2011 Legislative Session: Fourth Session, 39th Parliament

SELECT STANDING COMMITTEE ON HEALTH

MINUTES AND HANSARD

MINUTES SELECT STANDING COMMITTEE ON HEALTH

Tuesday, November 15, 2011

11:00 a.m.

Douglas Fir Committee Room

Parliament Buildings, Victoria, B.C.

Present: Norm Letnick, MLA (Chair); Mike Farnworth, MLA (Deputy Chair); Katrine Conroy, MLA; Guy Gentner, MLA; Colin Hansen, MLA; Dave S. Hayer, MLA; Richard T. Lee, MLA; Dr. Moira Stilwell, MLA.

Unavoidably Absent: Bill Bennett, MLA; Ron Cantelon, MLA; Sue Hammell, MLA

1. The Chair called the Committee to order at 11:07 a.m.

2. The Chair provided the Committee with an overview of Sub-committee deliberations regarding the KPMG proposal

3. The Committee reviewed and considered the KPMG proposal, as circulated.

4. The following witness appeared before the Committee and answered questions:

5. Resolved, that the Committee adopt the KPMG proposal as amended. (Dave S. Hayer, MLA)

6. Resolved, that the Committee invite the Michael Smith Foundation to host the two-day workshop. (Mike Farnworth, MLA)

7. The Committee adjourned to the call of the Chair at 12:10 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

Tuesday, November 15, 2011

Issue No. 3

ISSN 1499-4232

[ Page 7 ]

TUESDAY, NOVEMBER 15, 2011

The committee met at 11:07 a.m.

[N. Letnick in the chair.]

N. Letnick (Chair): If I could have a motion to approve the agenda, please.

D. Hayer: So moved.

Meeting agenda approved.

N. Letnick (Chair): Thank you very much, everyone, for coming today in Movember, in case anybody is wondering why I am supporting this little hair below my nose. I'd also like to remind everybody that this is being recorded by Hansard.

Thank you to our loyal Hansard staff for doing that in the room.

I'll just give a brief overview of where we've been up to this point, bringing us to No. 1 on the agenda, the report of the subcommittee.

Report on Subcommittee Deliberations

N. Letnick (Chair): We started back on August 29, 2011. This is where we had our first meeting under the previous Select Standing Committee on Health before we were prorogued.

The subcommittee of the Select Standing Committee on Health, made up of the Chair, the Deputy Chair and Dr. Margaret MacDiarmid, met with folks from the outside, including Giles Newman and Mary O'Callaghan, from KPMG. We also had Dr. Robert Evans from the Centre for Health Policy Research and also Dr. Kim McGrail. We had Morris Barer in attendance, and we had Marty Schechter as well, from the Michael Smith Foundation. Graham Whitmarsh, as deputy minister of the Ministry of Health, and his staff were also in attendance.

We went through the Select Standing Committee on Health's mandate, in particular No. 1, which is to examine the projected impact of the provincial health care system of demographic trends to the year 2036 on a sustainable health care system for British Columbians, and reviewed the mandate and put together some recommendations for the full select standing committee.

[1110]

In between that time we were prorogued, and a new Select Standing Committee on Health was constituted, made up of pretty close to the same members — one or two changes.

We now have had a second meeting of the subcommittee, which was on October 18, where the new subcommittee met, this time with the Chair, the Deputy Chair and Colin Hansen on the subcommittee. We met with Giles Newman from KPMG to discuss the proposal, dated November 1, 2011, from KPMG, and a motion was made to refer the proposal with a positive recommendation to the full Select Standing Committee on Health. That's why we are here today.

That, in a nutshell, gives us the timelines as to where we've come from. I'd just like, in addition to thanking Giles and all the people at KPMG, the people from CHSPR, from Michael Smith, from the Ministry of Health, our Clerks, of course, and the subcommittee — Mike and Colin — to thank everyone for their deliberations and their thoughts to help shape KPMG's letter to the point where it can now be fully discussed at this group.

I just want to reiterate that we are working with the first part of the three-part mandate only — the first part being, to repeat: to examine the projected impact on the provincial health care system of demographic trends to the year 2036 on a sustainable health care system for British Columbians.

The subcommittee recommended that we expand the interpretation of that, after the presentation by the Ministry of Health, to also include other significant impacts to the health care system, including inflation, health care inflation and capacity utilization and scope, essentially.

That is where the KPMG letter starts from, looking at how we would flesh out the evidence for that No. 1 piece of our mandate. I'm sure we all have a lot of questions on the proposal, so at this point what I thought would be best — if it's okay with you, Giles — is for you to go through your proposal. As you're going through your proposal, would you prefer to have questions along the way, or would you prefer to wait till the end, once you've gone through the proposal?

G. Newman: Happy to take them along the way, Chairman.

N. Letnick (Chair): Okay. Very good.

With that, we now move to No. 2, a consideration and review of the KPMG proposal.

Mr. Newman, take it away.

Consideration of KPMG Proposal

G. Newman: Ladies and gentlemen, our proposal is essentially to adopt a four-phase process for evidence, including a written report, in answer to part 1 of the committee's mandate.

Phase 1(a) should probably be titled "A Call for Evidence" — and apologies for the wording — which is to write out to the public and, with the public, to all associated organizations within British Columbia to ask them for evidence that they think is pertinent to this
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debate and to answering part 1 of the mandate. That process…. We have been in conversation with the Office of the Clerks and have agreed how that may run, subject to the committee today approving the process.

The second phase, phase 1(b), is a series of meetings with key stakeholders. We feel this is important to provide context to the debate and also provide the opportunity of feedback from those sessions to essentially inform both the committee and also inform the debate for phase 1(c), which is a two-day workshop.

[1115]

I believe that there is a proposal that the Michael Smith Foundation host this workshop, but that's yet to be agreed. Certainly, they would need to be invited by the committee formally to host the workshop. But we see this as essentially two one-day sessions that could be held concurrently. That depends on who chairs the session, with day 1 being presentations and discussion of the evidence and the findings from the interviews and day 2 being what I would describe as a rigorous academic debate around what the evidence suggests and, also, getting us to the point where the top academics within British Columbia and from further afield, if invited by Michael Smith, would get to a conclusion on the impact of the various inflationary factors on health care expenditure in order to answer the key question on sustainability.

Armed with that evidence, the fourth proposed phase is a report by my firm that takes into account all of the items listed in our letter and provides some context for the committee in terms of answering the key question on sustainability in part 1.

That is where the letter ends in terms of the scope for this phase of work. The committee would then need to, obviously, decide, depending on the outcome of the first part, precisely how it was going to look at structuring and attempt to get an answer to the questions raised in part 2 of the mandate.

N. Letnick (Chair): Thank you, Giles, for that summary.

Questions?

K. Conroy: Usually when the committees meet, groups come and present to the committee. Is what's being suggested here that you actually interview key stakeholders and get the information through that process as opposed to stakeholders coming and presenting to the committee?

G. Newman: Yes, in part because we think it's important for one party to collect the information rather than necessarily a series of public meetings with the committee.

Secondly, it's quite difficult for the committee, I understand, in terms of the mandate, to be holding its own meetings and workshops and discussion forums without it being in a public forum. So we felt that this was the best way to get the best of both worlds, which is to ensure that standard questions are asked, that standard feedback is obtained, that the report comes to the committee so that the committee can consider evidence, and that the report is then, after it has been through the committee, used to inform the debate at the workshop.

N. Letnick (Chair): If I can add to that, the intent is to go out to the general public of British Columbia and ask them to submit evidence. So everyone would be able to submit evidence to our committee. The letter says that KPMG would then specifically go after certain groups and try to build evidence, to get evidence from those listed by them in this letter.

The overarching piece is that we would ask all British Columbians who have evidence to provide data, whether it's peer-reviewed or not, directly to the committee without going and holding public hearings.

I think that's what you're referring to — where you have people speak just like Mr. Newman is and come and provide their 15 minutes for the evidence. If I have that correct, Giles — right?

G. Newman: Yeah. In terms of process, it felt to us that there are two important parts to the debate. The first is the call for evidence from the public. The second is to really understand what the views of the key organizations within the province are, and the list of those key organizations is in our letter.

What we are attempting to do is to really understand and have conversations with those who ought to have a view and ought to have access to key evidence, and that is then, essentially, enhanced by the public call for written evidence that would sit alongside it.

K. Conroy: So the information that comes from groups such as the BCMA or the different unions will come paraphrased from your organization? We won't be getting their entire presentation. We will be getting their presentation coming from your perspective.

[1120]

G. Newman: Not at all. What we will be doing is we will essentially be asking each organization a standard set of questions, and their responses will be recorded. We will, depending on the wishes of the committee, either write a verbatim report of that, a write-up of that, or we will essentially précis that to cut down the amount of paperwork.

M. Stilwell: I was just going to make an early suggestion, if I may, that I think the use of the word "evidence" is ill-advised. I think that we should be asking people for submissions, viewpoints, opinions and so on. I think
[ Page 9 ]
the word "evidence" is very loaded and codified. One man's evidence is another man's flat earth society and will create more difficulties than it will aid.

G. Newman: Can I answer that, Chair?

N. Letnick (Chair): Yes.

G. Newman: We thought long and hard about this, because what we didn't want to do was we didn't want to necessarily throw the doors open during part 1 to the debate that will naturally follow. I think that there will be a debate in part 2, and part 3 of the mandate is to consult more broadly with the public about the issues raised.

It was felt from the start, I think, from the meeting on the 29th of August, that it was important to ensure that there was, as far as possible, a structured answer to the key question on sustainability. That is why part 1 is concentrating on evidence rather than concentrating more on people's views and thoughts on the process, which will follow in due course.

M. Stilwell: Well, I would just say that what you're gathering, though, is not necessarily evidence, but you're allowing people to label it as such. Personally, I think that's not a good idea, but I'll….

G. Gentner: I guess the first blush, as a committee…. I know the subcommittee has already met. But just understanding your requirements to "examine the projected impact of provincial health care system, demographic trends in 2036 on a sustainable health care system for British Columbia…."

Any analysis, I assume, is a comparative analysis, so is there going to be a preamble of where we are so we can see where we're going? I would suspect, having a former Minister of Health in the room — or two, actually — that there's already a plan in place, I'd assume, for projected impacts. Are we going to look at that plan and why it is that maybe it's not copacetic with our new vision and how that compares with where we're going with this new projected impact?

I mean, I'm just looking at some substance before we move on where we are today, before we look at the demographic. Or is that not going to be covered under these terms of reference?

M. Farnworth (Deputy Chair): We need a baseline.

N. Letnick (Chair): Giles, do you want to answer that?

G. Newman: The subcommittee considered this point. There is, I think, an underlying assumption that we need to work with, which is that the system as currently defined — i.e., precisely what is paid for by the taxpayer and precisely what isn't paid for by the taxpayer — and projecting that forward are what this exercise is about.

There has been to date no discussion, in my view, of precisely where we are now in terms of whether or not the system is sustainable currently. The system is plainly being paid for by the taxpayer currently. The financial state of the health authorities is good, in general. Therefore, there is an underlying assumption, a working assumption, that the subcommittee made, which is that the system is sustainable at present.

[1125]

However, there was no concrete and definitive answer to whether it would be sustainable in 25 years' time, which is the timeline that the committee was considering. That is why the approach that we've adopted has been proposed.

G. Gentner: Well, I could discuss that one for some time, Chair. We've been dealing with projections in the discussion for some time, so I think it would be really great to have, as Mike mentioned, a baseline, even sort of a preamble, before we move on. Obviously, that may not be the purview of the committee.

Also, here's a question to the committee on its terms of reference. It's interesting we have three positions that the committee is empowered to do. Yet in the report from KPMG there is actually a definition of "sustainable health care" and a definition of "provincial health care system."

Why is that not being incorporated into these terms of reference? It seems to me they're a little ambiguous when we talk about a large provincial health care system and what is meant by sustainable health care system. Was that considered? Will we be going out to the public trying to explain what these positions really mean without any reference or glossary as projected by KPMG?

N. Letnick (Chair): Your subcommittee met at the first meeting to look at the mandate that was given to us by the Legislature. It was proposed that we expand the first piece of the mandate as described on page 2 of the KPMG letter. So it would be really up to this committee, the Select Standing Committee on Health, to interpret the first part of the mandate.

What I said in the preamble, Guy, was that when we got the presentation by the Ministry of Health on what exactly might challenge the sustainability of the system moving out 25 years, it was more than just the demographic shift, more than the boomers themselves working through the system. It also had a lot to do with inflationary impacts on health and, of course, system utilization.

They put forward the argument — and it was accepted by the subcommittee — that if we are going to look holistically at the sustainability of our publicly funded health
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care system over the next 25 years as the boomers move through, we should expand the scope of that first piece slightly but still keep it within the evidence base.

When you talk about baseline, I think that's a very valuable point. That's why KPMG is proposing in this work to come up with three sets of numbers. One is a baseline set of numbers. So if we continue doing roughly what we're doing, here's what the numbers project out to be. That, of course, would have to start at point zero, time zero, which is now. I'm pretty sure you would get what you're looking for in that piece.

The other two pieces are if there is a worst-case scenario and a best-case scenario on the sustainability front, which KPMG is also proposing to articulate in their report.

I value your point, and I think it's covered off in the KPMG report. Did you want to discuss this some more?

G. Gentner: Well, I do, because the terminology, I think, is quite ambivalent. There may be something in the public health care culture that people assume what they mean. But putting on my layman hat, I look at "outlying potential alternative strategies." There's no definition. "Alternative medicine" could be naturopath.

I'm not here to nitpick. I'm just trying to bring things into a succinct position where we understand. Are we talking potential alternative strategies as funding formulas? It's very ambivalent to me. I think we should start off with some definitive positions of what we're really trying to do.

[1130]

N. Letnick (Chair): I guess I have to be clear. Are you looking at part 2 of the mandate — the alternative strategies? If you are, we're solely focused on part 1, which is the data analysis of what the numbers tell us, the direction we're going towards in the next 25 years — and specifically on part 1 alone. When we communicate to ourselves and to the public at large — you bring up an excellent issue — we have to make sure the public at large understands that, at this point, we are solely focused on the first piece of our mandate.

Once we have those numbers to the satisfaction of all of us, as produced by KPMG, a totally independent group, then the next piece will be: what do the numbers tell us, and what can we do about it? That's when we go back to the public more in terms of what I think Katrine was talking about, which is: "All right. Here are the numbers; here's the baseline; here's the worst case, best case. The system is or is not sustainable the way we're doing it. What are our alternatives?" That's when we invite the public to propose their ideas.

I'm sure that when we go out to the public on No. 1, we're also going to get input — even though we're not asking for it at this point — into what their ideas are to make the system better or more sustainable. We'll receive those with respect and put them aside for the time being until we've finished with quantifying the scope of No. 1.

G. Gentner: So — excuse me — the terms of reference is a staged approach?

N. Letnick (Chair): Yes.

G. Gentner: Okay. It just doesn't quite say that here as specific and as well as you did.

N. Letnick (Chair): I apologize.

G. Gentner: The devil's in the detail. That's why I'm asking. I mean, I understand to keep it clear and succinct, but it didn't tell me that after examining…. "Examine the potential impact, and then upon completion, move to an outline." It doesn't say that. My misunderstanding, but it just didn't read that way to me.

N. Letnick (Chair): Again, when we went through the KPMG proposal, I should have identified the last step in their report, on page 5. The last bullet says: "Next steps, including a preliminary timeline, suggestions for planning part 2." The intent is to do all of part 1 first before we even start looking at planning part 2.

R. Lee: It's my pleasure to be sitting on this committee. I have two questions. I think one is a comment on the baseline. The Ministry of Health, as I can see, and the Ministry of Finance will be presenting in phase 1(b). I think the opportunity for them to establish a baseline is there, with some evidence.

My other question is on evidence admissibility. Who is going to decide what kind of evidence will be admissible to be considered as one of the factors or parameters or data set in your conclusion?

G. Newman: In terms of the public evidence? The reason for the definition on the call for written evidence of peer-reviewed, published academic studies and other high-quality research is that we hope to work with the Clerks to get essentially an agreed checklist of questions which the Clerks will answer themselves when looking at the evidence obtained, so that we can obtain a standard view on what evidence will be considered and what won't be considered by the workshop.

There will be two ways that the evidence is essentially collected. The first is through the call for written evidence and from the public, which the Clerks will undertake. They will provide a summary internal document of the evidence that is submitted by the public. The second is through the standard process that we will adopt in terms of requests for evidence through the interviews.
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Those will be brought together for the workshops, and Michael Smith will take a view in terms of, if they are asked to be the chair of that session, precisely how they manage and run the evidence base that has been collected.

[1135]

R. Lee: Yeah. My understanding is that there is a lot of evidence probably based on modelling and projections and an awful lot of assumptions. I think that's for academia to debate.

In the first stage, as gatekeeper — I don't know if "gatekeeper" is the correct word or not — you have to somehow get some of the data admissible before you submit to the debate — right? I don't know how much discretion you have to select the evidence and base on…. Are those hard numbers? Are those perceptions or surveys, that kind of thing? How do you define that more precisely?

G. Newman: I think this comes to the definition for the call for evidence, which is around whether the studies have been published and have been peer-reviewed in terms of academic studies.

Coming back to one of the other member's comments earlier on, it's going to be quite essential to the debate that we ensure that the pool of evidence is kept to a manageable level. Otherwise, I think this process does have the opportunity to not answer part 1 but go into part 2. So what we need to do is we need to try, as far as possible, to condense that evidence.

Now, what we haven't yet agreed with the Office of the Clerk is precisely what the checklist is that they will use in terms of discerning what evidence is in and what evidence is out of the process. That's something that we would seek to do as they gear up for the call for written evidence and go out to the public. By the time that that process starts, we will have agreed that, and I'm very happy to bring that back to the committee for the committee to discuss whether or not those are the right questions for the Clerks to ask.

N. Letnick (Chair): If I can interject for a sec, Giles. Would it be fair to say that with the Clerks we could accept all submissions? I'm going to use "submissions" instead of "evidence" for the time being. We could accept all submissions as a select standing committee, and then it would be up to the select standing committee…. This is the question part. Is it up to the select standing committee or is it up to KPMG, in consultation with the host, for example, of the two-day workshop, to determine how each submission would be weighted in terms of usability for your report?

I wouldn't want us to dictate to you, who are writing a report as an independent body, to say which ones you can use and can't use. I think we need to put a little more meat on this bone here.

G. Newman: I understand, Chair, and I think that is a good challenge. At the moment the intention is to ensure that there is an open process so that the Clerks can understand the remit and then understand how the evidence is gathered in terms of the report.

We could, alternatively, view this as Michael Smith and KMPG between us would essentially set the bar and then would understand which studies were in or out. That is not the way that the letter and the scope of the work is currently written, but I am very happy to take suggestions if it's felt that that is actually a better way to do it.

N. Letnick (Chair): We might have to come back to that.

C. Hansen: I joined the subcommittee when it was largely into this process, and of course, Margaret had served on the subcommittee prior to that. So I was only part of the last two meetings, which were relatively brief meetings.

[1140]

One of the things that struck me as we were going through that process is that I think we have to be very cognizant of the terms of reference that the Legislature has given us. I think they help us to put this discussion into a box that is hopefully manageable. I'm not going to say "is manageable," because the issue around health care and sustainability is so big and so emotional and there are so many organizations, stakeholder groups, families that have a vested interest and a real, emotional concern about the answer to the question that we have.

I think both Mike and I have served as Health ministers in the past, and I think we both know firsthand that there is no end of input. We will get swamped with that input in a way that is not manageable if we don't, right from the get-go, be cognizant of the fact that even though the terms of reference are limiting, I think we have to approach the work of our committee to sort of draw that scope in even tighter so that we can come up with something at the end of the process that I think will be informative, will encourage the future dialog and will be helpful and not allow us to sort of get buried under the huge volume of input that is potentially out there.

So when we look at part 1 and the words, "Examine the projected impact on the provincial health care system of demographic trends to the year 2036 on a sustainable health care system for British Columbians," I think all of us have to keep those words in the back of our mind. As we're interacting with outside groups that would like to have an impact on the future of health care, we need to be able to steer some of that input back to the minister's office or the Ministry of Health, as opposed to saying, "Come one, come all," and we'll be the receiving end of everything under the sun to do with health care in British Columbia.
[ Page 12 ]

I just think we all have a role to play in sort of saying: "Look, the role of the committee is within the scope of the terms of reference." I think we have to make sure that we continue to keep it within that scope and, if anything, tighten the scope as we proceed through the process.

G. Gentner: It's a good thing that I'm following Colin, who is a former Minister of Finance, as well, who understands the huge responsibility we have in managing our finances regarding the demographic shift, which our terms of reference is all about.

I think it is important — I agree with Colin — that we have to understand our mandate before we get bogged down. We have to understand our terms of reference. We talked about sustainability. I'm going to Giles's recommendation or review of sustainable health, and it states that further it was proposed a publically funded health care system should take a "fixed proportion of government revenue to maintain quality."

So let's get the mandate straight here. Are we talking about a static, fixed portion of revenue per annum, or are we looking at a percentage? Is there any fluidity here, any flexibility, or are we looking at a cap on the revenue stream as defined as "sustainable health care"?

G. Newman: The problem, if you don't set the bar at the level that it's at, at the moment in terms of a percentage, say, of GDP around health spending, is that you quite quickly get into a debate on policy, both on taxation policy and also health care policy compared with and in comparison to spending in other areas.

It was very strongly felt at the meeting on the 29th that this was not the remit of the committee. The remit of the committee was not to set tax revenues and was not to view health in proportion to the whole but to say, "Okay. In terms of what we are doing now, then how does that work into the future?" and not necessarily getting involved in the wider debate.

[1145]

Now, I think that there is a very good case to say that it is difficult to divorce the two going forward. However, I don't see how you can take a 25-year view into the future unless you take the view that nothing is going to change in terms of the proportional nature of health spending compared with other components of public spending at the moment.

G. Gentner: Just a supplemental. Just a wherefore or what-if, and that will be subject to this. I mean, we look at Canada Health Transfer payments…. I mean, they do shift now and then, and part of our funding is from the government of Canada. In this formula, sustainable health care — if we're looking at a fixed proportion of government revenue to maintain quality — is going to need some fluidity here in order to deal with those scenarios. If we're going to a very static position over the next 25 years, there's got to be some wiggle room.

I would offer to you that our view of sustainable health care, whether it's dependent on the GDP, has also got to look at other factors, including the external influences and funding from the federal government.

G. Newman: And there are some projections for that going forward. But again, it's difficult — in fact, impossible — to project what the impact of current and future policy may be within that 25-year time horizon. So we have to make some assumptions, and the assumptions are based and have to be based around the information that is available today, the studies that have been conducted to date and a view on what those impacts may be in the future.

The KPMG work, particularly around income and GDP, is not to move the debate along but is actually to say: in terms of the studies that exist, then, this is what is recognized to be, by the province of British Columbia and also from the Canadian government's perspective, a reasonable position on income and GDP into the future.

D. Hayer: Thank you very much, Giles. Thank you for your information.

Are there any other provinces or other jurisdictions in western countries that are looking at the same issue? When I talk to people, they say: "Look, this is not a phenomenon in British Columbia only. This is happening in almost all the western countries and all the provinces."

Who else is doing maybe a 20-year, 25-year study to see: how do we sustain it, and where are we going? What are the demographics in reality, rather than what we just read in the media?

G. Newman: The answer is: it is a common debate, and there are instances around the world — Australia, the U.K. — where we can point to similar studies.

The issue, I guess, for British Columbia is that the system in British Columbia, and the services provided by publicly funded dollars, is different to that provided in other countries and other jurisdictions, and therefore, it needs to be put into the context of British Columbia. But there is learning from around the world that KPMG will be looking to bring into the report to see and understand what other systems are looking at — their definitions of sustainability and also what they consider to be their position on sustainability.

N. Letnick (Chair): I was just about to say that seeing no further questions, I have some amendments to propose, but go ahead, Richard.

R. Lee: I just listened to Dave's question. I understand KPMG is also a very big organization. You have different experts around the world. I think evidence somehow
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from other jurisdictions probably is usable here, and our study's data probably will be usable in other places.

In the contract I also see that your company will be permitted to use the results of the research done here. At what point would those results be used? I think my question is about the timeline. Also, what kind of results would be available to the committee that probably won't be available to an outside party, or vice versa?

[1150]

G. Newman: Sure, I understand.

Well, firstly, the report will be the property of the committee, so we will be looking to use the conclusions that are drawn by the report in terms of a global debate. We will also, as part of our work, look to bring in evidence from the global debate for consideration by the workshops and the academics.

One thing that I can say with surety is that KPMG has, I think, a leading-edge health care practice globally and has the ability very quickly to obtain evidence from around the world. That process and the structure that we have will very much be used as part of, firstly, the debate and, secondly, the report.

R. Lee: I think my question is: at what point could the results here be used outside B.C.

G. Newman: Well, I think the report will be useful to other systems in the world, much as any reports that have been compiled to date around the world will be useful to this report. In terms of that, I would expect that the committee uses the report and the next steps to get into phase 2 of the work. I will make sure with colleagues that the results of the report are known so that that will be able to be played back into other health systems across the world.

I don't really think that there is a timeline or any hidden agenda here as far as KPMG is concerned. This is just something where, because of the work we're doing, because of the investment we're making in this process, we would like to use the results from it to inform the wider global debate. I think that's entirely appropriate.

N. Letnick (Chair): I'd just like to, on that, thank all the folks at KPMG for their contribution of time pro bono in this process up to this point. It has been outstanding cooperation, not only with our subcommittee but also with the Chair, working through this over the last few months. And even though I have asked Giles to get a residual for the province of B.C. for every time they use our report for other provinces, he has, however, respectfully declined to provide that.

If I can at this point, what I'd like to do is propose some changes to the letter, which were distributed on one sheet of paper. The purpose for the changes is to make sure that the scope tightly fits with the mandate, as per No. 1 of our select standing committee mandate.

That's why, in the letter, it currently says on page 2 that KPMG would ask the list of participants that it has identified for itself to approach whether they think the health care system is sustainable and why.

I don't believe that fits very tightly with No. 1 of our mandate in seeking the data as to coming up with a baseline, a worst-case and a best-case scenario. It appears also on page 3 — the same line. So I would propose that with, of course, the agreement of KPMG — it's their letter, their proposal — and the members of the committee, we delete those two lines and focus solely on the submissions, the data that people have to offer, whereby KPMG can do its financial projections as to what the expenses are going to look like over the next 25 years versus the revenue.

Before I go to the committee, are you comfortable with that, Giles?

G. Newman: Very much so.

N. Letnick (Chair): Okay. Committee members, how do you feel one way or the other?

I call a friendly amendment to your proposal. I see no hands, so we'll move forward with that.

[1155]

Also on page 5 it talks about something which was already brought up in today's meeting by Guy. That's the whole issue of looking at the numerator in this equation — the numerator being the economic ability to sustain our health care system, and the denominator being, of course, the cost.

The numerator in the letter shows two items, economic growth and taxation revenue growth, which would really put us into the whole situation of: what is the appropriate level of taxation? We don't have the mandate to look at the growth piece of that.

So I propose to you, as well, Giles, that we merge those two to basically say "economic growth and taxation revenue" into one bullet, and call it "projected economic growth and government revenue." The reason, as I said, is that I think that would give a more accurate picture as to where we're going in the future without proposing one alternative or another as far as taxation policy.

If you average it out over the last 20 years, government revenue is running around 19.25 percent of GDP. Just at a high level, if you projected 19.25 percent of GDP over the next 25 years, you could see what the level of access to funds would be for government to use in whatever way it wanted to, whether it's health care or otherwise. I think it'd be safer if you would accept that also as a friendly amendment to your note.

G. Newman: I agree with that, particularly in light of my previous comments around not wanting to bring
[ Page 14 ]
policy debate into this part or indeed the remit of the committee.

N. Letnick (Chair): Okay.

M. Stilwell: I just had a question about the use of the word "inflationary." I think of that as an economic term, but you seem to be using it as just something that increases every year. So I just wonder if that's the right term to use.

G. Newman: Well, yes, it's a fair challenge. I suppose I haven't been able to come up with a better word, so I'm very happy to accept….

M. Stilwell: I don't necessarily have a suggestion. Some words are kind of codified, you know, and I'm just trying to get clarity around that. Government could choose to increase spending. That's not inflation. Anyway, you understand what I mean.

G. Newman: I do understand.

M. Stilwell: I take it as an economic term.

G. Newman: The intent, I can assure you, is just to look at the individual parts of health care spending that can be projected. In most cases — in fact, probably in all cases — those are going to be inflationary by their nature.

N. Letnick (Chair): So we should then, seeing no further hands, move on to the two outstanding issues that….

Oh, sorry. Guy?

G. Gentner: Amendment 4. On page 2, I really have a problem with: "Provincial health care system" — bullet 2, top of the page — "may be defined as health care paid by the governments of Canada and B.C." And then you put a quantifier in there: "Delivery system may be private." Now, there's a red herring if I ever saw one.

Were you intending on saying that the whole delivery system may be private, or are you suggesting some delivery systems may be private? Under the Canada Health Act we can get into a lot of trouble with that statement. So either you eliminate it or at least come to a compromise and admit that there are some delivery systems that may be private.

G. Newman: I'm happy to amend that to say something like "where the delivery system may be public or private." I think that then assists with….

N. Letnick (Chair): Reflects the status quo.

G. Newman: Yeah, absolutely.

N. Letnick (Chair): Most family physicians are private business operators.

Guy, would that satisfy you?

G. Gentner: Yup.

N. Letnick (Chair): Okay. That's fine. Thank you. Another friendly amendment.

Any other friendly amendments?

Okay, so on the issue of evidence versus submissions. This also brings into question the ad that was put on our tables by our Committee Clerk.

Thank you, Susan, for putting this together — you and your team. It has your name on it, anyway.

It says: "For a call for written evidence."

Moira, do we have a different word that you would propose?

M. Stilwell: I propose just "submissions." Can I just add something to that?

N. Letnick (Chair): Of course.

[1200]

M. Stilwell: When Giles talked about the submissions, he talked about published, which has all sorts of spectrum. But when you talked about it earlier, you said it may or may not be peer-reviewed. I'm of the mind that you are — that you should accept a wide range of opinions if that is indeed what you're seeking through this ad. So I would used the word "submissions."

Then I have a question about what it is you want people to actually submit.

N. Letnick (Chair): Right. So the concept is that yes, of course, research published would be acceptable. Peer-reviewed would be acceptable — also data that is not published or peer-reviewed. For example, all the Ministry of Health information that we could use might not be published or peer-reviewed, but it would still be very valuable evidence — and Ministry of Finance and other groups out there.

G. Newman: That's why the wording talks about other high-quality published research. That's where I think we need to agree with the Clerks and then possibly come back to the committee about the criteria that we use for high quality.

I suppose the intention is to ensure that, for example, the papers of the ministry or the papers of a body like CIHI, who have got a view on this and have published reports on this, are very much considered but that an individual who may write a letter about what they consider to be sustainable and what they consider not to be
[ Page 15 ]
is not necessarily taken forward in part 1 in terms of the evidence that the academic workshops will consider.

G. Gentner: Maybe I'm missing something here. I'm going to wear my prevention hat for a second. When you look in demographics and how we're going to deal with the chronic situation and the call for written evidence, there's no mention of how we're going to weigh in on the success of preventing chronic situations.

In the 25-year period the savings that will be made by, let's say, eating broccoli…. I know the government opposite spent some time years ago putting together a whole notion of good eating. Is that going to be part of this whole idea of sustainability?

Interjection.

G. Gentner: It's going to come under 2?

You're calling for written evidence, and I'm just wondering: where are you going to find that evidence regarding, I think, probably one of the more essential pieces of the sustainable puzzle?

G. Newman: I think this is a good example, looking again at the remit, of alternative strategies. A good example of an alternative strategy may be to invest in public health to a greater extent than the province is currently, but that will be just one of a number of alternative strategies that need to be considered. So I would agree that that is, in my mind, very much a part 2 issue, rather than answering the question on sustainability in part 1.

N. Letnick (Chair): If I may take this ball a little bit and run with it, could we not as a committee receive evidence, data or research that's already been published out there or created, which would show that eating broccoli, as Guy said, actually would have…

Interjection.

N. Letnick (Chair): Or spinach. I don't want to discriminate against spinach-lovers.

…an impact on the projections over the next 25 years, that the whole keep healthy campaign is having an impact and therefore is reducing the slope of the cost curve. That might already be out there, and we would gather that as we go out to the B.C. public and ask for the evidence.

Is that not right, Giles?

[1205]

G. Newman: It is, Chair. I think the debate about public health compared with health care provision is an interesting one. I'll go back to MLA Hansen's point earlier on, which is: do we wish as a committee to broaden the scope of what we're looking at, or do we wish to condense it?

My personal view, and the reason that the letter is written the way it is, is that we're trying all of the time to bring it back to something that's manageable, rather than starting to throw it out. I think the second part does do that and absolutely has to do that. But I think you do need to have, as a committee, some definitive answer to part 1 before you can move forward into that. My recommendation to you would be, in terms of structuring your work, that you try and keep this part as manageable and tight as possible in terms of scope, rather than keeping to expand it.

N. Letnick (Chair): If I see no other hands, is it the feeling of the committee that you're prepared to move forward with this proposal? Are you comfortable?

R. Lee: In terms of demographic data, I think ages, gender…. All those are important. But there are other factors — for example, the population of aboriginal population; immigration policy changes, with admitting more seniors; that kind of thing. I think it's changing right now. I think sometimes policy will affect the demographic data a little bit. Are you taking care of those data?

G. Newman: The intention is that, again, we come back to: we know what we know, and we're not going to guess what we don't know 25 years out. So we're going to take whatever the current policy position is, and that will be the aspect that will be rolled forward for 25 years.

There may be policy under discussion currently in this parliament, and that may change, but it's not going to be taken into account as far as this review is concerned. What we're going to be doing is that we'll draw a line and say: "This is where we are now, and this is the impact of where we are now into the future."

N. Letnick (Chair): I would propose that the Deputy Chair and the Chair meet to go over the proposed call for evidence, submissions — whatever — and work out the wording to our satisfaction, if that's okay with you, Giles, and the Clerk's office.

I would also ask, unless there are other issues, if someone would like to make a motion to accept the letter from KPMG as amended, as a guide for us for our workplan. Don't all jump up at once.

D. Hayer: I'll do it, then.

N. Letnick (Chair): David. Okay. Thank you.

Discussion on the motion?

Motion approved.

N. Letnick (Chair): Before I get to the next one, thank you very much again. Your work has been outstanding — you and your firm — over the last few months.
[ Page 16 ]

Other Business

N. Letnick (Chair): The issue of host. In the letter that we just accepted, the issue of host is left open. On the piece of paper that I circulated, it tells you a little bit about the Michael Smith Foundation, for those of us who didn't know about the Michael Smith.

They, through a telephone call after they had sat on our subcommittee, offered to host the two-day workshop and the process involved with that. I said, of course, I'd bring it back to the full committee and see if you want to go to some kind of open request or if you'd be comfortable with moving forward with the Michael Smith Foundation. I would write a letter to them, asking them to indeed proceed with hosting the two-day workshop.

What are your thoughts on the matter?

M. Farnworth (Deputy Chair): I think it's good.

N. Letnick (Chair): You think it's good. Michael thinks it's good. Colin is shaking his head up and down, for Hansard's record. Seeing no objection, then, if we could have a motion.

Mike, would you like to make that motion — that we invite the Michael Smith Foundation to host the workshop and work with KPMG and the Clerk's office on the criteria involved with determining who's going to be at the workshop?

M. Farnworth (Deputy Chair): Yup — so moved.

Motion approved.

N. Letnick (Chair): That's basically our agenda for today. Is there any other business that members would like to bring up?

Motion to adjourn? Richard.

The committee adjourned at 12:10 p.m.

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