Health — Issue No. 2 — Thursday, November 7, 2013 (HTML)

370 HSBC Executive Meeting Room
Morris J. Wosk Centre for Dialogue
580 West Hastings Street, Vancouver, B.C.

Present: Norm Letnick, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Donna Barnett, MLA; Sue Hammell, MLA; Linda Larson, MLA; Richard T. Lee, MLA; Jane Jae Kyung Shin, MLA; Michelle Stilwell, MLA

2. The Committee reviewed its Terms of Reference related to the conclusions of the Select Standing Committee on Health Interim Report 2011-12.

3. The Committee reviewed and discussed a preliminary draft of a background document prepared by the Parliamentary Committees Office regarding inter-provincial and international comparisons of healthcare services and delivery.

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


CONTENTS
Page
Committee Interim Report 2011-12 and Committee Terms of Reference	7
Review and Discussion of Committee Research Briefing	10
Committee Meeting Schedule	22

N. Letnick (Chair): The first order of business, I would guess, is to get approval of the agenda, even though that's not on the agenda.

Do we need approval of the agenda, Madam Clerk? No, just go ahead with the agenda as is?

In that case, we have Susan, who's going to walk us through No. 1: review the committee's terms of reference relating to the conclusion of the Select Standing Committee on Health Interim Report 2011-12.

N. Letnick (Chair): It's okay. We just started. Thank you very much for coming on. If at any time you would like to ask a question or make a comment, just yell out, and we'll put you in the queue along with those people that are here around the table. I hope everything is going well for you back at home.

We're going to start the agenda on No. 1. If you can start, Susan, and take us through this, that would be great.

Donna, just so that you know, we're doing the review of the committee's terms of reference related to the conclusions of the Select Standing Committee on Health Interim Report, the report of the committee in the previous parliament.

Welcome, everybody. It's a nice and cozy atmosphere here. You've got a group of documents in front of you. One is a folder that Josie will walk you through. Those are documents related to the background note that Josie prepared that we'll discuss as item 2 on the agenda.

The other document that's in front of you is the actual Interim Report from the committee from last session. As you may know, the committee was activated about halfway through the 39th parliament, in 2011. It was assigned a three-stage mandate and in the last parliament dealt with just the first stage of the committee's mandate, which was to conduct an inquiry focused on the impact of the demographic trends on the sustainability of the health care system, looking 25 years in to the future.

In order to conduct that inquiry, the first thing the committee did was establish a steering committee, which was composed of the Chair; the Deputy Chair — at the time it was Mike Farnworth; as well as a third member of committee. It started off with Margaret MacDiarmid, and then the second part of it was Colin Hansen.

The steering committee essentially developed the timelines for the committee as well as a proposal that KPMG act as advisers to the committee. KPMG assisted the committee in developing its consultation process. If you look in the committee's report, on page 4 you have an outline of the consultation process.

The objective was to create, essentially, a snapshot of the health care system as it was so that committee members would have a baseline for analysis going forward. The first part of that snapshot was a call for written submissions. The committee was looking for peer-reviewed academic studies that would quantify the impact of the demographic challenges, utilization, inflation pressures as well as other factors on the sustainability of the health care system.

In the appendix on page 11 you'll see a list of all the submissions that the committee received. There are about 50, and they are posted on our current committee website. The new terms of reference transferred all the submissions, all the evidence the committee received in the last session to this committee, so it's still available to the committee.

The next part was an interview with stakeholders that KPMG coordinated. Stakeholders were suggested by the committee. The committee came up with a list of stakeholders for KPMG to interview. They wanted to find out from these stakeholders what they thought would be the impacts of the various inflationary factors on the health system.

What they got back from the stakeholders was that in addition to the financial aspects of sustainability, there were other elements of sustainability that should be looked at — outcomes, access to care and services. Patient satisfaction should also be included, according to the stakeholders that KPMG interviewed.

Also, they identified other what they call commonly identified cost drivers, and they were listed at the bottom of page 4: demographics, an aging population, pharmaceuticals and drugs, utilization of services, general price inflation, technology and the impacts of technology, and system design. So there are numerous cost factors.

The committee then, with the help of both KPMG and the Michael Smith Foundation, organized a two-day workshop for committee members. The Michael Smith Foundation was the host of that workshop, and it was essentially to discuss key health care issues and concerns and to learn more about these cost drivers. It was to give the committee very much an overview. We had one day with stakeholders, a second day with academics. On page 12 you'll see a list of all the participants in that workshop.

The final aspect of that was the report from KPMG, which is included as an appendix in your interim report. The KPMG report also included some questions that the stakeholders had for the committee. It's on page 12 of the KPMG report.
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There are questions that the stakeholders felt the committee should keep in the back of their minds as they're going forward. For example, how can physicians become more incorporated into the system and engaged in system change, especially in primary and community care models? Can accountability across the system be better defined and managed? There are five questions there that the stakeholders had asked the committee to keep in mind.

The committee itself, in its report — and you'll see the conclusions of its report on page 8 — essentially determined that population aging was just one of the cost drivers. In addition to aging, there was population growth, health-related inflation, general price inflation and increased utilization.

Those were the conclusions of the previous committee. Your committee, in its terms of reference…. The first part of the terms of reference is to consider the conclusions contained in the interim report and all the evidence and submissions that were received.

For the committee to have, really, a context for those conclusions, we've organized this overview of the health care system — as Norm calls it, I think, health care 101 — for committee members. Going forward the committee will eventually undertake consultations or perhaps will require additional research.

The committees office will be here to support the committee in whichever direction the committee needs to go or wants to go. Certainly, bring forward your ideas to the Chair and Deputy Chair, and we'll implement them for the committee, under the direction of the Chair and Deputy Chair.

N. Letnick (Chair): It was a labour of love for a year and a half, but it's only one piece. It's only the first piece of a comprehensive puzzle. The second piece, which we are going to be engaging with probably when we get back to the Legislature in February, is: what do we do about it?

Now that we have a good idea as to what's happening, and over the next couple or three sessions we'll have a good idea as to how we got there, the next piece is where we go from here as to answering the question: what do we do about these challenges that have been identified through the first piece?

Just on that, as Susan said, framing that discussion is going to be really important, because we don't want to just go out to British Columbians and say: "Okay, tell us what we do about it." That's not going to be as productive as actually framing the discussion around some key questions.

So what we'll do over the course of the next few months — we're just in November, so November, December, January and then into February — is come up with some preliminary ideas — and I’ll work with Judy and Susan on that — to present to you as a committee as to how we frame that discussion, going forward.

In the meantime, we have a little bit of an opportunity here, as we design, with your instructions, the next few days of looking at the system. How does the system work? We have different levels of knowledge around the table. We have some people, such as doctors and nurses, who are really engaged in the health care systems, and then we have other people who aren't as knowledgable.

I wanted to make sure that, as much as possible, we all come up to a common understanding of the issues and how they work and also to be able to ask those tough questions that we got to ask during phase 1, which Susan so aptly summarized, of health professionals, of the Ministry of Health — fair questions, but tough questions.

When we, at some point, go out and ask people for ideas, we need to know ourselves whether or not what they're talking about is doable, realistic, measurable — all those things that we need to have. If we don't have that level of knowledge, then somebody can really give us a great speech and really blow us away. Then we'd go, "Wow, it's too bad we can't do that," after the fact.

So it's good to have that knowledge so that we can actually ask tough questions of the docs that are coming forward, and I mean PhDs as well as medical doctors. I would encourage you over the next few days — and I don't mean in sequence, because we're going to have a day tomorrow, but then in December and then probably in February, before we actually sit — to ask those fair but tough questions of all our presenters.

Everything that we say is on the record. The only time we would go off the record in in-camera meetings — and correct me if I'm wrong, Susan — is if there was a personnel issue, a land issue, something with a pecuniary interest involved. But if it's a general question, a general issue on health care, then we can use this opportunity of us asking these difficult, challenging questions to educate not only ourselves but to educate our colleagues, who aren't going to be at these meetings. They can choose to go on Hansard and review the record.

Of course, we can use that as an opportunity — and here's the teacher in me, Judy — to educate the general public. The media might be interested in checking what we're doing and through them to the broad public so they can understand: what does it really mean to ask anything when it comes to health care? There are so many different moving parts.

With that, if there are no questions on what Susan has come up with, then we'll move into stage 2.

S. Hammell: Last time we had some difficulty with the
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ministry in terms of presentation, with them requiring….

N. Letnick (Chair): Yes. To elaborate, we did ask the ministry to present some evidence to us in the first phase, and it did take some persuasion to get them to come forward. They did so in the end, but it wasn't as easy as this time.

I've had a meeting with the deputy minister. He's fully in tune with what we're doing. They want to be part of the process. They also want it to be constructive, right? They want to be there to help us to frame whatever else we're doing so that whatever we get back is actually going to be able to be implemented, or at least reviewed fairly, by government.

As I said before, we're one team. That's why we're sitting in different seats, not one side or the other. The thing I want to make sure of, when we're finished this whole process, is that our collection of recommendations — which has also been vetted by the public in phase 3 of our mandate — actually gets done, as opposed to, "Well, that's a nice report," and it sits on the shelf. Right?

That's why we have to work together, and the Ministry of Health is there with us to try to help us wherever they can, as a resource, Sue. So that is a concern that I'm not worried about this time. Thank you for that.

J. Shin: Just a quick comment. I just want to thank both Chairs and Susan for the kinds of presentations that are being scheduled and the way that we are moving forward on this issue together. And I just want to say that I really appreciate the collaboration that I think is happening here.

J. Darcy (Deputy Chair): I'm glad to hear that about the Ministry of Health. Certainly, the deputy is a great guy, and I'm not surprised to hear that.

What about health authorities? Do we have the ability to call and ask to speak with people from various health authorities or people within health authorities who are responsible for certain areas of work?

N. Letnick (Chair): The intent, at least the committee's intent before — the older, now disbanded committee from the last parliament — was, during phase 2, to go around the province asking for submissions in areas where the health authorities are actually located. We would then at that point be able to invite health authorities to come — again, based on a set of questions that we'd framed, right? That way, they'd have enough lead time to put together their answers.

So yes — and Susan, correct me if I'm wrong — we, as a parliamentary committee, have the ability to ask anyone to come and present. And if we as a committee this time wish to have health authorities present — which, I would think, would be of great value — then that would happen. Based on…. I've only talked to my health authority, in the Interior. They're anxious to come and provide their ideas on how we can sustain and improve our publicly funded health care system. I would imagine the others would be as well.

J. Darcy (Deputy Chair): Does that apply also…? I mean, there are some great pilot projects, as I'll call them. We're really good in health care at pilot projects and not so good at system change, right? But it might be very interesting to be able to talk directly to some people who are involved in a particular program or project or community health centre or whatever that really is doing something serious about prevention, multidisciplinary teams, that kind of thing. That's all within…?

N. Letnick (Chair): Yes, absolutely. You're absolutely right. Again, not to put the cart before the horse, but I envision us doing two tours of the province.

The first is in phase 2, which is to go out to parts of the province that we need to hear from, based on the submissions that we get, and then again in phase 3, which is to go out again throughout the province and say, "Here are the problems or challenges that were identified in phase 1. Here are some of the solutions that we've received during phase 2, which, by the way, we did go around the province and discuss with you." And No. 3, in phase 3, is, "What do you think about them?" so we'd have to go through that process again.

We need to talk about that. We need to talk about how that's going to flesh out, but I see us having that opportunity for sure.

When we go out to the public in phase 2 and ask them for their input, we're going to get all kinds of input, for sure. With some of them, we're going to go: "Wow, I never thought of that" or "Isn't that great? Maybe we should actually talk to them in person, as opposed to just their written submission." Right? Since we're touring the province anyway, we might as well go to where they are.

So yeah, some of them will be in central B.C., like in Vanderhoof, which is the geographic centre of British Columbia, and some of them will be up north — like really up north. Then others will be in the Lower Mainland and the Interior and others, and we can plan our trip during phase 2 accordingly.

Okay. Well, seeing no other hands and hearing no one
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on the telephone wishing to continue that, we'll go to No. 2, review and discussion on briefing note prepared by committee research — in other words, by Josie and team — comparing how B.C. is doing relative to other provinces and how Canada ranks relative to other OECD countries.

Just a little caveat on that before Josie starts. I think in our presentation tomorrow — if not tomorrow, next time — one of the presenters' thesis is "Be Careful How You Measure Outcomes," and actually uses the Conference Board of Canada measuring system as an example of maybe what not to do.

Anyway, what we can do, though, is, during this process as we get these people, say: "Well, if you don't think this is the right one, then what is?" What tools do we have at our disposal so that when we're looking for submissions from the public on how we improve our system and sustain it, we have some measuring stick here. We can't just go at this blind.

We're starting with these tools. They're great tools, and Josie will talk about those. By all means, if you have any questions as Josie's going through, you can either choose to write them down and keep them to the end, or you can come in at any time during the discussion.

J. Schofield: Good afternoon, Members. Just by way of background, the research staff of parliamentary committees office was involved with stage 1 of your inquiry, which did involve us, of course, working in collaboration with KPMG and the Michael Smith Foundation. So there were sort of three entities all involved in getting to the conclusion and producing the interim report. Personally, I have been involved with the Health Committee since stage 1 began.

As you all know, at the meeting on July 24 committee research staff was asked to undertake on your behalf an assignment, which, I think, just for the record, Chair, I wouldn't mind just repeating what it was. I know you did, quickly.

Compare how our health system is serving British Columbians as studied by other third-party groups, such as the Conference Board of Canada, and how Canada scores on different outcomes when compared to other OECD countries. Subsequently, we were asked to include some data about health expenditure, which I've tried to incorporate into this briefing note.

I would just like to emphasize that this briefing note is very much a preliminary document from our perspective. It is not designed at all to be inclusive. It's really — if I can use the analogy of a snapshot — to introduce members to some of the information that's out there. Because of that, we would welcome members' suggestions. If we've missed something that's really important, it would be helpful for us to know that.

Just in terms of the criteria we used to select the few reports covered in the briefing note, as I say on page 1, an important criterion was whether the data are presented in a reader-friendly way. I personally think the report card method is a useful snapshot. I accept that from an academic perspective it may not be all that reliable, but it is reader-friendly, and tomorrow we will learn how we should read the report cards in a more circumspect way.

We've also tried to use recent information with the caveat that one of our reports on expenditure was actually updated on the 29th of October, so we're always sort of behind sometimes. But I decided just to keep the one that went up to 2012, as that's the information you had already received.

What I'd like to do next, if it's okay, is just to go quickly through this binder, highlighting the important findings from each of the reports that we discussed in the note, if that's all right with the members.

S. Sourial (Committee Clerk): No. Sorry, Donna, you would only have the briefing note, not the binder. I have your binder here with me to give to you tomorrow.

J. Shin: I'm just curious to find out…. For the contents, I appreciate the criteria that was used to exclude certain data. In using the first criteria, it says that the annual data from WHO, the Canadian Institute of Health Information and Stats Canada…. I mean, I'm just a little curious to find out…. Don't they represent some significant data that we should have had represented in our information?

J. Schofield: Oh, there's no question that their data are significant. It was the question of how it was presented. It seemed to me, when we looked at this one that I reference under the contents section of page 1….

The reason, I suppose, why we made a judgment call about excluding it was that it struck us as really being primary data that didn't have, I suppose, much narrative attached to it, and I wasn't sure how well that would go down with the members. But by all means, it wasn't a judgment about that it was insignificant. It was more on the readability for people who were sort of new to the exercise.

J. Shin: Right. But can I assume, then, that the data and the records that we have in place of these would be more or less reflective of what we would have found in the WHO or any other sources that have been excluded?

Turning, then, to page 2 of the notes, here what we were trying to do was to provide members with what I wouldn't say was a comprehensive answer but with some information on how the B.C. health care system performs compared to other provinces and give members some idea of the cost associated with not only our health care system, a publicly funded one, but also other provinces within Canada.

As requested in the original assignment, the first report we looked at was the Conference Board of Canada report, which was published in May 2013. I would just draw members' attention to the fact that this report contains profiles of each province. The B.C. profile I did separate out for the committee when this was sent electronically, and it's actually included in your first sleeve here.

J. Darcy (Deputy Chair): The document that you're speaking from is the one that we were sent electronically called "briefing note."

J. Darcy (Deputy Chair): Okay. Just for people on the line, they would have that document from previously….

J. Schofield: Yes, Donna has received the briefing note. She just hasn't received the….

J. Darcy (Deputy Chair): It's just the one called "briefing note" — background for Donna.

J. Schofield: So we might come back to look at, maybe later on this afternoon…. I don't know what the Chair's intention is. The British Columbia profile is to me a very useful snapshot, and it came from this Conference Board of Canada report.

The report itself assesses provincial health system performance across 90 indicators in four categories: lifestyle factors, health status, health resources and health care system performance. In terms of overall performance, the good news is that British Columbia actually scores, along with Alberta and Ontario, an A grade.

Another piece of good news is that British Columbia scores the best overall performance in the lifestyle factors category, obtaining A's in all but one indicator. Fruit and vegetable consumption is where it has the lowest score.

J. Schofield: It actually gets a B if you look at the profile on page 63. The relative scores for B.C. are summarized here.

J. Darcy (Deputy Chair): So when we go on the road we'll give out fruit and vegetables.

J. Schofield: Another piece of good news, maybe, I think — the final piece for the afternoon. We obtain the only A grade regarding daily smoking. Only 11 percent of British Columbians smoke every day. I think in lifestyle factors B.C. is doing well. That is how I would sum it up for you on overall performance.

Now, if we look at health care system performance, which is captured in one of these tables at the top of page 3, Donna, of the briefing note…. In terms of this category there are seven subcategories you'll see. I have tried with my assistant's help to just give you the definitions on the next page.

One of them I would probably just like to reference is the subcategory of patient centredness. Actually, I think I'm right in saying that seven of ten provinces, including B.C., receive a B or C grade for patient centredness, which is a more subjective measure.

In terms of health care system performance, B.C. along with Saskatchewan, Manitoba and Quebec each receive a C grade there — so, if you like, middle of the pack, one would say. However, using another subcategory, accessibility, British Columbia as well as Ontario and Nova Scotia obtain the highest grades.

The authors of the Conference Board report point out that this subcategory — accessibility — because it has the largest number of indicators, has the greatest influence
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on the overall health care system performance grade. So without sounding too judgmental, that is quite a significant place to be, I think, for our province.

I hope that the seven subcategories, with the definitions that are used in the Conference Board report, are quite self-evident, with a caveat that I think this patient-centredness one is really subjective because it's actually asking patients about their experiences — how they rate quality of health care.

N. Letnick (Chair): It's true. But in the first report, KPMG did say that in consultations with stakeholders, "it was noted that in addition to financial aspects of sustainability, other elements like outcomes, access to care and services, and patient satisfaction should be included in measuring and defining sustainability."

J. Schofield: Oh, I think it's very important to include, but it has that sort of subjective component within it, I think.

N. Letnick (Chair): Josie, did you get the chance to read the submission that we are going to get tomorrow regarding this particular matrix and how it is constructed and the caveat around it? If you didn't, that's fine. I wouldn't expect it. But if you did….

J. Schofield: How does Conference Board assign grades? May as well have it on the record.

J. Schofield: It divides the difference between top and bottom performance by four.

J. Schofield: From Dr. Morgan, "No matter how wide or narrow or important or meaningless the differences are" — three exclamation marks.

N. Letnick (Chair): In other words, you can have all the provinces being 99 percent well — between, let's say, 90 and 100 percent doing well — but the one at 99 percent would get an A and the one at 92 percent would get a D — is what he's saying, right?

So we don't know the raw numbers that made up this graph. I think the question — and I think I've already said it today — we'll have tomorrow is: well, if this doesn't do the job that we need, because we need something that tells us where we're doing well and where we're not…. If this doesn't do it, then what does?

R. Lee: I think that's probably ranking. Once you use ranking as a statistic measure, then you always have that, unless you have a very detailed score. I mean, an absolute value compared to what? Right? I think that's the question. How do you make up standards so that you can compare with…? In Canada you use the ranking comparing different provinces. That's the fundamental problem of our statistics.

J. Schofield: Of course, you know, I mean, from the research office perspective, I think we would take the methodology for granted, if I can put it that way. I'm certainly not an expert on the methodology used in health studies or health reports. I think it would be interesting to see whether there are more reliable studies that we can use.

N. Letnick (Chair): Or at least have the background data that goes with these graphs, so we can understand for ourselves. But we also need something that's repeatable so that whatever we come up with can be measured on an annual basis or every five years or whatever the period is. We are talking long term here, right?

We're not talking about, really, the snapshot today. We're using this as an example. What we're looking for is over the next generation, the 25-year period, as the baby boomers age out, age through, to see that whatever recommendations government adopts from our report, they're actually working to achieve improvement in the outcomes and to maintain the sustainability of the system.

Whatever tool we get to use, it has to be a tool that hopefully continues to measure in roughly the same way over a long period. That way it would be a fair comparison from one time period to another time period. Accountants do that all the time, right? They'll make sure the financial statements stay as consistent as possible over time so they can compare the ratios. The last thing you want to do is change the accounting system every three years. Then, of course, it makes it impossible to compare apples to apples over the long term.

L. Larson: Is this like establishing a baseline, then, Norm? Is that the idea? Where we're at right now — this is the baseline? Then anything that happens in the next ten or 20 years, these are the changes it made to the base we established today.

N. Letnick (Chair): We need to decide what the base-
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line is and where we want to go, because if we don't have an indication as to where we want to go, then any path will take us there. At some point, before we go to the public and say, "Okay, we have a problem or a challenge; let's fix it," we need to articulate what that is.

Our biggest challenge, according to this document, is screening and prevention, because it got a D, or effectiveness, because it also got a D. Then fine. We'll decide, as a group, what our biggest key challenge areas are, and then go to the public and say, "Here are the biggest challenges in improving the system and making sure it's sustainable over the long term," and hopefully, in some empirical way, have those measurements done not by us, but somewhere out there that we can rely on. That way we can go to the public and say: "Okay, how do we resolve this particular challenge over the long term?"

It doesn't have to happen tomorrow. We're not going to put the Ministry of Health up on a petard and say: "You're not doing your job right." That's not our place. Our place is to…. By all means, you can do that apart from this group. But our place in this group is to look for long-term, collaborative solutions, right? What we want to do is make sure that if we are headed towards improving X, Y and Z and at least maintaining A, B and C, we can one, identify what those are, and two, make sure we can measure progress over the long term on those items.

J. Shin: There has been historically, just coming into this conversation…. The Health Committee hasn't identified those performance indicators that we can measure. Okay, so gotcha.

N. Letnick (Chair): Report No. 1, the interim report, is everything. Now, there's a lot of information that went to building the report, right? Many volumes, many inches of paper — the official record — went to building this report. But no, we did not say: "Here are the areas that we need to focus on." We will decide that as a committee, and that might be one of our questions, if we can't do it ourselves — to go to the public and say: "What are the areas?"

But actually, I think by the time we're done health care 101 and gone through enough of these reports, we'll have a good feeling as to where we think the biggest opportunities for change, for improvement, are, and also what we need to do to make sure the system — the publicly funded system; I always come back to that piece — is sustainable over the long term.

As this report indicates, the pressures on the system are growing 5 to 6 percent a year over the next 25 years, and the economy is only growing at 3 to 4 percent a year. Obviously, a financial disconnect is going to happen sooner or later. There will be a performance gap there.

Again, as the report says, while that's important — very important — there are also other things we need to consider, as I read out already. We, as a team, need to decide what those things are that we are going to be measuring over the long term.

S. Sourial (Committee Clerk): I just wanted to clarify that there have been previous Health committees who have undertaken studies going back — well, in my records — as far as 2001. In 2001 they were looking at ways to improve the provision of health care service and to ensure that the health care system could be sustained, but they've never actually come up with those performance measures.

J. Shin: Right. It would be good to quantify and be able to quantify and measure that progress as we set out objectives that we want to focus on for the long haul.

N. Letnick (Chair): I would say the Ministry of Health also has objectives that they have set out for themselves to achieve, and we will ask them what they are when they come and present to us. My hunch, though, is that their objectives are more short-term than the 25-year time span that we're looking at.

We need to cover all aspects of the aging demographic from cradle to grave, and I'm not too sure if that's the three-year plan of the Ministry of Health. We'll find out. Maybe they have all the answers and all we have to do is copy-paste, but I've got the funny feeling that we have a lot of work ahead of us.

J. Schofield: Could we move, then, to the second sleeve, which really just has the summary, the Health Council of Canada report? The summary, Donna, is on page 4 of the briefing note.

Just a few things to highlight here. First of all, in the past decade, I suppose, or almost a decade…. This report does identify three pressing issues that have been addressed since 2003 — Canada-wide here, of course. I'm not talking B.C. in particular.

The first one they credit with some improvement: our wait times. Particularly, hip and knee replacements have improved over the past decade.

The second issue that has been addressed is primary care reform: more interdisciplinary teams — which is something that Judy mentioned earlier, I think — new models for chronic disease management and care coordination. There have been some improvements there.

The third issue where they see some improvement is in terms of drug coverage — the affordability of drug coverage, with a caveat in the report that the cost of drugs does
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still remain a barrier for what they estimate to be one in ten Canadians.

That's, in a sense, some good news, too, but then the report actually has a rather sober conclusion, if I can put it that way, that "the health system in Canada has not kept pace with the evolving needs of Canadians." They give three reasons there why not.

Spending on hospital care, drugs and physicians is still the dominant part, compared, for example, to if you think about the need to have more funding for better prevention and management of chronic disease. And they list where they think the funding priorities should move to.

Spending on drugs remains high, despite the collaborative action by the provinces. Also, from their perspective, the spending on health human resources continues to claim a large portion of health care dollars.

What this report does include — and I've included their table in the briefing note on page 5 — is a summary of Canada's performance on a number of patient care indicators compared with other high-income countries.

Now, once again, following what we were talking about earlier — this patient-centredness criterion…. Actually, if you look at the perceptions of care, Canada scores quite highly there — third out of 11 countries. On the quality of medical care — rated as excellent or very good.

But when you look at the other patient care measures in this table, Canada's ranking is relatively low, I would say.

N. Letnick (Chair): Is there anything in these reports that you found that compares rural jurisdictions versus urban? In particular, of course, one of the key asks of the committee is that we look at rural health. It's good to have knowledge on how we're doing as a province relative to other provinces and how we're doing as a country relative to other countries.

It would also be interesting to note how we're doing in rural B.C. relative to other rural parts of the country or how we're doing as a province, with a large part of our province which is rural, compared to other jurisdictions that also have a large part of their area as rural.

I'm not saying you have to have it. I'm just asking if you've seen any of that in your research.

J. Schofield: Well, I know some of the reports do break the data down by age and gender. Off the top of my head, I can't just name whether the question of rural versus urban…. I'm pretty sure that in the reports we reviewed…. Yes. I just don't know which one it is. I just can't recall it now.

I wonder if we could ask them tomorrow. There's someone who's coming tomorrow….

J. Schofield: Yeah. But certainly, when I get back to the office, I'll probably be able to….

N. Letnick (Chair): Okay. I guess what I'm asking is that we keep that rural lens always in our mind for everything that we do, because there is quite a difference between rural British Columbia and the Lower Mainland. It would be important to have that in the back of our minds as we go through this process.

D. Barnett: Thank you, Norm. I was waiting for that. We talked about that before. The whole world has to revolve around the rural lens.

But that's a fair question for when we meet our experts over the next few sessions: do you have any research on rural jurisdictions? What do they do that's different than what we're doing? What's better? What's worse?

J. Schofield: Can we now turn, then, to page 6 of the notes? Looking at the financial data, what I'd like the members who are in Vancouver to reference is in their sleeve, under the heading "Health expenditure trends." I hope that there is a table there that summarizes what I'm going to say.

J. Schofield: This is the national health expenditure trend. The latest version has just been released. I think I referenced that earlier, on October 29. Susan has sent you the latest report this morning, which would be 1975 to 2013. Just to give you some idea of the size of it….

N. Letnick (Chair): On the beach in Mexico you'll have all kinds of stuff to read.

J. Schofield: Yesterday afternoon I did a quick scan of the key findings for within Canada and then for the international expenditures, and I don't think that the differences are significant. If you'll bear with me, we can just review what the key findings are on spending trends from 1975 to 2010 as well as their forecasts for 2011 and '12.

In terms of the first finding, when we're looking at total health expenditure per capita, the lowest per-person expenditures are forecast for Quebec, followed by British Columbia.

The second bullet. For British Columbia the health-expenditure-to-provincial-GDP ratio, which is always an important measure, is forecast to be 11.8 percent. I realize that that figure hanging there on its own is a bit misleading. The $26.5 billion was the amount of the total health expenditure of B.C. in that, if you look at this table here — $26.5 billion. I should have explained what the $26.5 billion was rather than just put a bracket. It's actually the total health expenditure.

R. Lee: I think this is including the provincial budget plus other expenses. Is that right? I think the budget is about $17 billion. What are the other components of that?

N. Letnick (Chair): Well, the figure that's being referenced now is total health care spending, including private. If you move to the right, you'll see that provincial health spending is $17.1 billion.

If we're just focused on public sector — that would be the fourth series of numbers with "Total public sector" at the top — you would have a total expenditure of $18.3 billion compared to…. Josie was comparing to Quebec, so let's say $3,900 for B.C. versus $3,800 for Quebec on a per-capita basis.

The public sector expenditure has been pretty constant — around 70 percent of health care spending in the province over the last 15 years or so — with 30 percent being private sector spending. The private sector mostly encompasses things like dental, eyeglasses. Other things that aren't covered by the Canada Health Act, deemed medically necessary, are covered in….

N. Letnick (Chair): Yes, unless it's covered because of social assistance or something to that effect, or if it's done in a hospital. If it's done in a hospital, then it's covered.

While Josie is looking at the complete total on the left, it is including both public as well as private sector.

J. Schofield: Would that explain, Chair, the difference then, if we move to bullet 4, when they're looking at key findings?

J. Darcy (Deputy Chair): Sorry, can I ask a question? I'm just trying to understand, because the spending is total, public and private. Am I missing…? Is there a figure for public spending as a percentage of GDP?

J. Darcy (Deputy Chair): That's total spending. I said public spending as a percentage of GDP.

N. Letnick (Chair): It doesn't look like there's one in this report, but it's easily calculable.

J. Darcy (Deputy Chair): Yeah. I don't need it now, but I wonder if you could just identify that for us.

N. Letnick (Chair): If you do the math, 70 percent is public. Therefore, 11.8 percent times 70 percent would give you the number that you're looking for, so roughly 8 percent of GDP is the number that…. I think it's more like 7.8 percent, but 8 percent would be close enough. Get out your cell phones; punch in some numbers.

J. Darcy (Deputy Chair): Sorry. I didn't mean to bog us down in doing mathematical calculations, but it would be an interesting one to know and to know in terms of trends.

N. Letnick (Chair): Close enough. Not bad. You were just testing. That's what you were doing.

J. Schofield: Okay. Then the third bullet that looks at the relative distribution between the publicly funded
[ Page 16 ]
health care systems and the private sector, in terms of public sector funding, the share is expected to be highest in the territories and lowest in Ontario, which is quite interesting, I note.

Then when you look at health expenditure by provincial or territorial government, the lowest per-person health spending is once again forecast for Quebec, followed by B.C. Then the table also gives information about private sector expenditure with the respective forecasts.

There are other findings that I've identified here with regard to hospital spending and drug category and physician spending. I suppose the thing to highlight really, where B.C. gets a mention, is under the drug category.

N. Letnick (Chair): Before we get into international comparisons of Canada relative to other OECD countries, let's take a pause here. Does anyone have a question or a comment on internal comparisons, the province versus other provinces — with the understanding that we have a lot more work that needs to be done on getting the measurements? And we can ask our experts over the next few sessions as to where we get that information, including Ministry of Health.

J. Shin: If you can summarize in a snapshot or in a sound bite of how we are doing in comparison to other provinces according to the amount of expenditure as percentage of GDP over the performance indicators that we were looking at in the report card, what's the general consensus on our performance for the dollars that we are spending? Are we doing fairly well or…? I mean, a report card is one thing, but for the dollar value invested, how are we doing?

N. Letnick (Chair): I couldn't answer that question yet. I need more information. Personally — there is more information out there — before saying something on the record, I want to make sure we have all the evidence in front of us.

J. Shin: The report card measurements are one thing, but it's another to find out why we are sitting at those grades, as per the dollars actually spent. I was wondering if there was any sort of interpretation that was done in that sense. But there isn't yet.

N. Letnick (Chair): Right. But remember: the report card, as we're going to find out in the next session and as we discussed already, might actually be saying we're doing very well, but because everyone else is doing very well also, statistically, we're the worst of the very well. The question is: with the limited resources — and we know we are living in a world of scarcity with limited resources that are available for health — is that where we want to spend those limited resources?

Even though according to the Conference Board of Canada report, in one section we have a D…. If we were doing relatively well there, do we really need to spend a lot of scarce dollars to get us up to a B or a C or an A when we might be better off focusing on something else that over the long term — again, we're talking long term — would actually have a greater improvement for our constituency, the 4.4 million people across the province? These are the kinds of things we're going to have to flush out over the course of the next few weeks, few months.

Just relying on one report, for me, is not enough. We need more outcome measurement reports where we can all come to consensus: "You know what? On wait times, we're doing this well," or this poorly. "We really need to work on that." Or we don't. "We really need to focus on preventative health care because that's where we'll get the biggest bang for our buck." Or maybe we don't. "We need to really work on end-of-life decisions because that's where we get the biggest improvement, the biggest bang for our buck."

There are all these different trade-offs in this complex system, which is another session we'll have tomorrow, that we'll have to work through.

J. Darcy (Deputy Chair): Yeah, and I think even within each of those categories, with their rankings, it's also about peeling away more layers of the onion and digging deeper in them. On the wait times, we've done well in knees and hips, right? We've done well in…

J. Darcy (Deputy Chair): …four out of five of the ones that were identified as targets in the health care accord in 2004 or whatever. But there are a whole number of areas, some where we're not doing very well and some we don't measure at all.

I think it would be interesting in the area of wait times…. So we could say: "We've done well in those areas. How do we learn from what we did? How did we achieve that? And do we need to be focusing in others areas around wait times that are not considered among the top five but still have a very big impact on the population?" You know? It's not so much even one category versus another. It's also about digging deeper in some of those areas.

J. Shin: And that's why I appreciate the fact that we're also doing international comparisons to help us set it to a new perspective so we know how we fare compared to other countries.

N. Letnick (Chair): Right. Which is a great segue to the next section — international comparisons.
[ Page 17 ]

J. Schofield: This section of the briefing note — from pages 7 to 11, I think it ends on — is really designed to give members some information on how Canada's health outcomes compare to those of other OECD countries.

The first report that we review under this heading is the OECD report for 2011, which identifies three major trends since the OECD was created in 1961. It's looking at these trends over quite a long time period, the first being the remarkable gains in life expectancy that reflect the large declines in mortality at all ages and a reduction to risk factors.

If you look at the table on the top of page 8, this trend is summarized in the table headed "Summary of OECD health status indicators." In terms of life expectancy, Japan leads the OECD countries, but there's a large group including Canada in which life expectancy at birth is currently 80 years or more. It's actually, if I look at the table, 80.7 years, which places Canada as 12th out of 40 countries in the table.

The other measure, if you like, of this trend is the reduction in risk factors measured by self-perceived health status. Here again Canada is among the leading countries, with about nine out of ten people reporting being in good health, which is captured in this table — fourth from the end of it — "Adults reporting good health." Canada's score is 88.5 percent.

Diabetes prevalence and incidence in most OECD countries — the rate is between 5 and 10 percent of the adult population. Canada is reporting 9.7 percent, which won't be a surprise to…. I'm sure that statistic should be 9.2, according to here. Anyway, over 9 percent.

They also look at cancer incidence and AIDS incidence. Again, I don't think it would be surprising to members that the highest AIDS incidence rate is in the States. Canada's is lower.

I don't think, really, there are many surprises there, I wouldn't have said, Chair, just in terms of that trend and how these different indicators….

N. Letnick (Chair): It might not be a surprise, but it was a wow moment when I saw the diabetes prevalence — that we were actually that high: 29 out of 32 countries.

N. Letnick (Chair): It's because you women live so much longer and, therefore, you open yourselves up to cancers, right? I'm not a doctor. I'm just….

N. Letnick (Chair): The good news is we're living longer. The bad news is we're living longer — and with all the great things that the golden years have to offer.

J. Schofield: Remember, though, aging itself is really not all that big a problem. That's what we've found, stage 1. Stage 1 — trying to establish how big a problem it was.

N. Letnick (Chair): When it comes to the sustainability of the health care system — that's right.

J. Schofield: Can I move to the second major trend, then, identified by the OECD. I'm on page 8 now, below the table.

J. Schofield: The changing nature of risk factors to health is the second major trend among OECD countries. In Canada and the States smoking rates fell from 42 percent in 1965 to 16 percent in 2009. Alcohol consumption has also fallen in most countries. But actually, if you look, it's on the rise in Nordic countries and the U.K. and Ireland.

J. Schofield: Obesity — again, members won't be surprised to learn that that is on the rise, not just in North America but in other countries within the OECD.

The third trend which, again, wouldn't be a surprise is that there has been a steady growth in health spending. This report gives several statistics to illustrate that trend, which is summarized in the first table on page 9. I have to look at "Health expenditure in relation to GDP." I have to look at that for you, Judy.

Now, this report did have some rather interesting statistics on what they call key outcomes measures, which I know is top of mind for committee members in terms of this stage. So the last paragraph of page 9 actually talks about these key outcomes measures as being defined as "survival rates following heart attack, stroke and cancer."

And the report does have a lot of information on each of these different types of cancer, broken down by age and gender, but I just wanted to give you a higher-level summary of what the key figures were here.

J. Shin: I just find it a little disappointing in the sense that when we are looking at these international comparisons, it's not something that we can compare directly with the report card that we were looking at on a national basis. These are outcome measures, in a way. It doesn't really speak to us as to how Canada measures as far as
[ Page 18 ]
our wait times and our post-surgery follow-up, patient education — all those indicators that we were looking at in the previous report. This one is just straightforward population statistics of….

There are so many factors besides the health care that will play a role in the numbers that we see here. Is there anything that we can look into as far as being able to compare how Canada does on our wait times versus how Korea is doing, for example? Is there any direct…?

N. Letnick (Chair): The answer is yes. The OECD has published reports on wait-time comparisons, so that's available.

Again, just to reiterate what Josie has said, this is just preliminary work. We should have a full inventory of reports that the academics buy into through this process of health 101, and maybe they can even help us put together that literature review so that we can answer those questions that you're asking.

J. Darcy (Deputy Chair): There is some of that, Jane, in…. There were a lot of things that we sent out, and I didn't often check before I printed them — about how many pages there were.

J. Darcy (Deputy Chair): So we are contributing to the forestry industry in a very big way. But one of the…. There's Health at a Glance 2011: OECD Indicators. It does comparisons.

J. Darcy (Deputy Chair): No, it's not much of a glance. This is like a continuation of the same thing, so that's like a massive tome.

J. Darcy (Deputy Chair): Yeah, some of it is there. It's tough going, wading through it, but it's there.

J. Schofield: Okay? Page 10. This report by the Canadian Institute for Health Information has a more narrow focus, if I can put it like that, by looking just at the group of seven within the OECD. What we've done here is to basically just summarize the key messages. I don't think there are any tables at all included in the…. There's just a summary here, but I haven't singled out, particularly, from my notes.

First of all, the first key message on behavioural factors. Compared with other countries, Canada has made significant progress in reducing the prevalence of smoking. However, the prevalence of obesity and overweight in Canada, especially among children, is higher than in many countries.

Second key message. Canadian five-year relative survival rates for colorectal and breast cancers are among the highest in the OECD. Canada is also relatively successful with screening for cervical and breast cancers.

Third key message. On many of the measures of quality of health care, Canadian results are in or near the top 25 percent of OECD country results. I've listed the particular measures there. But there are a handful of measures where results appear worse than those reported by other countries. These include the occurrence of adverse events from surgical procedures — such as a foreign body left in and accidental puncture or laceration.

S. Sourial (Committee Clerk): Sorry, Josie, just before we go on to the next report, in the excerpt you have it includes a table on wait times — "Access to care performance profile." It's on page 14 of this, the Canadian Institute for Health Information report. There's a table that has waiting times for specialists, elective surgeries, physician visits and where Canada ranks.

J. Darcy (Deputy Chair): What's the document called again? Learning from the Best — okay.

N. Letnick (Chair): Is this available electronically for Donna, if she wants to read it tonight?

S. Sourial (Committee Clerk): Yeah. It's linked in the briefing note. The PDF was embedded in the briefing note.

Can we send out a note to all the members of the committee that aren't here today, that are coming tomorrow, to ask them to review the material? Actually, just send it to everybody. Ask us to review our material prior to tomorrow's meeting — and that the full reports are available through the links on the report.
[ Page 19 ]

R. Lee: Under the prevention column, when they do this ranking, is vaccination included as part of it?

J. Schofield: Yes. Now page 11…. I've got all the tables in the final sleeve, which I think will make a lot more sense if you go along with me. I hope I've got them in the right order.

Just very quickly: "Canada is among five countries with the highest ratio of total health expenditure to GDP." And it's shown very clearly in this table that's how it ranks — fifth. Each of these bullets actually corresponds to the table in the handout.

Moving to the second table, "Total health expenditure per capita," Canada was among the seven countries with the highest per-capita spending on health. Now, that's the second table, page 65 of the handout.

N. Letnick (Chair): For all you budding health economists now — because that's what you're going to be after this is all over; some of you already are — don't forget: these tables are for total expenditure. Some of these countries don't have much in the way of private provision; it's 100 percent public.

We're comparing Canada versus Finland, for example, and it shows that we're spending way more. But Finland might be paying 100 percent of the health care dollar, while we're only spending — not "only" but 70 percent of it, right? So just take all these with a grain of salt.

J. Schofield: Well, if I move to the next page, 66, of the handout, it actually focuses on the share of total expenditure funded by the public sector, with Canada's at just over 70 percent. I don't think it will be surprising that actually the States has one of the lowest public sector shares — Mexico and the States — although that might change, of course, with the implementation of Obamacare.

The next table, on page 68: "Public sector spending on health as a percentage of GDP." Canada was within the higher third of the countries. Page 69: Norway had the highest public sector per-capita spending, but Canada was within the top ten countries. In terms of sources of financing, page 70….

R. Lee: It's interesting. United States is actually higher than Canada in terms of public sector health spending per capita.

N. Letnick (Chair): The system for poor people and the system for old people — what's it called? It's called Medicare.

N. Letnick (Chair): That's right — Medicare and Medicaid. So the programs are there for those that are of a certain age and also those that don't have a lot of money.

But you'll find that in the States a lot of the cost drivers are from specialists who are getting, for the most part, paid for their work through insurance companies and through private people. You will also find in the research that just because you're spending a lot of money doesn't mean you actually end up with better health outcomes. There's a lot of examples where there's a lot of money being spent, and the health outcomes are actually worse than other places in the States.

It's important to know how we rank in terms of our expenditures in both public and private health, but at the end of the day, it's the outcomes we really care about, right? I don't have a goal personally. You might have a different one. I don't have a goal of being the jurisdiction in the world that spends the most on health care. I want to have the best outcomes, right?

No matter which government has been in power for the last 30 years in this province, every government has faced limits on what it can spend on health care. It's just the way it goes. Now, maybe ten years from now we'll have liquefied natural gas, and we'll have all this money, which will be great. I think we're all hoping that that happens and working towards that. But in the meantime, we do have a limit as to how much money we can spend — again, no matter what government is there.

Therefore, the question is: how do we get the best outcomes, given limited resources? It's more a question, I guess, of envelopes rather than credit card. When you do
[ Page 20 ]
your budget at home, you have different envelopes. We're in the same place here. We have different envelopes, and we have to decide…. Well, not decide, because we don't make decisions.

We have to make a recommendation at the end of the day as if the money is actually in the right envelopes — given the long-term challenges that we're going to be facing with the health care system over the next 25 years — to achieve the best outcomes.

J. Schofield: Yes. I'm just looking at these key bullets here. The relative proportion of private sector and public sector funding is outlined in two bullets there. I don't think we necessarily need to go there.

J. Darcy (Deputy Chair): Can I just…? Page 67 is actually quite interesting, because it gives the…. Just in a really visual way, it does the breakdown of public and private share.

J. Darcy (Deputy Chair): Just for the committee's reference, because it's something we were talking about earlier, and you can sort of see it there in front of you.

J. Schofield: That's fine. The last three bullets, actually, I think all relate to the use of funds. One of them is the amount spent on hospitals. That's on page 74.

Canada fell within the middle of the OECD countries on the amount spent on hospitals. There is some text on page 74 looking at other countries' share, as well as a table on page 75 looking at expenditure on services provided by hospitals per capita.

With regard to drugs, Canada had the second-highest expenditure on drugs per capita after the U.S.

Finally, physicians' offices. Canada was the fourth-highest spending per capita on offices of physicians after the U.S., Switzerland and Germany. That's illustrated on page 77.

N. Letnick (Chair): I'm sure these reports, and that one in particular, will give us a lot of food for thought and questions of our experts over the next few sessions as to why this is happening and what, if anything, they would propose we can do about it.

N. Letnick (Chair): I appreciate that. As you said, this is just a starting point. I'm sure that many of these reports will form part of our final report on this.

S. Hammell: Could we ask, Josie — or those of us who perhaps want them, the reports — to have the whole report? There are some that are quite big, but I wouldn't mind having…

N. Letnick (Chair): Maybe what we can do, since we have three or four members that aren't here…. We can just ask them, maybe put a shopping list together. Put all the reports down, and people can choose which ones they want. Okay? So that can go around to everybody electronically.

S. Sourial (Committee Clerk): PDF Expert? Certainly what we'd love to do — working towards — is that all members would have just electronic versions, presuming that everybody had an iPad or whatever. But we're not there yet. In the meantime….

N. Letnick (Chair): The default will be electronic, but there are some members that prefer to highlight on paper and make notes in the margins.

S. Sourial (Committee Clerk): What I'll do is early next week I'll send out a list of all the reports that are included in this binder.
[ Page 21 ]

J. Schofield: And we'll get more references tomorrow, won't we, from the academics?

S. Sourial (Committee Clerk): Exactly. And then I'll send out a list and any reports that members want printed versions of. Let us know, and what we'll do is mail them to your constituency offices. I think that would probably be the best, unless you prefer to have it sent to the Victoria office. You can let us know.

J. Shin: Would there be a way to observe the session tomorrow? I sent in my regrets — I'm required elsewhere — but I would like to just tune in and check in every now and then.

S. Sourial (Committee Clerk): The only way would be for a conference call, and we'd have to know ahead of time when you were calling in so that we could call in as well to connect you.

S. Sourial (Committee Clerk): There's no video, at this point in time, of committee meetings.

J. Shin: Right. Unless maybe I can convince Richard to open up my laptop for me and use Skype and I can see everybody. Okay. Got you. I'll try to call in and check in, then.

S. Sourial (Committee Clerk): If you are going to call in, let us know, because I don't think we've got a phone scheduled for tomorrow.

J. Shin: Oh, is that right? Okay. Yeah, I'll send you a memo and see, realistically, what time frame I can….

N. Letnick (Chair): We can put her on my iPhone, for that matter, as long as we have local Wi-Fi. Maybe Mike and team will see if we can hook up the Wi-Fi.

J. Shin: That'd be great, because the audio is really hard to follow when the presentation is being made with the slides. But I'll e-mail and bug you about that later.

J. Darcy (Deputy Chair): Can I ask one very quick question, maybe to note…? I'd be really interested to know, just on the graph on page 77, about expenditure on services provided by offices of physicians per capita for OECD — whether we know or whether it's in any of those reports what the payment method is for physicians in those other countries. I think that would be interesting to know.

N. Letnick (Chair): Last year, maybe two years ago, I attended a conference which was in Vancouver — here — that dealt purely with payment methods for physicians — international comparisons. So the reports from those should be available. The Coles Notes version was that there are pros and cons to all three: fee-for-service versus salary versus blended. There wasn't any perfect payment method.

That presentation should be available through the Michael Smith Foundation, because I believe they hosted it. If you talk to the Michael Smith Foundation.... That, by the way, is a foundation that's funded in large part by the provincial government, so they're non-politically aligned and able to help us in this process.

So, yeah, if you ask for that report…. I think it was Dr. Busse. They'll know what I'm talking about when you talk about physician remuneration comparisons across OECD countries.

J. Darcy (Deputy Chair): It would just be interesting to see if there's any correlation between physician costs and payment methods.

R. Lee: Interestingly, some countries are actually including drugs in the office of the physician spending…

J. Darcy (Deputy Chair): Yes. True. There could be lots of different things that go into it.

R. Lee: …and also staff. I don't know. So it's kind of like comparing apples with oranges.

J. Darcy (Deputy Chair): You're right. That's true, because it could be that there are doctors' offices where the cost of a nurse practitioner or a dietician is covered and
[ Page 22 ]
then…. But they could still be fee-for-service. Yeah. It's complicated.

N. Letnick (Chair): If there are no further questions on that portion, we'll move to the next item on the agenda, which is just to say that we have some meetings that are coming up. Tomorrow is one. December 13.

The agenda for tomorrow is pretty well set. We're working on finalizing the agenda for December 13. Stay tuned. Things will come.

If we need to, we'll have one more session in February, prior to sitting. I think when we get together again to sit is usually tenth or 11th-ish in February.

Everybody will be back from their holidays, wherever they're going in January. We won't do anything in January. I don't want to take you away from whatever plans you have. I'd also like to make sure everybody's there, so we'll start again in February and go full bore.

S. Sourial (Committee Clerk): No. Essentially, as Norm said, we're working on the agenda for the 13th. So far, we do have the Ministry of Health, but we're still working on exactly what they'll present. We'll see other questions that may come out of tomorrow's meeting and could possibly result in other presentations, either on the 13th or in February.

N. Letnick (Chair): Just remember, the purpose of all this is to give us the tools that we need to ask those tough questions and to also look critically when somebody makes a submission to us later on.

When somebody says to us at some point, "Oh, all you need to do is start paying physicians. Put them all on salary," we're going to go: "Well, wait a second. We saw this report that compared different remuneration methods all across the world, and that's not the golden answer, because there are always pros and cons to doing that."

Or if somebody else says, "Put them all on fee-for-service and get rid of hospitalists" or something like that, then we can come back and say: "Well, hang on a second."

The gem of all this is that we can then ask better questions, I think, at the end of the day and be critical of the presentations.

If there's nothing else, then…. You guys are awesome. Thank you so much for coming in today, and I look forward to seeing you tomorrow. Make sure there's lots of coffee tomorrow, because we have a full day here.

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Chair:	* Norm Letnick (Kelowna–Lake Country BC Liberal)
Deputy Chair:	* Judy Darcy (New Westminster NDP)
Members:	* Donna Barnett (Cariboo-Chilcotin BC Liberal)
	Dr. Doug Bing (Maple Ridge–Pitt Meadows BC Liberal)
	Katrine Conroy (Kootenay West NDP)
	* Sue Hammell (Surrey–Green Timbers NDP)
	* Linda Larson (Boundary-Similkameen BC Liberal)
	* Richard T. Lee (Burnaby North BC Liberal)
	* Jane Jae Kyung Shin (Burnaby-Lougheed NDP)
	* Michelle Stilwell (Parksville-Qualicum BC Liberal)
	* denotes member present
Clerk:	Susan Sourial
Committee Staff:	Josie Schofield (Manager, Committee Research Services)

REPORT OF PROCEEDINGS(Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH