, occupational therapists, physicians, chiropractors. It showcased the benefits of interdisciplinary collaboration and patient-centred care at that event. Working together, these health care professionals provided the best patient outcomes for the athletes vis-à-vis patients and in a manner which was efficient, timely and certainly cost-effective.

The approach around that has actually also been demonstrated in such jurisdictions as the Mayo Clinic in Rochester, Minnesota, where registered massage therapists are an integral partner in the delivery of health care for both cardiac surgery and thoracic surgery patients. The integration has led to a significant reduction in pain for those patients, both pre-op and post-op.

The results of a recent survey conducted in the United States by a number of hospitals show that massage therapy was offered by over 40 percent of the hospitals that were surveyed and that it was one of the most widely used modalities in hospitals, predominantly for stress management, comfort and pain management. Extensive evaluation has shown that massage therapy effectively improved outcomes in a number of areas, including reductions in pain, anxiety and lymphedema, as well as decreased muscle tension, heart rate, blood pressure and galvanic skin response.

The association shares this perspective, again, as mentioned earlier, with some other health care professions who have also made previous submissions to the committee in response to interdisciplinary practice.

[0940]

We support the move to a high-performance health care system where full integration of both primary and acute care takes place. The association seeks to work with both government and our other health care colleagues to break down barriers and to move the agenda of patient-centred care forward, ultimately leading to improved patient outcomes and a reduction in the funding necessary to support the system.

A team approach is the answer to improved patient outcomes, and this only occurs where better coordination between all health professions occurs and practitioners are able to provide their respective skills and apply training within an interdisciplinary team.

Team-based interprofessional care would serve communities through the assembly of a team of health care professionals whose skills match the needs of the community. Studies have demonstrated that stable, existing connections between health care professionals lead to excellent continuity of care and improved patient outcomes. Of course, this is only possible where RMTs are allowed to practise to their full scope of training.

Again, the RMTBC supports a collaborative practice approach, which ensures that patients receive the appropriate care in a correct setting and in a timely manner. Of course, we believe that improving patient outcomes through collaboration with other health care professionals, as I stated, is key to that occurring.

On the issue of rural services in British Columbia, it’s our view that in order to provide a stable and adequate supply of health care services to rural areas of B.C., it’s imperative that an adequate supply of health care professionals, including massage therapists, be available in these regions. Where an adequate supply of health care providers is not maintained, of course, the health care needs of the residents in those areas will not be met.

Health human resource data shows that there’s a significant shortage of both occupational therapists and physiotherapists in rural areas of the province. The Canadian centre for health information, CIHI, reported in 2013 that with the continued attrition through retirement of individuals in those two professions and the move to part-time work and the large number of practitioners retiring or moving to the private sector, the availability of rehabilitation and pain management services to residents in those regions will become more difficult.

In 2014, our association actually undertook a public awareness survey. The survey, which was conducted with a random sampling of about 759 individuals, showed that the visitation rates by the public had increased 81 percent since the 2008 survey of the same type was undertaken.

Further, the survey demonstrated that all 73 percent of residents have visited a physiotherapist, 67 percent had visited an RMT. An interesting note is that over the past five years, residents have reported visiting RMTs by up to 52 percent versus that of 50 percent for physiotherapists. And when these same residents were asked what they think of medical professions — which ones come to their mind — RMTs rated higher than naturopaths, acupuncturists or traditional Chinese medicine practitioners. Of course, RMTs were only slightly less known than physiotherapists.

Again, the association recommends that registered massage therapists be considered, where appropriate, as a resource to those health care services in rural areas. RMTs could be utilized as an additional health care resource to those residents seeking health care services for such issues as pain management, anxiety, rehabilitation, etc.

While a lot of RMTs primarily work as private health care providers, we believe that our skills and abilities could be used within the public health care system. The
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average age of an RMT is currently 34 years, which is considerably younger than that of many of the other health care professions. As a human resource in the health sector, RMTs offer a long-term workforce commitment. Integrating massage therapists into acute care facilities, community care facilities, long-term care, hospice and palliative care units and elsewhere would offer the benefits of massage therapy to a broader audience, producing, ultimately, a healthier population.

Again we get back to the issue of building the concept of interdisciplinary teams. One of the things that our association has done, in particular, within the rural community, is…. We have a First Nations professional practice group. It’s led by an individual who is of First Nations heritage. The intent of that group is to bring knowledge to massage therapists who are seeking and very interested in working within the aboriginal and First Nations community in the province of B.C.

In fact, the PPG group has reached out to a number of First Nations communities over the last year or so in order to see how RMTs could become a key contributor to delivery of health care in those communities.

[0945]

This proactive approach by the profession in moving forward to key areas such as that would align with government’s strategic plan for health care. It’s why we, as massage therapists, should be considered a valued partner in any future health care planning.

On the issue of best practices for end-of-life. It’s an issue which has a significant impact on both the economy and individual well-being in the province of B.C. and Canadians as a whole. It’s certainly going to be…. For a lack of effective, economical and sustainable hospice, palliative and end care, currently many British Columbians, of course, are passing away in hospital settings. This is both costly and doesn’t necessarily meet the wishes of those or their loved ones.

The association believes that all British Columbians have a right to quality end-of-life, which allows them to die in dignity, free of pain, surrounded by loved ones and in a setting of their choice. This approach will only occur where a collaborative, sustainable strategy of hospice, palliative care and end-of-life care is developed and where there, again, is that interdisciplinary approach.

The RMTBC supports the Ministry of Health’s provincial end-of-life care action plan for an integrated population needs–based approach. While RMTs primarily treat musculoskeletal injuries and pain, it’s our belief that in the area of end-of-life, RMTs may assist in providing treatment to those facing the end of life by lessening anxiety, depression, well-being, reducing pain, increasing mobility and offering a touch in a therapeutic manner.

Again, we recommend that the ministry establish integrated services with interprofessional health care teams, inclusive of RMTs, across all levels of hospice and palliative care.

In closing, the association appreciates the opportunity to provide this submission to you today. We would certainly welcome any follow-up questions or a follow-up presentation.

L. Larson (Chair): Thank you. Fingers are going up madly already here for questions.

I’m a huge fan. I have vertigo. I use a massage therapist, and I don’t have any problems. So I know the value for all kinds of different types of things. We have heard, as we’ve gone over the province, how valuable physiotherapy, massage therapy, etc., are to teams. You’re telling us something that we like anyway and support.

J. Darcy (Deputy Chair): Thank you so much. Ditto to what the Chair just said. Massage therapists have certainly reduced my pain and improved my quality of life many times over many years. I certainly appreciate what you contribute to health care.

It was wonderful to hear you speak specifically to end-of-life care, hospice care, palliative care. That’s a really important contribution. You spoke about acute care and the Mayo Clinic, in particular.

I wonder if you are familiar with models where registered massage therapists are integrated in a better way in primary care — in this province, this country or other jurisdictions — that we could look at and, if you are aware of them, if you’re aware of the funding models that are used in order to facilitate that. Given that most massage therapists, the majority, work in private practice, how does that actually work on a practical basis? If you could speak to that.

G. MacDonald: I should say probably the United States and the east coast of the United States — and, of course, at the Mayo Clinic, in particular. Last year we held a summit, as an association, and brought in a speaker who is an RMT from the Mayo Clinic to speak of the integration that they’ve undertaken. In fact, they’ve been able to reduce the cost of stays of patients there considerably. I think that’s probably one of the most recent models.

A large number of acute care facilities in the United States are also using RMTs in a triage situation within the emergency department, where RMTs are working in an interdisciplinary team with physicians and physiotherapists. A large number of people who present to the emergency department actually bring forward issues around lower back pain. Of course, that can tie up the emergency department for quite some time.

[0950]

In fact, even in Washington state…. There’s a model currently in King County that is utilizing RMTs within the emergency department so that people are actually triaged out of emergency and then on to a side clinic where they can be dealt with effectively.
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J. Darcy (Deputy Chair): On primary care, specifically? Anything that you can share with us on that — on family practice or part of a family practice team?

B. Haraldsson: There are RMTs in B.C. that work in family practices. The funding model is extended health, MSP, WCB, ICBC. Those are the ones that cover us, mainly. As far as public health, it’s MSP that covers us, partially, and WCB and ICBC for the public insurers.

As far as models, the best one would be to look at our sister professions, which are physiotherapy, chiropractic. There are a few models there that they’ve used, particularly in Ontario right now. There are chiropractors that are working in hospitals that are part of the triage team. So when people come in with musculoskeletal issues, they get triaged to a chiropractor that’s working with a physician. They’re a part of that team in the hospital. I think it was Sunnybrook that’s doing it.

If you want more information on that, I’m glad to find that for you.

D. Barnett: Thank you very much. I, too, am a fan. Believe you me.

We’ve heard over and over and over — not just the last week but prior to this, in our last tour that we did and taking submissions — about interdisciplinary teams. Please tell us how we get there.

G. MacDonald: Well, unfortunately…. I’ve been involved in health care for the better part of 15 years now, and part of the problem really is the hierarchy within the system. As much as I think we all honour our colleagues in the medical profession, the ability to be able to knock down some barriers and allow individuals to — as we’ve said earlier in the presentation — work to their full scope would certainly be beneficial. It’s interesting that a lot of patients actually present to RMTs without having to go to their physician. That has certainly, obviously, worked for some.

Again, I think there’s also a lack of awareness of the depth and breadth of education, particularly for registered massage therapists. Not all of the other health professionals actually know the scope of practice or the education background and the modalities that are able to be treated by registered massage therapists. So any education that could be honoured around that, I think, would go a long way to helping that whole move towards interdisciplinary teams.

M. Dalton: Thank you very much for your presentation.

Just questions on the training. Where is it offered in B.C.? How many students actually graduate? How long is the program? You mentioned about it. What’s the job market like? So that’s four little…. That was a quick question, wasn’t it?

B. Locke: I’ll take part of that on. One of the challenges that we find as a profession is that our training is primarily in private schools. We certainly would like to see that moved into public education. That may address one of the issues that Ms. Barnett just raised about integration. When we are learning in an environment where there are other practitioners, that also will encourage some of that knowledge and ability for people to work cross-discipline. So that’s one of the issues that we face, that we are primarily only in for-profit schools. That’s a significant issue for us.

The life span of an RMT. Is that what you were asking?

M. Dalton: How many students are graduated? How long is the program? And job market.

B. Locke: Right now we’re probably seeing about 250 new grads a year. It’s pretty significant — probably more than any other…. Certainly more than physios and chiropractors and those. We are seeing a significant amount of new grads coming into the profession.

[0955]

They’re all coming in and landing good jobs. The NOC, national occupational classification, documents talk about massage therapy, but that doesn’t fit the B.C. model. B.C.’s massage therapists are trained quite differently than is probably recognized as typical. They are very well trained in B.C.

J. Shin: Good morning. It’s certainly really great to see some of my former colleagues in the massage therapy education and regulations. Welcome again and thanks for your presentation.

I just wanted to ask you a few questions, actually. The first one is…. I understand that you’re looking at a lot of the U.S. models as well as the models for other Canadian health care occupations. With that said, I would be curious to find out if there are any other Canadian jurisdictions in other provinces that are leading a conversation in the interdisciplinary approach that you’ve mentioned. I’m curious to see if there is a conversation like that developing elsewhere.

The second thing is on the issue of the practitioners in the rural communities here in B.C. It does say that the association recommends that the massage therapists be considered, where appropriate, as a resource in health care in the rural areas. I was just wondering if that’s a matter of the supply of professionals that we train in B.C. or if it’s a matter of our ability to attract and retain those professionals in rural areas. If you can provide clarification around that, I would appreciate it.

B. Locke: I’ll speak to the first piece around other jurisdictions that may be on the same page as we are in terms of training, etc. Ontario, certainly, is training their RMTs well. They’re doing similar to what we are in B.C.
[ Page 471 ]

In fact, B.C. actually is a leader in what we do. We have the only paid and functioning research department in Canada, which the association funds. We do most of the knowledge transfer. That’s Bodhi’s job. We’re sharing information across the country, and we’ve really taken that role seriously and with a lot of responsibility. We’ve really led a lot of that.

The second part of your question was…

J. Shin: …about the rural communities and our ability to attract and retain the practitioners there.

B. Locke: Gordon, maybe that’s more of a….

G. MacDonald: RMTs are not unlike a lot of other health care professionals. I think recruiting and retention of individuals to a large number of rural British Columbia has been difficult. Again, where there’s been success — say, in areas like Fort St. John and those areas — the success has come in respect of those individuals being able to practise to their full scope and being able to also have a sustainable career.

I think that where that can be offered to RMTs, there certainly is an interest on the part of some within the profession to be able to move forward with that. Again, that integration into, say, acute care facilities, as an example, where…. Currently, that only occurs if a family has, in fact, invited the RMT in to work with either the individual themselves or if the family has requested such. Where that could be broadened and RMTs become an integral part of the services that are available to individuals requiring that…. I think that would go a long way to certainly opening up the opportunities for RMTs in rural parts of B.C., along with urban parts of the province as well.

L. Larson (Chair): Thank you very much. Excellent….

Very quick, Darryl. We have half of a minute.

D. Plecas: Just a very quick question. I guess any of you could answer this. When you talk about full scope of practice and you talk about not being able to exercise that, what are the parts of the practice that are more difficult, as part of that full scope, and that you can’t do? Why is it that you’re not able to do it?

B. Locke: Okay. Super question that we normally wouldn’t share in this kind of room.

D. Plecas: The microphone is off.

[1000]

B. Locke: One of the challenges that we have is how the colleges interact. That can also be a big challenge to how we perform our scope of practice. How we interpret scope and how they interpret scope can sometimes not look the same. So that can and is a challenge for us.

Likewise, with other colleges — how our college and another college actually see their roles so that they’re not all siloed. That’s part of that challenge for us, for sure.

L. Larson (Chair): Very diplomatically done.

B. Locke: Thank you.

D. Plecas: Yeah, I was going to say it was a very diplomatic answer.

L. Larson (Chair): Thank you so much for coming this morning. We really appreciate it. We appreciate your input, and we will capture these things in our report. So thank you for being here.

We’re going to take a moment to switch out one of the computers so that we can start using the PowerPoints. So give us two minutes here.

[1005]

We are ready to go here, and I would like to welcome, from the Vancouver Citizens Health Initiative, Kyle Pearce.

The floor is yours.

K. Pearce: Thank you very much, and thank you for doing this marathon of listening and reading in the interests of our health care system. It’s an incredibly complex challenge you have in front of yourselves, so thank you for spending all this time and attention over days and days.

I am Kyle Pearce. I represent the Vancouver Citizens Health Initiative. We’re an incorporated non-profit organization dedicated to a sustainable health care system. I’m happy to speak to you, honoured to be here and honoured to be speaking on the traditional territories of Musqueam, Squamish and Tsleil-Waututh territories.

The question to which we are responding is simply one: “How can we create a cost-effective system of primary and community care built around interdisciplinary teams?” First of all, I want to let you know that we love this question. It goes to the heart of how primary care is governed, funded, operated and how income from the provision of health care is distributed.

More importantly, the issue speaks to the core of therapeutic relationships, interprofessional respect, scope of practice and the nature of the patient-provider relationship. Our perspective, just to spoil it, is that there’s a generational, technological and cultural shift that requires us to rethink how we deliver primary care.

Today I’ll introduce our organization. I’ll explain our interdisciplinary business model of primary care and then share our next steps and hopes for health care in B.C. My goal today is to share a new approach to co-designing models of primary care that address the needs of patients, providers and the public. I’ll also share ways that you can
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help catalyze innovation to solve the increasingly urgent problem of health care system sustainability.

So us. Vancouver CHI, as we call it — Citizens Health Initiative — has two main purposes. One is to involve citizens in understanding and influencing health care system improvements. The second is to co-design, build, operate and evaluate primary care clinics that some would call a patient’s medical home. I’m going to direct you to this side of the two-sided sheet.

Our board members include Brett Sparks, who is a talent specialist in the tech sector. He works at Hootsuite. He’s an expert on high-performing collaborative teams and has a lot of experience working with the millennial workforce.

Samiran Lakshman is another board member. He’s a Crown counsel. You’ll note that there are no physicians or clinicians on our board currently, but we’re building. Samiran Lakshman is a Crown counsel who brings a critical perspective and a focus on integrating technology to make health care fit our lives.

Then our other board member is Trilby Smith, an evaluation consultant in health and community services. She was formerly with the Michael Smith Foundation for Health Research. She’s our evaluation person.

I’m a co-founder, a board member and the operational lead of Vancouver CHI. I’m a consultant in the health and community services sector with a history of business innovations in oral and primary health care. For example, I founded and developed a dental clinic in the Downtown Eastside that has — and continues for 15 years now — enabled thousands of low-income children to access dental care. It’s called the Strathcona Community Dental Clinic. It’s right down the street here.

I spent five years in the world of physician-led primary care innovation, incorporating the first divisions of family practice and leading the prototype phase for the provincial A GP for Me initiative. That’s the one where we succeeded in enabling White Rock–South Surrey to solve the problem of physician shortage. I’ve also led primary care engagement in research and research with the Vancouver division of family practice.

With my work provincially and in Vancouver, I’ve engaged over 600 family physicians and over 2,000 citizens around the question that you have posed. Our approach at Van CHI comes from listening to both patients and providers as they do two things. They declare the importance of strong primary care relationships, and they lament how difficult it is to get one in a timely way.

Vancouver Citizens Health Initiative is an unaffiliated organization with a set of non-negotiable values that are non-partisan. We believe that a high-quality, universally accessible and publicly funded health care system is a treasured public good and that everyone who participates has a stake in its sustained success. We believe wellness begins with relationships. While we need to treat disease, as a collective enterprise, we should be aiming at something higher that addresses what patrons of the health care system really want.

[1010]

We believe that primary care is only one element of wellness. Our frame of reference includes social supports, interpersonal connectedness, exercise, education, housing and access to food. We believe that primary care can and should be transparently accountable to patrons, providers and the public interest.

As board members, we’re all parents, and we want desperately to know that everyone — including our kids — will be able to enjoy the benefits of universally accessible health care. Our motto is “Health care for everyone, now and in the future.” I want to direct your attention to this. I’m actually going to speak to it.

Our perspective. Our primary focus is on the wellness of people — patrons, we call them — who engage with the health care system in our community. At an individual level, it includes everyone who’s ever had contact with the health care system. Right now, the biggest problem from this perspective includes too many people that don’t have timely access to a family doctor.

In my health community, VCH’s research estimates that there are 170,000 people in Vancouver alone, and about 900,000 across the province, who don’t have a GP. If you’re lucky to have a family doctor, getting an appointment can take a lot of time. Almost 20 percent of daytime visits at Vancouver General Hospital are for people who have a family doctor, who visit for issues that could be better treated in a primary care setting. It’s a waste of our money.

Secondly, providers. Patrons need consistent, productive, well-rested health care providers. Physician wellness is central to our vision. Right now, most providers take the risk of starting up their own business using a model that’s 100 years old, resulting in burnout and low satisfaction levels for physicians. Some are lucrative businesses, but nonetheless, they prove to be very unsatisfying for many. Younger doctors are less likely to be interested in that traditional model, which is why so many patients are being orphaned when their doctor retires.

The public. The public includes everyone who has a stake in the success of the collective enterprise of health care. You are guardians of the public interest in British Columbia. This means we need a system that functions well and is sustainable. Right now, tax-based and out-of-pocket expenses are rising, leaving less funding for other valuable investments that keep people well — like income security, housing, education, recreation and healthy food.

At the centre of everything we do is wellness. Well patrons getting care from well providers in a well-connected and functioning system is our goal.

Our response to the question of creating a cost-effective system of primary and community care built around interdisciplinary teams is that we need to critically interrogate the assumptions that limit our ability to create
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new mental and primary care models. I want to use three examples of this outmoded thinking and then move into our actual clinical model.

First of all, there’s a belief that interdisciplinary care is not financially feasible within fee-for-service. In fact, with new GPSC incentives — General Practice Services Committee incentives — we’ve developed a model that has nurses, doctors and other providers working to optimal scope and provides fair compensation to an extended team that includes clinical pharmacists, navigation supports and a social worker.

A second assumption is that primary care relationships are about how much time a doctor spends with their patient. We believe the nature of relationships is changing. It’s true that patients want to spend some time with their doctor or nurse practitioner when they have an appointment, but most would rather skip a second appointment and instead text their pharmacist when a prescription isn’t working or email a member of their interdisciplinary team when the symptoms don’t subside.

If health care can adapt to this, then primary care relationships can displace wearables and grocery store magazines as the authoritative sources of wellness information. It’s about a deeper relationship.

Third, there’s a belief that younger doctors are lazy and it’s going to take two of them to replace every experienced family physician. In fact, we’ve found that many in the new generation of GPs want to work in a qualitatively different way that is collaborative, integrates technology and focuses on prevention. Contrary to this assumption, we believe that if we provide opportunities for younger docs to practise the way they want — and incidentally, the way they are currently trained — then the system will have enough capacity for everyone to have a family doctor.

Let’s look at the Vancouver G platform for interdisciplinary primary care. That’s the other side of your piece of paper.

[1015]

The platform for our model of care has been developed through discussions with a big number of people and organizations. That includes GP residents, recent graduates and physicians who’ve been practising for decades — some of them leaders in physician-led primary care change — nurses and pharmacists.

We’ve spoken with Ministry of Health senior directors in primary care. We’ve spoken with Vancouver Coastal Health and Providence primary care physicians. We’ve spoken with the B.C. College of Family Physicians. We’ve worked with the UBC primary care research team — that’s CHSPR — and in fact, Vancouver CHI is a member of the B.C. Primary Health Care Research Network.

We reach out and speak regularly with Mid-Main and REACH community health care centres, and we have a special connection with the PLoT group, the Pharmacy Leaders of Tomorrow, who are going to be speaking with you at 11 o’clock. That’s Aaron Sihota.

While we listen to everyone who has an opinion — and people in the health care system don’t hold weak opinions; they hold strong ones — the model is also a reflection of our values for universal access to a single-tier system.

I want to describe some of the features of the model that you have in front of you. At the core of the model are teams of one physician working with two registered nurses. We could involve nurse practitioners if revenue generation is not through fee-for-service. Administration and business management of this is done by non-clinical staff.

The patient experience for a typical visit. When you go to an exam room, you’re welcomed by a nurse, who discusses the patient’s wellness plan and any changes in their health, does an assessment within the nurse’s scope of practice and identifies all the issues that are relevant to the patient.

When the doctor arrives in the examination room, the nurse inputs the information into the EMR. So the nurse is at the computer, and the doctor and the patient have unmediated contact time. After the doctor performs an evaluation — diagnosis in collaboration with the nurse and the patient — and determines a course of treatment, which is their optimal scope, they leave the nurse to complete the visit.

The medication choices can be supported by a clinical pharmacist who’s embedded in the team. If the patient needs to see a specialist or has a visit to the emergency department or needs a community-based wellness support program, a navigator within our team helps and ensures that the information is incorporated in the patient’s medical record. Patrons can make on-line appointments if they wish and have control over their medical record, enabling others to see elements of it if they want.

Scaled-down versions. This is like a modular model, so scaled-down versions are possible and sustainable. We think we can work with a minimum of two teams. Scaled-up versions are more attractive, so you can do a whole bunch of things. If you imagine a team of seven physicians and 14 nurses, you can do things like provide 24-7 telephone access on a rotational basis. You can have four of those teams operating from nine to five and two of those teams working from one to nine. Then you can have one of those teams reaching out to do home visits, in-patient care, residential care, those kinds of things.

Evaluation is crucial to our model. We need to improve timeliness, quality and experience of care. We need to ensure that providers are satisfied, have a workplace and process that are efficient and convenient for them to provide the best care they can, and we need to ensure that the primary care clinic is having a positive impact on system costs such as emergency department visits and hospital readmissions.

The overall impact of the model. It greatly increases the panel capacity of a family physician — almost double. It provides a care team for every patient and allows for
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continuity as clinicians have life events. So if a doctor wants to have a baby and they go away for two years, you can still have continuity with the nurse for that patient. It provides timely access, same-day access, telephone, email and text connectivity. That’s going to reduce ED use, emergency department usage.

There’s a focus on wellness and integration of community resources that will slow the advance of chronic conditions. Providers get work-life balance. They have to work hard, mind you, but they get work-life balance and support for professional development, child care and those kinds of things. Then as a system, we have data to show the cost impact of wellness-based interdisciplinary care approaches.

This is not a pipe dream. Vancouver CHI has been in discussions with local recreation service agencies about the benefits of hosting a prototype within one of their facilities that helps clients achieve and maintain wellness.

[1020]

We have developed a business case, so we know what our start-up and initial operating costs are and what our break-even point is. We know that the model is actually profitable, with excess revenues that can provide incentives for providers or fund additional clinics or provide additional supports for patients.

We’ve started to think about how to properly govern and oversee the operation not of just one clinic but of clinics outside Vancouver. Our name is a bit of a limiter at this point in time.

We think that about one-third of new family physicians would be interested in working in this way and that if we scale this or any other like-minded model, we’ll have a significant impact on patient wellness and system costs.

Enough about us. Let’s come back to the question at stake here: how do we build a system of primary and community care built around interdisciplinary teams? As a citizen-driven patients medical home model, we might be one of the first to propose such a thing, but we hope we’re not the only one.

Our suggestion to you is to catalyze the creation of many models that are attractive to the next generation of family physicians and primary care providers. That means enabling the generation of new ideas, within certain criteria, and having them reviewed by a panel of experienced, forward-thinking experts, including citizens and young primary care providers.

Once a model passes a rigorous sniff test, provide interest-free loans or a combination of grants and loans to incent sustainability, with clear cut-off criteria of the funding tied to clinic revenues over expenditures and the interests of patients, providers and the public.

As we collectively build expertise in doing this, we’ll create an oversight body to build the capacity of less experienced developers and community groups that want to go down this path.

We suggest also providing money outside of the physician master agreement to incent citizen and clinician co-design.

Finally, we suggest that we embrace this as a fundamental business challenge and engage the public and providers in reimagining how primary care is delivered, governed, funded and evaluated.

Thank you for your time, for listening to me. I’d love to hear your feedback and a response to these ideas.

D. Plecas: Kyle, thank you for that incredible presentation.

Why not just do it? What’s stopping you? Where’s the barrier?

K. Pearce: The barrier right now is money. We are looking to have an agreement with Vancouver Coastal Health. Our understanding is that the ministry is very interested in this kind of model. We understand that they’re talking with VCH — Vancouver Coastal Health — about enabling some models like this.

We’ve been in constant conversation with Vancouver Coastal Health. In fact, we were waiting for an expression of interest to come out about two months ago. That has slowed down, but we’re hoping that some resources come available so that we can actually make this happen.

D. Plecas: My related question…. We’re only allowed….

K. Pearce: Is he allowed two questions?

Interjections.

D. Plecas: But this is a follow-up question.

You mentioned a patient navigator. The whole concept of a navigator, to me, is fantastic — so needed in so many different ways and so many different aspects of services. When I look at this, it’s placed on the outside somewhere. I’m almost thinking: “Man, people need a navigator right up front. I need a phone line to a navigator.”

K. Pearce: They are inside the system. They’re part of the team. You know, the navigator actually comes not from the patient perspective but from what doctors call the hassle factor. A patient goes to the hospital. They come in with a list of medications or maybe no list of medications. Nobody knows what has happened to the patient, what kind of care they receive and what kind of medication they have.

So the idea of the navigator is twofold. One is to help the patient navigate the system — make the appointment, get the treatment or the testing that they need.

But the other is an internal function, which is to ensure that any time a patient visits the emergency department, has a meeting with a specialist…. We are even thinking
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about it if they go to a registered massage therapist or a physiotherapy appointment or the Healthy Heart program. The navigator is there to make sure that that information appears in the patient’s medical record. It’s to remove the hassle factor for the clinic.

The whole point of this is: you can’t make it easier for patients to get care if you don’t make it more convenient for providers to provide the care. It’s not attention for us. It’s: how do we make it happen?

Did I answer that question?

D. Plecas: Very good answer.

[1025]

J. Darcy (Deputy Chair): Thank you very much. We’ve heard from a lot of folks over the last number of days about various pieces of it. But this is really, truly a comprehensive picture of what we could do about improving primary care.

It really resonates with what we’ve heard from a lot of health care providers, including — not here yet — what we hear from medical graduates who say they want various options about how to practice. There are very few options besides hanging out a shingle in the traditional way or doing walk-in clinics. I think you’re really speaking to a broad scope of concerns in talking about everybody truly working to their full scope across the team.

I want to come back…. It’s kind of the same question Darryl asked, but I’d like to just explore it some more. Can you just dig a little deeper? What are the barriers to moving forward with a model like this?

K. Pearce: Sure. When I think about this initiative, it’s very similar to the dental clinic that I mentioned before. It’s a community development process where you bring in subject-matter experts: a group, a board. It’s a non-profit, incorporated group that’s dominated by citizen interests focused on a compelling goal, a compelling vision.

When we did this, we worked for the dental clinic. We did that for 2½ years before. We tried multiple variations of a solution before we simply realized that we needed to create a dental clinic and operate it as a non-profit social enterprise.

At that time, there was a ministry around community development. They enabled us to create it. It was a $350,000 grant. We worked with other charitable providers. We worked with Vancity for an interest-free loan.

With this, the scale is much bigger in terms of finances. We’re thinking in terms of either a grant or a low-interest or no-interest loan, working with a Vancity or a Coast Capital to backstop other donations so that if people contribute to this, they’re not actually going to lose their money. An interdisciplinary board and implementation group.

Really, to catalyze these things, we have the expertise. We work with billing specialists. We have a very large team of people who know how to do this. The limitation right now….

I think what you need is a model that has been vetted and passes lots and lots of sniff tests. You need a location that works. The location we’re thinking of is in downtown Vancouver, which is the place in the province with the second-highest rate of unattached patients.

You need the skill set, you need the model, you need the location, and you need the resources to actually make it happen. That’s where we’re at.

L. Larson (Chair): Thank you.

I’m going to give the last question to Selina, because she hasn’t had one yet this morning.

S. Robinson: I want to agree with Judy and with Darryl. This is really the direction that we’ve been hearing about from many, whether it’s in Prince George and Kamloops, where we’ve been, or Victoria. We’ve heard examples of this kind of model. But this is probably the most defined that we have seen.

I’m interested in two things. One is governance. There’s this issue of governance that we haven’t heard a lot of detail about. Also, sort of the operational pieces, in terms of what needs to happen to pay everybody. How do you get to the next step?

Yes, you can find a location. But then in terms of having it operate, what do you see? Governance and operational funding.

K. Pearce: Let’s start with governance. The previous speaker spoke to this.

Interdisciplinary respect is seldom experienced in the health care field. There are dramatic hierarchies. Part of our modality is that we don’t think through hierarchies. We think through scopes of practice. We don’t see scopes of practice as a hierarchical issue. We see them as about the person’s attitude and aptitude and their ability to practice and what they bring to the table.

Coming back to the governance issue, we want to replicate that around the table. Citizen-driven, but with physician, nurse, pharmacist, social worker — clinical and non-clinical providers. You want to create that culture at the board level and then replicate that at the operational level.

In terms of operationally, it’s all through fee-for-service. With the dental clinic, for example, we knew we weren’t going to convince the ministry to publicly fund dental care.

[1030]

What we did was we looked at what is out there — non-insured health benefits currently now provided through the First Nations Health Authority, healthy kids funding for low-income families. We knew that we had Chinese seniors who would pay cash, and we could provide a discount to incent them to get proper care. We knew that there were other families — because it’s a mixed-revenue
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neighbourhood — who would have private insurance.

This is what I do for a living. I take very difficult ideas, and I find a way. I listen to a lot of people. We find a way to make them sustainable and operational. The revenues are fee-for-service. There’s some potential ancillary revenue generation through, let’s say, renting out to a registered massage therapist or an OT or a PT that supplements the wellness for our patients. Primarily, it’s fee-for-service and general practice services.

What we find is that if you, given this patient flow…. The patient flow, the clinical work flow, is different from what you currently see. It’s much more efficient. You basically have a doctor who has two nurses. If you think about it this way, each nurse is doing two 15-minute visits. I mean, it’s general, right? It’ll be messy and confusing, and we’ll sort it out. Each visit on an average will be 15 minutes, and the doctor is bouncing between two nurses’ rooms. That means a doctor can treat eight patients per hour.

We spend time at the beginning of the day for a huddle, because that’s a best practice. You can organize your patient workload, sort out who’s going to be in which room at what time, and then we debrief for a half an hour at the end of the day. It’s highly collaborative. While we intend to recruit people who are predisposed to this kind of work, we know that human factors require us to debrief and make sure.

All that to say, it’s a concentrated workday. People are going to work very hard in this. The fee-for-service revenues, as well as the general practice services…. This is for a general population, not for a specific one. We feel that we’ll have proportional representation of people with diabetes, COPD, all these other complex conditions, and those are revenue generators for a clinic such as ours.

Did I answer that?

L. Larson (Chair): Thank you so much. We are out of time. Thank you very much, Kyle, for your presentation. Very, very interesting and good to see the type of work that’s being done.

I’ll invite the Ambulance Paramedics please to take their seats up front here so that we can move right into the presentations and not get behind in our schedule. I think you have your PowerPoint already up on the screen there, so I’ll let you go right ahead. Clock starts ticking the moment you start to speak.

B. Barter: Maybe we’ll start with introductions. My name is Bronwyn Barter. I am the president of the Ambulance Paramedics of B.C. I’m also a practising paramedic. I’ve practised all around the province, and right now I’ve landed as the chief in Nelson, B.C.

C. Eby: Good morning. Cameron Eby. I’m provincial executive with the Ambulance Paramedics of B.C. and also a paramedic for 17 years and a chief in Courtenay.

M. Evashkevich: I’m Maureen Evashkevich. I’m a consultant with Ambulance Paramedics of British Columbia, and my specialization is in community paramedicine. I did a comprehensive evaluation of community paramedicine in Ontario as part of my master’s thesis and then did an evaluation as part of the Ministry of Health initiative. I wrote the implementation framework for B.C.

B. Barter: We’re not going to jump to the PowerPoint right away, but we will really quickly with our 15 minutes. We are here to talk to you about community paramedicine. You may be thinking, “Well, wait a sec. We’ve already done this, and it’s been implemented,” but we think it’s important to keep talking to you about it and also give you some success stories around rural and remote B.C., where it has been a success.

We also think it’ll address a lot of the issues and continue to address a lot of the issues that we’re talking about — improved health and health care services. We believe it’s going to be a long-term solution, improving recruitment and retention of paramedics. When we’re talking about it, you’ll also notice that we’re talking about a lot of interdisciplinary teams — teams with the nurses and the doctors and other people within the community.

[1035]

I’ll just start by saying on April 27, we announced, with the government — with a lot of help of a lot of different people — that there were going to be 73 rural and remote communities that were going to get the community paramedic in their communities. Since that, we’ve had a lot of really good experiences. This is something we’ve been working on for about ten years.

We worked really well. We had lots of discussions with all of the different stakeholders around it — the doctors, the nurses, a lot of different people, a lot of the politicians. We actually partnered with the Ministry of Health, and we moved this initiative forward. We did a lot of work initially with Deputy Minister Stephen Brown, and then it actually became a part of our negotiations, where we secured 85 positions throughout the province. It really has been a win for everybody.

On that note, going forward, what we’re looking at and why we’re here today is that it’s been a good start, but we believe we’re going to need to expand this further than 73 communities. We think that we are a huge solution to a lot of rural and remote issues.

On that note, I’m going to pass it over to Cameron.

C. Eby: Diving into our presentation, a little bit about us. We represent 4,000-plus paramedics, at various levels around the province, and emergency dispatchers. Historically we’re thought of as just an emergency service, and we respond to about 500,000-plus calls a year through various resources. The brand-new thing for us is community paramedicine and going into that non-
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emergent preventative medicine rather than reactive emergency medicine.

Some of the system challenges that we believe community paramedics can address are, obviously, the growth in health care spending. We’ve got an aging population increasing in chronic diseases, some of which I noticed the previous speaker touched on there quickly. Emergency overcrowding and increased pressure on EMS resources. More recently, the narcotic overdose epidemic that has been declared in the province. Then, of course, in rural and remote areas, we’ve got a struggle with access to health care services and keeping people in those communities.

Community paramedicine comes into that as a new model — or at least new for British Columbia; it’s been around for about a decade elsewhere — in how to bridge those gaps and solve some of those problems. The scope of paramedics is highly suitable for delivering solutions to these issues, because paramedics have a unique ability to go into somebody’s house — I’m speaking about emergency paramedics — and see what the true situation is.

It’s not a planned visit. They didn’t clean their house. They didn’t get dressed. You really see how people live, and that presents a unique opportunity for our emergency paramedics — 4,000 of them — to tie into a referral system where they can then highlight a patient that may need some services and refer either to the community paramedic program or perhaps one of the other aspects of that interdisciplinary team.

Community paramedicine and where we’re at today. In 2014, we released our major document, which was on implementing community paramedic programs in British Columbia. In 2014, the Ministry of Health agreed to support the implementation of CP. In April 2015, BCEHS officially launched the community paramedicine initiative. In November 2015, we reached a pretty significant benchmark with some regulatory changes to allow paramedics to work in this new function legally. And in April 2016, just recently, the official rollout began, with some job postings and the communities being identified, which Bronwyn talked about.

As Bronwyn mentioned, we’ve been working with the Ministry of Health, regional health authorities, First Nations Health Authority, other unions — basically anybody that we could think of that could be a stakeholder in this. Bronwyn ran through this. We’ve got 73 communities, 80 new FTEs. Through now and March 19…. We’ve had 32 positions posted so far and over 250 applicants to those 32 positions. We really see that when we talk about trying to retain health care professionals in rural and remote B.C., which has been a challenge, this program is not only retaining people there, but it’s attracting new people there.

[1040]

Two of the objectives that BCEHS has identified for their specific community paramedic program are to stabilize paramedic staffing in rural and remote communities and to help bridge health care delivery gaps. Part of that is for the emergency side of the organization. They’re having a real problem keeping qualified paramedics working in rural and remote B.C. because they’re essentially working on a paid-by-the-call model, and when there are little calls, there’s little pay. So there’s not a lot of incentive for them to stay there.

What community paramedic does is bring regular work to those communities that they can depend on. Then on their days off, the hope is that they are also going to provide emergency coverage with sort of a different hat on.

The program is targeted at four major patient populations: diabetes, COPD, CHF and patients that are at risk of falls. When you look at community paramedic programs across North America, those are usually the four high-risk patient populations.

We should note that we really believe it would be quite easy to expand those into more patient populations, such as substance abuse and how we can help address that; low-income populations; or very, very remote reserves — that sort of stuff. Some other possible activities include public wellness clinics, which we hear are being contemplated in some of these communities right now; community outreach and awareness; and general health promotion.

As I said before, recruitment and retention is a major part of the program, and we’re seeing that already. As I said, we’ve got 250-plus applicants for 32 positions. We’re seeing people that…. Haida Gwaii, for example. We had, I think, 18 applicants for two positions in Haida Gwaii. Some of those are people who are now living in Vancouver who grew up in Haida Gwaii and dreamed of one day being able to go back there and work in this profession. So we’re providing a road to do that.

Again, as I said before, bridging the health service delivery gaps in the community. Reducing 911 calls. That may or may not be in the rural areas as a target, but certainly, in urban and metropolitan areas, we’ve got an issue with the volume.

Wellness checks, outreach, home visits for our seniors population to keep them in their homes, rather than having to move people either out of their home into a care facility or out of their community into a larger community where those health services exist. When you have somebody who’s lived in a community or in their house for 30 or 40 years, the last thing they want to do is leave. That has a dramatic impact on their health status when they have to have such a significant change.

Interdisciplinary teams. Community paramedic programs have well integrated in other jurisdictions with teams of nurses, paramedics, nurse practitioners, physicians, home care workers, physiotherapists — you name it. It really has to be pulled together. As I heard the previous speaker, it’s about increasing the knowledge amongst all of those populations of what they can do.
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Paramedics, historically, really just haven’t been part of that team. This is about introducing them there and making sure that all those other people know how we can help — certainly not to replace any of those other people and what skills they have, but how we can augment them.

What we see as some future challenges. The further promotion of CP programs needed to build greater awareness — that’s, again, within the other disciplines; making sure that primary physicians out in these communities know that the community paramedicine program exists, that they can refer a patient to it, and raising that awareness of just what it can do; reviewing the possible CP deployment in the metropolitan or urban environment; and professional roles of interdisciplinary teams are not fully defined yet.

[1045]

We are just starting this. One of the big questions that we always hear is: what do community paramedics do? It’s a really hard question to answer, because it really could be anything. So I want to quickly touch on…. One of our first community paramedics that has been in a prototype community, which is Tofino — it’s one of the communities — shared a story with me and a few other people a few weeks ago.

She was seeing a client, an elderly lady, on a regular basis, and she noticed that at home, she didn’t have a lot of food in the fridge. Everything was liquid — a lot of Ensure and all this sort of stuff — and her weight was declining. So she dived into that. After some questions, she determined that she wasn’t eating properly because she broke her dentures, and that was leading to a decline in her health. The community paramedic was able to reach out and make a referral to Social Services to get the funding to get her some new teeth and get her eating again and keep her healthy.

That’s not something you would think a paramedic would be involved in, but it’s a really good example of: you’re there, you see what the issue is, and you try to find a solution to it.

I think that’s it for our PowerPoint.

B. Barter: Yeah, that’s it for the PowerPoint.

The only other thing we just want to add is that this is happening. It’s going forward. We’ve got 73 communities, and we want to keep it going. That’s going to take funding. We just want to keep talking about it.

Anything else to add, Maureen, before we go to questions?

M. Evashkevich: None other than that I think we have to look at some of the new models that can help in an urban area. We focused on rural communities so far. In most of the other jurisdictions, they started out in rural areas primarily in response to overcrowding in the emergency department. So the paramedics programs addressed overcrowding and access to health care services. “Let’s go visit them in their home to keep them there, and let’s refer them elsewhere so that they actually don’t end up in emerg.”

One of the problems they have in B.C. is that a paramedic, in the old model, cannot treat and release. So you go there, you determine that someone just needs to go to physio, and you actually have to put that patient in the vehicle, take them to emerg, where they sit for three, four, five, six hours.

We’ve got to take those steps back and look at: what is the fundamental issue? How can we do an intervention there? That has been a very, very successful model across the country and in other jurisdictions — treat and release or treat, refer and release. And that’s how we stop, because our most expensive care is in the acute care setting.

L. Larson (Chair): Thank you. I live in a small community. The paramedics are welcomed — you know what I mean? — in homes. People respect them and feel safe. I think that this program…. You will probably be able to see people on a level that others could not because of what you do, because your uniform is recognized, and there’s that comfort level.

I think this is a fabulous program. I know that when we talk about teams, in a lot of the rural areas, there are not enough people to fill all those team pieces. That’s where you kind of fill that void.

Thank you very much for all the work you’ve done in the background coming into this. We’re looking forward to it as it moves forward.

M. Dalton: Thank you for the presentation. It’s great news to hear about the expansion of the number of positions. Just a question on those new positions. What I’ve heard in the past was that paramedics would go outside, get their hours and then try to move to the bigger centres where they’d be able to have more employment, because they were getting standby wages, and it was pretty much impossible to really provide for the family. There’s kind of the rite of passage, almost, to go….

So is this a change? Is the funding going to be that similar, or is it going to be on a full-time basis, or how is that going to be working? If you can elaborate on that, I’d appreciate it.

B. Barter: Just what happened. I’m a perfect example of that. I started in Kaslo, then I went to Victoria, to Vancouver, Osoyoos, and I made my way back to Nelson. But, yes, the funding does basically stay in that community, and we’ll follow it. I don’t know if that answers your questions. The paramedics will go there, and basically, they will be making the full-time or regular part-time wages. They’ll have a regular schedule in those rural and remote communities.

Is it more the…? Do you want to add to that?

[1050]

C. Eby: Yeah. I think what you’re asking is: is it under the same sort of payment model for paramedics? The answer is no. These are new positions that are regular work. So when they are at work, they’re getting paid to be at work. They’re not on an ad hoc, on-call basis, which frankly, is what is attracting people there, right? People need to pay their mortgage and put food on their table.

B. Barter: It’s not on an on-call basis or anything like it is.

D. Barnett: Thank you very much. I come from real rural British Columbia, so I understand and appreciate your service immensely. You are the first person there to save a life. So this program is amazing.

The issue I have, the question I have, is that some of these positions are not full-time. In some of these small rural communities, you may only get part-time or half-time. Are you able to fill those with paramedics, or is there difficulty filling those positions because they’re not all full-time?

C. Eby: The 32 positions that I’ve mentioned that are posted so far are all 0.5, or 50 percent, positions. Essentially, instead of four days a week, they’re working two days a week. The reason that they’re structuring it that way — going into a community and putting two people at a 0.5 instead of one person at a full-time position — is the hope that on their days off, they’re going to supplement by working in the emergency capacity, outside of the community paramedic program.

When we talk about the 80 FTEs, that could be…. If they were all 0.5, that would be 160 actual paramedics or positions across the province. But it could be sliced up in different ways. When the actual needs of the community….

An assessment by BCEHS was done. We have funding right now for 80 FTEs through now and 2019. The actual need, according to BCEHS, is in the neighbourhood of about 260 FTEs across the whole province to properly roll this program out.

B. Barter: And that’s why we’re here.

C. Eby: That’s just about three times the funding, right? I will say that even at 0.5, those regular work positions have never existed before in these small communities. That’s why we’ve got 250-plus applicants for those 32 positions.

M. Evashkevich: There is some merit to say that the community paramedics should also be practising on the emergency side to maintain patient contact and skills, because the skills that they’ll be using are different. It depends on what kind of program it is.

D. Plecas: You’re one of my very, very favourite groups of people. You’re only problem is you don’t get paid enough. I will say that.

When you talk about expanding the scope of practice…. Boy, is this good news, particularly your last comment about treat and release.

My two-part question: one is…. It disturbs me to hear there are half-time people. All we’re hearing is that we need to create sustainability and keep people in communities. This is an uphill battle with half-time positions. It seems to me that when you think about all that you could do in the scope of practice, you could do much more than you’re doing now. That’s part of it.

Another…. I know this is a very sensitive issue, but I hear it all the time. When you think about other models, the point has been raised about merging some of your colleagues with fire. I sometimes think to myself: “Well, why wouldn’t you do that?”

B. Barter: First of all, a lot of people have been watching too much Chicago Fire. The second thing is that in rural and remote B.C., most of the fire departments are volunteer as well. In our experience, too…. I’m married to a firefighter, too, not that I want to admit that. They have a role with what we do, too, at the scenes — what is an emergency and everything else.

They do have a role to play, but we are very different. We think that the patient should get the best care at the beginning from their medical professional, which we believe is the paramedic. Then what they do is they also take that all the way through the hospital experience as well.

[1055]

We’re a provincial service. There are municipalities. I know a lot of people think: “Oh, that’s the way, the solution.” But really, the patient needs the front-line professional, which is the paramedic, and that’s just not a model that we can see that would work.

D. Plecas: But it is a model that has been used successfully in other jurisdictions.

B. Barter: Yeah it is, and then it has been undone. For example, in Winnipeg there are a lot of problems that have happened there, and people are actually moving away from that. A lot of people say: “Well, why don’t we regionalize or download the services of the Ambulance Service, as well?” There are a lot of benefits to having a provincial ambulance service as well. I think government has even looked at the pros and cons of all that.

M. Evashkevich: Alberta’s a good example to look at. Albert’s a perfect example. They had fire integrated services, so fire and EMS integrated. They did a comprehensive assessment on dismantling and separating them.

The birthplace of EMS was in public safety, and over the years, we’ve realized that it belongs in health. Trying
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to actually extricate those two and put EMS with health rather than public safety has been quite challenging. But they did a lot of cost-benefit analysis in Alberta, and Strathcona and St. Albert found it a benefit to stay as an integrated model. There’s lots of amazing information out of there.

D. Plecas: But then how do you get past the duplication of services? The ambulance shows up; fire shows up. Like, hello.

M. Evashkevich: Yeah, that was because of the utilization.

B. Barter: What it is, too…. That’s a whole other issue on how AMPDSE and everything else…. The way BCEHS said: “Oh, you guys can respond if you want, or not.” But in rural and remote B.C., they have….

Interjection.

B. Barter: Yeah, FR3, and fire actually….

D. Plecas: But it is related to models.

B. Barter: It is, but they do actually have a role. They do have first-responder level 3, and they do provide a certain level of skills, whether they’re there or whether they’re before or after and all the rest. They are part of the team, but they shouldn’t be part of the big, medical aspect of it.

M. Evashkevich: If you want some further information on it, we can get you the stuff from the other analyses that were done.

D. Plecas: No, I’ve looked at it fairly exhaustively. That’s why I raised the question.

I just want to emphasize that I think we need to have more discussion about expanding the scope, if you will, of what you do. If we’re saying that we want to get the greatest use of what you do in rural communities, let’s get you to do it.

L. Larson (Chair): Darryl, you’re cut off.

S. Robinson: I’m also pleased to see paramedicine come to life. What caught my attention, because I come from a suburban part of greater Vancouver, was this idea of expanding scope to a more suburban-urban sort of environment and what that would look like, so doing forward thinking.

I’m wondering about the research and the data that you’re collecting as you’re rolling this out. The anecdotal stories are always fabulous. They always speak volumes. I think we all sort of got it and understood how a little thing like that can make such a significant difference. But I’m wondering about the data that you’re collecting around the impact in terms of any cost savings there might be and the impact on people’s wellness.

C. Eby: There’s lots of that data from other jurisdictions, obviously. Because it’s brand new, that’s just beginning now. But BCEHS is charged with that, and we’ve been on a development committee to put a performance matrix around the community paramedic program, because we have to be able to measure if it’s being successful or not.

There are a number of key metrics in there about hospital readmissions, general patient satisfaction. There’s a whole list. BCEHS has actually, to their credit, brought in some really good people that have been involved in the industry, in our community paramedic industry, to help develop the matrix and make sure that the program is being successful.

Looking down the road, we can say: “We’ve had these successes in rural and remote B.C. Perhaps we’ll have these successes in the urban model.”

B. Barter: Just to add to that quickly. Us doing this program is something we’re also advocating in urban and metropolitan as well. We think that this will be a huge solution to keep people in their homes and not clogging the emerg rooms or the hospitals.

[1100]

Basically, it’s like pushing back everyone to the home and treating the things there. Then there’s room for the real emergencies and the people that need to be at the hospital and things won’t escalate and so they’re a bigger burden on the health care system as well. We think this is a huge solution — metropolitan as well.

Also, with the harm reduction strategies and targeted services, we know the hot spots where all the overdoses are, etc. We’re actually working with BCEHS to put a targeted community paramedic on being proactive and responsive to the fentanyl and overdose crises as well.

Today we’re trying to stick to this, but we’d love to have more conversations with you about that as well.

L. Larson (Chair): Thank you. We’re out of time. I promise I won’t let Darryl ask a question next time. Thank you so much for being here. Judy will ask you a question as you’re leaving your table because….

J. Darcy (Deputy Chair): It’s a request. This came up in some of our earlier conversations. Can you please send us information about the training and the qualifications of different levels of paramedics so that we understand that. That came up yesterday. That would be greatly appreciated — and also the studies from elsewhere on both rural and urban community paramedicine.

B. Barter: We can do that.
[ Page 481 ]

M. Evashkevich: The evaluations that have been done?

J. Darcy (Deputy Chair): Yes.

L. Larson (Chair): Thank you for being here.

I’d like to invite Aaron and Robson. Come up a little closer, please.

As soon as you’re ready, please start. You have 15 minutes for your presentation, and then whatever time is left, we will ask questions.

A. Sihota: Perfect. Thanks so much for having us today. We’re really pleased to be here, and hopefully, everyone is enjoying the rainy July morning in Vancouver here. My name is Aaron Sihota.

R. Liu: My name is Robson Liu.

A. Sihota: We’re fairly recent pharmacy grads. We’re both front-line practising pharmacists, and we’re going to talk a little bit today about the health innovation economy and its role in advancing care in British Columbia.

You guys talked a little bit about…. There was a call-out made to the public about health care sustainability and solutions that can be pitched towards three areas: rural health, interdisciplinary teams and the effectiveness of addiction recovery programs.

Now, I know you guys have been touring some sites across the province and talking to various stakeholders, which is great, and you’ll continue to do so in the next few days and next week. Our solution encompasses — at a more macro, a larger scale — some of the stuff that you guys have probably heard about. So we’re taking one step back, and we’re talking about sort of a larger-scale solution to a large-scale problem.

R. Liu: So what is the gap? From a large-scale perspective, there is opportunity in the health care system, and that’s something that we’re just trying to address and provide a solution to. One big gap is: can people find a physician? Can people find a primary care doctor, a specialist?

Also, the gap in…. There’s a huge opportunity in spending in health care, as you’re well aware. It’s 42 percent of the provincial budget — a huge expenditure. This is something that we’re just trying to address.

A. Sihota: Yeah. And then if you think of not only the primary care practitioner aspect but specialists. How long does it take for…? I’m sure some of you have had experience of trying to book a specialist appointment. How can we get technology to really bridge the gap and connect the dots?

[1105]

Robson, can you give me your phone? More and more health care is taking place through this device. Telehealth is bringing patients and clinicians a lot closer together. This is one example of the sort of solutions that innovation can bring towards health.

New models of care are emerging as well. Patient care can be taking place at home now more and more, instead of traditional institutions. That, I think, is a priority of the ministry and the government. It would interest them because it’s a more cost-effective means, and it’s a more comfortable means. If you have mobility issues, how hard is it to get to see your primary care practitioner? How much effort does it take to really get your care needs taken care of?

There have been attempts to connect patients using technology across other jurisdictions, as well, in North America and the world. But more and more, this will be your primary care clinician.

R. Liu: We’ve identified that B.C. doesn’t currently have a specific guiding body, a council per se, to provide direction on not only health care but on how to integrate technology, innovation and health care together and how we can move forward to not only reduce costs to the system but to improve the effectiveness and quality of that care.

Like Aaron just alluded to, we are moving more towards a technology-based solution in many different other sectors, and we believe that health care shouldn’t be excluded from that. But we do believe that there is a lot of work to be done in terms of putting together a council and putting together a group that is both expert in bringing that to front-line care as well as integrating that technology and innovation together.

A. Sihota: We all know that innovation is a key driver of economic growth, and we want to continue along that pathway. We want to attract some of the best minds to conduct their business in British Columbia. We want to attract their business and bring it here to our province so that we can create job opportunities for citizens. At the end of the day, the beneficiaries are the public and British Columbians, so it’s a no-brainer that investing in innovation is a key component to ensuring the viability and success of not only health care but other industries across the province.

That kind of leads us to our next slide about the B.C. Innovation Council, which I’m sure all of you are aware of.

R. Liu: In our research, we found that the BCIC’s main mandate is to advance commercialization through a focus to support start-up companies, to integrate technology and to bring a better use of that to different sectors. In our research…. This council has partners in many different sectors, but health care is actually missing from that. That’s something that we’ve identified as an opportunity for us.

A. Sihota: We have everything from natural gas, agrifoods, international education, tourism, technology,
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transportation, mining and forestry — very important sectors in a province to make sure that we’re maintaining growth and viability of everything. But surprisingly, health is not part of the agenda. We looked a little bit, did some research and saw who’s kind of sitting as part of this body and council. We find that there are individuals from finance, business, the community, marketing, geography and not health care.

We see this more as an opportunity to add a ninth sector, a very critical sector. As Robson mentioned, over 40 percent of our budget is spent on health, so there should be an absolute emphasis on this area.

R. Liu: Perhaps we’re a little biased, but we think health care is pretty important.

A. Sihota: A little bit — yeah.

R. Liu: So we’ve tried to look to other provinces and other forms of government that have been able to put something together like this. We find that Ontario has something very compelling. They’ve taken and put together an Ontario Health Innovation Council. I’m not sure if everybody is familiar with that. In a nutshell, they have put together different leaders in the health care sector — being industry, government, front-line clinicians, faculty, academia — to put together recommendations on how they can improve the effectiveness of their health care system as well as reducing the cost of it.

[1110]

They facilitate technological innovations. They also use the purchasing power of the province. They make recommendations on that, as a council, and also on expanding the adoption of innovative new technologies and bringing together…. Not only trying to reduce, per se, our health care system costs but how to bring value to that. How do we not only reduce the costs of a hospital admission but reduce hospital admissions altogether?

They facilitate technological innovations. They also use the purchasing power of the province. They make recommendations on that, as a council, and also on expanding the adoption of innovative new technologies and bringing together…. Not only trying to reduce, per se, our health care system costs but how to bring value to that. How do we not only reduce the costs of a hospital admission but reduce hospital admissions altogether?

A. Sihota: Exactly. There’s more of a push across the health disciplines to focus on outcome-based care rather than volume-based care. We see that shift as front-line clinicians. More and more patients are being educated in the pre-diabetes state, before they actually get diabetes. What’s the impact of lifestyle and food and exercise, which can be just as important as medication in terms of managing their chronic medical conditions? It’s a big burden and a big cost to our province and society, especially managing chronic medical conditions in today’s world.

You guys are probably also interested in where, currently, this OHIC is at. It’s great you’ve created this council, probably invested a bit of money in doing that too. But are there any outcomes?

This council was struck in 2013, and they made a report. I would highly recommend you google or search this report when you get a chance. It’s called The Catalyst. So if you google “OHIC catalyst.” An amazing report that breaks down recommendations by this council, which was established as a broad, multidisciplinary council of health and other stakeholders. All the recommendations were accepted by the provincial government of Ontario.

What materialized out of that was something called the Office of the Chief Health Innovation Strategist in September 2015. This office works now on behalf of innovators to remove barriers and improve access to Ontario’s health care system and also to support made-in-Ontario solutions and really support pilots, accelerate and commercialize them, so they become viable economic ventures. Basically, it’s all about improving patient quality of life.

Also, health care procurement. As Robson mentioned, when you’re purchasing on a large scale, especially in the health care system, whether it be MRI machines, etc., there should be some systematic and coordinated way of doing that to ensure that you’re not only getting the cheapest price but that it’s value and that it will actually improve the outcomes of patients.

Just a few other things that came out of this office. They’re also looking at…. What interested me, as well, is how you enhance aboriginal health by advancing digital health care. That was one of the key priorities that they focused on — providing better care closer to home. So enabling clinicians to connect with patients via virtual, mobile and digital health technologies. As you mention, it’s going to be a large part of health care, as we know. Again, really focusing on the value-based procurement strategy that allows for value-based acquisition of equipment and medical supplies.

B.C. is supporting a very health innovative–focused ecosystem within the province so that there’s a network of innovators that can connect. It’s almost a form of mentorship, as well, because they can help support the next generation of ventures that come out of the province.

R. Liu: Another thing that came out of the council was the establishment of a health technologies fund, which is active right now. It’s a $20 million fund. It’s just, basically: how can they use this to accelerate any adoption of innovative technologies that are able to really improve the health care system, either reducing costs or improving quality? That’s just something that we’ve found as well.

A. Sihota: I just want to touch a little bit on positive disruption. You guys have probably heard this term — proactive disruption, positive disruption. It’s taking place across a multitude of sectors. Good examples are Uber
[ Page 483 ]
and Airbnb and so on. It’s always that the regulatory environment falls behind the innovation.

This disruption is happening in a positive way in health care. As we mentioned, care is taking place in different areas and in different means. Companies, at least in the private sector, have set up these innovation labs. I’m not sure if you’ve heard of this concept. How many people have heard of an innovation lab before? Okay. A few. They’re basically hubs that seek to disrupt their own internal work flow and business models before an outside force comes and disrupts them. There’s a threat. You might have a start-up with a couple of kids in a garage. That might be actually a threat to your company.

[1115]

I don’t know if you’re aware, but TD Bank actually has its own innovation lab, believe it or not. The banking sector is vulnerable just as much as any other sector towards these disruptive forces. But it’s the thinking that goes along with it.

At UBC, for example, they’re teaching entrepreneurship now. There’s a formal program at the Robert H. Lee Alumni Centre. It’s called entrepreneurship@UBC. They’re actually teaching you how to be an entrepreneur and what concepts are involved, what the lean method is involved in.

It’s just the recognition and focus that, as we move forward, this will be an important part of every industry and that it should be ingrained within our students, from the elementary years to higher education. It will continue to be a key emerging theme.

R. Liu: As health care evolves in Canada, in B.C…. Demographics change. People use technology differently. They’re used to interacting with their clinician differently or with various aspects of the health care system. We need to evolve as we well. Chronic disease management and being able to move towards a more effective technology-based solution, I think, is the solution to really reducing our costs as well as improving our quality.

A. Sihota: You guys are probably thinking about something called the #BCTECH strategy document. We want to look at how this can all synergize with what’s going on. We took this verbatim from the document. It’s great to see the Ministry of Health has begun a process to explore how industry can collaborate better with health innovation and increase the productivity of the health care system. As I mentioned, we’ve seen this across other sectors.

This document was released in January 2016. It’s good that there’s a recognition from the ministry that technology and health need to go hand in hand.

These are some good examples of collaborative environments that basically emulate what we talk about: the Michael Smith Foundation; the Centre for Health Innovation and Improvement; and the CDRD, which is the Centre for Drug Research and Development. When you get a chance, I encourage you to look and see what kinds of stakeholders are collaborating with each other and what kinds of outcomes they’re achieving. It’s quite amazing to see what’s going on.

R. Liu: This is word for word from the #BCTECH strategy as well: “Establish a working group involving the Ministry of Health…to develop policy, strategies….” It’s to integrate innovations into the health care system and improve our health care system itself.

We believe what we are presenting here as a solution augments that and integrates with that and supplements the values of what was just recently put forth by the provincial government. This is something that we can put together to supplement that.

A. Sihota: We can always do better, and I think that there’s no better time than now. We’re going to talk a little bit about our primary recommendations. One of them is that we need this body up and running as soon as possible. We can’t wait any longer. We’re competing with other jurisdictions and neighbouring provinces, and they already seem to be a few steps ahead of the game when it comes to this area.

We established three points that we’d like to highlight to the committee today. First of all is: establishing a B.C. health innovation council type of body. We know the tech strategy document outlines this working group, which is great. We just need to accelerate it so that it’s there and it’s ready to go and we’re working on collaborating amongst the different sectors with Health.

Another option is — and this may be an easier one, we think — including health care as one of the sectors in the BCIC mandate. That’s a simple step that can be done within the next few months. And add the stakeholders as part of that advisory group from Health. That would be the quickest way. Then we can always work towards establishing a full-on council.

Third is that we really, really highly recommend ensuring that you have front-line clinicians, primary care clinicians, as part of any advisory group that you create with regards to health and innovation. Sometimes we find that there are industry representatives and those who are a bit removed from the primary care environment, removed from patients. They also have a different perspective.

Naturally, we all know that. But, especially as recent grads and young practitioners, I think that we have a bit of a different take on how patients are taken care of today, what their needs are and where we can bridge their needs and unmet needs and really prioritize the marrying of technology and health as part of the #BCTECH strategy.

[1120]

It’s more of a sense of urgency than anything. These are three solutions that we are proposing to you, this committee, and we hope that there will be some follow-up and that maybe in a few months we can come back and
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talk to you. We’re happy to help you guys, as well, in ensuring that something like this is implemented. Any way we can assist, more than happy to.

L. Larson (Chair): Thank you.

Questions? Judy, I’ll let you go first this time.

J. Darcy (Deputy Chair): A wonderful presentation. If you were running health care in British Columbia, what would you identify as, say, two or three priority areas where we need to advance innovation in health care?

A. Sihota: One, I think, starting off, is patients these days are bringing in their own health data. More and more you have these Fitbits; you have smartphones. They record things like blood glucose levels, your heart rate, sleep cycles. You bring it to your clinician — let’s say, for example, a physician — and you want to include it as part of the EMR, as part of the repository of health history.

They still need someone to type it up and put it on there and upload it. There’s such a gap in terms of syncing everything. There’s not a good sort of syncing of the EMR systems we have today. That’s a huge problem.

When a patient comes to the pharmacy — I’ll give you an example — we have to really suss out what the diagnosis is. You know, you have a prescription written for something; it can be for five different things. So you have to ask the right questions, etc. But it would be great if we could see the charting notes of the prescriber, as part of that process. It’s really about sharing the information and knowledge.

To tell you the truth, we see the patient probably more often in between visits than someone like a GP, so we have an opportunity to document follow-up. I think it would benefit the GP as well, because they’d have it ready to go and right in front of them. It’s that shared communication between the patient, the clinician, the system. It is a challenge in terms of coordination, but that’s one area that definitely, if I was running that portfolio, I’d be interested in focusing on.

D. Bing: Thanks for coming. I really appreciated your enthusiasm and your passion for this. I was just thinking, though, when you were saying that we should add health care to the B.C. Innovation Council, I wondered if we shouldn’t just bypass that and go straight to the B.C. health innovation council.

A. Sihota: Even better, if you can get it done. When the initial submission was made about a year and a half ago, I think that’s what we called it: the B.C. health innovation council. Absolutely, if you ranked priorities, that would be the first. It just takes, I’m sure, more logistics and more work to establish a body with its own mandate, rather than adding on to the current, existing infrastructure. But yeah, that would be great, just part of the tech strategy.

J. Shin: Thank you for your presentation. I really enjoyed it. I was wondering if you could speak to one aspect that did catch my attention, which is that the global market for the medical devices is about $440 billion in the next few years. As far as the efforts to accelerate this shift for strategic value-based procurement, for example, I was wondering if you know of any quantitative studies or analyses as far as how far B.C. may be lagging behind — or what the cost to our public treasury looks like, just even on that front.

A. Sihota: That’s a great question. I can’t really speak to that. I’m not aware of how far, quantitatively, we are.

Keep in mind, I think, that government has a role in regulating some of this whole environment. Digital health is a fairly new concept. Studies are being done as to what kinds of outcomes patients experience by using the iPhone or smartphone to track their health data. They’re trying to quantify: “Okay, this intervention is made. What’s the outcome?” We’re still at the phase of studying that whole area. I think more and more studies will be emerging with regard to this.

But it’s a great question. As you can see, I think, Ontario is really on the ball game — at least within Canada, we found. They’re quite ahead with their infrastructure. They set up that $20 million fund. I know we have a $100 million tech fund, but again, that’s tech for everything. They’ve established a dedicated $20 million health technologies fund — as a means of comparison.

L. Larson (Chair): Thank you. I think that’s it for questions. Amazing work that you’ve done.

Did I miss somebody?

J. Shin: Do we have a bit more time for one more question?

L. Larson (Chair): One more, okay.

[1125]

J. Shin: This is not just specific to the facts that you presented today. As health care practitioners, you’re all aware of the cultural shift among the health care providers who want to see a holistic approach for patient care as opposed to each practitioner coming out of school and setting up their own shop, so to speak. It’s about working together as a part of a team and putting the patient at the centre as opposed to our constant, incidental reactive ways of looking at diseases and treating symptoms as they appear.

On that front, as health care professionals, could you just comment a little bit on the interdisciplinary approach that has been a constant subject that’s come up on these public hearings and beyond? If you can give us your thoughts on it.

R. Liu: As we go throughout our training…. We just recently graduated a few years ago. There was quite a lot
[ Page 485 ]
of emphasis on trying to, at least, get the faculties to talk to each other and just sit on different case studies together and just try to present together. “Hey, like, this is what we think of from medicine. This is what we think of from physios, what we think of from pharmacy,” all from the patient-centred approach.

It is a cultural shift. I find in practice, it depends who you’re talking to. It depends on the actual connection. There is a generational divide, you know, between practising physicians and pharmacists. Even in older generations, they’re not used to that. They weren’t trained that way. For us, we definitely invite and accept that, based on our training. I think that, sitting here in front of everyone, we would definitely say that this is a big, big opportunity.

We can say this all we want, and we can try to bridge our little islands together, but we are on islands, you know. There isn’t a good way that we actually integrate together unless we really do work in the same building, on the same team, in the same hospital, little team that they have. There’s just no set form of communication that we can just see everything.

How many times have we practised where we wish we had the lab values in front of us? We wish we had…. The patient comes to us. We’re only dealing with what the patient is actually telling us, but we know that there’s all this data and records and all that stuff just buried somewhere that we just have no access to.

A. Sihota: One more comment. It comes down to: on paper it looks good; in practice, it’s a lot different. There are new, emerging models of care. That’s one thing, and then the reimbursem*nt is the other thing. I’m sure you guys are very well aware of how we reimburse our clinicians across the province.

Then there are scopes of practice. I know, for example, our college thinks about submitting something about certified pharmacists prescribing. Some are saying that’s already in place in Alberta. Pharmacists there can prescribe for every drug except schedule narcotics. That’s quite big, if you get the training.

There are opportunities in terms of scope. Then there will be overlap. I mean, there will be people who will be against it, absolutely. Again, at the end of the day, it’s: what’s the best interest of the patient?

There’s also, I think, an onus on the public, too, to demand care. When someone complains and says, “I can’t get in to see my clinician” or “Why can’t you do this for me? Can’t you just prescribe this for me?” I think there should be a concerted effort amongst them to advocate to the biggest payer — which is, right now, the provincial government for at least our industry — to do that so that you guys recognize that there’s a need.

There are huge problems. We can almost have a full-day long session, and you guys have heard so many people. There’s so much opportunity at the same time. Health care I don’t see as really cutting costs. It’s more about creating efficiencies with what you have. You’re not going to go from 42 percent to 15 percent overnight or anything like that. It’s more about maximizing what you have.

L. Larson (Chair): Thank you.

Donna, last comment, because we’re out of time.

D. Barnett: I just have one question.

Thank you for your presentation. Have you had the opportunity to make this presentation to the ministry or any of the ministry staff?

R. Liu: This is actually the first time that we’ve presented anything of this kind.

A. Sihota: We’re pretty excited to be here. Thanks for the opportunity, but we would be happy to and would love to engage with the ministry on this. I think it just presents sort of a younger generation of that perspective.

D. Barnett: Have you made the request to the ministry yet?

A. Sihota: No, you can maybe help guide us in that.

R. Liu: We’re actually not sure what that would look like.

D. Barnett: We would be very happy to try and guide you there.

L. Larson (Chair): We will do that. Thank you very much for being here and for your presentation. We really appreciated it. Very interesting and some great ideas, so thank you.

[1130]

Can I invite Dr. Newton and Toby to the table please?

All right. We are right on time. I welcome you to the committee this morning, from the British Columbia College of Family Physicians, and ask you to just go ahead with your presentation. We have 15 minutes for your presentation and 15 minutes for questions, depending on the time.

Please go ahead.

C. Newton: Thank you inviting us to present. I am Christie Newton. I am the president of the B.C. College of Family Physicians. With me is Ms. Toby Kirshin, the executive director of the College of Family Physicians in B.C.

As you are aware, the B.C. College of Family Physicians is the provincial chapter of the College of Family Physicians of Canada. We are the home of family medicine in the province. We represent just over 4,600 family physician members.

The organization is responsible for setting the standards for training, certification and accreditation in family medicine. Our mandate is to support family phys-
[ Page 486 ]
icians in providing the highest quality of patient care through practice improvement and continuing professional development, and for advocating for the patient’s medical home model of care — patient-centred, team-based family medicine.

Our recommendations will address the standing committee’s queries regarding team-based care implementation and sustainability in British Columbia. The presentation will focus on the patient’s medical home. We will really look at how the pillars of the model support family physicians in providing the highest quality of care, optimize working conditions to support recruitment and retention, and enable primary and community care efficiencies through supporting collaborative interprofessional teams.

Our vision for the patient’s medical home in British Columbia is that every British Columbian will have timely access to team-based, patient-centred, comprehensive, coordinated continuous care within a family practice that serves as their medical home.

[1135]

Family physicians and other health care providers, patients and the community, if engaged in the patient’s medical home model, can achieve improved health outcomes across the province.

I expect many of you are familiar with the patient’s medical home model. I’m just going to briefly touch on this slide, partly to make sure that we are thinking of the same model and the ten pillars but also to clarify.

I really don’t like this diagram. The pillars look rigid, and the model was actually designed to be flexible. Any one of those attributes can be introduced at any time in any combination. It was designed, nationally, to be flexible, to ensure that it could accommodate provincial and local priorities, care needs and resources, recognizing that all pillars, in that order…. One may not be able to introduce them, so it’s sequential based on priorities and needs.

Over the past decade or so, several medical home models have been introduced across Canada. Some have had variable uptake, and some have been integrated provincewide. The benefit for British Columbia is that over the past decade, we have collected a lot of data on how these models have been implemented — what the challenges are and what the successes are.

As recently as this week, there was a report released from Alberta on the challenges they faced with the primary care networks. We can use that information to support implementation and rollout of the medical home model in British Columbia.

The evidence that we have collected does show that the patient’s medical home model improves timely access. It does enhance comprehensive and coordinated care. It allows teams to shift from just dealing with disease to looking at health promotion and illness prevention. And it provides value for money.

This is based not only on national work but also on international work, such as that of Starfield, that health care quality follows a bell curve. Health care costs follow a bell curve. Those bell curves do not align, but there is a sweet spot. It turns out the patient’s medical home model fits and hits that sweet spot.

The other thing that we have learned, in addition to providing all of these things and supporting all of these things, is that the medical home model needs to be flexible and needs-driven. The design, implementation and composition of the team must be determined by the health care providers and services in a community and the patient and community needs.

How does this align with what’s happening in British Columbia right now? Well, in the spring, the government released its policy paper on primary care homes, what they’ve described as integrated systems of primary care based, in part, on establishing formal linkages between family practices and community care services. The aim, of course, is to better meet the needs of patients and communities through improved communication and coordination of care providers.

The BCCFP suggests that the expected efficiencies of the primary care homes will only be achieved by ensuring that those family practices are also adequately resourced to implement the pillars of the patient’s medical home. Our view of success would be something like this: clusters of patient medical homes connected and linked to community services within a primary care home.

How are we going to get there? We believe that there are five areas that we need to work on. The first and foremost is team-based care. To support team-based care are the remaining four: continuing education, infrastructure review, remuneration review and flexibility in implementation and composition. I’ll just go through each of those briefly.

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Results from our member survey last year and the GPSC visioning exercise clearly demonstrated that the family physicians of the province are interested and looking for team-based care opportunities.

This was further reinforced recently by the family medicine longitudinal survey. This is a survey given to residents as they enter a residency and as they exit residency. The most recent one on exit shows that over 87 percent of our new grads want to practise in team-based models of care. As we’ve already established, team-based models of care can support all of these things. I won’t dwell on that.

How do we support our teams in the community? That is really what the standing committee was looking at.

Continuing education. As the organization that sets the standards for education, we have expertise in this area. Continuing education must be multimodal. It must be local. It must be team-oriented. It must go beyond just looking at and supporting clinical collaborative practice.
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It needs to also support skills and knowledge in team processes, like collaborative communication, conflict management and rural overlap negotiation, which we just heard mentioned. We need to look at team-based practice improvement, in addition to quality improvement. In particular, experience internationally shows that we need to also provide education on change management.

The current practitioners — as we’ve also just heard — have not trained in the collaborative care model. They have trained in a siloed model, and when they get into practice, they fall back into what they’ve been trained in. Now, as director of interprofessional education for the faculty of medicine at UBC, I know that our new grads are trained in the collaborative care model. However, they are entering a world of siloed practice. Continuing education will be key but not just on clinical content.

Infrastructure. The majority of practices across the province have not been designed to support or accommodate teams of health care providers. We’ll have to take a look at what space we have and provide resources to redesign some of those or to relocate to ensure that these teams can properly collaborate. Similarly, the community services have not been organized in an integrated way for the primary care homes. Resources will also have to be directed towards aligning those and supporting communication.

This is where we get into virtual or technology support. Electronic medical records have not been introduced in an integrated way. There are several EMRs across the province — in community and in acute — and there is very poor interfacing ability. We need to look at that and how we might be able to support that with what we’ve already implemented.

What’s interesting is that the literature also shows that health care professionals do not use EMRs in the same way. A health care professional…. Each discipline accesses and enters data into different fields in the same EMR. So when they report on a patient, they report from what they look at and what they see, which ends up having gaps in communication and information — patient care gaps. We need to look at, again, education and training for EMR use as a team to ensure that those gaps are addressed or to at least acknowledge that there is the potential for gaps.

Remuneration models. Should I say: “Enough said”?

L. Larson (Chair): Yes, we’ve heard this one.

C. Newton: Teams need to be supported to engage in continuing education and practice redesign, in addition to direct patient care.

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As you know, nationally, we’ve produced a remuneration guide for the patients medical home. Nationally, we continue to evaluate the different models that have been implemented, and further guides are being developed. I believe there was one released today. As the organization that sits on the national patients medical home steering committee, we are able to translate new information and these particular guides into the local or provincial context.

Flexibility. Again, I’ve mentioned this. However, we have tried introducing team-based care models in the province before. When they placed a chronic disease nurse in my practice a while ago, I was involved in one of the earlier integrated health networks. There are collaborative services committees. There is attachment. There is GP for Me. All of these — but fairly fixed. Again, there needs to be flexibility.

I know you’ve heard presentations today from dentistry, from the Justice Institute or the paramedical group, from pharmacy. All of these are great collaborative projects. If there’s enough flexibility in a patients medical home model, then these can all be integrated, because they will address specific local needs.

In summary, through robust provincial and regional support, we believe every family practice can become a patient’s medical home. We believe that they can offer timely access to patient-centred, comprehensive, coordinated, continuing, team-based care, with family physicians integrated into supportive, collaborative teams and those patients medical homes then connected to the community services and integrated in the primary care homes.

But success will depend on leadership, public engagement and resources. All stakeholders, government, all professions, administrators and managers and the public need to not only buy in to system change; they need to co-own it.

L. Larson (Chair): Thank you very much. It’s so great to hear, from your particular background and who you represent, that this model that we’ve been looking at and talking about all over the province is one that is totally supported by the family physicians.

The only comment I might make before I ask for other questions is that obviously, if you’re looking at a team and this type of situation in an urban versus extreme rural, that’s where you can see where part of that team would be the paramedics, because we don’t have all those other entities with ready access. So the teams will look quite different based on what the availability in any one community is — if the community has only got a population of 1,000 people or less versus 50,000 people.

C. Newton: And that’s that flexibility piece.

L. Larson (Chair): That’s the flexibility part.

C. Newton: The needs of the community and what services…. You need to do a survey of what services are there. You need to do a survey of what the needs of the physician patient panel are. Then, with the expertise of
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that family physician being undifferentiated and complex, what other services are needed to support and fill out, to address those specific needs, as you say?

We tried not to emphasize the rural piece. We recognize that one or the other…. However, in early implementation, if we’re looking at pilots for success, rural communities are the ideal spot to start them.

L. Larson (Chair): They’re controlled.

C. Newton: Yes. It’s not that teams do not work in urban centres. As you shift from successful pilots in rural to urban, you want to then start to look at specific populations and then to the general family practice or primary care communities.

L. Larson (Chair): We have had presentations from a few healthy community coalition groups that have come from small communities of citizens — which is, again, part of your overall thing — who identified what the shortages or what the resource needs were in their communities as they connected to the family physician, etc. So I think there are a lot of people on the same track.

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J. Darcy (Deputy Chair): Thank you for a wonderful presentation. You’re really, really comprehensive. You answered a lot of questions and also provoked a number.

You just mentioned, briefly, remuneration, but I suspect — well, I know — that there are different models, as you’ve said. We need flexibility. There are different models of delivering, implementing, primary medical home…. You’ve referred to what exists in different provinces, right?

We’ve got fee-for-service, surrounded by a team, which I think is the family health team in Ontario. We have community health centres and other forms of alternate payment plan, and we have capitation. I wonder if you could comment. I think we’re most familiar with fee-for-service, of course, because that’s the most common. Could you explain how fee-for-service works with a team and also what those other models are, for the sake of the committee?

C. Newton: In general, fee-for-service doesn’t work with a team. The GPSC has tried to support team-based care through the fee-for-service model incentives — so looking at complex care, frail elderly, chronic disease — providing additional fees to support that in the hopes that family physicians will then hire other health professionals to support their care. Those that have, have actually been very successful. The money up front results in significant improved efficiencies in care that then pay for themselves. It’s difficult to get that aha moment with many family physicians.

We do think, in looking at remuneration, that the incentives need to be re-evaluated. They may not need to be directed at clinical issues but at incentives for providing full scope or comprehensive or timely access. How are you going to do that? Incentivizing the things that support the patient’s medical home model, as opposed to diabetes care or congestive heart failure — again, frail elderly…. So looking at the incentives if you’re going to stick with fee-for-service.

We know the most successful models are actually blended models. Interestingly, that longitudinal survey that I referenced, from the residents, shows that over 83 percent want to enter into a blended service model. They want the opportunity to pay off their debts, working their butts off with some fee-for-service. However, they also want the stability of that sort of additional support to allow them to provide the care that they are now being trained to do.

Does that help?

J. Darcy (Deputy Chair): I do think that it would be important for the committee to understand alternate payment plan. What does blended mean, what does alternate payment plan mean, and what does capitation mean? There are different models of doing this.

C. Newton: I work in a blended clinic at UBC, where the ministry provides us a block of funds annually to provide services to a set number of patients. What’s interesting is that that block of funds has not changed over the past decade, yet the number of patients I see has moved from 600 to 4,500-plus.

We are also blended in that I am a faculty member, so I have a faculty salary as well. That supports some of our clinicians within the clinic to support their teaching. We have a pharmacist who is a faculty member, who is also supported to do that. We have a midwife who is a faculty member. That’s blended.

Many of the clinicians in our clinic, because we are a teaching clinic, are fee-for-service model as well. That also supports us in maintaining a level of care but also maintaining some teaching in the fee-for-service model. Although we’re optimistic that that will change, we still think that our trainees need to learn about the fee-for-service model.

There was primary care reform, I believe, almost two decades ago. Some practices in the province were identified.

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One of our sister practices at UBC was rostered. So their patients, if they see the physician within that clinic three times…. They will receive a certain fee for that patient for the year to continue to provide 24-7. Again, both clinics are required to provide shadow billing to ensure that we’re providing the services.

There is a practice in Langley — again a primary care reform practice and again a different alternate payment model. I’m not even sure of the details of that. So there are a variety of options.
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We do have, fortunately, the ability to look across and see. For example, Ontario did not introduce the ideal fee-for-service model or blended model in that their panel did not look at complexity of their patients. Panels were filled with healthy patients, leaving the complex ones without family physicians and not on a panel.

So there are issues, and we are able to learn and look at how we could improve that if we consider this for British Columbia.

M. Dalton: Thank you very much for coming and making the presentation. I appreciate it.

Just wondering, from your lens, what have been the big trends or the changes for GPs over the past, say, couple of decades? What can you highlight, say, in the past ten, 20 years? Sometimes we get the sense that there’s real rigidity. Maybe that’s more with the fee-for structure. But have there been some big changes, and where do you see it going?

C. Newton: Well, I’m going to talk about the drivers for those changes, and that is the complexity of the patients. They’re living longer. They’re getting more things. They’re more difficult. It used to be that a family physician could remember all of the things that they needed to, to manage patient care. Now we can’t.

Not only that. Knowledge — exponential increase, new diagnostic tasks, new treatments, new subspecialities. It’s no longer ophthalmology. It’s retinal ophthalmology. Then it’s neuro-ophthalmology. I used to say: “Send them to the eye specialist.” But now you have to be very specific. So that complexity of the system and the patient has driven us to say: “We need help.”

We need to develop these relationships with our colleagues, learn about their expertise, so that we can make appropriate referrals and optimize the care.

There are systems…. What else has changed? There is a Shared Care Committee which has been very valuable. We talk about interprofessional, but there are also intraprofessional issues, where often the patient gets lost. We refer to a specialist, and then we never know exactly what happens. So that Shared Care Committee is working on improved communication. We have seen that.

What other changes have we seen? We are being supported, to some extent, with our incentives, to provide care, to move from the eight-minute visits to cover our overhead to provide the 15-minute visits — again, to manage somewhat more complex patients. But as I say, to manage that complexity, I think we need to go even further.

D. Barnett: I have a question. Who should take the lead in assisting to put these types of models together, the team-based model? Should it be the health authorities? Should it be the division of family practice? Who needs to take the leadership role?

C. Newton: I’m going to say that it should be a collaborative leadership. As I said at the very end, all stakeholders need to co-own the change.

Different communities will have different natural leaders. There may be a community that requires the health authority administrative lead to bring people together.

Fort St. John was an example where I don’t think the family physicians were aligned well enough, and somebody else needed to take that leadership. I think it’s going to be community dependent. But I do believe that all of the stakeholders need to co-own it and then, with flexibility of the model, look at the community needs and say: “Maybe it is the division in that need.”

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I was on the original board of the Vancouver Division of Family Practice. It now has reached over 1,000 members. Aligning those 1,000 members and taking the leadership of organizing teams I don’t think will happen. Again, that division — not a good choice.

However, the division in Kamloops, for example, has a very strong leadership, and it could be the leadership of that particular change model.

L. Larson (Chair): Sue, last question.

S. Hammell: We had a presentation, not this time but the previous time when we were out, where one of our presenters talked about the fact that doctors were working at about 18 percent of their scope; they were focused largely on the more simple tasks.

I know from experience that sometimes when I’ve gone in to a doctor, my doctor, particularly if it’s something about renewing a prescription or something that isn’t major — I’m just worried about something — I could see a nurse or a nurse practitioner. So in this team-based concept, do you actually see people working more to the high end of their scope rather than a doctor doing something that a nurse could do or even…?

C. Newton: Exactly.

S. Hammell: Do you see that as, in the long run, just being incredibly cost-effective? I do think…. We had a presentation yesterday where the person talked about the system breaking under the weight of what we’re doing now and that there is some kind of imperative that we do move into a different model.

C. Newton: There are many ways to address that. First of all, we call a patient in to renew a prescription because we need that eight-minute visit to bill the fee-for-service and cover our overhead. We have about 40 percent overhead. So yes, if a nurse was supported in providing that care, we would not need to.

More importantly, based on the presentation I think you just had, there is an expansion in the scope of phar-
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macists. They can renew medications, and they’re asking to actually prescribe medications.

Going to the most appropriate provider for what you need — that way, you could get your prescription renewal. But you just said you were worried about something. I would be happy to sit down and talk to you about what you’re actually worried about and not focus on: “Oh, here’s your prescription. Thank you very much. See you next time.”

Supporting, in different ways, people to work to full scope will provide cost savings. It will also…. We talk about recruitment and retention issues. There are huge recruitment and retention…. That is because we’re not fulfilled in what we do.

We do not enjoy prescription writing. We do not enjoy those menial things and wasting people’s time. We know you’re working people, and you don’t need to take time off to come and get a prescription renewal. The system could be much better.

But we need to ensure that the communication from the pharmacist who renews that prescription and perhaps says, “You know, you may need an adjustment,” comes back to us so that when you come in to talk to me about your worry, I can say: “You know what? The pharmacist also called me and said you got this renewed. Should we be considering a change in that?”

Many changes are required. But yes. I’d be much more satisfied in my job, which means I’m likely to stay. And pharmacists are likely to stay, and the nurse who feels a part of the team and engaged in care is more likely to stay.

L. Larson (Chair): Thank you so much for being here this morning and for speaking to us. You’ve talked to things that we have been hearing all week in a very practical, pragmatic way. We will take everything you say to heart.

C. Newton: We have submitted a written report to summarize.

L. Larson (Chair): Yes, perfect. Thank you for being here.

We will go off air now.

The committee recessed from 12:04 p.m. to 12:58 p.m.

[L. Larson in the chair.]

L. Larson (Chair): Good afternoon. I’d like to welcome the Association of Registered Nurses of British Columbia and their spokespeople today — Joy, Patrick and Andrea.

Welcome to the committee. We have a 15-minute time slot for you to present, and then some time for the committee to question.

Just leap right in.

A. Burton: I will so do.

Thank you for having us back. It’s really great to be here. Trying to fit 15 minutes into 15 minutes — everything that we wanted to talk about — was a bit of a challenge. I think you can probably anticipate we may submit something written by the end of the month as well.

I also just wanted to mention that we have a student with us today, Katherine Villegas. Katherine’s last day of school is tomorrow at Kwantlen. She is a nursing student. She has been interning with us. So exciting to have her here.

I am going to jump right into it and tell you a little bit about some things that have been going on in nursing for the last year and a bit and give you some sense of some of the things that we’re thinking about.

[1300]

To start off, I wanted to mention the B.C. Coalition of Nursing Associations. I know I mentioned it last year, but since then, we’ve actually formalized, under the Society Act, and signed an MOU. That is the four nursing professional organizations that represent registered nurses, registered psychiatric nurses, licensed practical nurses and nurse practitioners, as well as the educators.

As far as we know, it’s probably the first time in Canada, maybe even in the world, that nurses have come together with one voice specifically to say: “We have to work together across our different disciplines. We have to bring a cohesive voice to government, to discussions with health authorities and to everything else that we do.” That’s been formalized.

We’ve signed an MOU between the five organizations on how we’re going to work together. I have to say it’s interesting, because you always hear about the silos in health care and the barriers, and of course we ran into that when we were putting the coalition together. So I think it’s a really powerful testimony to the nursing group that we’ve actually overcome all that and got to a place where we are one cohesive voice.

Some of you who were at our Leg. day and maybe had a teddy bear and a little note to us…. If you’ve seen the video…. It’s on our website. Some of the things we’ve done are that, but we’ve actually done some policy work.

The first thing that the coalition decided to work on was trying to convince the world that we need to have one nursing college in the province, not three. Right now there are three nursing colleges. Really, the problems that causes for the profession are fairly significant in terms of not having alignment with standards and conditions and guidelines and that sort of thing.

The coalition really advocated strongly with government, with the ministry and with the colleges to move towards that. Not entirely because of us, by any stretch, but that has been announced by the registrars as something that they are doing and they are moving towards. We’re pretty happy about that. We recognized some real benefits that will happen for both patients and for nursing.
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Consistency around standards and guidelines is absolutely huge. You hear that in the news when you hear people talking about the scope of practice overlap and who’s doing what and who’s replacing who. Hopefully, by having one consolidated college, we’ll start to manage to collaborate a bit on those things so that we’re not quite as much all over the place.

Obviously, there are savings when you bring three groups into one group. We’re hoping that there’ll be some realized actual economies of scale around that, which will be beneficial too. Also, just some consistency in terms of the committee so everyone doesn’t need to have a QA committee and a program and education and oversight and discipline committee. Pulling some of those together into one college will have an enormous impact on the profession.

As for patients, right now I don’t think most patients know, when a nurse walks in the room, if it’s an LPN or an RN. They just know it’s a nurse in front of them. Really, for patients, if they want to find a nurse right now, there are three different databases that they would have to search to find them. So stuff like that gets streamlined and gives them the opportunity to go to one place to find a nurse, and also if they have a complaint.

All of that has come together, and the coalition is really proud to have played even some role in that.

We also, as you know, have new nursing regulations that came out in December of last year. When they put out regulations, they give a 60-day consultation period. Previously, every nursing group would submit their own thoughts on the regulations. So they would get four, 20, 50 different responses, and they didn’t necessarily agree with each other.

What we did as a coalition is we sat down and actually talked through all of the regulation. What do we agree on as a group? What don’t we agree on? Can we come to consensus as a whole profession and then submit that to government and make their job a lot easier than trying to go to everybody? Government is thrilled with it. It’s worked really well. They keep telling us it’s about time. Now we have other provinces saying to us: “How do we replicate this?”

Part of the reason I wanted to share that is because the coalition itself, the very backbone of it, is the whole sense of intraprofessional. It’s taking the four different designations in B.C. and saying: “We actually can work together. Nursing can work across these boundaries and silos that have been built, and we can actually work effectively.” Multiprofessional, multidisciplinary teams, interprofessional, collaborative practice — all of those things have been around for decades and decades. It’s part of the health care discourse.

I thought I’d mention that in 2008, I had the privilege of being one of the co-authors for the World Health Organization’s framework on interprofessional education and collaborative practice. We went over to Geneva, and we were digging around in the archives. There’s a very small file at WHO because, to be honest with you, it’s not one of their top priorities when they have AIDS and other really urgent, pressing problems. But there is a small file, and what we discovered was that the same document, basically, had been written. Every 25 years or so, that same document was written.

What was happening and what is still continuing to happen is that governments get really interested in interprofessional and multidisciplinary, and they think: “Wow, this is a great way to transform the health care system. Let’s do it.” They dump a bunch of money. They write a bunch of policy.

[1305]

Usually, that money goes to the educators, because that’s really where you have to start with something like that. Educators can educate with, from and about, send everyone out into the world, and then they’ll practise that way. The problem is that they can’t practise that way when they get into practice. We’ve discovered that with segments and segments of students that come out of school and say: “I was ready to be interprofessional, but actually, I can’t practise like that.”

This is a cycle that we see, and then government says, “Well, why would we continue to fund this?” because you’re not actually changing the culture at St. Paul’s Hospital or at VGH. It’s flights here and there, and there are pilot projects, but how are you going to actually change the whole system?

It’s interesting, because we expect people to work in teams, but we don’t necessarily regulate them in teams. We don’t, as an association, work with them in teams. We need to start to change that dynamic too. I don’t think, to my knowledge, that there’s ever been a government that has turned to the professional associations anywhere and said: “You know what? These people are yours to deal with. You guys figure out how to be multiprofessional. You figure out how to make this work.”

That’s something that I think the coalition is starting to show that we can do, and we need to expand it beyond our group. Within that whole interprofessional thing, we do have a couple of areas that come to the top. I do want to say that nurse practitioners are at the top of our list for a profession that we have had in B.C. since 2005. It’s 2016, and we still don’t have a funding model that works and makes it so that nurse practitioners can work anywhere, everywhere that they’re needed. That’s something we desperately need.

You’re going to hear from the B.C. Nurse Practitioner Association. I know they’re going to put a submission in by the end of the month. We firmly support their perspective on this, which is that something needs to change. The farther away we get from 2005 without that in place, the harder it’s going to be to put into place. We need to have a really focused attempt to fix this. We’re ready to do that, and we’ve been trying to send that message to
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government, to say; “Listen, it’s time to sort this out, and we’re ready to step up to the plate and figure it out.”

It may be a very hybrid model; we don’t know, but we need to look at it. Really right now, I think most nurse practitioners would tell you we’re spinning our wheels a little bit in the province in terms of really making it so that they can practise here.

In our original submission, we talked about paramedics and the use of paramedics. We’ve also had some recent discussions with the Canadian Association of Physician Assistants. These are controversial conversations for nurses to have. Like any health profession, there’s a sense of protection, right? There’s a sense of: “That’s our job. We don’t want to share.” But we also realize that there are a lot of patients, and a lot of patients who have a lot of issues, and there’s enough trouble to go around for everyone.

Really, it’s time that as a profession, in the spirit of the interprofessional and the collaboration, we sit down with all of these professions and we have the respectful conversations. In terms of interprofessional, we’re trying to model that. If we can model that at the association level and start to really demonstrate that, maybe we can actually make some inroads into something beyond just the education sector, because education can only go so far.

When it comes to rural and remote, we have a very strong sense that there are some services that are really being eroded in rural health care. Believe me, we get it. It’s a lot. You’re never going to have a respiratory therapist and a brain surgeon in every little town across British Columbia. There is a need to centralize some of these things. The challenge with that is that it decreases the ability of the local health care providers to understand what to do when a situation arises that they’re not familiar with.

Maternity is a really good example. According to every government in the world and primary health care and world health organization, it is one of the basic tenets of primary health care. It’s something that every population needs. But babies don’t send you a notice to tell you when they’re going to be born or where or how or why. They just tend to show up, and they show up all over British Columbia — which is great, but when there are fewer births in rural communities, when people are being sent to the centre, the nurses are left wondering: do they actually have the skills? When they have no choice, do they have the skills to help the physicians and to help the midwives in delivering these babies?

There’s a gap there. Our nurses are identifying it, and they’re saying: “But there’s no way for us to fill that gap.” As a nurse, part of their responsibility is to know the courses that they need to take, the specialty education they need to take in order to get their skills to where they feel comfortable practising. That’s part of what CRNBC sets out in its standards. But for our nurses, there isn’t always funding for that.

So we’ve been working really hard, talking to governments and saying: “We actually need to fund nurses — to understand what their needs are, to know that they can go and get those met, that they can update their skills as needed and get back to their community and be able to do the job that they need to be able to do.”

Employers really vary significantly across the province in terms of what they’re willing to pay for. A lot of them offer packages: “You can take one of these four courses.” Sometimes that doesn’t fit the bill. I think yesterday you heard from the B.C. Transport Nurses, and they talked a little bit about that as well — that they see that as a real gap.

One of the things that we are doing right now is we’re setting up a policy table, at the request of government, around rural and remote health. That will, hopefully, give us an opportunity to bring some of the nursing issues forward that we hear constantly from our constituents about, what they feel is really missing around how they’re able to conduct their practice.

[1310]

When it comes to recovery models…. When we did our initial submission, we did talk quite a bit about that. We’ve actually sort of switched our perspective in the last little while to really focus on what we need to do around harm reduction, recognizing — and I think nurses recognize it — that it’s not always about recovering people. Sometimes you have to meet people where they’re at, and some people aren’t recovering yet. They still just need to be kept alive, and they need to be kept in the best health possible.

No one, I think, understands better than nurses the need for programs such as Insite. We were, I think, like everyone, dismayed — I guess would be the word — when Dr. Kendall felt that he had no choice but to declare a public health emergency around the fact that fentanyl has increased in our supply of heroin in the province and that there are subsequently quite a few deaths.

The response…. You know, naloxone is great, and the increasing of a database that can help respond to emergencies is also very important. I will say that, as the province who led the charge for supervised injection sites — as the only province that actually has had them for quite a long time — we were disappointed that there wasn’t more consideration put into what we need to do to expand that program.

We hear from nurses from all over the province — Nanaimo, Kamloops, Prince George — saying: “Why is it that supervised injection sites are only available in the Downtown Eastside? We have people who are drug addicts here, too, and we need that kind of help.”

One of the things that we’ve really been looking at in terms of harm reduction is how we can actually make a difference and start to advocate for some more of those things that will prevent people from actually dying, because you can’t get them into recovery unless you can
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keep them alive. That’s an important thing that we’re looking at: how we can really support the idea of more safe injection sites. There’s another word for it now, but you know what I mean.

The other thing that we are looking at is how to keep the prison population healthy, again recognizing that it’s controversial. They’re not putting things in their veins that are safe and sanctioned. They’re putting in contraband materials. At the same time, from a nursing perspective, there is a harm-reduction aspect to keeping people safe and healthy regardless of where they are, recognizing that they have an impact on each other.

Then the last piece on this that we’re really looking at right now is looking at education around transgender health. One of the things that we’re hearing a lot about is that health professionals don’t really know how to deal with the transgender population when they come in for health care services. It’s a pretty significant gap, and it’s something that’s becoming more and more relevant. We need people to be prepared and ready to manage that when it does come in front of them.

Those are sort of the main things around harm reduction.

How am I doing?

L. Larson (Chair): You’re doing great. It’s okay. You’ve got three minutes still to go.

A. Burton: If I was going to summarize the main things — and like I said, it feels hard to squish it all into such a short presentation — certainly the things that stick out to me, on the interprofessional scale….

It’s time to look at it from a different lens and stop just focusing on the academia. Even though that’s great and it needs to be there, I think you would find that most people would say that academia actually knows how to teach interprofessional. What we don’t know how to do is bridge the gap into practice, and that’s where we’re falling short. Great to have sites and pilot projects, but we actually need to figure out how to change the culture.

If I was government and I was smart, I would be asking the associations to take a role in this, because really when a person graduates from school, associations are the ones responsible, for the rest of their career, for helping in guiding them. That would be one thing that I would be saying: “Get everybody together in a room and fight it out.” That’s partly what has to happen.

Learn from that B.C. CMA experience. It was hard work. While where we’ve gotten is impressive and amazing, you will continue to hear one voice of nursing that you’ve never heard before, which really is saying to government: “We will never come with a problem unless we come with a solution.” We feel really strongly about that.

We need to find some options to support nurses in their continuing education, particularly the ones who are rural and remote and have no ability to access that unless they pay for it out of pocket. We need to give nurses the right to make their own decisions. Let’s just say that physicians get tons of funding, so we need to be able to figure out a way to get that extended to some of the other health professions. It’s really important that everyone has a chance to continue upgrading their skills.

Lastly, I would say for the committee, as important as we believe the recovery models are — and we do — is to add that element of harm reduction in, as much as you possibly can. As we walk through this and talk to people, we realize that that’s really where a lot of people are at. We have to meet them where they are, because just talking about recovery doesn’t necessarily cover everybody.

L. Larson (Chair): Thank you. That was amazing. Wow. Very good, and in that space of time, you’ve managed to tell us some pretty great things that you’ve been doing. I couldn’t agree with you more.

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As we go through this process about bringing all of the colleges together and getting on one plate, that has come up more than once. Glad that you’re in agreement with that as well.

J. Darcy (Deputy Chair): I want to ask you a question that goes back to some of the things you spoke about in your previous presentation. We’re now very focused on it, so it would be good to be refreshed on it.

We’ve been talking a lot about interdisciplinary teams in primary care in particular. I wonder if you could talk about what role nurses, nurse practitioners, the range of nurses that you represent, can play in expanding access to primary care that isn’t just a physician-centred model and what the barriers are.

On nurse practitioners, I think it would be helpful for us to understand what those payment model issues are when we’re grappling with our recommendations.

A. Burton: Yeah. Doctors are a fee-for-service in this province, and nurse practitioners are not. That’s the basis of the problem. Nurse practitioners are salaried employees from the health authorities unless they have special arrangements. There are some cases where they do, which are working, but by and large, nurse practitioners have to wait until a job comes up through a health authority.

There have been some programs. Initially, when the nurse practitioner program was started, there was a huge chunk of funding that was given to each health authority in order to sustain the nurse practitioners for a certain amount of time. We are still not entirely sure where that is. There was an FOI request that went in around it. Some of the health authorities have maintained that; some have not. It’s sort of hard to pin down where all that money has gone.

Regardless, the problem was that it was a sum of money, a dump of money. After that, there was the NP for B.C. program, which wasn’t as effective as we would have
[ Page 494 ]
liked it to be. That involved a physician or as a community putting together an application to say that they needed a nurse practitioner. The nurse practitioner would apply, and they would fund it that way.

The challenge was that some of the positions that were put forward were actually really not NP positions. They were RN positions. So we ended up having NPs appear to do a job that they actually were overqualified for, which could have been done by someone else, or you’d have NPs showing up and there was no money put in — there has never been money put in — for overhead for nurse practitioners.

For a nurse practitioner who wants to open or wants to work with a group to open a clinic, there’s no overhead included in their salary. Even if the health authority was to say, “Sure. We’ll hire you to run a nurse practitioner–led clinic,” unless the clinic is already all set up and everything is already paid for, there is actually no way for them to do that unless they charge patients, which of course, you can’t do.

If you look at places like Ontario, where they do have quite a few NP- or NP/RN-led clinics, they’re very successful, but they’ve actually built into their funding model ways for nurse practitioners to move forward. We’ve looked at lots of options here.

There’s a clinic in White Rock that has a hybrid model and actually has a nurse practitioner who was hired through the NP for B.C. program, and there’s another one who was hired by the clinic and is a consultant. The differences even in their practice within that clinic are quite acute.

One of them is working under health authority rules. She takes health authority benefits, health authority breaks, health authority time off. All of that works. She works the same hours. The other one is a consultant. She can work as many hours or as few hours as she wants. She takes holidays; she doesn’t get paid. She has no benefits. It actually is fairly equitable in terms of what their actual take-home salary is, but it’s just a different way of looking at it and servicing the model.

We’ve looked at population-based funding as one potential for nurse practitioners. Alternate payment plans is another way. Some of the clinics feel like they could sustain them. It’s the question, again, of overhead that becomes really challenging for a lot of the clinics.

There are certainly ways to do it. We just need to sit down and hammer out what works in B.C. Certainly, it’s been relayed back to us that putting nurses on MSP is not really an option right now. That’s the other thing that some provinces are looking at. Can we actually have them billed the same way the physicians do?

D. Barnett: I’m quite interesting in your education program that I know you’re very engaged in — educating nurses in different cultures. What have you…? I don’t know how to say this.

The First Nations community. How engaged is your nurse’s organization with the First Nations community and their culture and the new way that we’re going to be delivering health care with their culture, etc., and the training that’s going to be in the universities, etc., to train nurses to be more cohesive with the culture of the First Nations communities?

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A. Burton: Oh quite. In the last year, ARNBC has actually established a First Nations board seat because we recognize that that is an area that we need to have a concerted focus on. We’re working pretty closely with FNHA on a few things that they’re working on right now as well.

Nurses who work in First Nations health are challenged because they’re not part of the usual health authority structure. When there are conferences and events, they don’t get included. They don’t get included in the education pieces. I know that Becky Palmer at First Nations Health is really trying to change that, because they need to be part of a community too. Often they feel quite isolated.

In terms of some of the program, we have a position statement that’s out on leadership capacity and really focuses on how we actually increase the leadership capacity for aboriginal nurses, getting them to feel like they can take on some of the more advanced roles in the health care system. We have one in the works right now around cultural competency, which is that teaching in schools.

Does that answer….?

D. Barnett: It does. Thanks.

A. Burton: So quite invested in it. It’s one of our top five policy priorities, and it will continue to be. Right now we’re doing a white paper on the seven recommendations that are the Truth and Reconciliation report from a nursing perspective — what our response needs to be to those.

D. Barnett: So the First Nations Health Authority is engaged with you, are they?

A. Burton: Right. We have a couple things that we’re working on with them. One is interns in undergrad, like Katherine is…. They actually are supposed to do clinical all the way. Obviously, we’re not a clinical placement. So we have started taking interns at ARNBC, and First Nations Health has identified that they’d also like to be part of that program and be able to have nursing students come and spend time with them.

We’ve also been chatting with them about working with them on some surveying, because they have different needs for surveying, as do we. There are questions we can’t ask that they can and questions they can’t…. We’re probably going to do a joint collaborative survey of nurses to get a sense of where things are with nursing and aboriginal health nursing.
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Then, of course, they’re doing their declaration with the health authorities, and they’ve asked us to be one of the endorsers. We do work pretty closely with them.

M. Dalton: I know in Fraser Health, there were about 300 more nursing positions that were added this year. A lot of the focus is moving into home care. I’m just wondering if you could speak to that — how that’s working out, as far as nurses visiting patients in their homes. Is it happening? Is it positive? Do you have comments on the whole community health approach in home visits?

A. Burton: I think there are positions added, but they’re not all filled. That’s the first challenge — right? — to actually get people in all the positions. I think there’s still a lot of work to do to develop what that program looks like.

But we know that community health is one of the most prevalent things that we’re working on as a profession across the country. There’s a meeting at the end of this month in Edmonton, a pan-Canadian meeting, specifically around community health and home support and how we actually advance this as a profession. I think you’re going to see more of it.

From our perspective, it’s keeping in touch with that community and trying to figure out what the nursing needs are. But when a health authority makes a structural decision like that, it take a while for us to get the downstream understanding of where we need to fill the gaps or help educate and work with the nurses who are actually involved in that.

I would say that we don’t have numbers at this point. But I’m sure if we come back in a year, we probably will.

S. Hammell: It’s good to see and hear you again. It’s great.

This morning we listened to a person from the College of Family Physicians. It was very clear from her that fee-for-service just did not work with a team-based approach to health care — at least on the surface, it doesn’t. But you have mentioned fee-for-service for nurse practitioners.

Does that imply that a nurse practitioner would set up a facility like a physician does now, sort of on its own, and sort of replicates the physician model of fee-for-service? Or are you suggesting that that can be implemented into team care?

A. Burton: A nurse practitioner accessing MSP is one concept for how they could run their practice, but not specifically in team care. If you’re looking at primary care centres…. This is something that we know from Ontario as well. We’ve had physicians say that they have a challenge because there may be a naturopathic doctor or some kind of alternate care provider — that massage therapist — that the doctor can’t actually send his patients to, because they’re paid differently. He can’t send them because they’re not insured.

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I was talking to a physician from Ottawa who was saying his biggest challenge is that he’ll have a patient, and he’ll be like, “Well, you need to see a massage therapist,” and then he has to just cut them loose and say: “Go find one.” He can’t just refer them, even if the person is next door.

In team-based care, I don’t know that we would say fee-for-service would be anything that would work. It would really have to be looked at. There are certain nurse practitioners working in different types of situations where it may work. Some of them are quite embedded in hospitals, for example, and take on a role much more like a hospitalist or a physician in a hospital.

I think we need to look at all of the options for nurse practitioners and then figure out the solutions for each. But in team-based primary care, it would be very hard to do a fee-for-service model. We’ve learned that.

L. Larson (Chair): I can speak to the nurse practitioner. I have a little community called Rock Creek, and we have a nurse practitioner there. But the building that she works out of is handled by a non-profit society who covers all of that, because there is no money to pay for her space — so very difficult. The community, of course, has always stepped up and is there and so on, but it’s very, very hard. She’s wonderful.

A. Burton: Nurse practitioners tell horror stories of showing up at their office the first day and there was a plank and a saw and that was it. They can tell you some really scary stories. We had one who was trying to do her practice out of the back of a gas station.

There’s definitely a problem there. I don’t know that we have all of the answers, but I know that we need to sit down and really seriously focus on getting the answers. Even though there are lots of meetings about what we should do, it actually has never been: “Let’s sit down and actually figure this out, and we’re going to sit at this table until we do.” Really, that’s what’s needed.

L. Larson (Chair): That’s what needs to happen, yes. This is a lovely little clinic, so she was very lucky, but I know what’s going on out there.

Thank you very much for being here and for sharing the update and all of the great work that you’ve done over the past year, pulling everybody together. We need, as I said before, to see more of that happen. So thank you.

A. Burton: You’re welcome. Thanks for having us.

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G. Boniface: Do you think we should start?

L. Larson (Chair): Yes, I do, so that we can certainly listen to you, give you your full 15 minutes, and have some opportunity for us to ask questions. Otherwise we will be running into the next presentation.
[ Page 496 ]

Welcome to the Canadian Association of Occupational Therapists. I’ll let you introduce yourselves and then go right into your presentation.

G. Boniface: My name is Giovanna Boniface. I’m an OT, and I’m the managing director of CAOT-BC, the British Columbia division.

S. Forwell: I’m her sidekick. I’m the department head of the only program in British Columbia in occupational therapy at the University of British Columbia.

G. Boniface: You’ve all got a copy, so we’ll just follow along. We’ll go to the next slide, which is addressing rural health and well-being. Although we recognize that the select standing committee is looking at three different topics, we’re going to focus on one today, just because they’re such large topics.

We will be focusing on improving health and health care services in rural B.C., as well as the long-term solutions that can address challenges of recruitment and retention of health care professionals in rural B.C.

Obviously, we’re occupational therapists, so we’re going to be coming from the occupational therapy lens. Our slides…. We’re focusing on solutions and really what is required, ethical and important for British Columbians. That’s getting on with life, whatever the illness or disability.

For some of you, if you know, I’ll just very briefly…. Occupational therapists are regulated health professionals under the Health Professions Act in B.C. Our role is to enable individuals with the occupations of life. “Occupations” refers to every single thing a person does in their day, not just work, which is what some people might think.

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Really, what we’re focusing on is what people need and want to do in their day to day. Some examples there are getting dressed, prepping a meal, going to work, participating in sports and leisure and the management of chronic conditions and illnesses.

In terms of solutions, what we’d like to focus on today are three things that we think are really key — that is, ensuring an adequate workforce, augmenting timely provision of services and reducing maldistribution of health care professionals in our province.

Just a quick snapshot for you. Our current workforce…. There are just under 2,300 OTs in the province. We’re a primarily female profession. Our workforce is both in the public sector and in the private sector. When we say private sector, those are therapists that are delivering services through third-party funders like WorkSafe B.C. and ICBC, those Crown corps.

But as well, our private sector is starting to pick up a lot of the overflow from the public sector. So a lot of times public sector is going out and actually asking our private OTs: “Can you manage our wait-list?” or “Can you help with that?” That doesn’t happen very well either, because they also have very long wait-lists in the private sector, because they’re servicing those Crown corporations and meeting their health care needs.

So the next slide is…. There’s a lot of information on this. It’s a snapshot of what our supply has looked like over the past five years. The key take-away here is that just over 27 percent of our workforce in the past five years has come from our province. We are — our workforce — heavily dependent on in-migration to our province both from Canada but also externally.

What does that mean from a consequence perspective? Three-quarters of our workforce is not trained in our political system or in our health care system. Also, we’re at risk because our supply chain is dependent on in-migration. We’re not producing our own people.

In terms of the workforce demand, we have high demand in both the public sector and the private sector. We’ll start first with the public sector. You can see here. These are just two reports within the past week of what the vacancies are in Northern Health as well as in Coastal. It’s small print, but I’d like you to…. There’s a quote there that I have from a senior practice leader in the north who’s been there for years. This is their perspective on the challenges that they’re facing:

“We’re lucky if we can people to stay for more than two years. Everyone’s facing the same issues — high caseloads, little mentorship — because many of the positions are sole charge or because experienced people don’t stay because they don’t have the support.

“New grads are willing to come, but they often find it much too challenging, and they fear that they either don’t know enough or they’re being expected to do too much, creating some ethical tension around what they should be doing and what they can do.”

In terms of private sector, the next slide is a snapshot of what that looks like. We have significant demand there too. So 60 percent of our employers currently have vacancies, and 55 percent of them project hiring over the next few years.

In terms of wait-lists, on the next slide you can see, in the private sector, we’ve got almost 50 percent reporting wait-lists. Between 27 percent and 39 percent are not even able to meet referral demands. So they can’t help meet the needs from the Crown corporations’ clients but also in the public sector clients.

Some of the solutions that we have identified regarding adequate workforce supply…. Well, one is: let’s try and increase the number of health care professionals that are trained in our province. They can help meet both the public and private sector demands, reducing reliance on in-migration into our province. We really think that is a significant risk to our health professionals working across the province. And to allow our British Columbians whose desired goal is to be an OT….

Actually, Sue, maybe you can speak a little bit to that.

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S. Forwell: This year, in our program, we had 339 young people applying to our program. Of those we interviewed, a third — about 128 — all had an average of 82 percent or above. To get 82 percent in a bachelor’s degree is extraordinarily difficult. We had easily a third. Our cut score was 82 percent. So we have highly educated and highly qualified individuals that want to become occupational therapists. We can accept 48.

We’re not short at all of those that desire, in this province, to become occupational therapists and work here. There are several other reasons that they’ve chosen to want to be educated in British Columbia. I think this is a very serious issue that we need to address.

G. Boniface: Moving to our next slide, looking at the solution of augmenting timely provision of services. We’ll go right to the next one that’s titled “Current realities.” These are some examples.

First, with the kids. That first slide shows you…. This is from the provincial advocate for the B.C. Association of Child Development and Intervention. This is a snapshot of the wait-list for early intervention for OTs. You can see that ranges from four months to over a year in some regions.

Going to the next slide, we’re going to look at adults. Very recently reported by Vancouver Coastal Health, we have priority 1 clients. They’re considered high risk. They’re medically fragile. They’ve probably just been discharged from hospital. The standard is to be seen within 24 hours of discharge, and the reality is that they’re being seen within three weeks. So we’re not seeing them on time.

Reported by all health authorities, including the north, we have wait times between three months and over a year for any adult or older adult that’s being referred for whatever reason, whether it’s a home assessment, a wheelchair assessment, mobility — whatever that is.

Then in one of the health regions — which I can’t name because I was asked not to — occupational therapy is not even part of the palliative care just because they’re not able to, despite that the goal is to make individuals comfortable in their last days. So that’s for adults.

Then moving on to seniors. This information, from the first three bullets, comes right from the seniors advocate’s report. We know that only 9 percent in residential care have seen OT in the past seven days. The most recent report, in 2016, reports that 90 percent don’t receive the minimum.

Then looking at the RAI-MAPLe data, which is the method for assigning priority levels, 53.2 percent of home care residents have very high or high scores. What that means is that they’re the most at risk and require priority in terms of home care. They’re the most likely to see caregiver burnout, injury at home. They’re also the most likely to end up going into residential care and re-admission back into hospital.

The next slide. I’ll send you the update. Really, for this one here, some of the solutions that we have identified for all three — kids, adults and senior populations — are: have adequate staffing to reduce caseload burden; start implementing preventative home safety visits for those high and very high MAPLe clients which we have identified are at risk for re-admission or admission to hospital or admission into care; addition of occupational therapy to the skill mix in residential care facilities, particularly with the expertise of seating to reduce falls, skin health to manage pressure sores, and for functional eating; and then, very importantly, engagement in meaningful activities.

Then another solution is to include the therapists, with our expertise, to help design some of the programming and then delegate some of those tasks to professionals that can do it and that cost less. That could be to personal support workers, rehab assistants or whoever is available in that client care team.

I’m going to hand this over to Sue now.

S. Forwell: The next thing we’re going to talk about is our third solution related to reducing the maldistribution of health care professionals across the province. I hope you find our next slide interesting. The circled numbers there are the distribution of our workforce compared to the population breakdown.

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As you can see, Fraser and the north are grossly underserviced per population. I think that’s not new information. I think that’s probably what you’re hearing from other sectors. What is very interesting to me is that we can actually service the Fraser Valley quite easily from Vancouver, but we simply just don’t have the manpower to do it. It’s not even like the strain of the north, which has a different set of issues. Just even so close to home, we can’t deal with it because of the lack of manpower.

Actually, VGH has recently reported a crisis. They have in 20 years never seen a situation where they do not have the supply of occupational therapists, even from our graduating class, to deal with the next four months of services that are required. This has not happened in the last 20 years, in recent memory — VGH, our biggest hospital and the one that you would think has got all the services. Not so.

I’d also like to point out the Vancouver Coastal number there, how it appears that our workforce is double that of the population. Well, that may be true, but the needs of the Vancouver Coastal area are also different. When people become injured, they tend to…. Like, if they’re at G.F. Strong, a lot of them don’t return to Prince Rupert. They stay in Vancouver because this is where the services are. So while that looks disproportionate, I would argue that if we actually took a population reference point, in terms of persons with disabilities, we would see that Vancouver is more heavily weighted than other areas of
[ Page 498 ]
the province. So that distribution — while it looks very hefty and promising and ideal, I think it’s not necessarily related to the demand of the piece.

We’ve also suggested some solutions to maldistribution. We’ve put it into five categories that I’ll let you read there. I’m going to have a slide for each one of these categories.

First is to support rural clinicians. This is a really easy one that we can do. I would say that the cost of doing this is a rounding error in the B.C. budget.

The rural clinicians are completely overwhelmed with demand. What we need to do is increase opportunities for OTs in underserviced areas; support the current OTs in terms of managing their caseloads; provide them with CPD information to help them with caseload management; build in education about professional self-care; and decrease burnout, which is very high in the rural areas.

We would also like to incorporate rural clinicians into the delivery of our program, for the occupational therapy program. That would be ideal, but we do not have the resources currently to do it. I should point out that there’s a high motivation among our therapists to be involved in our program. Examples are through distributed learning and identifying a point person in the region to serve as the regional expert in a particular area.

The next one is related to rural field work. This is another one that is very easy to accomplish. We currently require every student to do at least one placement outside of the Lower Mainland. They must. We probably should do two, but we don’t have the placements to do that, or once they’ve met that criteria, they want to stay, because their rent is here and they’re paying for an apartment.

We need to provide incentives, which is very small amounts of money again, for them to go to those regions and pay their apartment fees for that six-week period, which is not an expensive thing. But these are incentives that students need to actually go and do more rural placements. These are examples.

The development of student-run clinics in rural locations is an excellent opportunity and really increases the resources that service an area.

I’d like to move on to train and maintain. I think you’ve heard this. We know that students that are trained in a particular area stay there, continue to work there. I just want to point out that over 90 percent of our students do remain in British Columbia, so we do have a very high retention rate. We do know from the distributed medical program that the data is starting now to come in to show that that is actually a reasonable model.

I want to just go to the distributed-learning model and talk about that at length. I’ve provided you with some data to show you that we do have applicants from all over the province applying to our program, but they don’t necessarily get in because of our small numbers in our program.

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In terms of retention and recruitment, that’s a list that has come from the literature. It’s cited from a meta-analysis. I’ve got the citation there, the reference point. A meta-analysis is an extremely persuasive data point, because what it does is it collects all the studies on a particular topic and actually summarizes them — what the direction is that it points to.

This particular meta-analysis showed that these eight different strategies are useful for retention and recruitment. I’m not going to go into all of them. I’ll just talk about the interprofessional teams and skill mix.

One of the things that has been demonstrated in the data is that a qualified and appropriate skill mix is more efficient and cheaper in terms of our health care costs because of the downstream effects. Because it’s more cost-effective, of course that’s the direction we want to go in. But we have a problem with that, given that we don’t have the numbers of OTs to do that.

I want to point out also…. My last line there is that health care is not just medical care. As the best medical care, it does not assure optimal health care, okay? So it’s not just about the cells and the biology. It’s also attending to the social network. It’s also attending to what they can do for themselves. If you ask your mother what they want to do, what they want to do is have Sunday night dinner with you, despite the fact that they may be in a residential care facility.

Okay. I just want to, finally, return to one example about getting some bang for your buck with occupational therapy. I’m going to focus on falls. I actually have lots of data in this area, but because it’s a constrained talk, I just want to focus on one area, which is falls.

It’s been clearly shown that occupational therapy intervention, when somebody is at risk for falls…. When occupational therapy goes in…. The chance of compliance with intervention and reduced falls is increased fourfold when occupational therapy is involved — to the next fall. And we know that the number one predictor of a fall is a previous fall. So if you can actually stop that second fall, that makes a huge difference. We’d love if we could stop the first one, but they don’t get identified in our system. But they certainly are identified once they fall.

I hope you think…. I’m back to talking about solutions. We looked at three areas that we thought we could offer some solutions on and how we think we can improve health care to health care services in British Columbia.

I want to thank you very much. I’m happy to take any questions.

L. Larson (Chair): We have about five minutes for questions. That means those of you that talk a long time at this table have to shorten it up a little bit.

Questions?

J. Darcy (Deputy Chair): I’ll be quick, as I’ve had the advantage of meeting quite recently with the association.
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You’ve given one very powerful example about seniors and falls and what occupational therapists can do by way of prevention and hospitalization and so on. Could you talk about the same thing as it relates to children and adults so that we can understand it in human terms?

S. Forwell: In terms of…. You want dollars?

J. Darcy (Deputy Chair): No. What early interventions by occupational therapists can mean for patients. You have a really good example about seniors.

S. Forwell: Okay. Let me do one for adults, then — somebody with multiple sclerosis, recently diagnosed with multiple sclerosis. The number one precursor to unemployment and, therefore, poverty among persons with multiple sclerosis is just subtle cognitive changes — that they can no longer master the complexities of their workspace. We have cognitive rehabilitation programs that are extremely effective that very few people have access to.

I would maintain and it’s been demonstrated in the U.S. — there are very few in Canada — that those in the U.S that have access to cognitive rehabilitation are likely to work a mean of five and a half years longer. That is incredible. That’s just one example.

L. Larson (Chair): Good. Thank you.

Any other questions?

D. Bing: Thank you for your presentation.

I was wondering about the education component. First of all, are the 120 graduates coming from outside the province qualified the same? Is it the same qualifications?

S. Forwell: Let’s clarify. The in-migration allows us to register about 160 OTs a year, of which 48 come from British Columbia. We only educate 48 British Columbians. The 128 figure was all those that we interviewed, that had a GPA over 82 percent.

The question is: the 48 that we…?

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D. Bing: Well, what I’m really getting to is: what is the barrier to increasing the number trained in B.C.?

S. Forwell: That’s a great question. We can’t get seats. We’ve been lobbying for ten years to increase the number of seats from 48 to…. We’ve put proposals in for 120, 80, 12 seats and have been not accepted. Or they’re…. Like I like to say in Saskatchewan, the potash industry hasn’t reared its head. But that’s the barrier. It’s a very cheap-ticket item, compared to medicine or….

G. Boniface: I’ll just add that our profession has been identified as a priority profession, but it just has not made it for funding. That’s all it is. It comes down to the budget.

S. Robinson: I want to say how shocked I am at the Fraser Health number, representing part of Fraser Health — Coquitlam-Maillardville.

I want to know…. I will strongly advocate. How many are we supposed to have in Fraser Health? Based on our population, what would one expect? How many occupational therapists would you expect in a region that size?

G. Boniface: I’m just thinking about how it’s benchmarked across Canada. We’re using the CIHI and looking at those numbers. They benchmark per 100,000. B.C. is the second lowest from the bottom — of the number of OTs per 100,000. So we fall behind. I think we’re only behind PEI. Provinces that do a better job of delivering OT, like Alberta and Quebec, have closer to between 40 and 50 OTs per 100,000. I think we land around 32, I want to say. We can certainly get you….

S. Forwell: I can get you that data.

S. Robinson: That would be very helpful.

I know that the purpose of this committee is to look at rural, and I get that. This is suburbia, and it’s actually worse than the north, when you take a look at the population. This is the first time that we’re seeing that, given all of the different associations that we’re hearing from. I’m quite surprised and quite shocked.

Thank you, at least, for that. It helps me to understand what I need to be pushing for on behalf of my residents.

M. Dalton: What percentage of occupational therapists are, say, with Workers Compensation? Where are they? You’re saying private and public are different.

S. Forwell: It’s a 25-75 split — 25 percent in private sector, 75 percent in public sector.

G. Boniface: Of that 25 percent…. It’s only about 100 occupational therapists in this province that are service providers under contract for WorkSafe B.C.

M. Dalton: Just a follow-up, real quick. Do the personnel have various specialties? They go into a home or a business and try to improve or allow them to get back to work or just carry on with life in different aspects. I guess the question is: do you find there’s a lot of specialization in the field or not?

S. Forwell: Yes, there is. There are private practices that solely deal with long-term care access therapists, for example — that just deal with long-term care clients. Then there are others that deal with primarily vocational rehab, and only vocational rehab, or ergonomics. There are other groups that just deal with brain injury. So there are selected people….

Then there are full-service companies that have 75 OTs
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working for them. They are more full-service and they have more of across the board.

Thank you for that question.

L. Larson (Chair): Thank you. I apologize for the technical difficulties that we started out with for your presentation. Thank you very much for going through this as succinctly as you did and for answering our questions.

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We are right on time, so I will invite the representatives from the College of Physicians and Surgeons of British Columbia to please introduce yourselves and then launch right into the 15 minutes that we’ve given you to make a presentation.

S. Prins: Thank you very much. My name is Susan Prins, and I’m the director of communications and public affairs for the college.

H. Oetter: I’m Heidi Oetter. I’ve met some of you before. I’m the registrar at the college.

G. Vaughan: I’m Gerry Vaughan. I’m the president of the college. Thanks very much for asking us to come. We’re pleased to provide a response to your three questions. I think our purpose is to assist you to identify strategies for maintaining the sustainability and quality of our province’s health care system.

The three questions, if I understand them, are about improving health and health care in rural B.C.; secondly, to enhance a multidisciplinary approach, a team approach, to care — including occupational therapists; and, thirdly, to improve addictions services.

First, some facts about us. On slide 1, you’ll see the main points that we’d like to cover, which are what we do. If you’re not already aware, we’re the statutory licensing authority for the physicians and surgeons of British Columbia. We set standards for entry. That’s our registration function. We set standards for practice. I think you will probably have received in your package our opiate standards and our walk-in-clinic standards, because they fit this presentation today.

We have a complaint investigation practice of about 1,000 a year, which is a considerable volume and does educate us about some of the facts that we’ll bring up today.

We have a disciplinary function. We accredit lab and imaging facilities and private medical and surgical facilities. We are involved in quality assurance activities. That’s to ensure that physicians remain competent throughout their careers.

We can show you this slide which, in another way, describes what we do. You’ll see that we try to be fair and transparent, impartial and objective in what we do in those spheres that I mentioned. The primary function that we have is public protection. We are public advocates; we’re not professional doctor advocates. That’s for some other body. Our core values that guide us are accountability, justice, integrity and collaboration.

I should tell you a bit about myself, because some of what I’ll say can be explained by the fact that I’ve been in practice — in full-service, general practice — for 40 years. I’ve had experience at the health authority level as HAMAC chair. I’ve heard the questions that you’re posing for all of that time, so the solutions are obviously difficult. I don’t want you to think that we’ve got all the answers, but we’d love to give you some ideas.

The first question was about rural health and health services and how we can improve those. In the short term, first of all, we believe that all practitioners from all of the professions should be supported to work to the maximum of their skill set as a part of a collaborative team.

We should, as a society — yourselves — consider the greater use of physician assistants and anaesthesia assistants. Those play a big role in U.S. programs but not very much in Canada. They’re largely militarily trained, and that might be the reason.

Telemedicine is a help, but the telemedicine providers should be part of a care team and have an ongoing relationship to a community. The current system we have is in evolution but leads to one-off consultations, and perhaps it aggravates the fragmentation that we see.

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In the medium to long term, we believe that we should train health practitioners in distributed sites, in rural sites. They should be trained in interdisciplinary teams, with well-resourced, continuing professional development resources where they are. Encourage those in rural communities to be practitioners. I know that’s been ongoing, but I think it needs to be beefed up.

With regard to supply and distribution, that’s not a primary role of the college, but we have ideas. You know, we do need explicit management and a right combination of carrots and sticks. I know the carrots are usually monetary. Those are important, but they’re not the only ones.

I think there should be continuing professional development in the rural sites, and good connections to secondary and tertiary services that are reliable and immediately available. In this day of IT, we should be able to have that.

I think that other ones are return-of-service contracts, like Saskatchewan uses. Yellowknife has a good example of how these are used. Perhaps disincentives have a role for persisting in an urban centre. I don’t know how that would look.

We regulate individuals but not the system. Nevertheless, we’re reminded in the college, regularly, through our complaints process, how individual physician performance and morale can be affected by systemic factors.

Going on to the second question — the transformation of primary care. This is a fairly bold recommenda-
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tion, really. The system needs to be transformed. The current system focuses on management of acute health care services with little to no management of primary care in communities. I’m community-based as a family physician, and that’s definitely true.

All high-performing systems — an example might be Kaiser Permanente — explicitly manage and integrate care, primary through to tertiary. Our current system is fragmented, poorly coordinated and not founded on multi- or interdisciplinary teams that provide comprehensive longitudinal care, which we like to describe as a medical home. I think the medical home is a key concept that I’d certainly like you to take away.

We need a provincewide approach to managing and measuring primary care. A lot of these things need to be measured to prove their worth. It’s hard to improve things without measuring them.

Our system should pay for only what is effective, efficient, patient-centred, safe and appropriate. An example might be, as has recently been in the media, that in B.C., we don’t pay for routine physical exams on healthy people. The literature doesn’t support doing it. It doesn’t appear to be appropriate to do that. The public, we believe, should be made more aware of what is covered and what isn’t.

My experience has been that trying to get people and a team together to do things — like counselling, social work, pastoral care, nursing care — has been difficult. It’s a siloed system, and they all exist in different sites, geographically. They’re hard to get together and manage. It takes a lot of our time in primary care to get that to happen.

So what do we do? Our vision is rather bold. That’s one of explicit management that is the funding and delivery of health services done in a systemic way. Groups of interdisciplinary providers should be present to provide defined services through contract, always keeping central the triple aim of better health, better care and better value.

It’s not a regulatory function or responsibility, but we see the breakdown causing some of our registrants to come to our attention. That’s why we have the ideas about this.

Speaking for most senior physicians in primary care, I think we, as a majority, would like to have a very frank discussion about the limitations of fee-for-service, which does aggravate fragmentation and make multidisciplinary teams harder to do.

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You might find that there’s an exception amongst our colleagues who work in walk-in clinics. We believe that longitudinal care in a primary care home reduces fragmentation, so we have a standard that you have in your package that helps walk-in clinics see their more appropriate role in that regard.

The third question you had asked us was about addiction services. We believe that basic addiction services should be readily available, equitably distributed and provided in multidisciplinary teams. That keeps coming up, and it’s on purpose. We believe in this concept. That team should include mental health and counselling services. You may not be aware that most of those are not covered by MSP and haven’t ever been covered. Psychiatrists are covered, but they are usually not the people we’re referring to here.

It’s difficult to find these professionals often, particularly in rural areas. We believe, and the literature would support, that addiction is a lifelong disease. It’s a disease and should be approached as a chronic disease, using the established methods, very well established now, of chronic disease management. That’s a way of looking at the care of your patients that is funded in British Columbia, but not for this yet.

Addiction services are particularly well suited to an interdisciplinary team approach. But the members of these teams are maldistributed and are really not available in much of British Columbia like they might be in the Lower Mainland.

As a college, we strongly promote the safe prescribing of drugs of potential abuse, and those prescribers would be physicians, nurse practitioners, midwives, dentists, and pharmacists, perhaps. We would like to see the pharmacists, by the way — because it’s a hot political item, I think — as part of a team, not as another siloed group that are prescribing on their own. We would like to see them prescribing in a team environment, which is safer.

We’d like to shift from an educational approach to a standards approach to safe prescribing. In your package is our standards document.

We would like to have PharmaNet access for all prescribers. Right now it’s a small percentage, relatively. The PharmaNet database needs to be more robust, to support its use in all physician offices. That is a goal we have.

We’d like to promote the idea — it’s not a new idea — that opioids are not the first choice for acute and chronic pain in many settings. They are in others, but there is a so-called ladder approach, where you go up the rungs of the ladder. The higher rungs are the opiate rungs. We don’t like co-prescribing of opioids and sedatives, the Valium-like drugs. It’s a dangerous combination, and that is part of our current guidelines now.

We believe in frequent, modest dispenses and not using more than 100 milligrams of a morphine-equivalent daily dose for 24 hours. There doesn’t seem to be any support for using doses higher than that. Urine drug testing should be routine on all the patients you have on these drugs.

These things I’ve mentioned are often called the universal precautions when you’re dealing with your patients on opiates, particularly.

For patients, these are things we’d like to see. Society has as much of an obligation to have these changes occur as any group. Hence, we’re telling you.

We’d like more information about the risks of taking opiates to spread amongst the public, and other drugs too
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— nicotine, alcohol, stimulants and sedatives. Opioids aren’t the only issue.

Our society needs to make naloxone readily available, and I think that’s coming soon. That’s the drug you can get to save someone who has an opioid overdose — save their life in an immediate fashion.

Also, the college believes that those who suffer addiction should have improved access to substitution therapy, which has, up until recently, been called methadone maintenance but now also includes a drug called Suboxone, which may be safer.

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You know, the maldistribution issue is important, and I think of a lone doctor in Lillooet — maybe that’s not the right town — who’s expected to do everything and doesn’t have members of a team. He or she just can’t do that safely for addicted patients, I don’t believe — unless they’re remarkable people.

That’s our submission, and we’re ready for questions.

L. Larson (Chair): Thank you very much. Certainly, you’ve touched on some of the things that have come across our desk in the last few days. The team, and perhaps we’ve been looking at it maybe slightly more broadly than what you have, as to who you would call team members — definitely pharmacists but also physiotherapists, massage therapists, chiropractors, a whole range of people who are part of a team. Certainly, in lots of the rural communities, it’s those types of people that you need to rely on.

I have one quick question first, before I turn it over to the rest of the group here. Credentials, the recognition of credentials from other countries. Has the time it takes to move into full practice improved at all in the last ten years for somebody coming to British Columbia from another jurisdiction with their medical certificate in hand.

G. Vaughan: I’m going to give that to Dr. Oetter.

H. Oetter: Certainly, we rely on our national certifying colleges — that would be the Royal College of Physicians and Surgeons of Canada as well as the College of Family Physicians of Canada — to assist us as a regulator in identifying comparable credentials.

I think it’s really important just to reflect that to be a doctor, you have to start your career path with a medical degree. It’s not the end of your career path. It’s after medical school that you then do your post-graduate training that actually makes you a physician. Internationally, many jurisdictions graduate doctors from medical school, and then they actually compete for their residency positions, so there are lots of people out there who have medical degrees and nothing more, and they’re not eligible for registration.

Right now the Royal College has a process where they actually recognize 29 jurisdictions as having comparable training programs. Some programs are simply not comparable — as an example, many of the residency programs in the South American countries. It’s a two-year program for radiology; ours is five. They’re just not comparable.

The College of Family Physicians has moved to do reciprocal recognition with a number of programs, so in fact that has fast-tracked individuals coming from those jurisdictions. Many jurisdictions chose not to participate — like South Africa and Nigeria and places like that — because they don’t want to lose their doctors anymore. There’s that aspect as well.

But it is a rigorous process. And given the need to make sure that people are truly paper to paper in what is evaluating people whose training programs actually span more like eight years as opposed to four years, there is rigour in that.

What I can say…. In fact, I was just looking at the data this morning. We’re actually seeing a decline in the number of internationally educated physicians coming here, for a whole variety of reasons that we don’t think have anything to do with how quickly they get their credentials recognized. But we’re quite confident Brexit will be to our advantage.

L. Larson (Chair): I should think so.

Of the 29 countries, or whatever, that have been identified as being comparable, if one of those shows up on the doorstep of the college, how long before they have a certificate that they can work in British Columbia?

H. Oetter: Often it’s actually getting their work permit that’s the bigger hold up, coming through Citizenship and Immigration Canada. If they don’t speak English, that would be the other barrier. But for somebody who’s coming, say, from the United States with comparable certificates and stuff, usually their work permit is going to take longer than getting here.

D. Plecas: We’ve had so many fantastic presentations expressing great ideas, and yours has certainly been a good example of that — wonderful ideas.

Have you turned your mind at all to what the costs might be of all of this? We’re hearing so much…. I don’t think we’ve asked this question before, but is there…? When I think of all of the things we need to do, we’re already at 42 percent of the provincial budget. Given the demographics, I think: “Oh my God. How would we ever pay for all of this?” Can you make a comment about that?

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H. Oetter: Do I think there’s enough money in the system? Yes, but I’m a regulator, and we actually only take out our calculators to look at licensing fees.

If you look at the OECD country reports, you will see that, on a per-capita basis, I think we spend enough. It’s
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just how we spend it. That’s what we’re talking about: system transformation. It’s not our role to talk about health policy. Again, we’re regulators. We’re just saying that people complain to us about the quality in the system, and we say to them: “If you really want to get to quality, you need to measure their performance. You need to actually align the funding and the service delivery with people who are buying services that they want. You need to think about contracts.” None of those exist in our system right now.

They’re bold, transformative steps. Doctors of B.C. probably wouldn’t be happy that we would be saying these things, but I think that there are different ways to skin the cat in terms of how you pay for physicians, how you pay for care teams. We’re just saying that we think that you need to look at high-performing health care systems, take the principles from those systems, and say: “What does it take to import those to our system to make that work?”

D. Plecas: In short, you’re saying that it’s reasonable to think we could do all that you think we ought to do without spending more money.

H. Oetter: Spend wisely.

D. Plecas: This is good, thanks.

J. Darcy (Deputy Chair): Wow. I only have one question. It is wonderful to hear your presentation, because everybody talks about the barriers to system transformation, and it’s always someone else that is seen as the barrier. I think it’s really heartening for our committee to hear from the College of Physicians and Surgeons, talking about the need for system transformation in a variety of different ways.

I want to zero in on something very particular, and that has to do with the foreign credentials. I recently met with a group of Iranian physicians — and several of my colleagues have — some of them 16 years running an emergency department, 12 years in family practice. There were a number of barriers, but the specific one they referred to in British Columbia had to do with a program that is 24 months here but 18 months in most other provinces in order to qualify.

I wonder if you could speak to…. It would be great…. Maybe you can provide us the list of who the 29 countries are that are seen as having comparable training to Canada or to British Columbia. Is there a variation in that length of qualifying period?

H. Oetter: I’m not sure where this group of physicians are seeing the bottleneck. What I can tell you is that we have what’s called a practice-ready assessment process, and it is designed for individuals who come from jurisdictions of which we really don’t know much about their training and certainly not to the level that we can do a paper to paper and say that yes, it’s comparable.

We’re certainly dealing now with Syrian physicians where we actually can’t even confirm that their medical school still has the bricks and mortars, right? There are a lot of issues around that. The capacity to assess people as family physicians is, I believe, two cohorts of 15 — so it’s like 30 — people a year that can be assessed for this. There is a bottleneck there.

Now, that’s at the family practice side. I’m part of the national consortium that’s looking at developing capacity to do these for specialist physicians. There’s probably going to be some capacity now to assess internal medicine and psychiatry, but again, it will be highly competitive and very limited spots. It just is what it is, because every one of those that is being generated is at the expense of another residency training site.

There have been some good starts. There have been some false starts. Bottom line is that we kind of don’t really need another ophthalmologist in British Columbia, even though you might wait to see an ophthalmologist. We certainly have pockets of oversupply, particularly some of the procedural-based-type physicians. Sadly, we probably don’t have room to absorb them into our system, even if we did have the dollars to do assessments around that.

Manitoba probably has one of the best developed programs right now. Why? They’re kind of a have-not province in terms of what they generate. The people, if they’re going to move from province to province, are likely to go from Alberta to B.C. or Manitoba to B.C., not the other way around.

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They have the best experience at it. Very expensive. Their success rate is between 25 and 75 percent, depending on the disciplines going through. So even though these individuals come saying, “I worked as X in this academic centre there,” when they come and we ask if they are truly comparable in an overtime experience in a Canadian setting, it’s not 100 percent that they are as they said they were.

M. Dalton: If you can confirm…. I believe there are about 225 medical seats.

H. Oetter: It’s 228.

M. Dalton: Okay, 228 — close, eh? — in the province. Are they guaranteed residency? That’s the first question.

How many residency positions are there? Are we open to having students from other jurisdictions coming here and training?

H. Oetter: They aren’t guaranteed, but they are certainly preferred. It seems a bit unfair to put them through the medical school training and then sort of drop them
[ Page 504 ]
off with no hopes of a residency program at the other end. The philosophy is to have 1.25 residency positions for every one that you graduate, so it allows people the flexibility to come back, retrain — do all of that. It is a funding decision of the Advanced Ed Ministry because the number…. My understanding is that there are more residency spots by a little bit, compared to the number that we graduate. They do go through the Canadian association of whatever — the resident matching service, which is that federal process that matches them.

G. Vaughan: CaRMS.

H. Oetter: Yeah, CaRMS. There are a fair number of people who come with foreign medical degrees and are successful in either the first or second iteration of that match.

M. Dalton: What’s our intention like, as far as those that go through a residency program — keeping them in B.C.?

H. Oetter: The stats are that the place where you do your residency is where you’re most likely to stay. And I think that, certainly, besides the distributed medical education program, we have a distributed family practice training program as well. It’s still early days for their data, but it is showing that the students who go through, graduate from the UBC northern program and go on to do their residency in Fort St. John, stay there.

G. Vaughan: If I could add my experience in Nanaimo. There is a residency program for family practice, and our shortage has largely been dealt with as a result of having a residency program there.

L. Larson (Chair): Sue, last question.

S. Hammell: I am actually going to slip in two. It’s just a carry-on. One is just simple. The qualifications for foreign-trained doctors — are they consistent across the country?

H. Oetter: Actually, we do have national standards for registration. I’m happy to send you a PowerPoint deck on that. They are reasonably comparable across Canada. What the difference is, is largely the capacity to do practice-ready assessments in each jurisdiction for those who don’t have paper-to-paper recognition.

S. Hammell: Okay. So my question is around your comments in your presentation on opiates. It’s interesting what you’ve said. First off, we have the second-highest use of opiates in the world, right?

H. Oetter: Yeah, I know. Wow.

S. Hammell: Do you play a role? You say here: “However, physicians also play a role in over-prescribing opiates.” That’s beyond other reasons — sedatives and stimulants. It’s a concern to you. So do you have any ability to influence that behaviour, and do you have the ability to do it with some kind of teeth?

H. Oetter: Yes. In fact, what we’re hoping is that we can actually go to the ministry and talk about a renewed strategy for actually analyzing the PharmaNet database. We want to use that PharmaNet database to have it tell us who the potentially poor prescribers are so that we can intervene with those individuals.

We currently run a number of educational programs every year that doctors get invited to go to. I think you’ve already heard Minister Philpott talk about mandatory education. We’re well positioned to meet that accommodation. We run about three or four educational workshops a year about safe prescribing. We know that the doctor’s pen isn’t the whole story. We obviously have a rather large market of illicit fentanyl being imported from other places in the world.

But we’ve come through, essentially, a decade or two of doctors being encouraged to prescribe more liberally. We now have more people dying of accidental opiate overdose deaths coming from the end of their pen than we do in motor vehicle accidents, and we need to turn that tide. It’s about centring that pendulum.

We need to bring safe prescribing back, and I think we are well positioned, with the assistance of the ministry at not much cost to the ministry. It’s really about making it a priority to be able to march down there.

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I’m hoping we don’t have to do like they did in the state of New York this week, where they actually had to bring in legislation saying: “Doctors will not do this. Pharmacists will not do that.” We’d like to see it as a professional obligation of the regulators to lead in that regard.

L. Larson (Chair): Just a follow-up to the amount of foreign doctors, or doctors trained in other countries. What percentage are we able to take into British Columbia versus the percentage that we turn away? Is that based solely on the fact that you can only roll over this group of 30, these intakes, in a certain amount of time? Of 100 people that come to our door, how many of them actually get through the door?

H. Oetter: We take in about…. Susan, I’m looking at you because you’ve probably….

S. Prins: Yeah, I was thinking that the annual report probably has the most recent numbers in terms of intake for the year and overall total, but it wouldn’t say out of how many.
[ Page 505 ]

L. Larson (Chair): Yeah, I wanted to know how many were rejected.

S. Prins: Actually applied?

L. Larson (Chair): Yeah, actually applied versus actually made it through the door.

H. Oetter: Yeah, because we have what’s called a prescreening process, we just don’t think it’s fair to take hundreds of dollars from candidates when they don’t have a hope in getting a licence. They have the ability to self-select whether they’ve got that. They also have to start writing their Canadian exams anyway, so many of them may have wanted to come, but in fact they got a failing….

L. Larson (Chair): They changed their mind.

H. Oetter: Yeah, and all of that.

L. Larson (Chair): Thank you so much for the time you’ve spent with us today. We really appreciate it. We will read your report and add it to ours.

I’d like to welcome Greg Kozak, Patients and Supporters of Mid-Main Community Health Centre.

Even though we’re running a minute late, we will not cut you off. You will get your full 15 minutes, but I will cut these guys off when it comes to questions, okay?

G. Kozak: Sure. I hope to make up time, then.

Good afternoon. Thank you for hearing me today. I’m Greg Kozak, and I’m here speaking on behalf of Patients and Supporters of Mid-Main Community Health Centre. Just as background, I do not have a background in health care; I just have a background as a patient and a user of the health care system.

Today I’d like just to cover off the question that we’ll be looking at specifically, who we are as a group, as well as share experiences with Mid-Main Community Health Centre, as background to our conclusions that we’ll be presenting.

I’d also like to thank two of my patient colleagues who are sitting in the back, who are here to support me — JoAnn and Merry.

D. Plecas: Sitting there patiently.

G. Kozak: Yes, very patiently.

We’re providing comments today just on question No. 2, with the specific focus on the cost-effectiveness of such a system there. We sort of tweaked in that the focus was meant to be on that part there.

In terms of who we are as a patient group, we were formed in 2014. It was more of a reaction to Vancouver Coastal Health moving to defund Mid-Main Community Health Centre and switch it to a fee-for-service format from, I imagine, an alternative payment arrangement where the doctors were salaried and had funds for supporting other medical professionals to assist them — an interdisciplinary, multidisciplinary team model.

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As part of that process, of course, we held the standard town halls, petitions, group meetings, as well as meeting with Vancouver Coastal Health. We did have a chance to meet with the Deputy Minister of Health, Stephen Brown, to discuss options for maintaining a non-fee-for-service model at Mid-Main. We looked at the population-based health funding model, which actually did not work out, how it was currently structured.

As of April 2016, we understood Mid-Main had fully transitioned to fee-for-service, and that’s where we sort of had our crisis of existence and decided to disband ourselves as a group. Not to make this an existential question, but we decided to re-form to come back and give our thoughts on this after receiving the invitation.

Just to be clear, I’m not speaking on behalf of Mid-Main Community Health Centre. I understand they may be putting in a submission of their own, but we’re strictly here as the patient group. Our experiences, again, are based on what we’ve perceived of how Mid-Main functioned when it was under the alternative payment structure with the supporting professionals in it.

We’ve come up with five characteristics of what we’ve seen as an effective model of community health care delivery. The first one is the aspect of team. This very much meant all the professionals in that team — whether it’s the medical office assistants at the front desk, the clinical pharmacist, the nurse practitioner, the physicians themselves — work together collegially as a team.

From a patient perspective, we saw each one of them in turn and didn’t really differentiate, in a negative way, who we were seeing. They could all support us equally. We understood that they shared their experiences, their best practices, to create a stronger system to support us. Even though our main physician knew the most about us, we were equally happy to see any of the other physicians at the community health centre.

The other characteristic we identified is time. That’s actually time to see the patients. Many of the patients that go to Mid-Main are actually complex, chronic and have stronger needs — than myself, definitely. What was afforded under the structure is that time could be given to the more complex patients, the more elderly patients, those that I guess, if it was in the fee-for-service, needed more than the four fee codes to actually provide them with full support as a patient themselves. That was another aspect to it.

The third is groups and volunteers. As part of a community health centre, actually, patients did volunteer to assist in setting up support groups to bring in other patients to mutually support. This was a lot of the buy-in that the patients had into the system itself. Here we speak
[ Page 506 ]
of support groups on diabetes as well as high blood pressure and so forth.

This was more bringing patients back in, in a supportive situation, supportive setting, where it actually provided them incentive to better control their own health, and encouraging them to take on a more healthy lifestyle. Many times this was led by the clinical pharmacist who was on staff, who then could consult individually with the patients if there were any medication questions or anything like that.

The fourth one is attachment and satisfaction. This just gets down to that, as a patient group, we have a high level of attachment to our not particular physician but also to our community health centre. This translates to lots of the anecdotal feedback that we’ve received from our fellow patients that there was less incentive to go elsewhere — to go to the walk-in clinic, go to the ER, go to any other potential provider of health services. We would wait for our appointments and know that contact was always there with them.

[1440]

The final one, which is alluded to here, is actually less secondary care use. Lots of the services that were provided through the community health centre, by virtue of the team atmosphere — whether it is the clinical pharmacist, the nurse practitioner or the physicians themselves — allow many of the patients to avoid unnecessary secondary care visits. In this particular example here, it was the after-hours call, the 24-7 availability of one of the physicians to talk us through any medical issue and follow-up support in that way — so to be able to really rely on our health centres, the first point of primary care, and not worry too much about unnecessary secondary care.

Our conclusions out of this are that…. What we’ve noticed is that there are lots of successful funding models out there that are not necessarily fee-for-service, such as population-based or capitation. There’s a significant amount of research that looks at community health centres and non-fee-for-service models across Canada but not in B.C., unfortunately. The only real research that we could find was the Auditor General’s report that looked at health outcomes from the fee-for-service model and raised certain concerns about fee-for-service supporting complex or aging populations and the value for money there.

Out of this, we’re concluding or, actually, recommending looking at alternative funding models — as the previous presenter said, using our budget, the taxpayers’ budget, more wisely — and whether these different funding models could support the community health centre model as well as provide better health outcomes. That’s what our conclusions are.

L. Larson (Chair): You were basically operating a very successful clinic until, all of a sudden, fee-for-service became the only funding model that you had access to. What funding model were you using before?

G. Kozak: As I said, I can’t speak for Mid-Main Community Health Centre.

L. Larson (Chair): Do you have any idea how it was funded?

A Voice: Alternate payment plan.

L. Larson (Chair): Was it an alternate payment plan?

G. Kozak: Yes. Administrated through Vancouver Coastal Health.

L. Larson (Chair): Through the health authority.

G. Kozak: Yes.

L. Larson (Chair): Okay. All right. So it was through the health authority. Thank you.

Questions?

S. Robinson: Thank you very much for your presentation and for giving the user perspective, which oftentimes is missing from these sorts of things. We love to hear from the professional groups, but there’s the other side that, I think, we forget to hear from. So I’m really grateful.

Sometimes there are unintended outcomes of these sorts of programs. Can you think of…? You were very carefully documenting, by way of story, about where it’s saved money. What are some of the other benefits, when you think about…? I mean, I have my own experience of community care teams in this context. In what other ways do you think the community benefits by having this sort of setup within the community? Can you highlight some of the other…? It may be indirect benefits.

G. Kozak: Right. I don’t know if you know where Mid-Main is located. It’s on Main Street and 24th there. It is seen as, actually, a community hub for health care–related issues. It is seen as part of the community. I know they run other small programs out of it — I think Parents as Teachers, which engages with parents to promote their understanding of health care with regards to their children. It acts as a perfect springboard for other health-focused initiatives that can be, probably, set up a lot quicker and more efficiently through an existing health care centre that is supported through the various paraprofessionals.

S. Robinson: So kind of like classes that help people in their own health care and in managing their own….

G. Kozak: Yes.

S. Robinson: It’s beyond what we would…. I mean, we might consider prevention and education part of primary
[ Page 507 ]
care, but it’s even a little further upstream. They’re able to actually deliver other kinds of services.

[1445]

G. Kozak: Yes. That meets the classic definition of a community health centre — that it’s focused on illness prevention and better health for the individuals instead of just treating the illnesses at the back end.

S. Robinson: Health and wellness. Great. Thank you.

L. Larson (Chair): Judy, did you have a comment?

J. Darcy (Deputy Chair): Yes.

Thank you for coming, Greg, and for all of your efforts in trying to preserve and improve the model of health care that you had going at the community health centre. I’m certainly very familiar with it, as you know, and advocated pretty strongly for building even more robust teams.

I wonder if you could talk some more…. I think it would be important for the committee to understand more about some of these — like the diabetes and the peer counselling groups. Because my understanding is that they would involve both health care professionals as well as peer counselling, things like frail visits for the home elderly. If you could just describe more of the programs that were part of your community health centre.

G. Kozak: From my understanding, in terms of the group sessions, those that were prone or subject to, say, diabetes or high blood pressure actually came in and consulted with the various people — the health professionals that would be there, such as the clinical pharmacists, as I mentioned, as well as a physician that may be there. Your weight would be taken, blood could be checked at that time.

It was very much to assist in monitoring and provide positive reinforcement to dietary changes or other lifestyle changes that could really increase the health of the people that visited and partook in those groups there. They were very much promoted by the entire team there and well-known that these sessions were available to anyone like that.

I do know that physicians did regularly go on house visits for those frail or unable to come to the clinic themselves. That was a point of pride — that they did go out to maintain aging or ill people within the communities within which they lived. So that was a major benefit that we…. That gets back to: how does this benefit your community? As we like to have people that we know stay in our communities, that was a way of supporting that.

I don’t know how much more I can say.

L. Larson (Chair): Darryl’s got a question for you, here.

D. Plecas: Greg, I can’t thank you enough for your presentation. I think you should be inspired that we have heard your perspective over and over and over again. So many people have been telling us to head off in this direction.

What isn’t so inspiring: you come and tell us that everything everybody’s telling us to do is being shut down. As far as you know, what was the rationale?

G. Kozak: I know there’s innuendo that I could talk about. But as….

L. Larson (Chair): Remember this is a patient, not the manager.

G. Kozak: Yes. But we knew about what the…. What Vancouver Coastal Health was doing was they needed money to devote someplace else. So that’s as far as…. They just took the money away from the system and devoted it to — actually, what was one of the other points that you mentioned, from what I remember — a more super-clinic for the very marginalized and drug addicted individuals within the neighbourhood. So it was taking from one and moving to another.

L. Larson (Chair): Any other questions?

Doug, quickly.

D. Bing: Yeah. Thanks for coming, Greg.

I’m just wondering. Do you know who funds REACH Community Health Centre down on Commercial Drive? Is that the same people?

G. Kozak: Yeah. Vancouver Coastal.

A Voice: They’re in the process of doing to them what they did to us.

D. Bing: They’re doing the same thing?

G. Kozak: Yes. REACH is, I think, on a year notice or something around there.

D. Bing: They’ve been there about 45 years or something like that, yeah.

G. Kozak: Yeah. It’s tenuous.

L. Larson (Chair): Any other questions for our guest?

Thank you so much, Greg, for coming and sharing your experiences. It’s exactly what we’ve heard everybody wants to do, and it’s very disheartening to hear that you were doing it and doing it right, and now you’re no longer doing it.

Thank you for bringing your other patient friends with you. We really appreciate the fact that you took the time to come today.

Can we take five-minute recess?
[ Page 508 ]

The committee recessed from 2:50 p.m. to 3:01 p.m.

[L. Larson in the chair.]

L. Larson (Chair): We, as a committee, do have presentations from all spectrums. Certainly, there is always more than one side to any story. We all have passions that relate to whatever might be going on, as well, but we have to recognize that there is always more than one side to a story.

Keeping that in mind, we will move on to the University of British Columbia office of the vice-provost, health.

I’ll let you introduce yourselves. Thank you.

L. Nasmith: Indeed, I’ll introduce myself, and I will let Bill introduce himself. First of all, thank you very much for accepting our presentation and to come and speak with you today.

Our focus is looking at primary community team-based care with a particular message, which I’m just going to get to very quickly. I will do the quick presentation, and then Bill and I are happy to field any questions.

I’m Louise Nasmith. My official role at UBC is associate provost, health, but I need to tell you that I’m a family physician, so it was fascinating listening to the previous two presentations. I’ve actually had the incredible privilege of working primarily in team-based care settings, in Montreal when the groupe de médicine de famille was being formed, in Toronto when the family health teams were being formed, and now I’ve been out here for nine years sort of waiting for something to be formed.

B. Miller: I’m actually not from the office of the vice-provost, health, but I am from the faculty of medicine at UBC. Interestingly enough, I am not a physician; I am an occupational therapist by background, professionally. What I do represent within the faculty of medicine are those health professions embedded within medicine that aren’t actually doctors — so occupational therapists, physical therapists and midwives, among others.

You’ll actually see a slide of the 16 disciplines that are trained at UBC, on slide 10. Within the faculty of medicine, we have seven of those represented, between Louise and I here. So we’re hopefully giving you a team profile.

L. Nasmith: That’s the intent. We’re presenting on behalf of a large group of people at UBC.

My main message — let’s just cut to the chase. Our main message is that for team-based care to work, we, the collective we, need to invest in education. I’ll explain that as we go along.

I’m going to start with two stories, based on my own experience, that I think give us a few messages. The first: when I was a family doctor in Montreal, I had a young woman who was referred to me from a colleague who was moving out of the province. These two stories, actually, could happen anywhere. They could happen in any one of your ridings.

[1505]

This young lady had severe post-traumatic stress disorder after quite a violent sexual assault. I have to admit that when she came to me, I sort of gulped, thinking: “I’m not sure. What am I going to actually be able to do other than to provide regular care?” But as I started talking with her, I asked her: “What’s your goal in life? What’s your dream?” She wanted to be a teacher. She actually was enrolled in a bachelor of education at one of the local universities, but it was a tough slog for her because she had to do it very slowly.

As I got to know her, I realized she also had a psychiatrist. She was on, I think, three different medications. She also had a therapist.

Over time, I figured out how to sort of work with the psychiatrist. It didn’t work all that well, but we kind of worked together. But I also figured out, with her help, how to work with the therapist so that we actually could make sure that we were synergistic in our approach — that I could complement, that she could complement and that we weren’t giving crossed messages.

Well, over a period of time, she stopped seeing the psychiatrist, was off all her meds. That’s not to disparage psychiatry. She needed those meds for a time, but she was able to get off of them, which was good news.

When I left — that was one of the sad things for me; some of these patients are pretty important — she was still enrolled in her bachelor’s of education. Fortunately, we’ve been able to keep very sort of sporadic email, and now she has been, I think for the last three or four years, a teacher. So there’s a success story.

My second story is when I was in Toronto. The receptionist came to see me and said: “Oh, Louise. You’ve got a real dilly of a patient.” I thought: “Oh. What’s this?” So I went out to the waiting room, and there was this young man lying on the floor of the waiting room — right? — with all the other patients kind of looking at him, thinking…. I thought: “Oh dear. Okay.” So in he came.

He also had a tragic story. He was a truck driver in northern Ontario, I think, had some terrible accident — I don’t know what the nature of it was — and required back surgery. He subsequently developed an abscess on his spine — so a bad infection of his spine. And here is a young guy who had chronic pain. You’ve probably heard a lot about chronic pain.

Again, I kind of went: “Gulp. How am I going to…?” So again, I got to know him and figured out that…. He told me. I said — I guess I’m using the same approach: “What’s your dream? What does success look like for you?” He wanted to be a photographer. This was a really…. I mean, it was hard.

But, over time, I also had the joy of working with a social worker and a pharmacist. They happened to be in our clinic. Things started to just unfold. I uncovered
[ Page 509 ]
stuff, and we were trying different medication. I really felt I was getting in over my head in terms of really sorting out everything, so I was able to engage with the pharmacist, who really did help adjust medications.

We also helped him take control back of his life, because he had lost control. So he was controlling his own meds, documenting his pain and could really see relationships with certain things he was doing that would provoke it, etc.

He needed some help with housing, and again, I had no way of being able to…. One way was to say: “Sorry. Good luck. I hope you find something.” But I figured, well, I’ll go talk to the social worker. Maybe the social worker can help. Sure enough, the social worker had all kinds of tricks that he was able to bring into the care package.

He actually did get into a course in photography. He really minimized his meds. But I realized later on — I didn’t know much about occupational therapists, to my chagrin — that I should have had an occupational therapist involved. It was really too bad.

I don’t know the end of the story. Unfortunately, I haven’t kept up with him. All I know is that without the help of my colleagues, I couldn’t have done this.

The second part of the moral of my story is that I actually didn’t know how to work with them. I sort of flew by the seat of my pants. I intuitively sort of figured it out. I had never learnt.

You know, we talk about collaboration, and most people say: “Oh. I know how to do this.” Well, the reality is that we don’t. We actually do not know how to collaborate with our colleagues. Part of the reason is that we don’t really know what they do. Part of it is that we don’t really set up systems that will allow it to happen. Part of it is fee-for-service — a lot of other things.

[1510]

But what I’ve learnt — I want us to get back to the main message — is that we need to invest in helping providers learn how to work together, if we expect that they will.

What I’m going to turn to now are just some definitions. You’ve heard about primary care homes, right? There is some really good news in B.C. We now have primary care home or patients medical home. Those are the two terms that are being used. Here is the definition primary care homes are using for “interprofessional”: team providers work and collaborate together, support the health goals of patients and the health needs of a community population — an extremely inspiring definition.

Here’s another definition that’s a little bit more elaborate. This came out of Health Canada. I had the joy of being involved in the big Health Canada initiative over a decade ago. There are some really key elements here. It’s about promoting active participation of each discipline in patient care, right? It’s about enhancing patient- and family-centred goals and values. It’s ensuring that there’s continuous communication between health care providers. It makes sure that all of us have a role in clinical decision-making. It’s not the doc — and I can say that as a doc — who calls all the shots, right? It fosters respect for disciplinary contributions, and you can add a piece to this so that we can actually work to our full scope of practice.

This is actually a really lovely definition. I go back to it often. I was sort of sorting through it, and I went: “Oh. Let’s bring that forward.” If you can keep some of this in mind…. But looking at all this, this isn’t going to happen just because people are nice. Here’s another message. Putting people together does not make for a well-functioning team.

I don’t know. Are any of you from Trail or from that region? Well, there’s a wonderful example of a family physician working with a nurse practitioner. It was one of the early pilots. I think the nurse practitioner is funded through Interior Health. They’ve actually learned to work together, and they’ve got some incredibly good health stats about keeping people from going to emerg, keeping people from getting readmitted, etc. When they present, they talk about having to learn to work together, right? They’ve managed to do it, but nobody really gave them the heads-up to start with.

This is important. Whether or not they’re virtually together or even sharing the same office space, you can have people continue to work in silos very, very easily. Unfortunately, that is what happens.

What do we need? We actually need a lot. There are a few messages here, but when you’re building a team, you need to understand the population health needs. I remember in the early days when family health teams were being developed. I was part of a group trying to work with our own population to see what our needs would be. They made us go through sort of a needs assessment of the population. Strangely enough, they then came up…. This is government. Again, I’m not trying to be critical of: “Well, you have a family physician, a nurse and a pharmacist.”

Probably that is the core team, but in some cases, you probably will need a few mental health care workers. In other cases, you may need social workers. In other cases, it might be dietitians. In other cases, it may well be that you need physical therapists and occupational therapy. The needs of the practice population are really critical, and then defining the roles accordingly, defining the roles that your health care professionals are going to work.

The piece that we’re really trying to underline here is that you need to invest in education and training to achieve this. Once you’ve figured out the individuals who should be on the team, you’ve got to invest in education and training. It’s for the providers and for our students. That’s also an important piece of this.

We can do a whole bunch of stuff with our students in the classroom. Then they go out into practice, and they come back and go: “You guys were dreaming. You know, it’s not out there. It’s all a great lie. It’s a great idea, but we didn’t see it anywhere.” You can really just focus on
[ Page 510 ]
the providers, and then the students will come out, sort of going: “Uh, we don’t know what you’re talking about.” The two pieces. What goes in so that our grads are prepared…. The providers will need just as much investment in education.

However, we have good news. The good news is that a lot of people will say: “Well, what is collaboration? What does it look like? How do you teach it? Isn’t it just that people just talk to each other, and they’re nice, and what have you?” Well, we have, actually, a competency framework that’s a national competency framework. I’ll show it to you. I won’t go into a lot of detail, but it does spell out what people actually need to learn in order to work well together.

[1515]

The other really good news is that we in Canada, and specifically in British Columbia — and specifically, UBC — have a decade of experience in good interprofessional education. We’ve done a lot of work with our health authorities as well. It’s not just with our students. We can build on a lot of things. We don’t have to reinvent things. We’ve got an awful lot that we can share and give.

Here’s the competency framework. You can go on to the CIHC website if you want to look at this in more detail. Very briefly, the goal is good collaboration. It’s about being patient-centred.

In order to do that, you need to understand each other’s role. You need to understand how teams actually function, the whole issue of team dynamics. You need to basically look at how to resolve conflict, because whether you like it or not, there will be conflict. You need to actually look at how you share leadership. That’s an interesting piece to it, which, again, is an important one.

Here’s the slide that Bill was referring to. We have 16 health professional programs at UBC. The other bit of good news is that we are, for the most part, all working together and bringing our students together to learn together on specific issues. We’ve just developed an integrated ethics curriculum that is being run across eight or nine of our programs. There’s fertile ground here to work with.

We’ve developed curricula. We have clinical placements already so that you can actually get the students to go out, but we’re working more and more on developing more of these. It’s actually not easy to find and to develop the providers, as I talked about. But we’re working on that.

We’ve actually got quite a few years of professional development with our health authorities. Fraser Health actually has taken up a lot of this.

The primary care piece is still fairly new. It’s a part that’s dear to my heart and that I understand better than I do some of the in-patient work. But there’s a lot of work that we’ve already done, and we already have educational tools that we can use.

Our main message again: for team-based care to work, we need to invest in education. There’s lots of literature that supports this.

I think I will stop at that point and open it up for lots of discussion.

L. Larson (Chair): The team education, on how to work as a team…. Obviously, you’ve started it internally during the training of any of those medical professionals. Then you refer to that training continuing.

We had a presenter who actually said that in their clinic, they got together in the morning before they opened the doors and went through everything that was going to happen for the day and decided who was going to do what. At the end of the day, they got back together again to see how the day had gone — kind of a debriefing. That would be considered a type of team training, I’m assuming.

L. Nasmith: It would. It’s a piece of it. It’s a way of maintaining the team. I would actually call that a bit of having processes in place where you can actually figure out how you’re going to work together, right?

But to be able to go into the room and have the conversation, you need something up front. You can easily just put someone in that room, look at this with our eyes wide open and just figure…. I don’t actually know. I don’t even know what my role is going to be, let alone what your role will be.

That upfront work that needs to happen so that somebody could go into that room, regardless of where they are…. It doesn’t matter. They could be in Fraser Lake. They could be at the VGH. They could be anywhere, and they’ll just get it right away. It’ll just be natural for them to say, “Okay, this is a team meeting. We’re figuring this out. I can play my part,” rather than having to try to figure it out, if that makes sense.

L. Larson (Chair): Yes, definitely.

B. Miller: If I can add to that, I think that’s an excellent example of where we need to go, obviously. It demonstrates a lot of the characteristics of a good, functioning team: effective communication, sharing, probably distributing the leadership as well as sharing the goals, and having a clear understanding.

What we haven’t yet done — as Louise, I think, has nicely articulated — is be able to do that in a training environment, because that’s a one-off situation.

L. Larson (Chair): Questions?

D. Plecas: Thank you very much for your presentation.

In thinking about how we might do this, presumably you’re thinking you would build it into an existing curriculum — i.e., a course, right?

[1520]

I’m thinking: even if you did have the money, that must mean you’re going dump something out of the curriculum.
[ Page 511 ]

L. Nasmith: That’s a very good question. Bill can also answer this.

There are two main reasons why — at what we’ll call the pre-licensure, the student level — this is tough to do. The first is that our curriculums are packed. You can’t ask us to add one more thing.

The second is that if you want to bring students together, to learn together, face to face…. You can do stuff on line, but face to face is important for certain pieces.

We all have different timetables — so that whole notion of protecting time. Well, the good news is that we’re trying to take a different approach at UBC. Rather than say, “You are going to have another course,” we are integrating elements of this into the curriculum. There are pieces of this that are already being taught, so the approach is that we figure out: “All right. What needs to be learned? Where are we teaching it? Where is OT teaching it? Where is medicine teaching it?”

Rather than say, “You need to add extra hours,” we say: “We’ll create this integrated approach that will actually replace what you’re doing.”

D. Plecas: Across the curriculum.

L. Nasmith: Across that.

The second — and Bill knows this too — which is just hot off the press is that we finally have all of these programs agreeing to protect a time, that on Tuesday afternoons in October from whatever it is, all of the students will be free for interprofessional education.

L. Larson (Chair): Together in one room?

L. Nasmith: Well, they won’t all be together in one room, but the way we’ve done it…. I should have brought the spreadsheet to show you how we figured this out. It’s actually mind-boggling.

There are groups. We’ve been able to figure out which subsets of students when, so that if you wanted to — for ethics, for instance — have a case-based learning activity, you’d be able to know that, for these professions, we can actually get Tuesday afternoons for four consecutive weeks when we’ll break. We’ll have probably 25 different small groups running at the same time and the same thing repeated.

B. Miller: It was not a trivial task to actually pull that off, and it probably took close to ten years to accomplish it and to get agreement among all of the disciplines.

L. Nasmith: But we have it, and we’re doing it. That’s also symbolic of the fact that people see this as important.

B. Miller: The other thing, if I may, also…. I know we talked about a course. I think it’s clear that that was an example. But it goes beyond just the learning environment, the academic environment. We need to invest in protected time in the clinical environment for team learning. We need functioning teams within health care. Then, hopefully, that will role model.

I think that’s the other point that I want to emphasize that Louise made. Our target for this education is not just the students who are at the university, pre-licensure, but also the existing folks who are out there, because they don’t get it.

Donna made a really nice comment to us about 100 Mile House. There are family physicians there who’ve been there for a long time, so they’re entrenched in a common practice. They need the education as well.

L. Nasmith: As a matter of fact, I’d say that if there’s one real message, that’s the message. If we really believe in B.C. that we want to have more team-based care and really transform our system, then we need to help people do this. We can’t just expect that by throwing them together…. Even if we got to the point where we actually could have teams, it’s going to take them a long time and they’ll be frustrated, and we’ll waste time.

The investment sometimes is not a question of money. It may be lost income, which is why…. The physicians will say: “I can’t go to this session because I’m on fee-for-service, and I can’t afford it.”

That is why one of the big needs here is that I think we do need to look at other remuneration models. Like it or not, pure fee-for-service…. Maybe partial could work, but pure isn’t going to work — so the realization that we need to actually build this into our models.

We need to make sure people understand that — that they have protected time and that it’s recognized and rewarded in some way. I mean, rewarded is probably…. I don’t mean monetarily and any other way — but probably recognized as being important.

As I said, we have expertise to help do this. You don’t need to actually invest a lot of money in building programs for it, because we probably have enough programs. We probably have enough resources that we could do this with a minimum amount of money. Now, I may regret that I even said that, but I don’t think money is the issue here. I think it actually is a realization that we have to do this.

[1525]

S. Robinson: Thank you so much for your presentation and for loading it up with stories at the beginning, because I think they really help. I’m a family therapist, and I’ve had excellent physicians that I’ve worked with and difficult physicians in terms of finding out how to best manage a shared client.

I like how you framed it — not whether we should work collaboratively…. I think that’s something that we’ve heard a lot. It’s the how, and what our expectations should be around the how, and that we ought to be investing.
[ Page 512 ]

You’re doing this training. I loved hearing about the shared ethics course. That makes so much sense in giving people the opportunity. But then we have the old way. I’m wondering how you would envision, as we have these new graduates who have a different model, different expectation and a different passion for working collaboratively…. They have the how. Then we have these who don’t have the how. How do you envision the transition? I think that’s going to be the hardest part.

L. Nasmith: There are a lot of pieces to that transition. The first is that I think we need to be very clear that this is where we want to go. If team-based is indeed what we want to do…. Having a bunch of pilots is fine, except that B.C. has a lot of pilot projects. I mean, there are a lot of pilot projects. When I travel around or I hear people talk, I just think: “Wow, there’s so much good work going on, but no one is connecting the dots.” No one is actually creating a system of care.

One size will not fit all, which is one of the early slides. We said you need to look at…. If you think about it, you go into whatever community and get the divisions of family practice to work with you, and you can get others to define patient need — the real needs of a community, the population needs — and then figure out how you can build teams. What would they look like?

S. Robinson: Who would lead that? It becomes a question about: someone has to pull it together.

L. Nasmith: That’s the big problem. I would have thought when I first got here: “Well, health authorities should lead this.” But they have no jurisdiction over primary care.

I think one of the intended outcomes of the divisions was to create better relationships with the health authorities. I think that this would be government having the courage to actually make some very clear pronouncements of: “This is what you’re going to do. Guys, you’re going to need to figure this out. Here’s a sort of prototype. This is what it should look like. It will be contextually defined, but here’s your approach. These are our expectations, and we’re going to hold you accountable.”

I may be getting out on a limb saying that, but….

J. Darcy (Deputy Chair): Following on that last question. I mean, the divisions of family practice, on the one hand, would seem to make a lot of sense. They’re the ones that have been assuming the role about increased attachment, but most of the divisions of family practice only involve physicians.

There is a disconnect there. So is it about then transforming who is part of divisions of family practice so that those other parts of the health care providers…? I know it’s just one piece of it.

I agree with you, absolutely, about provincial leadership and about saying: “This is where we are going.” Then community by community, is it…?

L. Nasmith: It’s why I do believe that this has to be a partnership between…. I think the divisions have done a lot of good work. Just getting family doctors to work together is a big step. But using the divisions, working with the health authorities.

We don’t have a lot of extra money, if any, in the system. A lot of people are going to say: “Who’s going to pay for the nutritionist or the etc.?” The family doctors are going to go: “Don’t ask us to pay this out of our fee-for-service.” Nor should we, right? In all fairness, that is not right.

I actually believe we have enough resources in the system, probably in our hospitals, and we need to move them out. It’s a shifting. That means the health authorities have to be partners. That’s where government says: “Health authorities and divisions, figure this out. Here it is. These are some of the parameters you’re going to work with. We’ll come back and see where you’ve got to, but you’re going to have to get somewhere on this one.”

J. Darcy (Deputy Chair): Does that include other health professionals in the divisions of family practice, or in the health authorities, then?

[1530]

L. Nasmith: It’s in the health authorities, right? I think we just need to think of divisions as a good way of getting family doctors to work together. I wouldn’t try to get…. I think that’s an extra layer. You don’t need to include that.

But the other health professionals absolutely have to be part of the discussions. Otherwise, we won’t get it right.

L. Larson (Chair): Okay, Darryl. Last word.

D. Plecas: In academia, as you know better than anyone, there’s a need for continuing professional development, continuing education. In fact, universities provide that. One would expect that health care would be one place where there’d be a huge demand and need for professional development. Yet we don’t live in a world where funds are provided for that.

Do you have any comment on that? It would seem as though you would be the perfect people to lead that charge.

B. Miller: I think we would agree, right from the new president on down.

The interesting side note on that is I think continuing professional development at UBC in the faculty of medicine is probably looked upon as being a leader across Canada. There is a good platform for it. It is strictly focused right now on medicine. There is some growth into other areas, so the midwives are starting to
[ Page 513 ]
get some representation. PT has a strong movement going forward, but it is at a bare minimum. It’s partly because, I think, there are different regulatory requirements for physicians. They are required to do their CPE credits, and none of the other health professions are, or few are.

L. Nasmith: Actually, a few do. Nursing does a little bit.

B. Miller: There’s a way to generate money within medicine to pay for that continuing education, but it’s not across all of the health professions.

L. Nasmith: However, there are…. We are actually talking about this and looking at working together in the world of CPD across health professions. It can look different. It could be specifically on building teams, right? It could be a session on that, but it also could be: why is it that we all go to diabetes sessions separately when, probably, we have the exact same issues, right? We could actually learn from each other.

We’re just starting those conversations across the health professions at UBC. But beyond that, the funding issue is…. For the non-MD health professionals who work in health authorities, this needs to be seen as an important part of their job and not something they have to beg to go to. The health authorities have to recognize that this is actually something they should be doing.

The other, also interesting, piece around family physicians, who might…. Traditional CME, right? You go to a course on arthritis or what have you. You don’t go to a course on building teams. Who would do that? The B.C. College of Family Physicians, in their reflections on the patient’s medical home and trying to push it forward, have actually started to talk about incorporating, in some of their CPD days, sessions on this.

As a matter of fact, when they did a recent poll at their last conference, asking family docs across the province, “Would you be interested,” they had a huge positive response.

This is good news. This is meaning that family doctors are saying: “This is really important. We need it, and we would actually come.”

Funding — yes. It would be lovely if UBC got a whole bunch of money to be able to do this. I may be a Pollyanna on some sides. I’m not that naive to think that that’s likely to happen. I think that if we really believe this is important, we can make it happen. My worry is that we’ll get part of it right, and we’ll forget this part. Then we’ll get partial success, and we’ll have a lot of frustrated people, and it will take a lot longer than it needs to take.

L. Larson (Chair): We will try and capture it, for sure. Thank you so much for being here. We’ve run overtime, of course, because we always get too interested in everything that’s going on.

Thank you so much for coming and sharing, and the fabulous work that you’re doing out at UBC. It’s just really a gem for the whole country — what you do there.

Dr. Mathias, you can work your way up there as soon as you like. We’re already running a few minutes behind, but that’s okay. We’ll give you your full 15 minutes — late, regardless. I just won’t let these guys question you.

[1535]

R. Mathias: May I ask: how long have you been sitting as a group?

L. Larson (Chair): It’s our fourth day. You’re No. 11 for today only. You’re the 11th.

R. Mathias: Okay. I would suggest you all stand up and take a deep breath. Maybe even two or three.

L. Larson (Chair): All right. Everybody stand and stretch.

Thank you. We needed that.

Okay, it’s all yours, Dr. Mathias.

R. Mathias: Okay, first of all, I’m deaf. I have hearing aids in, but my wife claims that I don’t turn them on or that they don’t work. Pick your own poison there. So questions…. Please be loud and directive, and I’ll do the very best I can to deal with it, because I hope there are questions.

I have given you a handout, which contains, I think, a synopsis of what I want to say. But what I want to do here is to focus on the issue of cost-effective and primary and community care. I also want to challenge some very deeply held beliefs, and I want to do this because I think the health issues are immense.

When I was a medical student, which was a long time ago — and yes, I did graduate — I was actually, I think, a class ahead of John Blatherwick, who I’m sure many of you have heard of. I also taught Perry Kendall in community medicine. So I’ve been around a long time.

I’m reminded that during classes we used to smoke. During any break, we used to smoke. At a meeting like this, I would have expected that probably 60 to 70 percent of the people would have smoked, and it would have been not a problem. Four or five years later, you would have been thrown out on your ear. So the paradigm that smoking was not harmful, or at least was not sufficiently harmful that we should all quit, is one that we have come across before.

I’m going to propose to you today that we need to work together as a health care team, because I think we have an equally strong shift in our thinking that’s necessary. The Senate of Canada has very recently released a report basically on “A Whole-of-Society Approach for a Healthier Canada.” I would like to take some of their observations and bring them forward.
[ Page 514 ]

As I’m sure you all are aware that anybody who’s been a professor at UBC — particularly in health — can talk for an hour and give you absolutely no information whatsoever but sound important and pedantic, I encourage you to interrupt with questions as they come to you and that we don’t necessarily do this as a 15 and 15. I find it more fun that way, and I suspect it will be of more interest to you.

The issue that I want to address is obesity. Obesity as an isolated syndrome, as an isolated effect, should not be our major concern as health care people. The issue with obesity is that many of the people who have obesity have what we call metabolic syndrome.

They have higher risks of heart disease. They have higher risks of some cancers, and I’ve listed them for you in the handout. They have an immensely higher risk of type 2 diabetes, which I think we all recognize now is epidemic. And two more that you may or may not see listed so often are depression and the one that’s of particular interest to me, as I’m entering the age group: dementia. I’ll try to sort those out with you as we go through this.

[1540]

The World Health Organization, about five, six, seven years ago, declared obesity as a pandemic, which means that it’s a worldwide phenomenon. The causative issues behind this epidemic — and as an epidemiologist, that’s what I’m looking for — need to be able to be applied on a worldwide basis.

The current model that we often use is a behavioural model. People eat too much, and they exercise too little. That model is correct, but it has no explanatory power of why this is occurring. It’s an observation, not an explanation. The explanation is that we eat too much sugar.

We’ll do a little biochemistry. Why not? As you know, sucrose is made up of two components: fructose and glucose. Both of those have quite separate kinds of biochemical reactions. Glucose, as we all know, stimulates insulin. If you stimulate insulin with enough glucose, sooner or later the pancreas says, “Forget it. I’m not doing this anymore. I have too much work,” and you get type 2 diabetes.

But in the process of doing that, insulin also does some other things. It requires the storage of fat, because you can’t store very much glucose in a cell, but you can store lots of fat. So one of the actions of glucose is obesity. Another action of glucose that comes in is in the making of fat. It makes some very specific fats, which we now recognize are risk factors for coronary heart disease.

Fructose, on the other hand, does not get in the circulation at all. It’s released in the gut, goes to the liver, and the liver has to manage it. What we’re finding — or, at least, what has been reported to me from the endocrinologists at Children’s Hospital — is a syndrome, commonly, that we never saw before, which is non-alcoholic fatty liver disease. Basically, what’s happened is the fructose goes to the liver. The liver must change it into another form, and one of the things it changes it into is fats.

The other thing that happens to that, while it’s trying to do that, is inflammation. It produces a lot of inflammatory markers. That inflammation is, then, what is occurring in the rest of the body, because these markers are released into the circulation. Now we have a situation where we have the two major components of sucrose causing adverse effects, and these are actually pretty well known.

What do we do about that? Well, we’ve done some things in schools. We’ve tried to reduce sugar-laden drinks, but we have not taken that nearly as far as we need to as public health people. What we need to do is to reduce sugar intakes across the board.

Why do we have this dramatically increased amount of sugar consumption? Well, it tastes good, but there’s an underlying reason for it, and we have to take responsibility for that underlying reason. The underlying reason was promulgated widely in 1970 in “Diet for America.”

“Diet for America” said that the reason we’re having this epidemic of coronary heart disease was fat, and in particular, saturated fat. When you go back and look at the evidence that that was based on, they don’t have any. There was one very, very badly done — in a matter of fact, it was falsified — study, which was sort of the basis, because the person who did the study was a very forceful speaker and also was not a nice person. If you didn’t agree with him, you didn’t get research funding. And you’ve just heard from universities that we live on research funding.

[1545]

The idea that saturated fat is the underlying cause of heart disease is wrong. There was a study just done by McMaster University where they took a broad range of studies. They found that the risk of coronary heart disease or overall mortality, based on the consumption of saturated fat, is a one. That means there’s no risk. That’s been replicated now in many different places.

Our message to the public has been “reduce fat.” So what are you going to replace it with? Well, you replace it with carbohydrates. The carbohydrate that is sort of easiest to get and tastiest is really not broccoli, even though my grandchildren are not bad on broccoli. I’m not so keen myself. But we tend to do it with things that are sweet. I notice that right over there, you have a number of drinks. The Perrier is fine, but the fruit juices just in front of it will be high in sugar.

We cannot blame the food manufacturers for this, because we told them to get fat out of their products. They said: “Okay. We’ll do that.” So what did they replace it with? If you take fat out, you might be interested that much of your food will taste like this piece of cardboard, because fat tastes good. You take it out, and what you have left doesn’t taste very good at all.

What did they do? They put in something that tasted good. What was it? Well, it had to be cheap, and it had to be readily available. It was sucrose. Sometimes they
[ Page 515 ]
cheated a little bit and they put in high fructose corn syrup, because as you know, in the U.S., that’s a fairly major product.

Here we are. We have a problem. The prevalence of…. Well, we rank, in terms of 40 different countries, fifth in terms of obesity in adults and sixth for children. We need to do something about this. We need to do something that addresses both obesity and the underlying metabolic syndrome. That is that we need to change our dietary recommendations.

Now, can we do it? Oh yes. Dr. Jay Wortman and I did a project in Alert Bay. I’ve given you the URL to three videos from CBC called My Big Fat Diet, parts 1 through 3. I highly recommend you read it. A great result. As soon as the team disbanded, because of the end of funding, a number of people went back to where they were. So the team approach that we used up there is very important.

It’s also been replicated now in the north. A number of family physicians have gotten together with a health care team and started people on a very low-carb, high-fat diet. They’ve had dramatic results. Now, whether those will be sustained without a health care team support is very much open to question.

What my presentation here is: we need to change what we’re saying, but we need the change throughout the health care system. If we can bring out very low carb — particularly very low sugars — and increase the fat content, we’re going to improve the metabolic standard of people. That means we’re not going to need statins, because we’re going to change the cholesterol profile back to what it should be. We’re going to need very much less treatment for type 2 diabetes, because in much of it we can actually reverse the biochemical abnormalities. Can’t do a thing for type 1 — different issue.

Whether we will be able to reduce cancers I think is a long-term issue. I don’t think that will be something we can immediately see.

Depression, in some of the trials, has been reversed very quickly. That’s a major issue. Dementia has been less well studied, but Alzheimer’s is an inflammatory dementia. It seems only logical to me that if it’s an inflammatory dementia, getting rid of the inflammation is very likely to decrease the risk.

Now, I can’t give you five things that are more important for us to deal with as a health care team.

[1550]

There’s information in here. There are some references. That’s my presentation, and as usual, being a bloody long-winded academic, I’ve gone over my time.

L. Larson (Chair): That’s quite all right. Thank you. Incredibly interesting. We have — I’m sure all of us — over the last while, read and heard about some of the studies that have been done, especially regarding fat and whatnot. Questions?

J. Shin: Thank you so much for that. I mean, it’s exactly as you said: when you examine the prospective association with, say, type 2 diabetes and the sugar consumption before and after the adjustment for adiposity and estimate the population attributable fraction for that — all the systemic reviews, the meta-analysis, do point towards the fact that we need to do a better job in sending out a clear message and to campaign hard on reducing the sugar intake.

I recently had a conversation on this topic with several of my former colleagues, and we were all sort of scratching our heads, like: how exactly do we approach that? Can we, from a government side, talk with and reach out to the corporations and set a hard policy where we can put a maximum cap on the amount of sugar that our food products can come out with?

Do you know of any other jurisdictions, on a policy level or as a government initiative, that can do a better job in limiting, I suppose, the sugar intake? That is really hard in a free country.

R. Mathias: Well, it’s going to be difficult. I mean, my grandchildren love drinks. Unfortunately, some of the artificial sweeteners have similar effects to sucrose. I’m not quite sure of the mechanism for that, but you can’t just replace them with artificial sweeteners.

What we have to do is develop a public heath message that says: “Mea culpa. We were wrong. Saturated fat is not harmful.” We have to talk to the manufacturers to get saturated fat back in. An easy one: 1 percent milk should be banned. We should have our children drinking whole milk, which is 3½ percent fats. It’s not a huge shift, but conceptually, it’s a major shift. Personally, I like whipping cream.

L. Larson (Chair): Me too.

R. Mathias: Yeah, 33⅓ percent. That’s what I put on my cereal in the morning.

We need to reassure people that replacing sugars with fats is good. When we were doing the study at Alert Bay, one of the rules we had is that you never, ever go into the middle of a grocery store, under any circ*mstances. You go around the outside, where they have the vegetables, they have the meat, they have the cheeses — all of the things which are not particularly high-profit but which are much, much healthier.

We need to go back to…. We were trying to go to a traditional or “native”…. Well, we were trying to persuade them to have a traditional diet — critical for our First Nations peoples, because their only real source of fat was oolichans, for which now, of course, our fisheries management is such that there aren’t very many anymore. The fact is, we can reassure them: it’s okay. They used to literally dip smoked salmon in oolichan grease. That was the traditional way of eating it. We need to per-
[ Page 516 ]
suade them that it’s okay to go back to that style of diet. In so doing, hopefully we can get the message forward that fat is good for you.

Now, all fats? Absolutely not. The manufactured trans fats are clearly a problem. Even in the systematic review that I just quoted, for saturated fat, the risk was 1. That was not true of trans fats. They are inflammatory in and of themselves. We don’t want to replace sugar with manufactured or trans fats. We want to replace it with saturated fats or, in many cases, fats from olives and grains and other things.

One of my big problems is flour. It’s starches, because a starch has a backbone and then it hooks glucose to it. That’s how it stores the glucose for further use.

[1555]

Trying to deal with the issue of bread, I think, is going to be a really major one. I can’t do it, but we need to work with the nutritionists and the dietitians. I can’t…. Well, anyway.

The problem is….

Interjection.

R. Mathias: Yeah. It’s a real problem. They say whole wheat. You’ve got to remember, though, that whole wheat…. They have not taken it out, but they’ve left the white flour in. I mean, that’s not something that’s been removed. So there are a whole lot of very critical public health issues to be dealt with, with messages that need to come from people that can be trusted.

The tobacco manufacturers tried very hard to keep you quiet. The sugar manufacturers are going to be even more difficult. That’s your problem. That’s not my problem; that’s your problem. They went after the public messages, and they went after….

L. Larson (Chair): Marc’s got a question for you.

M. Dalton: Yes, kind of along the lines of what Jane was asking.

It’s fairly revolutionary. Now we’re talking about sugars, and we’re talking about carbs, but on the other side getting that message about fats, which people are quite adverse to. I mean, there is push back, too, inside, obviously. The nanny state’s type of mentality. I think of, for example, New York City — the extra fees they’re charging for, I believe, Big Gulps, or that they’re banning it.

My question is more along the lines of implementation. Is it more along Health Canada? Or just multilevel, I suppose, from the provincial side and messaging education? It’s all those, I suppose, on this.

R. Mathias: Certainly, this has been presented to Health Canada. I’ve done it, some years ago now. It is difficult to change a belief system. It’s a paradigm shift that we’re doing. It’s a tougher paradigm shift than smoking was. I think smoking was much easier. So I think we need to try to find out what’s the low-hanging fruit that we could get.

What I think one of the sets is that we should require hospitals and long-term care, and other places like that where food is being served, to offer a low-carb option. I don’t think that they’re going to shift immediately, but right now, if you’re in your hospital bed and your breakfast comes to you, it’s not a low-carb breakfast at all. It would be very helpful if we at least had an option where people could check off and say yes or your physician could say: “I want this patient on a low-carb option.” At the present time, there are not those kinds of options.

Now, go to White Spot. They have a low-carb breakfast. But there are not very many other places that do, so we need to push to at least give people options where they can be low-carb and have a greater chance of actually being able to find something that is low-carb. Good advertising for them; good health care for us.

D. Plecas: No question. I just wanted to make a comment. I thought your presentation was wonderful. Thank you very much for giving it.

R. Mathias: You’re most welcome, Darryl. I have had it once or twice before.

L. Larson (Chair): We never would have guessed. Thank you so much. While it’s not the type of presentation we’ve had on this road trip that we’re doing, what you’ve brought forward would be a huge saving to the health care system.

R. Mathias: Absolutely.

L. Larson (Chair): Absolutely huge. Thank you very much for putting that on the table, so to speak. We will make sure that we capture that in our report.

R. Mathias: Thank you very much. It made the trip in worthwhile.

L. Larson (Chair): There you go. Thank you, Dr. Mathias.

Interjections.

R. Mathias: Read the label. How much sugar’s in that? A lot.

Interjections.

R. Mathias: Don’t tell anybody, but alcohol is still okay, too, because it goes through a different metabolic process. Alcohol dehydrogenases. You don’t want to wipe your liver out, but if you want a glass of wine tonight, you
[ Page 517 ]
certainly won’t hear me object. If you want a glass of beer, now we have to talk carbs.

Interjections.

[1600]

J. Darcy (Deputy Chair): That was all on Hansard. Do you know that?

L. Larson (Chair): He does not mind — guarantee you.

All right. If I can ask the B.C. Chiropractic Association to come up to the table, please.

Welcome. As soon as you’re ready, you can start and introduce yourselves first, please, though your faces are familiar to most of us at this table. Still, I’d like you to do an introduction for the sake of Hansard, please.

J. Robinson: Sure. Well, thanks for having us here. I’m Dr. Jay Robinson. I’m the president of the Chiropractic Association here in B.C. This is Lisa Kallstrom. She’s our government affairs and policy person. We’re very proud to have her with us after we recently stole her from the Doctors of B.C.

J. Darcy (Deputy Chair): They’re coming tomorrow.

J. Robinson: That’s my ba-dum-bum for the start here.

You know, we really appreciate everyone’s participation in this committee, because there aren’t very many opportunities to have a laugh, I would imagine. The last presenter did give you one, and that’s welcome, I’m sure. I’ve sat through these things, and I really don’t know how you do it day after day. But thanks. I promise not to bore you with endless asks for money that you can’t give.

L. Larson (Chair): Okay. That would be good.

J. Robinson: I thought, maybe.

B.C. Chiropractic Association has been around for a long time. It was first conceptualized in the ’20s, put into place in the ’30s. One of our first presidents was the grandfather of a current MLA. The first president was Walter Sturdy, and Jordan Sturdy’s the West Vancouver–Sea to Sky MLA. That’s his grandfather. So there’s another interesting tidbit.

J. Darcy (Deputy Chair): Maybe you will get that money you asked for.

J. Robinson: I should have come with a bigger ask.

Since those humble beginnings, chiropractic has come a long way. We’ve got chairs in research in ten of the major universities in the country. We’ve got them tenured. We’ve got them working on all kinds of different things now, participating in health care. We’ve got chiropractors in hospitals. We’ve got chiropractors in regional health authorities and clinics all over the country — but not here in B.C. We’re sadly behind the curve in B.C. when it comes to musculoskeletal health care delivery compared to the rest of the country. We’ll get back to that in a moment.

What we know about chiropractic here in B.C. at the moment — that’s the one that starts with the 900,000 if anyone’s turning pages…. About a quarter of the population is seeing a chiropractor in any given year. That’s a lot of people who are seeing a chiropractor that currently aren’t really involved, in a communication sense, in health care. We’ve got chiropractic doing one stream. We’ve got traditional health care doing another. And really, chiropractic care is part of mainstream health care, and we need to do a better job of talking to each other.

We’re trying to do that on our end. Our college is part of the Health Regulators organizations. We’re trading information back and forth. We’re doing that on the association side. We’re doing that — attempting — in individuals and communities. We’re not doing that very well formally, and that puts patients at risk. It’s starting to be an issue as patients get smarter and read things on Google and start trying to play us all off of each other. I see some people nodding.

We also know that about 61% of patients have seen a chiropractor in their lifetime. That’s a large percentage of the population, really. We also know that a little over 80% of people would recommend a chiropractor to another person. So that’s good. We’re doing a good job in the patients’ minds, in their eyes.

[1605]

In the issues facing health care in B.C., musculoskeletal care…. That’s the muscles, joints, nervous system issues that we all end up facing, that we face more and more as we get older, that I look myself in the mirror every day and see I’ve got another one coming up. I’m sure we all do. About a third of all of us have a musculoskeletal condition. It’s that prevalent. The World Health Organization says that musculoskeletal care is the largest health care burden that we face. A majority of musculoskeletal care issues are low back pain. That’s chiropractic care.

Chiropractors are part of the World Health Organization, by the way. We’re part of that whole situation.

We have been looking at your health priorities. I guess this would be page 8, for those of you that are flipping things. We’re finding there is a really good fit between what you’re trying to do and we’ve been trying to do. So there are going to be things that, if we’re working together a little bit better, we’re going to see some efficiencies in. We know that because we’ve got research on that kind of thing now.

The research on putting chiropractic care into health care systems started in the ’80s with the Manga report, and since then, we’ve seen chiropractic care included all over the place in different ways and forms — and the research continues.
[ Page 518 ]

We know that interdisciplinary teams are cost effective. Chiropractic care is part of interdisciplinary teams all over the place, but not here. We know that we see addiction issues decrease when chiropractic care is involved in musculoskeletal care. It’s not being done here. We know that we get improved care in rural health situations because we have chiropractors living in rural areas. I’ll talk more about that in a minute.

We looked at your health system priorities that you’ve published, and funnily enough, we have a lot of those same ones too. We’re working outside the system. We have the same goals. In other provinces, throughout the U.S., Mexico, Europe and other parts of the world, health care systems have added chiropractors and are recognizing the benefits in cost reduction and patient satisfaction — patient care benefits of having chiropractors part of the team.

The collaborative, interdisciplinary team approach is strong. We’ve got extensive evidence, not just in chiropractic. We all know that this is the way that we need to be going in health care overall. It’s strong. We know here, in B.C., that emphasizing everybody’s scope of practice is the right call. It’s one of your goals, and it’s one of our goals. We want to work more with you in being an active participant in developing the collaborative care models here, in B.C., that chiropractic care is part of with everybody else.

We’ve heard people in health care say: “Oh, we’re doing this. We’ve got health care teams in places…. We don’t need it.” Chiropractors haven’t been invited to participate yet. But it’s kind of an odd thing. Did you know that other health care professionals are getting trained in delivery of chiropractic care? There are weekend seminars, there are different things like that, and they are part of the health care teams delivering the chiropractic care. That seems a little bit like your car mechanic fixing your $5,000 guitar. Sure, he’s good with his hands, but maybe it’s something different there.

We should be putting the chiropractors into those situations. The chiropractors are doctors. They’ve got undergraduate degrees. They’ve got four year post-graduate degrees, the same as a medical doctor. They’re the ones with the expertise to be participating. They’re also the ones who have the training in participating in teams. So the people that come here to work as chiropractors — the people who come to B.C. — are already trained as interdisciplinary team members.

So what happens when you put a chiropractor on the team? Well, there’s all kinds of evidence, for a long time now, that when you put a chiropractor on the sports teams, on the Olympics, into the hospitals and into the everyday clinics it goes really well. Everybody is really happy about working together.

The worries about barriers — where physicians are going to hate chiropractors and chiropractors are going to hate physicians and all that kind of stuff — have been completely unfounded. The outcome studies of that have shown that everybody’s really happy that someone else is doing a piece of work they don’t like to do, which is typically what does happen. We know that our MD colleagues really don’t care for having to deal with low back pain and things like that. For them, it’s a burden. For us, it’s a joy. When you put the two of us in the same room, we’re both smiling and getting along.

[1610]

That creates increased capacity in our system. It reduces wait times. This has been demonstrated in Ontario in their family practice models.

There’s something else that happens. We’re aware of the initiative to decrease MRI use and X-ray use and that type of stuff. Well, MRI requests go down 27 percent when you involve a chiropractor in the team. Patients who are referred to chiropractic care have 25 percent visits to their family physician. We also have the research showing that X-ray care itself, orders, goes way down when you involve a chiropractor.

The association, the place that I work, is currently co-funding a study that has chiropractors working at VGH through ICORD. ICORD is one of Canada’s leading spine treatment centres. Chiropractors are the only non-paid member of the team.

We volunteer to be part of that, and we’re there because it’s the right thing to do. It’s the right thing to demonstrate these outcomes that I’ve been talking about, which are in this paper — the decrease in wait times, the decrease in needed surgeries, the pressure off of the surgeons, the better outcomes with patients, the decreased opioid use. All this stuff shows up in these kinds of studies, so we feel it’s important to participate.

It’s our first salvo into getting into the system here. So it’s not surprising, maybe, that we’re doing it on a volunteer basis. We do wish to participate more. The outcomes and the research are well known everywhere else, and we can make a big difference here in this province by having this a little bit more ubiquitous.

We come to the diagnostic imaging and the X-rays and the things that I just mentioned a moment ago. Diagnostic imaging is part of what chiropractors are trained for and what we do. We have the right, under the college, to be able to take X-rays, to order X-rays, to send patients for X-rays, to interpret the X-rays, all that kind of stuff.

Here in B.C., because of the way our systems are organized, when a patient requires an X-ray in order that they may even start treatment or before they have an examination…. Let’s say they fell off their roof. Can you work on this person without an X-ray? No, you need to…. You can’t even examine them properly — that kind of thing.

So the patient goes back to their medical doctor. The medical doctor then does a procedural visit and goes: “Go get an X-ray.” They then go back, go to the lab, get the X-ray. Now they go back to the medical doctor. The med-
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ical doctor goes: “Here’s the report.” They now go back to the chiropractor. That can take over a month.

The chiropractor has all the education and training and everything in place to order that X-ray. You’re going to pay for it anyway. Or the MSP program is going to pay for it anyway.

The only person that benefits by having the chiropractor order the X-ray is the patient. The patient goes in through the system quicker. They see the chiropractor that first day. They go for the X-ray. They’re back to the chiropractor in a couple of days. The care can go forward. Or if there’s a finding of significance on the X-ray, the patient now shows up back at the medical doctor’s office as a qualified patient with a true reason to be there.

We’ve saved a visit, one visit. If we’re dealing with a million people a year…. Certainly, it’s not a million people needing X-rays. It’s a tiny fraction of that. But that means we’re saving some medical visits for people who really do need them instead of a procedural visit of just: “Here you go. Go get the X-ray before you can get any care, before you can get an examination.”

A chiropractic examination of a low back is much like an orthopedic surgeon’s exam. We have the results of the studies that show that chiropractors order X-rays dramatically less. Because you do a larger, more significant exam, you don’t default to sending someone for an X-ray.

We’ve got the studies that show that type of thing. So there’s not a worry about: “Oh my gosh. We’re adding people to the X-ray pool. There’s going to be more cost.” No. Two things. You’re already paying for the X-ray, and chiropractors are going to order less of them anyway. So it’s going to be a net savings there of some smaller amount and a savings of time to the medical doctor so that we’ve got better capacity to deal with the people that do need to be seen.

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It’s good when you can skip a whole page. That gets us to the addiction recovery programs page, in case anyone’s reading along.

That patient that was sitting there waiting for a month is just one type of patient that is sitting there, unable to work, unable to do anything because they’re at a high risk. That’s why we had to send them for the X-ray in the first place. They probably went to their medical doctor in the first place for a pain medication. The medical doctor probably sent them out and said: “Go to physio. Go to chiro.” Or whatever. That’s how they ended up in the chiropractor’s office.

The chiropractor is now saying: “You need an X-ray.” This person is waiting for a month to go through the system. Meanwhile, they’re taking opioids. A significant number of these people end up with opioid addiction. This is ridiculous. There is no need for that at all. They can be funnelled through the system much quicker, completely safely and never even get to that point where they can last long enough to develop an addiction.

This is just a simple stroke-of-the-pen change. It costs nothing. It saves people a lot of grief. We could do that today.

WorkSafe and ICBC recognize these things already, and WorkSafe and ICBC already include these diagnostic imaging types of rights with two chiropractors. It’s all paid for. It’s all covered if you’re under one of those kinds of claims. In fact, WorkSafe B.C.’s stats show that chiropractors get people back to work quicker than anyone else — very quickly. We’re motivated to.

Part of the chiropractic thing is the active lifestyle concept. That fits into one of the other things that we’re all about here. But I jumped a page, so I won’t go there quite yet.

We also have studies showing that when you’re dealing with other opioid chronic pain people, not just the one who fell off his roof, those people also benefit from receiving chiropractic care. We’ve got a couple of studies now that show there are dramatic reductions in the amount of opioid use, the severity of their problems and in how they can cope with their lives. Part of that is they’re having someone talk to them. They’re having someone work on them — all the different things.

We’ve got the studies that show that. It’s another compelling reason to involve a chiropractor on these health care teams.

When we talk about rural health care, we’ve got chiropractors everywhere, in all the tiny places of B.C. Anyone here heard of Tappen? No kidding? I’m impressed, Donna. There are 74 people living in Tappen. One of them is a chiropractor. Anyone heard of Celista? You know your way around. There are about 200 people living in Celista, and one of those is a chiropractor. And there’s Cobble Hill and Cowichan Bay. Those are around 500 people, and they’ve got chiropractors.

We’ve got capacity in these little towns. The chiropractors can step up and help in other ways and help with the burden of access in rural care. We’re ready to do it. The chiropractors are there already. We don’t have to do anything differently. We just have to say: “Yeah, okay. Sure.”

Creating access in these low-income, underserved areas is one of the issues with this.

Interjection.

J. Robinson: I’m glad you told me that, because I could talk for hours. I get going. Okay, thank you. How are we for time?

L. Larson (Chair): You’re past your 15 minutes, so you’re into our question time. It’s all right. We’ll just ask less questions. But if you want to finish off, by all means.

J. Robinson: I’ll tell you what. I will. I’ll only take another minute or two.
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I was just going to go on and talk about how chiropractic care makes a big difference in the future of the underserved populations that are typical in rural health care because you get people connected to receiving care earlier in their lives.

We know, for example, that when women receive care because they have children, they have better health care outcomes over time. Of course, anyone else who sees any kind of health care provider younger ends up with better health care down the road, because there are less issues. They don’t show up at 55 with a heart attack and an expensive problem.

We want a better future for B.C.’s patients. The research is in there, and we know that when we’re at the table, costs go down and satisfaction goes up. So let us help.

We have three recommendations that we’d like…. We’d like you to put those in your recommendations, when you make yours. It’s page 20.

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Basically, it’s simple. Include us more in collaborative primary care. Allow us to handle that X-ray issue I’ve described. Fund the Healthy Living Alliance so that all the patients are getting the same message from all of us about all of us. We don’t want patients getting different messages from chiropractors than from their family doctor or anything like that. We want them all to hear the same thing.

The Healthy Living Alliance is something that we’re a part of and something just about everyone else is part of, so it’s a good place to get the word out.

L. Larson (Chair): You’re welcome.

You know, we have heard throughout our travels that chiropractors, as much as massage therapists and pharmacists, do need to be part of the team that gives the whole care to people all over the province. I know, as Donna does, that in rural care, quite often the chiropractor is already involved a lot with the patient but just no connection to the physician that may also be the only other practitioner in the community.

Thank you very much for your presentation and for skipping a page or two.

Questions.

M. Dalton: Thank you, and I’m sorry I missed a little bit of your presentation. I’m just wondering about the numbers of chiropractors. Now, I know that a number of years ago there was a change to the fee structure. Is that correct? Or maybe it was held at a certain point as far as per visits. I’m just wondering what the impact has been and if, since that time, the numbers have gone down or up or…? How is that?

J. Robinson: No. Chiropractic, in numbers of chiropractors, has continued to grow. Utilization actually jumped dramatically, which makes no sense, after 2001. Not the first year, but it took quite some time before everyone starting using chiropractors even more and more.

Unfortunately, there has definitely been a problem with fees. They were stuck…. I think it was 1997. It goes back before I was involved in the regulatory — any of this stuff. It was stuck at $17.23, and that’s the foundation that ICBC still pays on. That’s the MSP foundation amount that has only crept up tiny bits.

The average chiropractic visit is about $50. So $17 has put us in a position that…. You can’t get paid for those kinds of dollars. And the only people that are getting paid for that are the people who are on income assistance on their MSP premiums. The average person was cut out of receiving care for chiro, physio, massage back in 2001, I believe it was — in case you weren’t familiar with that.

S. Hammell: I am going to bring up the issue of vaccinations. There seems to be a cohort of chiropractors who bring forward the notion that it is unhealthy to get vaccinations. I don’t think it has done a service to your….

J. Robinson: I would agree with you if…. I’m sorry. I’ll let you finish.

S. Hammell: The issue is…. I experienced it personally. I don’t want to generalize from one incident, but I’ve noticed that there is this kind of issue that doesn’t reflect well, I think, on the profession. I was wondering if you are actively involved in trying to correct that impression and that information that comes out.

J. Robinson: Yes, absolutely. If you’d be willing to put the name of that chiropractor forward to the college, that is a complainable offence. It is against the chiropractic scope of practice. It is not acceptable in any way, shape or form, and it is not what we stand for in the college or the association. We are members of health care in this province, and we support vaccination.

Bottom line: if there are individuals who are stepping out of that, that’s a complainable offence, and they need to be brought forward. Now, as in all health care colleges, we can’t act unless someone brings forward a complaint.

D. Barnett: Thank you for your presentation. Of course, I live in rural British Columbia. There must be a need for chiropractors because I can honestly say that in the areas that I represent, we have lots of chiropractors, which is a good thing.

Why do you think there has always been this disconnect in the health care system as far as recognizing chiropractors? Can you answer that?

J. Robinson: I absolutely can. I’m going to sound like a history professor giving a long, hourly lecture. Back in the ’20s, there was health care reform, and 80 percent of all of the health care colleges closed in North America.
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It was reduced down to the ones that were actually based on some sort of criteria at the time. It was based on some science and different things like that.

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Up until that time, the concept of germs, bacteria — the things that we now take for granted — weren’t really solidified in everybody’s mind. It was just an emerging science. We hadn’t really got into anaesthetic. We didn’t have medications. We hadn’t yet had penicillin or vaccinations. We’re talking about a lot of people believing things come through the air.

Traditional health care and osteopathy chose one path; chiropractic chose another path. Very quickly, the science side of being involved in medicine, pharmacology, surgery was starting to advance scientifically, and chiropractic was slower to take up that.

By the time we got to the ’50s, chiropractic was on board with everybody else. By the time we got to the ’70s, the research was being done with everybody else, and the time we get to now, we’re getting people being trained together. We all learn from the same people. If you talk to an orthopedic surgeon and you’re a chiropractor, you will quote exactly the same instructors — things like that. Things change.

There has been that difference from back then that we’re still trying to deal with, where chiropractors in that beginning phase were kind of hanging on to the: “It came out of the innate flow through the air, through different things like that.” Frankly, science has moved way past that. We’ve all moved way past that, but we’re still dragging that stone around.

J. Shin: I understand that, despite that, the effectiveness of the clinical practice guidelines in the medical and the chiropractic management of patients I think is getting more and better established. With that said, though, there is an established scope of practice for the chiropractors.

My question is just on the point of clarity. When you are asking the government, recommending us to look at the direct referral or ordering of the medical imaging and access to those results in the scans, you’re not asking for the clinical interpretation and diagnosis of those scans, right? Just to clarify. Because that’s an additional five years of training in radiology beyond medical school, for example, for doctors to make those calls.

J. Robinson: We are trained for that already, in musculoskeletal.

J. Shin: Oh. Within the four years?

J. Robinson: Yes.

J. Shin: For diagnostics?

J. Robinson: For diagnostics, yes.

J. Shin: Really. Okay, gotcha. So that’s the piece that you’re asking for in your presentation. It’s not just a referral and the access for the scans but, as well, it’s the diagnosis.

J. Robinson: No, we already have all that.

J. Shin: Oh, I see. Okay.

J. Robinson: What we don’t have…. The only piece that we don’t have is MSP to pay for it when we send the patient to the lab.

J. Shin: Gotcha.

J. Robinson: That’s the only piece. Every other part of it has all been solved decades ago. We have the training relative to our scope of practice. To be clear…. If you show me a heart image, I’d…. If you show me a low-back image, great.

It’s just that little piece about who’s funding that prescription for the X-ray, and that’s it.

J. Shin: Right. Okay.

D. Plecas: Thank you very much for a great presentation. I love what you had to say about how you can save this system money.

I mean, at some level, I say: “Duh. Like, why aren’t we on it?” It’s not encouraging, but for whatever reason, there’s always trouble in getting that to resonate with people. You know, people say: “Oh, isn’t that wonderful? We can save money.” But we’re still waiting to see people move on those things, on the prevention side.

My question is…. Okay, let’s say we accept your recommendations. How much money does that cost government? Let’s ignore, again, the part that would be offset by what you save in prevention.

J. Robinson: Yeah, forget the saving part. What’s it just going to cost?

D. Plecas: So you say: “Let’s do this.” What’s the bill to government?

J. Robinson: On the X-ray initiative, I don’t think there is a bill. You’re just going to have to have someone say: “Okay, chiropractors are allowed to do that.” There’s not going to be an extra cost to that. It’ll be a lower cost than you’re already paying. There’s no extra money for that.

When it comes to…. Well, funding the Healthy Living Alliance — that’s up to you. I don’t know what you’re going to fund them for.

When it comes to putting us into collaborative primary care and everything that that might entail, that’s a wide range, and it starts with concepts. Right now we can’t
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even go into a hospital. We need to be able to at least go in there. We need to be able to sit at a table and talk about: “Well, if we were allowed in here and you had a job that needed a chiropractor to do it, we could do it.”

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D. Plecas: That doesn’t cost money.

J. Robinson: That doesn’t really cost money — saying that you can be there.

D. Plecas: So what’s the stall?

J. Robinson: The stall is the permissions. We need to have the permissions to go forward. That’s everything from the PACS systems for X-ray on-line stuff to being able to go into a hospital to say: “Yeah, we can apply for that job. You need someone to help with that low-back-pain patient? We’ve got the qualifications. Okay, great. We’ll apply for that job.” On a sessional basis — whatever it is. Right now we can’t.

There is one possible cost of sticking us in electronic health records, like Alberta has. Chiropractors are part of the electronic health record. There may be a setup cost of that, adding us to that. I mean, it’s not ubiquitous here in B.C. as it is, but we and the Doctors of B.C. both recognize that would be a very good idea because there’s risk, as I mentioned, with patients manipulating us back and forth.

We’re not talking about money here in a big sense.

L. Larson (Chair): All right. We like it when you don’t talk about money in a big sense. Thank you very much for your presentation.

We’ll just do a very quick turnover here and then move on with the University of British Columbia faculty of medicine.

J. Robinson: Thanks, and see you all at the next one.

L. Larson (Chair): You betcha.

It feels a bit like an assembly line. I apologize for that, but to get through 14 presentations in one day, this is how it goes.

R. Wong: It’s a lot of work. We appreciate the opportunities.

L. Larson (Chair): You bet. You’re welcome to start as soon as your technology is up and running — and 15 minutes on your side. Then, hopefully, we’ll have time to ask you some questions.

R. Wong: Absolutely.

Good afternoon, ladies and gentlemen. It gives me great pleasure to be with you this afternoon, recognizing that I’m probably one of your later ones of this afternoon.

Hopefully, I will be able to tell you a couple of stories over the next 15 minutes to try to explain to you the perspective of the University of British Columbia in terms of the medical education program that it situated in the faculty of medicine in collaboration with a large number of partners throughout the province. I’ll be going over that.

Specifically, we’re here to address a solution, a contribution to improving rural health in British Columbia and the people residing in our province. You have a copy of the slides.

I just want to take this opportunity to start off by acknowledging the academic partners that engage in this very distributed and expanded endeavour, including the University of British Columbia, both in the Okanagan and Vancouver campuses, the University of Northern British Columbia and the University of Victoria. Again, our endeavour and project would not be possible without the significant participation and very generous sharing with our health authority partners, which are actually indicated on the slide.

I’m here today to tell you a story. The story is about how the government of British Columbia and the University of British Columbia faculty of medicine have collaborated in making a difference. The difference, in this case, is about helping to increase access to health care services for British Columbians by expanding and distributing medical education across the province. We are the largest distributed medical program in North America.

I’m hoping that by the end of these 15 minutes, I can share with you and convince you that this is a very good-value proposition that is worth the investments of resources and people and time because we’re making a positive difference for people in British Columbia.

More than ten years ago — exactly, in 2004 — the faculty of medicine at UBC started expanding its undergraduate medical education program in collaboration and partnership with the provincial government as well as the partner universities that I alluded to before and the health care authority partners that I mentioned before.

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The program is comprised of four different distributed sites geographically, which are indicated on this particular slide. We have: in the north, in the Interior, on the Island, in the Fraser Valley and the Vancouver area. This is truly a provincewide program. It is one of its kind.

In fact, we’re tremendously proud, because not only have we expanded the MD — or the medical doctor — undergraduate program; we’ve also expanded the residency training programs, postgraduate medical education programs and a number of our health profession programs.

When I talk about expansion, I’m talking about not only an increase in the numbers but also an increase in the number of geographic areas, whereby we train the students and learners locally, where we hope to make a
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difference for them to be practising locally as well. I’ll share some data with you as well.

This is actually a map that shows the extent and outreach of our medical programs as well as health profession programs. I want to draw to your attention, in particular, that we have developed very unique initiatives to attract learners and students from rural communities to become health practitioners. The example that I’m using here is the rural admission stream.

I’m aware that you might have heard about some of the very specific projects, such as the Travelling Roadshow, whereby our student representatives actually come around and speak to potential learners and students about what it is like to become a doctor, a physiotherapist and how you can do that while you are staying in the local geographic area. That is something that we’re tremendously proud of.

I also would point out that given the fact that we’re distributing this training across the province, our hypothesis, our storyline, is that we hope to influence people not only so they have more exposure to rural communities in British Columbia but so that they can actually become more familiar and attracted to practising there after they are done their training. I’ll come back to that.

Not only do we do that, but in fact we recognize that we’re a very diverse population across the province. Diversity is measured in a variety of different ways, but our mission is try to remove barriers and increase access to these students and learners from diverse backgrounds so that they have equitable access to medical education in British Columbia. We feel that it’s absolutely important because they get to return their service to the communities comprising those diverse populations.

Let me share with you an example. We, at the University of British Columbia, emphasize the importance of attracting aboriginal students into our health profession programs, such as in the medical doctor program. This is something that we have been tremendously proud of.

Over the years, we have actually set some targets for ourselves. We said, actually back more than ten years ago, that we would like to have 50 aboriginal students participating in our MD program so that they become doctors of the future. We originally wanted to achieve that goal by the year 2020. I’m delighted to share with you that five years prior to that timeline, by the year 2015, we were able to achieve that goal.

We have more than 50 aboriginal MD students, many of whom have just graduated, earlier this spring. I remember sitting in the Chan Centre and watching all the students walking across the stage — how tremendously proud they were and how tremendously proud we are. Now we know that we’ve trained enough of these doctors. We’re not going to stop there. We want to keep going there. In fact, they can return their service to their communities.

We do realize that in order to do this, it takes time. In fact, it takes times to train a doctor, quite a long time, some would say. By the time a student actually has expressed some kind of interest in medicine, for instance, normally they would have completed four years of undergraduate training. They then enter medical school for another four years of MD undergraduate training. When they graduate, they obtain a degree of doctor of medicine, but they are not really quite there, ready to practise independently.

They must go through further training — residency or postgraduate medical education — which ranges from two years for family medicine to anywhere between four and seven years for specialties and subspecialties. Here, in UBC, what we have done is expanded and distributed all parts of this training throughout the entire pathway across the province.

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In fact, that is a specific and intended strategy in order to try to address some of the health human resources needs that we have across different parts of the province, especially in rural and remote B.C.

We also have learned that there are multiple factors that can influence the choice of a doctor in terms of where they will end up practising. Some of these factors are very personal, whether it is about the support available to the doctors and their partners and their families — their loved ones, their children — or it is about system-related, policy-related issues — incentives that we provide for practitioners in rural communities, for instance.

We in UBC are a part of the solution in terms of the medical education aspect. It is an important component of a solution, but we realize and recognize our limitation, in that we are not the only solution. We therefore have to work very closely with the communities at large — in particular, in rural parts of the province — in order to make it attractive for doctors to go.

Allow me to share with you a real story. James Card is actually one of our first students who was admitted to the northern medical program in Prince George. He got into medical school in 2004, and then he graduated. He entered family medicine residency, also situated in the north, for a couple of years, as I’ve explained earlier. He then came out to actually practise, and he started practising in the Mackenzie district. That was in the year 2011.

This is an illustration whereby someone from the rural part of the province trained in the north and stayed in the north to practise, but his story doesn’t end there. What James has figured out is that it is absolutely important to build a community of other health practitioners. I’m a geriatric medicine specialist doctor, and in my practice, one person equals zero. I guess James, as a family doctor, gets the same concept.

What he has done is develop initiatives, such as this very interesting postcard, to talk about what is so attractive about practising in the Mackenzie area. Notice that what he talked about is the clean air, the affordability, the welcoming nature of the community — a lot of
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things that you would say: “Wait a minute, Roger. How come this resident does not talk about medicine?” It’s because we know, and James knows, that it is all these other very important pieces that are equally important in influencing the choice of a health practitioner in terms of whether they will end up settling and practising in rural and remote B.C.

I’m delighted to say that to this date, James has been very successful in attracting a cohort of doctors practising with him now in the Mackenzie area. This is a good story.

The good story doesn’t end there. If you then go across the water and look at the Island, we have another story to share with you. Here is the residency program that is regionally located in the Strathcona area — in particular, in the areas of Comox, Courtenay and Campbell River. This is actually a photograph of all our upcoming doctors — family doctors, specifically — who are trained in the Strathcona area to get out with their preceptors — with their teachers. Peter Gee is actually the head, the site director there. Some of you will know Peter.

In fact, the reason I share their story is because of its powerful nature. A majority of the graduates of our family medicine training program situated in Strathcona have ended up practising independently, after training, in rural B.C. This is an example whereby doctors who are trained rurally not only are more likely to stay in their immediate vicinity; they also can go to other rural areas and populate there. We feel that is a very important lesson we have learned.

I guess, ladies and gentlemen, what I am trying to say is that UBC is continuing to increase the supply of physicians to British Columbia.

If you allow me to show you some numbers…. Specifically, if you look at the number of medical students, the increase, we have increased more than 136 percent from the year 2000 to the year 2014. When you look at the resident doctors in training, the increase in numbers is even more astounding: 186 percent from the year 2000 to the year 2014. These are huge numbers.

In order to operate these numbers, they represent investments of resources, of people, of time. I’ve already shared with you that it takes time to train these proud practitioners. Again, my plea to you is that I hope I can convince you it is absolutely worth the while to make these investments.

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Financial pressures and capacity pressures have been daunting at times. I have to say that I have sat in front of various different tables, usually comprised of accountants, and tried to convince people of the value-add of what we are doing in terms of our core business. I hope I can convince you that it is worth our while every single time.

Let me share with you another angle of this story. Doctors in Canada are mobile. When they train, they can go, after training, to other places. Our learning that we have in British Columbia is very special. It’s unique to B.C. Certainly, in other jurisdictions and provinces and territories, we don’t see the same extent. In B.C., when a student enters medical school — say, training in UBC at one of our four different campuses — when they are done, some of them will stay in B.C. for residency training; some of them will go elsewhere.

When they are done residency training, for those who stayed in UBC, some of them end up staying practising in B.C. For some of them who have left the province for residency, they return to B.C. to practise. More interestingly, we actually are a net importer of people. When we have residents from outside of B.C. who come to B.C., they don’t leave after they’re done.

This is what I want to show you — the numbers. So 80 percent of UBC MD students who attended UBC actually stayed in B.C. for residency. Sixty percent of UBC residents who completed their doctorate degree outside of B.C. remained in B.C. More importantly, one-third of the MD students from UBC who did a residency in other parts of Canada come back.

What I’m trying to tell you is we actually are able to gain total number of doctors coming into training in B.C. This is important because a lot of times we try to help people understand that while there is mobility of physicians across Canada, people actually do come back, or for those who stayed to train here, they want to stay here.

The other thing that we also have observed is that we are very focused on enhancing health care delivery and capacity by increasing the number and the supply of primary care doctors, specifically family doctors. This is a very powerful figure that I’m sharing with you. Our number of first-year family medicine — entry-level residents — has gone up by 238 percent, comparing over the past 16-year period. This is a substantial growth.

We know that we need family doctors. We are training a lot of them, and we’re not stopping there. We’re continuing to do that. Not only are we training more, but we are training them in rural and small towns. Where training takes places, many of them tend to stay.

That’s the kind of story that I’ve been trying to tell. This is a picture of the Okanagan, and I can tell you many of my residents, when they go and train there, obviously we have an opportunity to really try to attract them to the lifestyle choices as well as the robustness of the practice in the local areas in rural B.C.

One of the numbers that I have learned over the years is that when you look at the medical students…. For instance, in this example from the north, two-thirds of our students trained in the north actually stay practising in rural communities afterwards. This is a very, very important number because even though it is true that it costs more to train doctors in rural and remote communities in British Columbia from a financial or fiscal point of view, the returns or the value proposition is substantial, and this is what I’m trying to share with you.
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In summary, what I guess I’m trying to share with you, ladies and gentlemen, is that at UBC, the faculty of medicine, we are contributing to rural physicians in British Columbia by doing three things. We’re increasing the overall supply of doctors. We are enhancing health care capacity by increasing the supply of family doctors and other generalist specialties as well — internal medicine specialist doctors, pediatric specialist doctors and psychiatry specialist doctors looking after mental health issues. Last but not least, we train doctors who are practising in rural and small towns where training takes place, and we have evidence to show that, actually, that model works.

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In summary, my plea to all of you ladies and gentlemen is I hope I have been able to share with you some stories to help you understand the value proposition of training doctors in medical education actually in a distributed model across the province and the value return that they provide for the province, in particular for rural areas in B.C. The same finding, we understand, applies when we look at other health professions.

The example that I will use, before we wrap up for questions, is in physiotherapy. A number of you would know that at UBC, in the faculty of medicine, we have distributed the training of physiotherapists above and beyond the Lower Mainland. We now train in the north and in rural areas, and 50 percent — one in two graduands — of our northern and rural training program in physiotherapy are now staying and practising in rural B.C. — very significant numbers.

I guess I’ll pause. I hope I haven’t gone overtime, and I invite….

L. Larson (Chair): That’s okay. I just won’t let them ask as many questions. They only have ten minutes.

Donna, you’re up first.

D. Barnett: I’m from rural British Columbia, and I’m the Parliamentary Secretary for Rural Economic Development. I’ve been engaged in my community, in politics, for many, many years. This is something that we’ve all worked for in rural British Columbia for so long, and it is just absolutely wonderful that finally we are reaching our vision, which is to train doctors, train nurses, train all the health care professionals in rural British Columbia, because they will stay there, and others will come. So thank you very much.

[J. Darcy in the chair.]

R. Wong: You’re very welcome, Donna, and again, we are delighted to be a partner with this. We are partners with our government; we are partners with our academic university institutions, as well as the health authorities.

Let me share with you that this has not been an easy road. It has not been an inexpensive road, as they constantly keep reminding me. I hope I do not sound like a broken record player, but the value proposition that is the case and what it means to the lives of people in rural British Columbia is beyond value. So I think we’re on the same page.

D. Barnett: I’m so happy that you sound like me. So I’m very pleased. Thank you.

D. Bing: Thanks for your presentation. Congratulations on reaching your 50 aboriginal students, and five years early. I think that’s great. I was wondering if any incentives were given to them, like free room and board or tuition or whatever, to encourage them to go into the program. I also wonder if you’re following them and tracking them and seeing where they do end up for their careers — whether they’re going to stay in B.C., leave B.C., go back to the communities they came from or go to the big city.

R. Wong: Sure, absolutely. We actually have a number of different initiatives that were designed, specifically tailored, to meeting the needs of our aboriginal potential learners. For instance, we start the process really early on, in the pre-admissions phase and the admissions phase. We actually have our students and our leadership from the faculty of medicine at UBC going out on outreach to communities and talking to students in high schools.

We know that if you really need to get people excited, you need to start early. Those kinds of initiatives, starting off at high school and having pre-admissions and admissions workshops…. We find and learn that it’s a very helpful and valuable opportunity. We also provide ongoing counselling support and peer mentoring as well, once people are into the program. This has, very much, all the features of a pipeline program that you could imagine.

Having said that, we actually are very clear that the standards that we want to meet in the university and at the faculty level are not being compromised by this. This is really important to help people understand, because we have some very top-notch students. In fact, one of our recent graduates this year, just a couple of months ago, won the gold medal prize as an aboriginal — the first aboriginal MD student who won the gold medal prize in an MD-PhD degree. It’s a combined degree. Those are the kinds of people that we want to really culture, to get them excited.

To answer the second part of your question, we do metrics, and we capture it, in terms of where they end up. We have a project that we collaboratively are conducting with the provincial government. We call it the long-term outcomes project, and we actually try to look at what happens to our graduates when they become independent practitioners.

J. Shin: I think we all know this: the education and training of more doctors is just one part of the equation.
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It really comes down to the fact that we have a maldistribution across our province that contributes to the lack of doctors that we see in the rural communities.

[1655]

[L. Larson in the chair.]

I’m really happy to hear about the initiative. You’re absolutely right. If we are finding and training doctors from those communities, our ability to keep them serving in those communities is far greater.

Now, I understand that in 2008 there was a rural retention program review, and 90-some recommendations came forward, out of which there was an incentive built — in fee-for-service and what have you — for those additional means to retain the doctors to serve in the rural communities. With that said, though, I’m curious to find out…. You did mention that it does cost our education system more money to have sort of off-site training programs, but it’s something that you definitely see a value of, and that we should be advocating harder for those programs.

So I’m curious to find out…. It’s been not quite ten years, but it has been a number of years already, and you’re starting to see palpable benefits from that program. Has there been any sort of cost analysis where we can say that we are spending X amount of dollars to incentivize doctors to stay — those are all real dollars from the public treasury — versus can we recommit those dollars to, say, educating off site? And where would our dollars be better spent? Has there been an analysis on that?

R. Wong: Right. An excellent question. My short response to that very complex question is that there has not been an exact financial analysis to that. I have an accounting background, so from a strictly accountant point of view, that analysis hasn’t been done. It also has a certain political overtone, as you can imagine, because you’re talking about redeployment of resources.

What we have done, however, is we have done a very fiscally responsible analysis of the costing of the education program. So we actually recognize that it costs more, and there are incremental costs in that, whereas from an accounting kind of perspective, in terms of training doctors in rural and remote communities….

What we need to do to balance the other side of the equation is to try to look at some of that value prop that I talk about — the value proposition — and translate it in terms of dollars when they end up staying and practising there, and therefore what kind of dollars can be relieved from the other incentives that we’re using.

I think that analysis…. Time will tell. But I welcome that analysis at some point.

J. Shin: Right. It would help us make a more compelling case to the government, so thank you.

R. Wong: Correct.

D. Plecas: Roger, I think you and UBC ought to be applauded for taking the initiative you have and the success that you’ve had. It’d sure be nice to see that effort and success continue going forward.

My question is: when we think of the students who come to UBC to study medicine from out of province, what percentage of those students decide to stay here?

R. Wong: I can answer that. First of all, we do accept out-of-province students entering our MD program — doctor of medicine program — here at UBC. As I explained before, a number of the students will stay to train in residency in B.C. A number of them will then leave. Then, some of them who left would then return.

When we look at the overall picture — to answer your question, sir — I would say two out of three students who have been exposed to the UBC system end up practising in B.C. That’s pretty good, considering they have multiple other options to choose from.

D. Plecas: What about the other side of that question — those who are from B.C. who go to study at U of T or wherever? How many come home?

R. Wong: We actually have that number that I showed you before.

A Voice: It’s also two-thirds, right?

L. Larson (Chair): It was in the package, Darryl. Okay, that’s it.

D. Plecas: I guess I should learn to read. I didn’t see that.

L. Larson (Chair): Sue, last question — quickly.

S. Hammell: My understanding is we have about 800,000 people in British Columbia that are not attached to a doctor. My question to you is: do you put that into your equation? Are you looking forward to seeing how many doctors we will need in the future? Does that mean that we should be adding more resources to train more doctors? Do you see any problems on the horizon around that, given that we are already 800,000 people short?

The last question, which is attached to it, is: are you feeling uncertain about your funding in terms of this program?

[1700]

R. Wong: I will answer the first part of the question by saying that at UBC, we are absolutely aware of — and respect, in fact — the importance of meeting societal needs when it comes to medical education. Therefore, not only are we concerned about the number of doctors
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that we’re training, but the type of doctors and where location of training is occurring, which is kind of the hypothesis of my presentation. So we are absolutely paying close attention to that.

The other observation that I would share with the group is that we know that it takes time to train doctors. This is now the first piece of evidence where we start to see kind of the tipping point. Things are changing, but perhaps it takes longer to change even further.

For the 800,000-plus people in the province who are waiting to find a doctor because they’re not attached to one at this point, we would hope that this program, the initiative that we’re talking about, at some point is going to make things a little bit easier — recognizing we’re not the only solution. We’re one of those three really big pieces: societal factors as well as personal factors and then education. We are kind of one piece.

Then a response to your final question. We recognize that there are incremental financial costs of training more, and also distributed. I’m doing my very best to convince my colleagues in the ministries that there is a value proposition. I recognize that the fiscal environment is tough all around, but again, in order to preserve the kind of training that we have and in such a model that we have…. I mean, I think this is a very worthwhile investment, because we’re investing in our people.

L. Larson (Chair): Thank you very much, Dr. Wong. That was really interesting. We’ve heard from many different parts of UBC today about all the great work that you’re doing. Please keep doing it. Thank you for taking the time out of your busy day to join us today.

R. Wong: Thank you, and you’re very welcome.

L. Larson (Chair): I’d like to welcome the representation from the First Nations Health Authority. Would you please introduce yourselves and then launch in.

J. Calla: Hi. My name’s Jason Calla. I serve on the board of directors as the treasurer of the First Nations Health Authority.

R. Jock: Richard Jock, chief operating officer for the First Nations Health Authority.

J. Calla: We’re pleased to be here today on Coast Salish territory to talk about how we can improve health and health care services in rural British Columbia.

My name, as I said, is Jason, and I’m serving on the board of directors. I’ve served since 2012, before the health authority was the actual health authority, before the transition. I’m also a member of the Squamish Nation, so this is home for me. I’m going to make some introductory remarks, and then I’m going to pass it over to Richard, who will take you through the balance of the presentation.

For those of you who might not be aware — I know you may have heard of the health council or the health authority — just a bit of quick background. In 2013, the First Nations Health Authority assumed the responsibility for delivering some health care programs to First Nations in all of British Columbia. Formerly, those responsibilities were held by Health Canada. There was a lot of work beforehand. It sounds like the health authority sort of came into existence in 2013, but actually the activity leading up to the transfer took place over a number of years.

I think it’s worth noting that it’s not easy for First Nations to agree on different things amongst ourselves. The fact that there are 200 First Nations in British Columbia that have come on board, I think, is a positive message. It’s one that’s easy to get on board with: that it would be nice to have better health overcomes. But nonetheless, that was a ton of work and a great, I think, political milestone to achieve — to have all First Nations on board for this. I wish we could do that in other areas as well.

In that time, the leadership basically reached a consensus that said we’d be better off if we assumed responsibility for our own health and wellness and if we were able to incorporate some First Nations perspectives into health and wellness programs. If we were able to incorporate those First Nations perspectives and if we were able to have better health outcomes, well, wouldn’t that be better for all First Nations people?

[1705]

But not only for First Nations. Wouldn’t it really be better for all British Columbians? Healthier people, hopefully, cost less on the system and all those things.

Just an example. I was interested to hear the last…. Actually, it was interesting hearing the presentations before, really. Although this is home, I’ve had an opportunity, through my work with the health authority and with other endeavours I’m involved with, to travel around the province in the last couple of years. You sort of think you know how big the province is, but you don’t really until you go to Fort Nelson, which is a long way away and several flights. It’s amazing to think that you’re still in the same province — to go to Prince Rupert, to Tsimshian territory, and go through Gitxsan territory, and through to Wet’suwet’en and Carrier-Sekani and Treaty 8 and these places, driving.

I was actually driving last week. It’s an incredible drive, by the way, if you ever have a chance to go to Terrace, to Rupert, at this time of year — holy. But it makes you realize that it’s not that easy to get health care. It’s not like living on the North Shore and going to Lions Gate Hospital. It’s a challenge.

So if you don’t have access to things like primary care in your community, or even in the town that’s close to you, maybe you’re waiting and letting things slip, and you’re not really dealing with your own personal wellness
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plan until you have to go to the emergency room. Now the emergency room is your first point of contact with the health care system. That’s not the model that we want, I think, at the health authority. I think Richard’s probably going to talk about that in a bit more detail.

The vision, really, is to have a chance to have First Nations really take control of their wellness path and their wellness responsibility. Working towards that vision is the job of the health authority here, and we’re guided in our work by seven directives that have been developed by leadership in the province.

I think, again, just as a quick background…. I know you’ve maybe heard from Doug Kelly or from the health council. There are several aspects to the health governance structure. There’s the health council and the health authority. The council is the political side, and the authority is the administrative business side.

There are five regions in the province that the health council is divided up into. There are three representatives from each region, making up a health council of 15. Those 15 appoint members to the board of directors of the health authority.

The health council, or the members, are in fact members of a society, in which the health authority exists. Just as an example, each year the health council has an ability to remove directors from the board, appoint directors to the board. As the treasurer of the First Nations Health Authority, it’s my responsibility to report on the audited financial statements to the members of the society, which is the health council.

Just, again, I know it gets a bit confusing with all these terms and new organizations. That gives you…. On the health authority board itself, I’m one of nine directors. Again, our job is to really work towards that vision, following those seven directives. I think one of the recent pieces of work that we’ve been doing is work on cultural humility and cultural safety.

I’m clicking through the slides here. I think you have the slides in your package.

L. Larson (Chair): Yes, we do. Thank you.

J. Calla: I’m mindful of time. I’m not going to go into detail about this, except to say that I think it acknowledges that we can do better in terms of cultural safety. That’s one piece of work that we’re proud of and that, I think, is worth acknowledging — that we’ve been working in partnership.

It amazes me. I’ve had an opportunity to sit at the table from time to time with provincial health, the Ministry of Health, and with the regional health authorities. I think the fact that there’s a voice for First Nations at the table now is a huge, huge step, and that we’re able to actually engage in a conversation and talk about these things is important. I want to acknowledge, really, the partnership of the province, of the Ministry of Health and of the regional health authorities in working with us on these issues.

So that’s one example. There are a number of other examples. Maybe I’ll pass it over to Richard to finish off.

R. Jock: Thanks, Jason, for your comments and introductions.

[1710]

One of the things that we think will be really important in terms of improving health care for rural B.C. is to really embark on and embrace the primary care model. So our definition that we particularly like is the Alma-Ata definition, which has been adopted through the World Health Organization. Just to highlight, some of the key features of that definition are really the focus on self-reliance and self-determination — obviously key interests for First Nations people. Really, it is an overall part of the system in the communities. It’s also a part of social and developmental fabrics.

Also, importantly, it’s that first level of contact with the health system. The key feature there is bringing the health care system as close as possible to where people live and work. Really, I think that’s the key area that I want to emphasize there.

We have done some work on modelling primary care, and I would say what we’re calling that is primary health care plus-plus. We believe in the multidisciplinary team model that would consist of a physician, nursing care, and nurses as coaches in particular, having also medical office assistants as well as mental health people, nutritionists, all within the system so that essentially this becomes a one-entry system, very efficient, and makes really good use of the primary care providers.

The plus-plus comes in where we try to make sure that mental wellness as well as traditional and cultural approaches are also part of our model. We do observe and do see that using tradition is really a vital response and is key in terms of being effective. Then, of course, having access to other specialties and so on is a key aspect of support.

What I would say is sort of needed in terms of making these more real for First Nations people is looking at more appropriate and better remuneration and employment models. Right now it’s a private practitioner model, which doesn’t work. Even if you have physicians trained, the model has to require attachment to certain-sized communities, and if there’s not enough population in a community, it really makes it difficult.

What we found through our models is…. We actually use a model where we employ the physicians. In one case in northern B.C., for example, we have an aboriginal physician, a recent graduate, ready to practise. That person couldn’t really develop a practice otherwise. What we did is we employed that person. They provide service to multi-communities. It’s a win-win all the way around.

Similarly, with nurse practitioners, the way that’s done is not sustainable. What the health authorities find is that
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there are not the supports for the nurse practitioners and, as well, the teams that also make those positions viable. So we actually complement those with resources and with team members, and we’ve found that this is a successful model. But we also believe that some direct employment through our primary care approaches, I think, would be a much more desirable approach.

Just a slight variation I just want to highlight very briefly. Even if you have relatively rural communities, you can have a certain approach. But if you get even smaller and more remote, then actually what we need is more telehealth, more enabling of supports and also the idea that these teams have to be highly mobile. The interest there is having these variable models against the service needs of the area. I just want to highlight that difference.

I just wanted to highlight that we have, in one instance…. Through a partnership with Interior Health, we’ve really looked in detail at the health matrix and some of the data that falls from that.

[1715]

I’ll just give you a couple of examples from that. It really shows that First Nations have lower access to physicians in the Interior region. That rate actually has declined over the last five years, from 2008 to 2009 to now. So dealing with rural issues is really important and demands a different approach.

Also, First Nations are more likely to use the ER for their physician services, compared to First Nations…. This rate also increased. So there’s quite a high cost to the health care system. Again, looking at the admissions to hospital, we really found that many of those conditions would have been responsive to a primary care approach. Nevertheless, it’s requiring a higher level of hospitalization and, thus, higher health care costs to the system.

I think it’s also worth highlighting that First Nations were three times more likely to be diagnosed with severe mental health and substance abuse issues and, as well, less likely to use physicians in terms of being screened for those mental health issues. Again, you can see some of the systematic problems, and we would say that the primary health care approach that we are suggesting would be a much more responsive way to deal with that.

This is not just conjecture. We have some funding that we jointly have developed with the province and the Ministry of Health and are implementing through partnerships with the regional health authorities. We actually have some proof-of-concepts for these models. I think that we’d be very prepared to share those at future discussions, because I think, again, these are promising practices. They’re a little bit different from the general plans being made by the province but are, I think, nevertheless, important ways of responding to these important health care needs.

Lastly, I’ll just highlight, as well, that…. I think the recruitment issues were well covered by the last speaker, but I would say that those are especially important for First Nations people. I think if we associate those aspects and those interests, as well, with new compensation models and show that people really can grow up and return and practise and do so in a way that’s not overly complicated, that will only enhance and support the efforts such as those described by UBC.

Very quickly, we have a whole addiction system. Ours is more culturally based, but I would say there is really a gap in our systems. We still need access to the highly complex opioid types of treatment. I think there’s much more room for collaboration between our two systems, but there are also some gaps. I think the legacy of residential schools is one that we really need to carefully address and do so throughout our system. In fact, trauma-informed care is a really important ingredient to improving care. But I would say that our systems need to complement each other better and that, really, developing these team approaches will lead to improvement.

I would say that there is really a lack of child- and youth-specific programming. We have one program, but it provides for 12 youth — 12 spaces for a three-month program. Obviously, it will take us a long time to really make a serious dent in terms of addiction issues for young people. I think looking at how to expand that model is absolutely vital. As I say, looking at addressing the gaps…. At this point, we have to pay for people to go to these non-NNADAP centres. To me, that’s a barrier to care, and I think it should be addressed in a timely way.

I’ve probably used up all the time, but at that point, I’ll just stop and leave that to you.

[1720]

L. Larson (Chair): Thank you. That gives us a chance to ask some questions. You made a referral to the residential schools. How long do you think before the legacy of those residential schools finally burns itself out of the First Nations people?

R. Jock: Well, I think there are a couple of aspects to that. One is that as long as our people feel uncomfortable with the system, as long as they feel that institutions are not friendly to them, then I think the legacy will not find its way out of the system.

L. Larson (Chair): What institutions now are not friendly? I mean, the residential schools were horrific. There’s no doubt about that. I have many friends, and some have died too young as a result of the connection through their parents. I’m talking generationally. How many generations is it going to take before the words “residential school” no longer play a part in how people feel?

R. Jock: Well, that one’s a tough question. I guess what I would say is that as long as people are feeling that they are being discriminated against when they present at a hospital or in any kind of a mainstream institution, then we’ll not see the end of that.
[ Page 530 ]

L. Larson (Chair): Kind of transferred.

R. Jock: It’s sort of that negative institutional approach that really has created that issue. I think we have to take care that our institutions are friendly, that they are culturally responsive and that I say are welcoming. So incidences like making sure that people are able to use their traditional practices when people are in their stages of life or dying — I think enabling and supporting those are important ways to start dealing with that legacy.

I think there are very concrete ways to do it. The others issues, I would say, are somewhat generational, and I really don’t want to speculate on.

J. Darcy (Deputy Chair): Thank you very much for your presentation.

I think the very first day of our hearings, in Victoria, we heard a really awesome presentation by Dr. Daniele Behn Smith at the Cowichan Tribes Health Centre. She talked about combining traditional medicine with western medicine — whatever term we want to use — as well as…. This was a term we hadn’t heard anywhere else until you mentioned it again today. She used the term “teamlet,” which we hadn’t heard — not just health care team, but teamlets.

She talked about the role of health care coaches — which could be LPNs or medical office assistants — and just affirming their role in helping to guide people through their clinic or their health centre, as well as dietitians, registered nurses, group visits — that kind of stuff.

I wonder if you can…. It appears to be very much what you’re talking about. Can you give us some sense of how wide…? I know she said some of the thinking came from health care coaches in Alaska. Can you talk about how widely? Is that the model you want to develop? Is it already in use in British Columbia, and do you see that as the way to go?

R. Jock: The Cowichan project is one example of the ones that we have funded through this Joint Project Board that I mentioned. We are looking at how to expand that across the province. I would say we have one or two in every region now.

What I would think we’re trying to do is to expand the number of these teams, or teamlets. For example, we’re implementing one in the northwest region of the north region. I’d say we have a good example, also, at Seabird Island. I would say we’re developing a very promising one on north Island, in terms of maternal child care. So these are expanding right across the province.

[1725]

What I would say is that we’re devoting some of our resources to hiring the physicians within those. If we could have more access to that physician resource pool, we could actually do more primary care centres, because we’re putting our money into physician compensation in those. I think developing those aspects of the model would really support this.

I would say that the customer-owner or client-focused…. I think that’s really something that across Canada and across North America is very much the trend and the interest. I would say, I would hope, that this is really something that will drive health care more in the future generally. I think it’s more than just sort of a fad. I think it’s really the way of the future.

M. Dalton: Thank you very much, Richard and Jason, for your informative presentation. I’m Métis myself.

There are a lot of disturbing health statistics with the aboriginal population, in terms of hep C or mental illness or type 2 diabetes. Is there any good news? Are there any positive trends that are helping out there in terms of health outcomes and things that are the right direction, as far as the Ministry of Health is going?

R. Jock: Yeah, well, it’s interesting. A part of what was done as part of the process Jason talked about is that we actually have seven indicators that we’re monitoring, over the past ten years. Over that period, all of those indicators are in a positive direction with the exception of infant mortality. That’s one that we’re looking at. We’re looking at what the causes of that are and whether that’s sort of a blip. But all of these indicators are moving in a positive direction.

I think the other piece of this is: how do we measure wellness? I think part of what we want to do is move to a scenario where we’re measuring wellness much more. I would say those kinds of elements will give us the kinds of information that you’re talking about.

I would say the other part of this is that if we look at our stats for those communities who are really managing their own health services and their own affairs, their stats are much better. Their suicide rates are much lower. So the whole idea of empowerment and self-determination that I mentioned earlier — those are really critical and I think are key elements of success. I would say those are really the promising elements that I would quote. I don’t know if Jason has others.

J. Calla: I don’t have data to fall back on, but one, I guess, experience I do have over the last couple of years is going to the regional caucus sessions that are held through the five regions.

I think the level of engagement that we’re seeing with people is going from sort of blaming the system to “really, it’s our system” — taking ownership and acknowledging that we have it within our control to make changes. It’s a pretty big change in attitude, I would say, at some of these caucus sessions.

You know, just the various initiatives, like Richard says, about wellness — the Days of Wellness, the wellness activities that we have on Aboriginal Day. It’s pretty neat
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stuff. Everyone’s getting out and doing activities and the Fitbit challenges. People are getting active. And yeah, I’ve got mine on.

I think there are some positive things that are happening. I know one of the amazing things to me, and I was referencing this earlier, is working with the province looking at data. I know Dr. Adams is working with his counterpart in the province and then looking at data outcomes and addressing these things in a very evidence- and data-based way. That’s pretty exciting stuff, and then, hopefully, we’ll be able to monitor the results of this change.

L. Larson (Chair): We’re sort of past time, but Sue and Donna still have a question, so if you can make it fairly brief.

S. Hammell: I’ll be very brief. There are two interesting things that are happening, from my perspective. We have listened to a number of…. We also listened to a presentation of an aboriginal health care centre in Prince George, which was just remarkable. Again, it has eliminated the…. They’re not operating under the same parameters that most of the health care system does.

[1730]

We also listened to rural communities talk about how alienated they are from the power around trying to create a health care system that meets their needs.

I’m not trying to be pandering in any way, but it seems to me that this may be a model for all of us in the end, because we’re looking into a team-based approach. The doctor, Daniele, from Cowichan was absolutely amazing. Again, Murry from the aboriginal centre in Prince George….

My only quick question, having said all of that, is…. My position is spokesperson or critic for mental health and addictions. So I’m just wondering how you are attaching that illness to your team-based system.

R. Jock: Well, part of the system…. At Cowichan, for example, we have a behaviourist position with that. What that’s intended to do is to…. It’s another word for “mental health.” We want to put a more positive description to it. But our primary care model does have mental health as one of the key elements built into it.

We are also, I would say, focusing a fair amount at this point on developing mental health and wellness teams. We have a number of specialty teams across the province. I think that’s really a reflection that we need to invest in this as the number one priority for First Nations.

We have these teams, but also the primary care teams themselves have those interlocking circles, if you would, so that we can focus on that in a comprehensive way and so that we are approaching it from a holistic point of view — that it’s the entire person that’s being dealt with, that their spiritual and emotional elements are equally as important as their physical needs.

L. Larson (Chair): Donna, last quick question.

D. Barnett: Part of that was my question. But the other question is: substance abuse. I know there is one facility in my area, the Nenqayni place, where the First Nations go for substance abuse. I don’t know how many spaces there are. Are there other facilities around the province that are already established?

R. Jock: We have 11 programs across the province. Part of what we’re doing, since we’ve taken over, is trying to make one system out of that. Before they were all isolated. So there might be vacancies in one area, overages in another. We are working on how to make sure that that’s one system rather than lots of pieces.

The other part is we’re having grief and loss, residential school issues. All these things are dealt with at the treatment programs. So they’re more like healing lodges than specifically dealing with addictions on their own.

We are changing our approach but also looking at: how do we interlock better with the systems offered through the regional health authorities and the province?

L. Larson (Chair): Thank you so much, gentlemen, for being here and for your presentation and for sharing what’s happening through the First Nations Health Authority around the province. We really do appreciate it. Thank you for being here.

And we are going off air.

The committee adjourned at 5:33 p.m.

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