Health — Issue No. 15 — Wednesday, May 13, 2015 (HTML)

Present: Linda Larson, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Donna Barnett, MLA; Dr. Doug Bing, MLA; Sue Hammell, MLA; Richard T. Lee, MLA; Dr. Darryl Plecas, MLA; Jennifer Rice, MLA; Bill Routley, MLA; Dr. Moira Stilwell, MLA

2. The following witnesses appeared before the Committee and answered questions on the recruitment and retention of health care professionals in rural British Columbia:

• Ted Patterson, Assistant Deputy Minister, Health Sector Workforce Division, Ministry of Health

• Doug Hughes, Assistant Deputy Minister, Health Services Policy and Quality Assurance Division

4. The following witnesses appeared before the Committee and answered questions on end of life care:

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
Ministry of Health: Recruitment and Retention of Health Care Professionals in Rural British Columbia	201
T. Patterson
Presentations: End-of-Life Care	208
J. Ranallo
R. Jock
B. Cavers
Committee Schedule	223

I want to thank very much Ted and Doug for coming this morning and doing this briefing for us on your rural strategy, rural physicians, rural health care — whatever is going on in that entity. We are actually, as a committee at the moment, looking at end-of-life care, but because we’re in Victoria and because you’re available, we thought we would touch on this point, which is also in our request for proposals or for consultations.

I think you probably know us all. Would you like us to run round the room and introduce ourselves, or have we all seen you at various times?

Ministry of Health: Recruitment and
Retention of Health Care Professionals
in Rural British Columbia

T. Patterson: Again, thank you for the opportunity to be here with you this morning. I’m Ted Patterson. I’m the assistant deputy minister for the health sector workforce division at Health. With me is Doug Hughes, the ADM responsible for health services policy and quality assurance at the Ministry of Health. Between the two of us, I think we end up dealing with the lion’s share of issues in health from a service perspective than a health human resources perspective.

What I hope to do this morning…. What I understood the presentation was to be about was primarily about physician recruitment and retention in rural communities. What we’ll try and do in the 20 minutes that we have is walk you through some of the context, talk about some of the things that we’re already doing in terms of recruitment and retention in rural communities in the province and then speak very briefly about, I guess, the direction going forward in terms of the ministry’s policy direction, a refresh of the strategic agenda.

I’ll move quickly through the first couple of slides. You have in front of you a paper copy of the slide deck as well as a Microsoft Visio chart that I’ll explain as we go through, and also a booklet I’ve handed around about some of the recruitment or retention incentives we have in the province.

It goes without saying, and I won’t spend much time on this, that B.C. is primarily a rural province. We know, of course, that rural communities are a significant generator of the economic activity for the province. One thing that I’ve learned over the past couple of years — in my role, in particular — is just about the diversity of local communities, rural communities throughout the province. It has been put to me by a physician that: “Once you’ve seen one rural community in B.C., you’ve seen one rural community in B.C.” So a lot of unique challenges in different communities throughout the province.

Of course, as I said, rural B.C. is vast. The slide that’s up there right now…. Our way of trying to organize our thinking about what is urban and rural and so on…. We’ve used a scheme that we adopted, I think, primarily from the Ambulance Service a number of years ago. For the purposes of our policy and planning, we talk about metropolitan areas, we talk about urban/rural areas, we talk about rural proper, and we talk about remote communities — each displayed on that chart and based on a population size, primarily.

Of course, as I said, when we’re doing health system strategy and planning, geography is one of the major considerations, obviously. I’ll speak a little bit more about that shortly.

As you’re aware, communities are often very spread out and difficult to access throughout the province. Some rural communities have unreliable or no road access and rely on water and air transport for basic necessities, including health care. Health authorities within this context have, I think, the rather difficult challenge at times of designing services that balance quality with access.

Often rural and remote communities are far from higher levels of hospital care and rely on ground and air transport to access those higher levels of care. We know that distance can be a barrier to access. And, of course, small communities often have limited services, including part-time physicians, nurses, allied professionals. The loss of one of these professionals in a rural or remote community can be significant, whereas it might not be the case in an urban centre.

In terms of what we know about patient population health status in these rural and remote communities, we do know that health status in general is somewhat poorer, relatively speaking, in rural and remote communities throughout the province: reduced life expectancy — as I understand it, somewhere on the order of five years — and greater incidence of motor vehicle accidents, suicide, dental surgery rates, chronic disease rates, maternal health challenges and so on. As well, we do know that social determinants of health, the socioeconomic status of many rural and remote communities, are poorer, I guess, relative to other more urban communities.

I won’t spend too much time on the next slide. That’s a mapping of the socioeconomic conditions by local health areas. What it would describe…. The green is higher socioeconomic status located in certain parts of the province.
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Linked to that, of course…. When we’re talking about rural health, we’re also talking about aboriginal health in large part. The health needs of our strong, growing aboriginal population need to be front and centre in considering how best to support rural health, so issues of cultural competency and sensitivity to long-term effects of residential schools, for example, are fundamental to remember.

I guess none of this will be new to any of you, but working our way through this, I think what it says is that in rural British Columbia we’ve got some unique challenges. We need to consider multiple different layers to the challenge at the same time: socioeconomics, the diversity of the populations, distance and so on.

In terms of the HHR part of this, which is what I wanted to jump into in the short time that we have here, we have seen a growth in the number of health care professionals choosing to live and work in rural British Columbia. I’ve provided some information about over the past five years. Some of this may look modest in terms of growth.

Rural family physicians have increased by 2 percent. Rural physicians overall, so that would be GPs and specialists, have increased by 8 percent and registered nurses by 2½ percent. Nurse practitioners have grown significantly. I think that’s because of recent efforts, programs like the nurse practitioners for B.C. program, where we’ve specifically targeted rural and remote communities for funding. Midwives, as well, have increased in rural communities over the past five years.

Like all provinces and territories in Canada, British Columbia struggles at times to find enough physicians, nurses, nurse practitioners and other health care professionals to live in rural and remote communities. I’ve been in discussions…. Some would suggest that for some professionals — in particular, physicians — our problem isn’t a supply problem, but it’s a distribution problem. So how do we address the distribution problem primarily?

Of course, this is not all for lack of trying. We’ve got a wide range of programs, incentive payments and other things in place to try and promote recruitment and retention, specifically for physicians. I’ll spend some time on physicians here for a moment.

On the slide you’ll see reference to Health Match B.C. We do have a provincial agency that supports health authorities and doctors in terms of placements in communities throughout the province and that also manages our GP locum program. We have a rural GP locum program that Health Match B.C. assists with.

Practice-ready assessment. That’s something I’ll say a few more words about in a moment, but we’re doing some work to promote international medical graduates locating in rural and remote communities throughout the province. We’ve also got an IMG-BC program, which is about international medical graduates still studying some post-graduate medical education in B.C. and taking their residencies in rural communities throughout the province.

In addition to those initiatives, we’ve got a pretty wide range of negotiated, if I could put it that way, programs that we work on collaboratively with the health authorities and the Doctors of B.C. through a committee called the Joint Standing Committee on Rural Issues: three of those listed on that slide — rural recruitment contingency fund, rural GPs for B.C. incentives, rural recruitment incentive funds — and then, on the next slide over, nine or ten more, different incentive programs.

These programs support recruitment and retention of physicians in eligible rural communities through the payment of additional premiums to physicians living and providing services in rural communities. They provide support for facilitated locum coverage in rural communities; additional financial supports for education, recognizing that physicians in rural communities have to travel to actually access educational opportunities; travel assistance to get to communities; isolation allowances; and subsidized leave, as well.

In total, the ministry invests about $107 million annually to support physician recruitment and retention in rural and remote communities throughout the province.

We recently settled the five-year physician master agreement — I think it would have been December it was ratified — and we’ll be adding another $12 million over a three-year period to support enhanced rural recruitment and retention initiatives. That’s in addition to about $55 million that was negotiated in that agreement to support recruitment and retention initiatives, broadly speaking — money going to recruitment and retention generally and then an additional amount for rural on top of that.

We do have a number of initiatives that target other health professionals, but I think one thing that I would say is that we need to do some work to examine whether we need to do more here, because recruitment and retention challenges for physicians are one thing, but nurses and allied professionals are every bit as important in rural communities around the province.

That’s some work that we’re going to do at the ministry, not only at the Ministry of Health, but we work with the Ministry of Advanced Education, for example, on the educational side of things and loan forgiveness. There are some existing programs for other health professionals, but as I say, that’s an area where I think we do need to do some work, and we will.

Again, in general, rural practice can be difficult for physicians and other health care providers. There is a sense…. I just came from a meeting with all of the nursing associations in the province where we talked about isolation and the stress on rural providers being responsible. Sometimes they’re the only providers in the community, and that’s a heavy burden to bear at times. We need to do some work to address the isolation and the workload for those folks.
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We’ve also got some challenges with respect to transition and the impact on community when a provider leaves. For example, we know that a physician leaving a small town like Alert Bay compared to a physician leaving a practice in Victoria — although both important and with impact, one can be significant and potentially…. I won’t say catastrophic, but the impact on a small, rural community is potentially far more significant.

We do have challenges, and I won’t go through all of those. What are we doing at the Ministry of Health? Well, over the past couple of years what we have been doing is a refresh of our strategic agenda. The minister’s mandate letter shortly after the election directed that he review what was, at the time, called the innovation and change agenda for the health care system, which was the strategic platform that had been in place for a number of years — to go away, have a look at what’s working well, what’s not working well and come back to government with a refresh of the plan.

We’ve been doing that work. There was a lot of analysis that took place in the ministry, a lot of consultation, a lot of speaking with stakeholder groups — their views about what’s working and what’s not working — and that resulted in two documents that you see referenced on this slide — Setting Priorities for the B.C. Health System, which is available on our website, as well as the B.C. Health System Strategy Implementation guide, which is also available on our website.

Those two basically review — the first document — three questions: what are the patient outcomes or patient population groups where we need to do a better job? What parts of the health system do we need to focus on in order to do a better job for those patients? And ultimately, what are the strategic enablers and barriers that exist that we need to address in order to do a better job for those folks?

Since that time, as part of that thinking…. I know you probably need a microscope to actually read the text on this. It looks really complicated, but it’s actually very simple. I’ll very quickly try and describe what this means.

This is basically our thinking at the Ministry of Health — everything you need to know about the health system. Some of you on this committee will have seen that my boss, the deputy minister, is quite active with Microsoft Visio. He comes up with these schematics, and he’ll read Hansard and probably be quite disappointed with me that I’ve referenced that here today.

What this says…. If you start with the boxes on the left, this is basically a performance management framework for the health system. The boxes on the far left describe patient outcomes, the outcomes that we want to achieve in terms of quality for patients.

The next set of boxes over describe patient population health needs. In order for us to drive outcome improvements, we need to actually understand what patient groups, what populations need in terms of health care.

Working back, the next set of boxes refer to service delivery. How are we going to provide those services to meet those needs, to achieve our outcomes?

The green boxes, second from the right, refer to the health human resources, the people that provide those services to meet those patient population needs, to achieve those outcomes. Then on the far right we have a number of boxes that are enabling support, such as IMIT and so on, which are tools for health providers to use.

The orange arrows along the side describe some of the considerations that we need to make in planning for health care. Along the one side, of course, we have to manage within budgets. We have to do so in a cost-effective manner. At the same time, we need to balance budget considerations against quality.

Then, the third arrow, diagonally across the middle — which I think is one of the reasons we’re here today — is we need to consider different geographies in the province and how we address patient population health needs in different parts of the province. So that’s basically our schematic for thinking about health care system improvement.

Now, all of this has evolved into a series of policy papers, which I’ll talk about in a moment. But through our analysis, we’ve landed on three major cross-sector strategic priorities: reduce demand on emergency departments, medical in-patient bed utilization and residential care by improving the effectiveness of services for patients with complex chronic conditions, cancer and moderate to severe mental illness; significantly improve timely access to surgical treatments and procedures; and establish a coherent and sustainable approach to delivering rural health services.

You can see that the ministry, the government, is taking the need to improve rural services very seriously. When we use the word “strategic,” we’re thinking about a major transformational shift in thinking as opposed to continuous improvement with respect to the core functions that we deliver, I guess, every day throughout the health care system.

These are the major priorities of the ministry right now with respect to the health system. As I said, we have tried to advance our thinking in each of these areas through a series of policy discussion papers at the ministry. There are currently five of those papers, with a couple more to come.

There are papers on patient-centred care, primary and community care, surgical services and health human resources, and as you see highlighted there, there’s a distinct policy paper on rural health services. Again, all of these are available on the ministry website.

We’ve been out meeting with stakeholders over the past couple of months, speaking about these papers. We’re treating them as propositions, bold ideas that we want to drive forward. We’re trying to build some con-
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sensus around the ideas in these papers, so we’ve been out meeting with professional associations, unions, regulatory colleges, patient representative groups, post-secondary institutions — a wide range of groups.

Specifically with respect to the rural paper, I won’t walk you through it in detail, but I guess a couple of important points. We’ve organized our thinking at three levels. When we think about improving the health system, we’re going to think about it at the practice level, at the organizational or regional level and then at the system or provincial level. You’ll see that reflected through all of the papers.

In terms of the rural paper, one of the things that you’ll see straightaway is that the health authorities will be doing work over the next few years to build community service plans for all rural and remote communities, with a focus particularly on population health, prevention and wellness and with the expectation that these plans will be refreshed every three years.

A number of other things flow from that. I guess the key point there is that through those plans, they’ll be doing detailed assessments of community patient population health needs so that we understand how actually to do workforce planning more effectively to meet those needs. From that flows our ability to manage at-risk communities and do contingency planning. As I mentioned, that’s a high priority.

Related to that, I mentioned primary and community care. That’s a priority across the province, not just in rural communities but particularly in rural and remote communities. So what you’ll see in the rural paper is a prioritization of establishing integrated multidisciplinary primary care practices in rural and remote communities, whether actual or virtual, with 24-7 emergency and urgent care capacity. The intention is, over a three-year period, for health authorities to — if I can put it this way — strategically and opportunistically implement these models.

I say strategically and opportunistically because there are some challenges in building multidisciplinary primary care practices. The traditional model, for example, for physicians has been solo practice in many communities throughout the province. We’re not in a position, nor would we want, to force physicians to change their practice per se, but there will be opportunities along the way — physicians retiring, for example, or changes in a community in terms of needs. Opportunities will arise for us to work with health authorities, doctors, other providers, local communities to create these sorts of practices. So it will take some time.

Another feature of the rural paper that you will see is the pathway or the link to higher levels of care and requiring that health authorities clearly set out those pathways, including improving inter-facility transfers by ground and air. Related to all of this, of course, is optimizing scope of practice, skill mix and flexibility with respect to how health care professionals are deployed in these models.

You will see in the paper reference to options to better support aging in place through improved home and residential care. Again, this will be a priority that you see in the primary and community care paper as well. I mentioned already establishing formal networks of specialist physicians to support rural and remote communities. An enabling requirement here in all of this is improving the flow and access to data and information for providers in order to, I guess, manage performance and to better link and coordinate services across communities.

We also propose to work with UBC to help strengthen rural generalist family practice so that medical school graduates have a comprehensive and culturally relevant set of skills to practise effectively and confidently in rural communities.

We believe this can be achieved in part through our distributed education programs in B.C., nationally recognized. I think we’ve got a fairly unique medical education program that’s got sites in a variety of communities throughout the province — Prince George, Kelowna, Kamloops, the Fraser Valley. We know, of course, that the likelihood of success of having practitioners stay in local rural and remote communities…. An important factor is where people are educated and trained. That goes not just for physicians but for nurses and other practitioners as well.

As I said earlier, most incentive programs right now at the ministry are targeted at physicians. However, we know that we need to do some work to shore up recruitment and retention incentives and opportunities in programs for other disciplines, and we need to find ways to make postings for nurses, nurse practitioners, physiotherapists and occupational therapists more attractive in rural communities.

Many health professionals, as I said a moment ago, are concerned about being isolated in rural or remote communities. The difference between knowing you’re the only practitioner in a community versus one of several practitioners can make a significant difference in terms of filling hard-to-fill vacancies. Creating care teams is one strategy, but technology can also help reduce the distance between communities and practitioners.

Health Match B.C. In terms of strengthening recruitment and retention, we’ll be speaking with them about enhancing their services, going forward, for recruitment and retention to rural communities.

Again, I referred to optimizing scopes of practice. I think there’s a tendency at times, for when the physician’s leaving a community, the community immediately thinks about replacing the position. But in many cases — we’ve seen this successfully in a number of communities — it might not be a physician that can fill the gap. We know in B.C. that we’ve got overlapping scopes of
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practice between health professionals. In many cases we know that other health professions can provide the same level of services to meet a community’s needs. We need to do a better job of looking at that.

One thing I will flag. The ministry, the Facilities Bargaining Association, B.C. emergency health services and the health authorities are all working together on implementing a community paramedicine program for the province, which you may have heard about. We’ve committed to investing funds to support the creation of 80 community paramedic positions throughout the province. That work is underway, and I believe a number of communities have been selected for our first tranche, or wave, of community paramedics.

Very quickly. I mentioned $12 million in new funding earmarked for rural physician recruitment and retention, in particular, and the other funds that were negotiated through the PMA to support recruitment and retention.

I will say that there’s a high degree of collaboration right now between all the folks that are involved, particularly on the physician side of things. We work closely with family docs, through the divisions of family practice, and with health authorities. Actually, what’s missing on that slide is local communities. The local communities highly engage in the recruitment process for physicians and other providers. We work closely with the College of Physicians and Surgeons and UBC, as well as UBCM, to strengthen recruitment and retention.

One of the things, as well, going forward, to support some of the ideas in the primary care paper and the rural paper with respect to new ways of practising new models of care for rural and remote communities, is we’re going to be doing some work to look at different funding and compensation models. We’ve got models that have been in place for quite some time, and maybe they’re not the best models to support different ways of practice in different types of communities.

We’re going to actually do some work to figure out ways that we can enable and support recruitment and retention through compensation and funding.

Finally, I mentioned earlier practice-ready assessment. B.C., like all provinces in Canada, has relied on internationally trained health professionals for a long time. Historically, B.C. has not had challenges recruiting these folks.

There were a number of changes at the national level with respect to national regulatory agencies for physicians that threw a bit of a speed bump in terms of our ability to recruit physicians from certain countries. We have reciprocal agreements through the national regulatory agencies with certain countries, where we recognize their medical education and training programs. That makes it easier for us to recruit internationally trained docs from those countries.

There are other countries…. South Africa in particular was one country where we’ve recruited a great number of physicians for rural communities. But the South African government has chosen not to participate in the reciprocal recognition process. That has led to the need for us to create a practice-ready assessment program in order to assess the medical education and training of doctors from these countries. We have created that, and we will have two intakes this year of 15 physicians — so 30 in this year. That comes with a two-year return of service in a community of need. We’re targeting all of those positions in rural and remote communities at this time.

I mentioned earlier the international medical graduate residency program. We’ll be graduating 52 new physicians per year to rural communities in B.C. That residency, as well, comes with a two-year return of service.

I mentioned the wide suite of rural recruitment and retention programs for physicians that are in place. We’re going to spend some time over the next year working with the Joint Standing Committee on Rural Issues, evaluating a number of those programs. We’re going to start with three in particular — the RP for B.C. program, the rural emergency enhancement fund, and the northern and isolation travel assistance outreach program as well as the rural GP locum program — to do a bit of review and identify whether those programs are still effective, whether they can be improved and whether we need to think about other programs going forward.

I should say the Joint Standing Committee on Rural Issues is a highly collaborative committee. It’s an ongoing challenge for the committee to identify new and innovative ways to support recruitment and retention. I think they actually do a pretty good job, and we know that other jurisdictions look at a number of our incentives. I think Alberta, in particular, has borrowed from us. But it’s an ongoing challenge, just as recruitment and retention in rural and remote communities is an ongoing challenge. So we will be working through that committee to, as I say, review the existing programs and try and align the various suite of programs with the policy papers moving forward.

L. Larson (Chair): Thank you, Ted. We’ve got about ten minutes. I’ll have to cut it off right at 9:15 because we have another presentation coming in.

Because I have control of this chair, I’m going to ask you a question. Then I’m going to turn it over to the vice-Chair for a question. Then we’ll bounce back and forth across the room. For anything that we can’t get an answer for today, we will put it in writing and just give you a list of questions that we weren’t able to get out on the floor in this few minutes. Then we’ll have you send those back to us, if that’s okay.

I’m just curious. The retiring versus the new — how big a gap is that? In other words, I know that there is X
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number of new physicians hitting the streets every year, but there’s also this huge amount of retirement happening, certainly in the remote areas, the rural communities.

Even for a community like Keremeos, which is less than 100 kilometres from the very great Central Okanagan and is just full of doctors and full of everything, it’s almost impossible to get a doctor to go there. They’re all retiring. So where’s that issue right now? How short are we still, and how much longer will we be short before we catch up?

T. Patterson: It’s a good question. Again, there’s a bit of a debate out there about whether we’re short or whether we’ve got distribution challenges or productivity challenges and so on. I think it’s a little bit of all of that.

One of the challenges with physicians is that they don’t retire in the same manner that other practitioners might. Some physicians stay on. I’ve heard of physicians well into their 70s, some in their 80s, and so on. They’re assessed by the college on an ongoing basis, and they have to be competent and current in their skills. So it’s a little more challenging to actually assess that.

That’s one of the things that we’re going to be focusing on over the next year in particular — improving the way we do resource planning generally for all health professions, but physicians in particular, working with the divisions of family practice locally to, as I said, assess local patient population health needs and do better supply planning from there and have a better understanding of the inflow and outflow into the system right now. But right now it’s actually challenging for us to say whether we have a gap and what that gap is.

L. Larson (Chair): You actually, at this point in time, don’t know how many…? You know how many are coming in, but the problem is knowing how many are going to go out?

T. Patterson: Right. We need to do some work in terms of the analytics around forecasting for the physician group.

J. Darcy (Deputy Chair): A couple questions, one just picking up on a question that the Chair asked. There’s this discussion paper and a great outlined plan. What’s the baseline that you start from? If we’re going to measure progress two years from now, five years from now, there needs to be a starting point, and that needs to be, surely, an assessment about where we are now in terms of shortages.

You say: “Don’t use the term ‘shortages.’” I understand that. But the lack of physician services and services of other health care professionals in particular communities…. Surely, there must be some assessment of where we are now in the various categories of health professionals.

This problem didn’t start today or yesterday. I’ve been in discussions — other movies — with you, Ted, and with other people in the ministry, on this same issue. It goes back a long way, and we seem to always have a real challenge with where we’re at now so that we can really assess where we need to get to.

My second question, quickly. You talked about multidisciplinary teams. Are you looking at different payment models for those multidisciplinary teams? Certainly, a lot of the study on this, the literature on this, indicates that payment models — for physicians in particular, and for nurse practitioners — can be a barrier to expanding team-based care. Are you looking at payment models and the barriers that that poses?

Are you looking at nurse practitioner–led clinics, which they have, for instance, in many rural and remote communities in Ontario — sometimes on a hub and spoke model, with the full team of health professionals, and sometimes not?

T. Patterson: In terms of the first question, the where we are now, we can provide information on the number of physicians in the province, the number of the different specialty groups and so on. But I think, as I said, one of the challenges is rather than…. Historically, the health system, at times, can be provider-centric and driven that way rather than patient-centric.

The work that needs to happen locally with provider groups to determine patient need — that’s work that we need to surface in order to have the discussion about health human resources. Based on the logic model I put up there, that’s the starting point.

From there, as I said, there are any number of health professionals…. So a competency-based approach to doing planning. We need to have the discussion about who best to provide the services and go from there.

We do have statistics on the number of docs in the province, and we can map out, with some work, where they are and where they’re located and so on. But I will say, compared to the everybody-but-physician side of the equation, we need to improve our forecasting work and our planning work on the physician side.

I think we’ve got a relatively good foundation or base for nurses, for example. Although specialty nursing — we need to make some improvements there. So we do have to do some work, some foundational work, with respect to resource planning for physicians, if I could put it that way.

The second question, very quickly. Yes, we’re quite interested in payment models that would enable different types of practice.

D. Barnett: Thank you very much for your presentation. It’s very exciting to see how far the ministry has come over the last couple of years in recognizing and working with rural health. It’s my life, and I know that I’ve been working hard on this, also with my colleague Moira Stilwell here.

The question I have is: in the international medical
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graduate program how many are immigrants, and how many B.C. students who are studying outside Canada are we taking back into the rural program?

T. Patterson: If I understand your question correctly, there’s a distinction, and there’s also a bit of debate about this. I don’t have the exact number. We consider Canadians who study abroad international medical graduates because they study at an international school. We have to be confident that their education and training at these international schools would meet Canadian standards. There’s quite a debate about whether we should look at opportunities specifically for that group because they are Canadians or British Columbians coming back.

I don’t have the number, the breakdown. I can go away and find that for you. But it’s an important and ongoing lively debate, if I can put it that way.

J. Rice: My first question. The rural GPs for B.C. incentive — is there a rural NPs for B.C. incentive?

J. Rice: Okay, I’m almost done. When you were talking about the practice-ready assessment, you were saying how the South African government has opted out of their reciprocal program. Why did they choose to opt out?

T. Patterson: Well, ironically, as I said, there was quite a stream of physicians from that country coming to British Columbia, and there still is. But they have challenges with their rural services as well, I think. My understanding of the situation — I could be wrong or corrected about this — was that they need to protect their supply. They’ve got concerns about physician supply as well.

J. Rice: Lastly, the 80 new paramedics — are they all designated to be for the community paramedicine program?

T. Patterson: Doug may be in a better position to answer this. I believe the project will roll out in a series of waves, I guess, with more and more positions being created. But I believe the first several communities have already been selected, so over the next six months.

L. Larson (Chair): I’ve got Darryl next, and then we’re going to wrap this up, simply because we’ve run out of time. We have a multitude of questions for you. We will put them in writing — any that we can’t get on the floor today — and ask you to get back to us as soon as possible.

D. Plecas: Thanks very much for the great presentation, Ted. Two things that I didn’t hear you talk about were teledoctoring, or what some people might describe as telehealth, and the whole notion of physician assistants. I’m just wondering: has the ministry given thought to how we might think about adopting those two issues?

Thirdly, when you talk about retention and recruitment, I just wonder which is the more serious problem. I ask that because the problem that we have with doctors is not unlike the problem they’ve had historically with public safety officials, like police officers, in limited-duration postings. It was always a problem with recruitment, but what they found was that after people spent a period of time there, they couldn’t get them out of there. I’m just wondering what the experience is regarding that.

T. Patterson: I guess, on telemedicine, I did…. I failed to mention that. I mentioned creating multidisciplinary primary care teams, whether that’s virtual or face to face. Telehealth has been, and needs to be going forward, a major part of the solution here.

We are doing work in the ministry, and you’ll see that. One of the papers that’s in draft form right now that will go up on our website eventually is a paper on IMIT policy as well. That will speak to improvements in telehealth technologies around the province.

On that, we’ve seen of late, with recent changes to the Medical Services Commission payment schedule, an opening up of, I guess, private sector companies, if I can put it that way, that enable people to access telemedicine anywhere in the province. You can use an iPad to have a GP visit. We’ve got to be careful with things like that to make sure that we’re not…. While there’s a role for walk-in clinics, for example, we don’t want to replicate certain types of behaviour through technology.

So technology will be a critical part of the solution. It has been important for rural communities, and it will be going forward.

On physician assistants, we did do some work. I think in the service plan last year we committed to doing an
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analysis of that. We have done some work. My thoughts on that, for what they’re worth, are that if you look at that performance management framework — the boxes with all the various health care providers that are listed in that set of boxes — the question that I would have is: what problem are we trying to solve that can’t be solved through an existing health care provider, for example?

We’re actually in active discussion and debate about whether introduction of physician assistants would be useful and beneficial in certain communities, but recognizing that there are other health care providers that can play the same role in fact. It actually takes a fair amount of work to introduce a new health care profession into the province. It’s harder than people might think.

Finally, on your question about whether retention or recruitment is a bigger challenge, I’m not sure I have a good answer on that. I think it’s a little bit of both, to be quite honest with you. On the financial side, we’ve got lots of incentives to get physicians, at least, into communities. But we’re trying to promote continuity of care and longitudinal care, so it’s important to keep them there.

There are a number of features that need to exist in order for any health care provider to feel comfortable in a community. Some of those things are access to other practitioners, to be part of a community of practice. To be able to actually get out of the community every now and then, whether it’s through a locum or otherwise, take a vacation and be confident that someone’s coming in to continue to provide services to the community. Where they’re educated or trained is important. Whether there are good schools or jobs for a spouse or partner or family. Those sorts of things.

I think, in terms of challenges, that would be the bigger box that we have to deal with, to be honest.

L. Larson (Chair): Thank you both, Ted and Doug, for being here this morning and for your great presentation. I know you’re going to get quite a long list of questions that are going to come because we just did not have enough time. We know how busy you are right now as well.

We’ll take a three-minute break here for everyone to get a fresh cup of coffee and for you to be able to move on.

L. Larson (Chair): Good morning, Mr. Ranallo. I’m Linda Larson. I’m the member for Boundary-Similkameen, and I’m Chair of the Select Standing Committee on Health. I’m going to ask the committee members to quickly introduce themselves to you, and then I will turn it over to you to do your introduction and to go right into it. We are running a few minutes late. My apologies for not starting right on time.

J. Darcy (Deputy Chair): Judy Darcy, Deputy Chair of the committee, member for New Westminster and official opposition spokesperson on Health.

R. Lee: Richard Lee, MLA for Burnaby North, also Parliamentary Secretary for Traditional Chinese Medicine.

D. Plecas: Darryl Plecas, MLA for Abbotsford South and also Parliamentary Secretary Responsible for Seniors.

L. Larson (Chair): I’ll turn it over to you now to do your introductions and to move right into your presentation. Thank you so much for being here this morning.

J. Ranallo: Thank you. It really is a pleasure to be here and to have met all of you. We are at a very important point in our history, particularly in health care, and this is a very opportune time for us to have these discussions.

Traditional Chinese medicine has made some fairly significant steps since the 1990s, when it was first regulated in B.C. This fall Kwantlen University will be offering the first university academic course on traditional Chinese medicine.

I am representing what’s called ATCMA, which is the British Columbia Association of Traditional Chinese Medicine and Acupuncture. I am the chairperson of the PR committee. As we are sort of the new kids on the block…. Well, we’ve been here a long time. Traditional Chinese medicine has been here, in B.C. almost its inception, except it hasn’t been at the publicity level that it is now.

We, as the new kids on the block, want to do our part to help to enhance the current system that’s there now. I
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want to emphasize that we’re not trying to replace it; we’re trying to enhance it and become part of it. It would be wonderful to give people, as they reach the end of their life, the benefits of two very, very powerful medical systems that exist in this world.

What I would like to focus on is what we can do — some of the things that we can do. And 15 minutes is not really a lot of time. I just want to make you aware that what I’m saying is just a small section of what we can do. We would be delighted to be asked to come and do a longer presentation at some time.

You do have the papers that have been handed out. I’ve worked this way because I’m from the Kootenays, and the words about the rural communities made a lot of sense to me. If we turn to page 1, which is after the cover page, here’s what I would like to go over very, very quickly: some of the ways that traditional Chinese medicine can enhance the medic system that we have right now.

First of all, because all diseases, including those that come with aging, are associated with energy blockages, traditional Chinese medicine can do much to assist the provincial medical system to address them. Basically what happened, over 6,000 years ago, was the Chinese discovered that once the big bang’s energy was released, we became part of that, and we’re still part of that right now.

If you turn to page 3 — just very, very briefly — this is what they discovered. That energy flows through everything, including the human body, through five elements. And those are…. Starting with wood, on the left-hand side, the energy goes from wood to fire to earth to metal to water and then again, and it keeps on going. Now, these are metaphors for the kinds of energy that exist.

Each of those elements is associated with at least two organs within the human body. One is a yin, and one is a yang — except fire. Fire is associated with four: the heart, which we know; the small intestine, which we know; the triple warmer, which is an organ that the Chinese recognized many years ago and is the entire chest and abdominal cavity and has three divisions; and the circulation-sex, which is actually what we call the pericardium today.

As long as energy keeps flowing, then we’re in good health. But once we block that energy…. And that can be done by external causes. Climate — if it’s too cold or if it’s too hot, if it’s too damp or if it’s too dry. If the body faces those, that will cause blockages.

Another one is internal, which is basically our emotions. Each of those five elements is connected to an emotion. Wood is connected to anger. Fire is connected to joy. Earth is connected to worry and using the brain, like studying. Metal is connected to sadness and grief. Water is connected to fear.

Now, the joy, for instance…. I’m sure you’ve all worked with somebody who is so overjoyed that it’s tiring to be around them. What’s happening there…. All of these emotions are important, but they need to be in balance. When they get out of balance, they tend to affect the flow of energy.

There are also other ways that we can block that energy — something like infections, injuries, our diet, insect bites, fatigue, lack of sleep. We could go on for a long time. Because traditional Chinese medicine has a way to identify — that is, diagnose — an imbalance and treat it, it can help with all imbalances, including those that come with the end of life.

Two, many aging-generated diseases involve blood stasis — that is, the blood is not flowing the way it should. The way the Chinese say it: “When energy is flowing, blood is flowing; when energy stops, then blood stops.” It then becomes like a stream that we block, and it becomes stagnant. Many of the health issues that people face towards the end of their life have to do with the flow of blood.

Now, three, I want to emphasize right from the beginning that we are talking about fully qualified TCM practitioners who take about 2,000 credit hours of training to be licensed. We’re not talking about the person who takes a weekend workshop and claims to be an acupuncturist. They’re not reliable for what we need.

The most important subdivision is classical Chinese medicine. That was largely what I was talking about earlier. We have one of the world’s authorities just down the street from here — Dr. Pan at, I think, 1620 Government Street. I haven’t had a chance to talk to him, but he spends most of his life now travelling to China and to Europe and teaching the very, very traditional Chinese medicine.

What happened somewhere, somehow, and it’s hard to say…. I was just reading an article the other day that science has discovered that there’s a line in the cells. What they’ve done now is taken healthy people and unhealthy people and analyzed the line. For those who are healthy, the line is long. For those who are not healthy, the line is not long. It’s just a discovery like that that would lead to ways of: what can we do with this to apply it to the human body? The Chinese discovered this 6,000 to 10,000 years ago and have used it.

The classical Chinese medicine — there are those who feel that this should be the only traditional Chinese medicine. But when it moves around in the world, it adapts and changes.

Chinese scalp acupuncture works on the same principles as traditional Chinese medicine, except that it works on lines on the scalp. Because it does that, it works with the brain. It is particularly useful with the end of life because it deals with issues such as paralysis, stroke, organ disorder and neuropsychological challenges.

The Germans, who are very technological, between the ’50s and now…. In Germany today there are something like 40,000 neurologists who have taken acupuncture as full training, and they have developed a system that works entirely on the ear.
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If you have a quick look at page 8…. First of all, I have to tell you I didn’t write the book. I just happened to have that one, and I got it duplicated.

Basically, it was actually a French doctor, a neurologist, Dr. Nogier, who ultimately came to the conclusion, and a sound one, that the ear is like an upside-down foetus. It has all the organs and sections of the foetus. The lobe is the head. You see the feet and the hands, which are at the bottom, as a foetus is. The hollow in here is the internal organs. Right up above the name of the publisher, who was Thieme, do you see those little dots along that line of the ear? That’s the spinal column. It’s a direct relationship — the seven cervical, 12 thorax and the five lumbar — and then the sacral will be underneath.

They’ve discovered a way of treating the entire body using what’s called a microsystem of the ear. If someone — let’s say a patient in an extended health care home — falls and hurts his or her neck, a very quick treatment can be done by treating that area close to there.

Back to the navel acupuncture, page 9. This is something that became an issue just recently. One of the world’s authorities in Canada is Dr. Weidong Yu, who is in Vancouver and is internationally known. He is the one who brought Dr. Yong Qi to Canada and to B.C.

What happened in this case…. The navel was forbidden to needle for 6,000 years, because they probably killed a few people at the beginning by putting the needle downwards. So we’ve stayed away from the navel. What this doctor, who was actually…. He is a plastic surgeon and was a martial artist. He wondered what would happen if we would place the bagua, which is in the diagram at the bottom, on top of the navel. What he discovered was that if you needle under the skin instead of into the bowels, it’s very safe. It’s painless, and it’s extremely effective.

At each of those points of the bagua…. You see the one at the very top, which is called li. That corresponds to the heart and the eyes. The next one going down corresponds to the abdominal cavity. That’s the spleen. The third one, dui, corresponds to the lung. The fourth one, qian, corresponds to the colon and the large intestine. Then the kidney, which is opposite to the heart at the bottom, and gen is the stomach. Liver is the next one. The gall bladder is xun.

It’s an effective, very quick, very painless and very safe way of doing treatments.

The last one that I want to mention happened in Korea in 1971. Dr. Tae Woo Yoo realized that the hand reflects the entire body. What’s particularly useful, I think, in this case is….

The hand works this way. You put the hands in front of you. Now you’re looking at the back of your body. Turn them this way, and you’re looking at the front of your body. You’re looking at the two outside, the thumb and the small, and those are the legs, with the ankle the first joint, the knee the second joint, the hip the third joint.

The next two fingers, which are inside, are the arms. Again, they’re a division of wrist, elbow. The middle finger on both hands is the mid-body. That tendon that you see going from the middle finger corresponds exactly with the spinal column. The first joint of the finger is the head, the second joint being the neck, the third joint becoming the shoulder — that goes into the arms — and so on.

Now, by treating both sides, we could do two identical treatments on a patient. You do one on the right and one on the left. We usually don’t use the thumb and the index finger, because we can use the other hand to do that. This hand, the left hand, corresponds to the left side of the body. This hand corresponds to the right side of the body.

Again, the reason I include this…. It would be so easy when someone hurts a knee to just…. Not only does it avoid the use of needles here. They’ve developed little pellets that you put…. So if any of you have a sore knee right now, if you feel around with the small finger on the side where the knee is, you’ll probably find a little sore spot. Just putting a pellet on that will take care of the pain.

Especially when we’re talking about the rural, we don’t have a lot to carry around. We have maybe a few pellets, a few needles. It’s quite mobile.

Go back to the beginning on page 1. The last one is acupoint therapy, which is biopuncture. It blends the best of both TCM and other injectionables that are part of western and eastern medicine. That is one that requires further training than the typical training for TCM. Because of these and a multitude of other TCM benefits, people are accessing TCM today. It would be, I think, a wonderful thing to be able to provide it as part of the care that is available to them. So as they leave this planet to go to other realms, they’ll thank us for having done that.

On the next page it’s with pleasure and delight that ATCMA, which is the largest association of TCM in B.C., has already begun its…. What we hope will happen will be our ability to join with the medical system. We have appointed one member of our board to each of the health care systems, and we’re waiting to engage these people in whatever we can do.

I think that this is…. We’re not asking for any major change. We just ask to continue what has been happening in B.C. B.C. is the leading province in Canada for traditional Chinese medicine, for this movement. In the ’70s traditional medicine was regulated. Then we received MSP coverage and just recently, the last couple of years, the HST and GST exemption, which is federal. We’re now offering TCM as an academic university course. It would be wonderful to provide TCM as an option and a choice for the end-of-life care.

L. Larson (Chair): Thank you very much. We’ve got about five minutes, and I’m sure there are a few questions. I just have one.

I understand — I’m not sure whether this applies to you or not — that if a person is in the hospital — for instance,
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in their last stages of life — in order for you to follow them into that hospital, it is through their general practitioner. Are they able to have you come in and see them in a hospital and provide some treatment if they’re in that end-of-life stage, or must you go through a health professional, a regular doctor, in order to get permission to do that?

J. Ranallo: Well, that’s a difficult question for me to answer. I have gone in the hospital and worked. I’ve also heard that sometimes the system says: “You can come in and do this.” So I’ve gone in, but I’m not sure…. What we would like to be able to see is a system that says: “Acupuncture is appropriate for you. Let’s bring an acupuncturist in.”

I’m not sure that I’m answering this question. I’m only answering on my own experience.

J. Darcy (Deputy Chair): My question is: what challenges do you see to integrating traditional Chinese medicine to a greater extent in the health care system?

J. Ranallo: Well, I think the biggest challenge is to get together. For too many years we have been seen as different worlds, but in a place like Canada, where the two systems are working together, we need to talk to each other. I see this opportunity today as a start for that.

We would need to discuss what needs to happen, and we are prepared to do that. I think it’s a question of willingness to provide more options for the patients.

M. Stilwell: Do you think that claims such as navel acupuncture resolving addiction, Alzheimer’s, fibromyalgia, infections, etc., are an obstacle to you participating in the hospital system? And I guess the second part of my question is: at the completion of a so-called academic program at Kwantlen, do you think your association will continue to encourage members to make those claims?

J. Ranallo: Well, all I can say is that I do the navel acupuncture, but I’m dealing with a patient who comes to me, not necessarily referred. So I cannot answer that question because I haven’t been in that position where I’ve had to deal with that. And I want to be honest.

R. Lee: For palliative care — end-of-life treatment — we know that a lot of pain treatment can be used. You can use acupuncture to do that.

R. Lee: That will enhance the quality of life at the end. Do you foresee any expansion of that kind of service, in the rural area especially? And what are the challenges?

J. Ranallo: This is sort of my own private vision: that we work with the other health care providers and determine what the best solution is for this person’s problems and then go ahead with that. This will take some time. We’re not doing that now.

In the rural area, where you have limited resources, I think it would be to the advantage of the system to increase the number of options that are available.

The other thing that I’d like to mention. I’m noticing now more than maybe even five years ago that medical doctors cannot really refer to me. Their insurance company won’t allow them to do that. But they do tell a patient: “I’ve done what I can with drugs for you. You might want to try a little acupuncture and see what happens.”

I think the system — at least my experience — is becoming more open and less defensive. I don’t know if that answered the questions entirely. But any change takes time.

R. Lee: Yeah, a follow-up question is…. Acupuncture — how do you…? Some of the physicians are trained with acupuncture, and they are using it on the side. Do you have any comments on how to cooperate with physicians to make the system better?

J. Ranallo: What the association would like…. It would like anybody who’s using acupuncture to have the same training as the acupuncturists who are licensed in B.C. The problem is that some of these trainings are very, very limited.

Acupuncture — maybe I’ve made it sound a little bit too easy. It’s much more complicated than what I’ve presented this morning. What happened two years ago in Ontario…. A massage therapist who took a short course in acupuncture crippled an Olympic athlete. The therapist did not have sufficient knowledge of the safety.

What we would like to propose is that anybody who’s allowed to use needles should have the same training as somebody who has been licensed to do acupuncture. The thinking seems to be: “If you’ve got another area of expertise, take a short course, and do that.” We would like to think of acupuncture as a very full system, a self-sufficient system in itself.

I’m going to have to quickly go to Doug. Make it a short one, and then we have to move on.

D. Bing: Right. I think my main concern would be the protection of the public and that we have assurance that your members have the training and expertise to do what they’re doing. Are you a regulated profession? Do you have…?
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J. Ranallo: Absolutely. We have a college, and it’s very thoroughly controlled. We are required to do 25 hours of new work every year for the entire system of our life — this is work that has to be approved by the college — and continue to stay informed on what is happening.

D. Bing: We know that western medicine doesn’t have all the answers, but I am concerned by some of the statements here that German auricular acupuncture can easily treat all aspects of emotional balances and that post-balancing can get to the root of all health issues. It seems like you’re kind of stretching a bit there, making claims like that.

J. Ranallo: Well, it may seem that way. And I do agree. But in parts of the world that is the only medicine, and it does that.

Just to give an example of the auricular. If you have, say, an emotional imbalance with grief, by putting a needle in the lung area, that will do much to take care of it — unless there are more complicated problems. That’s what I was referring to. If you have an emotional imbalance, it’s very easy to treat without going through all the tests. It does work, and it has worked for 6,000 years in some places.

This will be part of the issue that needs to be addressed. We need to talk to each other, and we need to discuss exactly what you said.

L. Larson (Chair): Thank you very much, Dr. Ranallo. It’s been incredibly interesting for all of us, and certainly, we’re open to looking at all aspects of making somebody’s life better at the end, however that might be. So thank you very much for your information this morning. If we have any questions, we’ll send them along to you, and hopefully, you’ll be able to get back to us. That would be great. Thank you very much for being here this morning. We very much appreciated it.

J. Ranallo: Thank you for the opportunity. I see this as a stepping stone to what we need to do, and that is to talk to each other more often than we do now.

L. Larson (Chair): All right. I’d like us to get back to the table here, and we’ll move on to our next presentation, which is Richard Jock, who’s the chief operating officer for First Nations Health Authority. We’re going to do it by teleconference here. He will do a presentation, and then we’ll be able to ask questions.

Good morning, Richard. It’s Linda Larson. I am Chair of the Select Standing Committee on Health. I’d like my committee to just quickly introduce themselves to you, and then we’ll turn it right over to you to get into the presentation.

L. Larson (Chair): I’m going to turn it over to you, then, Richard. We very much appreciate you taking the time this morning to talk to us.

I think, ideally, it would have been good to be there, so I apologize for having to do this via phone. The First Nations Health Authority really welcomes the opportunity to make some brief intervention. I will not go through the entire PowerPoint but really cover some of the highlights, in view of the time and really, I believe, your interest more in having an exchange and discussion.

I think it is worth pointing out that the First Nations Health Authority is a unique organization in Canada. It’s the first of its kind in terms of being a provincewide First Nations health delivery organization.

It is unique, and part of what also is unique is that we are delivering services based on the former federal resources but also have funds available through our provincial agreement which enable us to pursue integrated approaches and models — in particular, looking at primary care interests and mental health issues. But we are really in the early stages of this. We got full transfer in October 2013. I think that’s worth stating.

Part of what is also unique is that this really presents an important means by which First Nations people are able to also work with all of the health authorities that exist within the province, both the regional health authorities and the Provincial Health Authority.

One of the features of our activities has been the development of regional health and wellness plans. End-
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of-life care has arisen as part of the priorities from those regional health and wellness plans.

The issue that arises for First Nations. I think most people are pretty familiar with the fact that we have a very young population — that roughly 50 percent of the population are under the age of 25 — but what is not as well known is that we also have a significant part of our population in the aging cohort.

Really what that means is that we’re both very young, but once we live to a certain age, our people tend to live a long time. We almost have a double whammy, if you would.

Of course, some of the context for First Nations people, and perhaps more pervasive amongst First Nations people, is the fact that we are, in many cases, in remote and rural settings — that in many of those settings the communities are of small size and that, therefore, there is limited infrastructure that is generally available.

Cultural safety and cultural relevance of programs is really a huge issue. As we examine the interests with respect to end-of-life care, cultural safety, I would say, would be a predominant element and interest as we go forward. In particular, then, looking at how culture and traditional wellness would be part of approaches would be extremely important.

We do have home and community care services that are available from the federal resources that I mentioned earlier. However, end-of-life or palliative care is not part of the resourcing and is certainly not adequately resourced within that bucket of dollars.

I think the other piece of that is then the institutions for elder care are not necessarily available. Many times when people leave communities for dealing with their serious health issues, it’s really seen as a one-way trip from those communities, and essentially, they don’t return. Looking for new ways of providing elder care would certainly be a specific and emerging issue.

I mentioned already the access of palliative care services but also at both levels. Trying to assist those who wish to remain at home as long as possible but then permitting a return to home, with appropriate supports so that end-of-life and that aspect of care and of living are dealt with appropriately, would be a really specific issue for us.

Again, as we look at the key issues facing First Nations people, it’s really looking at the support and access to resources and resource persons, making sure that there is adequate and appropriate clinical care to support both patients and caregivers. It’s looking at some of what could be dealt with in terms of financial supports and emotional supports, especially as it relates to families who have to deal with a loved one who is in an acute care setting probably some distance from their home. It’s looking at that and having those supports available.

I think some of those are available in our system, but having that in a coordinated approach would be extremely important. As I say, looking at what kinds of supports are available and reasonable at the community level would be an important aspect of this. It is also dependent on the support that I just referenced.

I would say that culture and faith, being able to deal with designating appropriate space for cultural and traditional approaches and at times making sure that there is opportunity for the loved ones to be close to the patient so that they can be part of that important process, would be extremely important.

I would say the cultural issues and challenges relating to culture and language are also part of what really is needed. This really needs to be looked at in terms of discharge planning and staged planning so that families understand what’s available and are understanding all of the aspects of this.

I would say, in general, that those are the issues. We have identified some recommendations in the PowerPoint. Some of those relate to broadening eligibility for financial support for caregivers, and some of this is also related to the respite interest.

From both of our perspectives, it’s to look at funding to support families; to look at making sure that they’re really holistic strategies which look at mental health and spiritual elements, which are obviously of keen interest at this particular service point; and that we look at creating culturally competent materials and training, both for local people and also for any informal caregivers that are part of our interests going forward.

I would say that our partnerships and relationships between the health authorities and First Nations Health Authority to really develop an effective case management process would be an important development.

The idea of doing some assessment of what would be useful or helpful for any community end-of-life care and also some of the infrastructure, such as housing or complexes to support end-of-life care and palliative care, would be, I think, a specific area that could be quite helpful going forward and, just as part of our overall approach, making sure that communities and First Nations as collectives are also part of the design and planning of these approaches going forward. I think that’s a given from our perspective, and we would emphasize that this should be part of future interests in this area as well.

Obviously, we are keen to partner with whatever organizations and groups that do work in this area and to look at how to improve the relevance of such programs to First Nations people.

I would say that as we go forward we look at how to really measure the patient and caregiver experiences so that we can look at how to incrementally improve services. We’re part of SPOR, the support for patient-oriented research initiative, and we would think that it would be very important to have such measures built into an end-of-life strategy.
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I would say the other aspect is that we would recommend that there be a report card in terms of culturally safe practices, which again, can help us really measure, as we go forward, how effective our prospective interventions may be.

As I was saying, I think that the whole issue of adult care is also a base that we may need to look at, which would support some of these interests. I think that is a really huge gap that exists in the system. As we go forward, looking at how this might relevant for care closer to the home will be potentially also something of significant interest for First Nations.

I would say also, with the regional health authority, if the only option that exists at this point is very expensive acute care, and then very little option other than that….

Just to go with that, as I say, we have sent a PowerPoint which gives some of the other context. But for this morning, I thought focusing on those elements would be a first stage of, perhaps, our discussion.

I would offer, as appropriate, that we have a further conversation. I would say Dr. Evan Adams would be very interested in doing a presentation, as you deem appropriate. What I would then do is pause for further discussion.

L. Larson (Chair): Thank you very much, Richard. I really appreciate the fact that you were able to join us in this way. We did not receive your PowerPoint. We’ve checked everywhere, and it didn’t come through. We will get it. We will access it and make sure everybody has it, because it certainly will have more detail than you’ve been able to give us just by conversation.

We do have time for a few questions. I’m going to throw one out there to you first. Are there any pilots or trials being done right now on First Nations remote communities in dealing with end-of-life care in a manner to keep people at home?

I attended a conference in the northern territories a year and a half ago. They have the same issue, where someone gets to the point that they no longer can take care of themselves. They end up being sent from their community literally hundreds of miles away, and they end their life far from home.

They had talked about creating sort of a very small group home, where two or three or four of these elders could live together with someone to take care of them and be able to stay in place to the end of their life, providing they had at least some medical support.

Is there anything like that happening right now in any of the communities that you’re aware of?

R. Jock: Not that I’m aware of in B.C. However, I think there are a couple of examples in different provinces. For example, in Norway House, Manitoba, they actually had a group who worked with a physician specialist in end-of-life care. They were able to use their existing facilities to provide end-of-life care and enabled families to really be part of that process and that experience. They had a client care facility though, an adult care home.

Similarly, Akwesasne in Ontario has a very active palliative care program. Again, it’s supported a bit by a facility in that the rooms that are set aside for palliative care enabled the families to gather and also supported the provision of cultural support.

Some of the considerations for those kinds of facilities are that they need to be adequately ventilated as some cultures use burning of certain materials, whether it be cedar or sage or sweetgrass — that this is possible within the building code. I think in many facilities in B.C. that’s actually prohibited, so looking at those considerations would be important.

We can also give you some additional materials and do a bit more research on those examples, both within and externally. We’d be happy to do that.

L. Larson (Chair): Thank you. I’m just going put it out to questions around the table here, and I’ll ask whoever is asking the question to identify themselves first.

J. Darcy (Deputy Chair): Thank you so much for your presentation, Richard. It’s Judy Darcy.

In the presentations that we’ve had earlier on the issue of end-of-life care, and especially palliative care, what we’ve heard from a number of people is that sometimes we’re talking about needing spaces — beds, facilities — but we’re also very much talking about needing to ensure that health care providers have training in palliative care, the wide range of health care professionals, so that they are able to assist families and that there be services available to support families at end-of-life care.

Are there programs in place for providing that kind of education or training — whatever the word is — in palliative care that is culturally sensitive to First Nations people? Would you see that as being an important part of what needs to develop?

R. Jock: I would say that would be an important area of this. It is one of our recommendations. I would say that having the appropriate physician supports, especially when it comes to pain management and doing so in a way that is relevant within a community setting, would be a key part of this.

The whole area of palliative care has been identified as a gap. One of the things that we’re currently doing is a review of our home support nursing program to help address that concern. It’s clearly been a gap nationally.

R. Lee: Richard Lee, from Burnaby North. We heard from the Ministry of Health about the services in rural
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areas and the challenges. Of course, First Nations — you have a big community in rural areas. We also heard from traditional medicine, as well as acupuncture, in our previous presentation. You mentioned about pain management as one of the culturally sensitive items as well.

Are there any opportunities, for example, to integrate some of the end-of-life services with, say, acupuncture services and other aligned professionals in medicine?

R. Jock: I think that’s a really interesting question. Certainly, integrating traditional medicine into our approach would really be an important element. I may not have been as explicit about that as I intended to be. But really, traditional medicine and practising culture is a key aspect to an overall coordinated system of care. I think that would be a key and a keen interest on our part.

I would say that being really clear and working with professionals so that they understand the role and complementarity of traditional medicine within the system would be important. Thank you for raising that point. I would say that that would be a really important element.

L. Larson (Chair): Thank you very much. We really appreciate you taking your time this morning and also in mentioning Dr. Adams — I believe that was the name that you put out there — that perhaps that would be someone that we would also like to talk to at some point. Once we get your presentation, we will send any questions through to you, and hopefully, you’ll get back to us as soon as possible. Thank you for joining us this morning.

L. Larson (Chair): Good morning. My name is Linda Larson, and I am the member for Boundary-Similkameen and the Chair of this Select Standing Committee on Health. I’m going to ask the committee members to introduce themselves.

Dr. Cavers, I know you’ve probably met some of them, but we’ll still go around the room and just do a quick introduction, and then we’ll turn it over to you for your presentation.

D. Plecas: Good morning. Darryl Plecas. I’m the MLA for Abbotsford South and the Parliamentary Secretary for Seniors to the Minister of Health.

L. Larson (Chair): I’m going to turn it over to you, Dr. Cavers. You did bring us a presentation, so I really appreciate that.

B. Cavers: Thank you for the opportunity to discuss the Doctors of B.C.’s submission to this committee today. My name is Dr. Bill Cavers. I’m the president of the Doctors of B.C., the organization that represents over 12,000 physicians in the province. But first and foremost, I’m a family physician. I’ve been practising here in Victoria for 35 years, a mere stone’s throw away from this meeting room.

I’ve also been involved in primary health care reform. For eight years I served as a co-chair of the GP Services Committee, also called the GPSC, which is a partnership of the Doctors of B.C. and the B.C. government with a mandate to improve patient care.

My comments today will focus on one word, and if you remember only one word of my presentation, I do hope you’ll remember this one: collaboration. An easy word to say. Not always easy to put into practice, especially in the health care world, where, traditionally, different factions have battled to maintain and maximize their influence and their funding.

Today I’ll tell you how collaboration between physicians, government, health authority and others is bringing innovation and positive changes to our health care system. It’s benefiting patients and helping reduce per-capita health care costs. And that is how you make a sustainable system.

My comments will focus on two of the four areas outlined by the committee, those of primary care through interdisciplinary teams, and rural health care. The third and fourth categories, end-of-life care and addiction recovery, are addressed in our submission, but I prefer to use the limited time today to focus on the first two items that I’ve identified.
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What are these collaborative programs? First, I’d like to go back a few years ago, just a very few years ago, when the provincial government and physicians were at war. One headline from that time, “Doctors railing against stingy, short-sighted government, warning patients will be harmed,” and a second headline from that time: “Government blaming greedy doctors for fostering an unsustainable system, warning patients will be harmed.”

It was constant. It was destructive, and neither side benefited from this arm-wrestling gridlock. Finally, after many years of strife, both sides decided to take a unique and innovative approach. Starting in 2003, and building over the last few years, there has been a dramatic shift in our health care story. A new culture between government and the medical profession emerged based upon cooperation and collaboration. And here is what happened.

Government and the B.C. Medical Association, now known as the Doctors of B.C., created four committees focusing on primary care, specialist care, rural health and shared care, providing seamless transfers of care between those first three. These committees are comprised of physicians and government representatives, with a co-chair from each partner, and health authority participation as well. Building on the last presenter, the GP Services Committee has representation from the First Nations Health Authority.

Funding for the physician master agreement — money that would otherwise have gone to physician compensation — was put aside to be used by these committee partners to be innovative, to take some risks, but overall to make a positive change. Physicians’ dollars, co-managed by physicians, government and health authorities — that, in itself, was innovation.

Decisions of the committee are made by consensus of all partners, and each initiative needs to address three questions which we identify as a triple aim. How will this initiative improve our patients’ health? How will this initiative improve the experience of care by both the patient and the provider? How will this initiative address the per caps of the cost of care? With this focus on collaboration, consensus and quality improvement, amazing things started to happen.

Let’s start with primary care. The GP Services Committee created incentives so that GPs would be compensated for treating patients with more complex chronic conditions, including mental health and substance abuse and end-of-life challenges. This allowed them to spend more time with these patients.

We also created supports for physicians that benefit patients, such as training supports so that family doctors had better skills and tools to assess and treat these complicated patients, and practice supports, teaching them practice efficiencies and how to capture the power and efficiency of the computerized electronic medical records. And we have created maternity care networks and hospital in-patient care networks, improving patient care and making these aspects of practice much more sustainable.

As a result, family medicine has become much more appealing to medical students. From a 2003 low, when only 23 percent of graduates chose family medicine, this year in 2015, 40 percent of UBC graduates did so.

We also created divisions of family practice. These are community-based groups of physicians working collaboratively with the health authorities and Ministry of Health partners — and in many cases including municipal governments — to work at the grass roots to address community medical needs. Over the last six years we have created 34 divisions of family practice in British Columbia, covering 220 communities around the province and 4,700 physician members. And 95 percent of family physicians in the province have access to a divisional support.

Divisions are just now starting to roll out their programs under the GP for Me, a joint government and Doctors of B.C. initiative that I’m sure you’ve heard of. It helps British Columbians who don’t have a family doctor and want one, to get one.

One of the major themes emerging from that initiative is the growth of team-based, multidisciplinary care, something I know this committee is particularly interested in. Team-based care is collaboration in action on the front lines of medicine. We have team-based care in B.C.

In Chilliwack, division physicians work with seven nurse practitioners. They do outreach work, residential care, youth services and run a primary care clinic together. In the Fraser northwest division, two nurse practitioners provide primary care for frail homebound patients. Also, a nurse practitioner, in a team led by doctors, operates a clinic that supports the health needs of the South Asian population. We are going to see more of these team-based practices emerging through the GP for Me.

Some divisions are bringing nurse practitioners right into the organizations as associate members to incorporate them in the planning and the decision-making phase of the initiatives. Some divisions are partnering with community pharmacists for collaborative medication renewal and reviews. This Friday our association is meeting with the ambulance paramedics association to develop linkages between their rural community paramedics program and rural primary care.

Our organization is supportive of the general direction outlined in the Ministry of Health’s policy papers towards expansion of team-based care. It is good for patients. It’s good for sustainability of the system, and it makes the best use of our resources. However, we do have some areas of concern.

First, the Ministry of Health policy paper is vague on details of how we move from our current system to the proposed future, and the devil is often in the details.

Second, it is essential that government dedicates transitional funding to help make this change. It isn’t feasible
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to expect us to close our offices one evening and open in a new place or a new style of practice the very next morning. This kind of a change, as we have seen in other provinces, cannot come without financial support for engagement, training and transitional costs. Overall system costs will be reduced in the long run, but funds are needed to get the new system up and running so that it works. As I found out personally, renovations always cost.

Third, we would like to see funding models become more flexible to accommodate variations in a community’s health needs. Fee-for-service is still the main payment system in our province, and for many reasons, it is often the most efficient and cost-effective, but it doesn’t always work well in areas of lower volume of services, as one sees in smaller or more rural communities, or with more complicated, time-intensive patient populations such as the aged, the multiply comorbid or those with issues related to mental health or substance abuse.

Moreover, many younger physicians are leaning toward different payment mechanisms with a team-based setting. We believe it’s important to allow for a range of payment options, a range of payment methods with flexibility for different models based on the needs of the community and the specific clinic.

Fourth, team-based care is about medical professionals working side by side. It works, and it can work well, but we do believe that there needs to be a most responsible practitioner, who is designated and ultimately responsible for that patient’s care. In most cases, that is the physician.

Research robustly shows that an ongoing or longitudinal relationship with a family doctor results in better outcomes at significantly lower cost. Public surveys also consistently show that physicians are the most trusted health care providers. We will work side by side with other health care professionals — absolutely — to everyone’s full scope of practice — absolutely. But a patient needs to know that their physician is the clinical team leader with the ultimate responsibility for their care.

Fifth, we desperately, desperately need information technology infrastructure that allows the secure sharing of a patient’s clinical information across multidisciplinary team members and across different locations. Currently, different groups of physicians can’t interconnect and communicate. Currently, community physicians and hospitals cannot send messages, cannot communicate clinical information with each other via electronic medical records.

That isn’t workable. It’s not workable now. It doesn’t allow coordinated care. If it doesn’t work today, it’s certainly not going to work in a future team-based system.

Finally, I applaud government for using the health care policy papers as a vehicle for engagement and discussion. We have a history of success with our collaborative programs, so let us continue to build on this through ongoing consultation and partnership as we move into the future.

We also have a collaborative committee, called the Joint Standing Committee on Rural Issues, more easily referred to as JSC, comprised of physicians and government representatives working collaboratively. It has done excellent work with rural retention programs, locum programs and other initiatives that encourage doctors to practise in rural settings.

But how do we draw physicians to rural communities and encourage them to stay? In 2008 the JSC looked into this, and they found out the following: that physicians primarily consider non-financial factors first.

First and foremost is what we call the fear factor. How will I cope with all the variety of demands for medical skills: delivering a baby by C-section, treating major trauma or opening a patient’s throat to start an airway and then ventilating them?

Also, they ask: is the community family-friendly — good schools, neighbourhoods? Is it a safe, strong community? Can it provide me and my family with access to the pastimes and the pursuits that we love?

They’re also looking for more flexible schedules than physicians have had in the past — a more flexible workload, more flexible work schedules. They want the ability to easily access clinical backup in times of crisis and access to continuing professional development skills and tools.

Our collaborative programs have provided a strong foundation for a resilient primary and community care delivery system in models across the province in rural communities.

Moving forward, key elements are: first, enhanced exposure of medical students to rural medicine. One of the most important shifts we’ve seen in the last few years, and one that we heartily support and applaud, has been the University of B.C.’s new programs that do precisely this. They expose medical students to the benefits of rural practice, and that reduces or even removes that fear factor I mentioned above. It’s working. Many students with this experience have indeed returned to practise in a rural area.

Second, enhance the usage of information technology, such as telemedicine, not to replace a relationship with your family doctor but to enhance and expand that relationship. IT can facilitate patient care over a distance by removing the requirement of face-to-face contact. This would reduce the need for travel and would capture the efficiencies of non-face-to-face contact, shown in other countries. This, in turn, could dramatically expand the umbrella of care.

In the short time that I’ve been in this room, you were talking about end-of-life issues in rural communities. You can easily see how information technology can expand the umbrella of care to better provide for those rural communities.

IT can also enable vital backup for the rural doctor when needed, through telephone or video conferencing access to advice and consultations, and it can allow easier
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access for them to professional development and training.

Third, we need more flexible models of care in the rural areas. As an example, let’s throw out a rotating doctor, in which a small number of physicians have a home base elsewhere but rotate into a rural or remote community, in turn, and continue to provide non-face-to-face care between times.

Fourth, we need continued collaboration between the physicians, government, health authorities and local communities to coordinate efforts to recruit and retain rural doctors and provide a blend of incentives and supports. And foremost — just to deliberately repeat myself — I’m again referencing the need for ongoing collaboration by all parties, from the medical schools to the professional associations to governments at both provincial and municipal levels. This has been the sea change that has been occurring in British Columbia’s medical care system over the last decade, and it needs to continue.

In conclusion, while health care will always demand innovation and effective funding, there is evidence to show that B.C. is making excellent progress. The rate of growth in health care spending is slowing down significantly. After years of frightening 7 percent to 9 percent annual increases, the annual increase is now down to an almost respectable, almost sustainable, 2.6 percent.

B.C. has some of the best health care indicators in the country, such as the best cancer survival rates, the lowest maternity mortality rates, the lowest rates of avoidable hospital admission and the longest lifespans.

Our hope is that, moving forward, the foundation of positive change engendered by our collaborative programs with government, health authorities and other partners will expand throughout the system and will be embraced by other health care professions. It’s good for patients, it’s good for medical professionals, and it’s good for the health care system.

L. Larson (Chair): Thank you, Dr. Cavers. That was really excellent. I’m going to pull rank and get to ask the first question here.

I’m going to switch straight to end of life. We have seen quite a resurgence in people across Canada, across the country, with the right-to-die initiatives, or along that line. I’m wondering if the reason that that has become such a popular, if I can say that, option is because we are not making people comfortable enough in their final years that they want to continue for a little bit longer. In other words, we’re doing a poor job of keeping them pain-free or in their own homes, or whatever, that it might be that causes them to think: “I would be better off dead.” I would like your opinion on that.

Also, how open are the doctors now to moving more of the things towards pharmacists and other health professionals that they traditionally always did?

B. Cavers: Part of the end-of-life strategy has to include equitable access to a very robust palliative care system. That is an absolute. We have to do it. Are we doing enough right now? No. I think we can do better. I think the population needs that. Are we doing some? Yes. Is there an appetite to do more? Absolutely.

You can see how we can improve the palliative care — pain control, symptom management. That would obviate the need for some end-of-life issues in the future. We can use information technology. We can use video conferencing. We can have expert physicians located across the street, providing advice and care to somebody in a very rural community. We can do that. The GP Services has had a collaborative practice support module brought out — it’s been well attended by physicians — on end-of-life issues, including palliative care. We need to keep on going.

L. Larson (Chair): The other one was doctors letting go of some of the things and allowing pharmacists, etc., to….

B. Cavers: We have 12,000 members across the province, and I would have to say that the attitude towards that is across the spectrum. But I think right now this is the most opportune time for our professions to start working together.

We have a perfect storm. We have 42 to 43 percent of the province’s total budget going towards health care, and I’m saying it’s an almost respectable 2.5 percent. If you do 2.5 percent over ten years, that gets pretty scary.

We need to actually use different professionals to the full scope of practice and work out: how do we work together? There are things that I don’t need to do as a physician. To be honest, there are things I don’t want to do as a physician. We can work together.

We need to move the idea of team-based care well out from where we’re now standing in terms of nurse practitioners. Now, I’m sorry. We need to include nurse practitioners. We need to include nurses. We need to include pharmacists. We need to include social workers and community workers. We have to start looking at the idea of patient navigators through the system. I mentioned the community paramedic program. That’s now in the ambulance paramedic contract, and we’re meeting with them because they have skills, and they can assist physicians and health care teams in the rural areas.

J. Darcy (Deputy Chair): It’s impossible to do justice to the questions that we might have in a short time. I wonder if you could speak to the issue of barriers to integrating other health care professionals into team-based care.
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You said not just nurse practitioners. I’ll use an example, just because it’s a fresh one. The nurse practitioners have indicated that they receive about a call a week from family physicians saying: “We would like to integrate a nurse practitioner into our practice,” for example — and you’ve referred to other health providers as well — “but there are real barriers as far as the billing system.”

Sometimes what develops is what I’m sure you’re familiar with, known as shadow billing, which is not an approved practice but is something that people move to out of the desire to build more team-based care. I wonder if you could speak about what the barriers are — regarding billing, regarding funding models — to building more robust, team-based care.

B. Cavers: Let me start at the upper stratosphere and work down. One of the barriers is that if you get health care professionals discussing philosophically the idea of working in team-based care, there are all sorts of barriers philosophically that come up.

When you actually get down to the grass roots, into different areas that are doing it, it becomes the Nike solution, which is: “Just do it.” But at that level there are other barriers, as well, that you’re relating to.

Right now for a physician to be compensated under a fee-for-service system, the physician has to actually interact with the patient eyeball to eyeball. That is not reasonable in team-based care. I shouldn’t, as a physician, have to be going to a room to double-check what another team member is doing to their scope of practice.

The other aspect is that I am a physician who has leased the space. I pay rent. I pay overhead in my space. So if I have another health care provider that comes in, possibly even funded by the health authority, I am still faced with the barrier that if I’m not using those rooms, I’m still paying for those rooms.

We need to address the issue of covering physician overhead — or covering overhead, whoever has it. I don’t care who’s paying it. The overhead has to be covered — and the ability for the person to be paid or some compensation for team professionals to see patients. Absolutely. We need to do that this week.

M. Stilwell: My questions are a little more granular around distribution of physicians. Obviously, to do any of the things you’ve talked about, we need to have the physicians where we need them.

Many people have speculated about the factors and success of different incentives to get physicians to stay in more rural-remote areas. Some people think it’s where you go to medical school. I think it’s where you do your residency.

You have said many students go rural after they spend time with you. Probably all of these things have some factors, but the question is: how are we really doing?

I am told — and perhaps you can correct me if this is wrong — that UBC actually does not keep track of where its graduates go, so we really don’t know. It seems to me that the BCMA would be in a position to have a lot of data and be able to collect that kind of data.

I would just like to make a plea that a lot of the manpower planning does not seem to be based on meaningful data, so I’m interested in what you have to say about that.

The second thing. I am delighted that more people are going into family practice. I think the unemployment rates of specialists help, and I am not suggesting that’s necessarily a bad thing. I’m not a family physician; I’m a radiologist. But in my experience, some of the best specialists are people who’ve practised family medicine.

In fact, there used to be opportunities for re-entry, which no longer exist. I am given to understand that some provinces are going to use return of service as a criterion for allowing people into the very sought-after specialties, and I am wondering if the BCMA has talked about that, thought about that. In other words, somebody who does a family practice residency practises three years in a rural-remote area and decides that they really do want to be a plastic surgeon or a dermatologist. They have made a “public service” by going to places they’re needed.

Have you had any discussions around that — and the issue of re-entry, in general, for unemployed specialists? We know there are unemployed specialists, but there is no way for them to be trained to be family physicians or so-called general practitioners. I’m wondering if the BCMA is talking about that.

B. Cavers: First of all, the UBC and the increase of medical students in that area. Yes, we also would like more granular information on where those students come from, what they do when they graduate, where they do their residencies and what happens to them afterwards.

I agree. Our association agrees. We’re trying to get that data. We’re working with UBC. There’s more to do there. I think we can do a much better job, and I think it will certainly help our planning.

UBC has done a very good job in identifying that students who come from a rural area, who had experience growing up in a rural area, are more likely to return to a rural area. Also, during the training, if students are exposed to practice in a rural area and not downtown Vancouver alone, they’re more likely to return. They’ve been having some early successes, and they are tracking that.
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The re-entry places. There are still, although I think I’m going to date myself and….

I come from the era of a rotating internship. Everybody did a rotating internship. All those students came out with a basic experience in surgery, medicine, anaesthesia, emergency, obstetrics, etc. We had a common history and a common understanding of what a family doctor did.

Now we have what I’m going to say…. I’m going to step off script. We have a ridiculous system. Medical students are required to start channeling their electives in third year in order to be successful in the CaRMS match at graduation. In third year medical students haven’t had a scintilla of clinical experience to make an informed decision. That’s absolutely ludicrous.

The second one is: what happens if you get these students with the best of intentions, they make a decision, they go out, they work really hard, and they hate it? We don’t have the re-entry things to allow students to say: “Oops. I want to go back in and do something else.”

Now, the interesting thing is that it works against family practice more than against some specialties because it’s a bit easier to get into a family practice residency on re-entry. Students commonly say: “I think I better do my plastic surgery residency because it will be a bit easier to get into family practice than the reverse.” We need to fix this.

M. Stilwell: I won’t monopolize, but I think this is a situation across Canada that is a disaster. In fact, the incentive for medical students is not to be a good generalist because you cannot get matched if you haven’t done electives. Some specialties even stipulate that you cannot apply in the match if you have not done an elective there. It encourages people to be very, very narrow to the detriment of patients and the distribution of physicians. Thank you.

D. Plecas: Thank you, Dr. Cavers. I want to stand up and cheer. You’re very, very exciting to listen to.

You mentioned at the beginning that if we want to remember one word, it’s “being collaborative.” Now, it seems to me that one thing which is fundamental to that — to effective and efficient collaboration — is good IT infrastructure. You mentioned that that’s one of the things that we desperately need. What is the challenge there? What is making this so difficult to do?

B. Cavers: When I was referring to collaboration, I was referring to the relationships that we needed to develop across the boundaries between government health authorities, profession, in talking about the problems and how we jointly get to a solution.

In terms of the IT, we’re faced with a tower of babel. I have a very, very powerful electronic medical record computerized system in my office. I can identify different patient groups. I can identify union groups — A plus B. I can identify intersection groups of people only with diabetes and heart failure. I can identify people around certain medications.

I can do whatever you want, but when it comes to sending a referral for my patient to a specialist, when it comes to sending my patient into the hospital, do you know what I do? I type up a referral letter, I print it out, and then I fax it in. What does the specialist do? That specialist gets the fax, and they scan it into their EMR.

I received a telephone call at 12:30 at night from a colleague of mine, Dr. Jeff Harries in Penticton. I know he will not mind my mentioning his name. He said: “I’m phoning you because you’ve outed yourself. You have just sent me an e-mail.”

I want to tell you what happened. You know I’ve been running the community of practice — it’s in Penticton — in which Jeff managed to get people onto the same EMR so that they could communicate. He said: “Well, I sent a patient of mine to a specialist today, and that patient saw the specialist.” “Okay, and you’re phoning me after midnight?”

“Well, I know that, because the patient saw the specialist at one o’clock, and I got the consultation report before I left at 4:30. In the report was a new diagnosis, and there were tasks assigned: these lab tests should be ordered in two weeks, follow-up done in three months. All I had to do was click on ‘Accept the medication’ and ‘Accept the tasks.’ Now I’ve got computerized reminders.” That’s the holy grail.

What’s happening now? That functionality, that ability for me to share information when somebody goes into the hospital that they have a deathly allergy to penicillin and they haven’t had a good reaction before…. That should be vendor-agnostic. It shouldn’t depend on whether I’m on the same software company as the other doctor. Right now what I refer to as the Rosetta stone hasn’t been built. We are actually testing the interconnectivity between two software companies available in B.C., and we’re testing it in Saskatchewan.

L. Larson (Chair): In the interests of time and the fact that we’ve already kind of got ourselves a whole month’s worth of work coming up, I’ll go on to Richard.

R. Lee: A very short question. You mentioned about how to integrate an IT system. But now I see a doctor spend time more time doing the record, typing up the report on a patient. Do you think this is…? How do you improve the system so that a doctor will spend more time on the patient instead of doing data entry?

B. Cavers: Very good question. First of all, I want to say with some pride that I don’t type. I use voice recognition software, and I dictate. But what you’re identifying is a real issue in that physicians are feeling that managing a software program is taking time away from spending with a patient. Actually, you have to be very careful in an interaction with a patient because you develop trust by eye-to-eye contact and non-verbal communication. You’re not going to get that trust if you’ve got your back to the patient or you’re not even making eye contact.

There are actually training modules now saying…. How do you maintain the interpersonal relationship when you’re actually looking at the computer? How do you prevent physicians from having to spend time on data entry? How do you prevent the situation that’s currently in the emergency departments in the States in which stenographers walk around with the doctor?

You make the programs sensible, so you actually include the clinical management before you roll out some grand idea that hasn’t really been tested in terms of validity of clinical use. You make it user-friendly, you involve the doctors who are actually going to use it, and — I’m going to be very inflammatory now — you put the clinical providers in control of the IT.

Really, which is the tail, and which is the dog? You put the people who are going to need the IT in charge to say what it is they need, how they need it to be presented, and then the IT department, ministry or whatever should actually comply with those clinical requirements. We shouldn’t have to use something that the guy in Future Shop thought would be a good idea.

D. Bing: Thanks for your presentation. I was at a health conference in San Francisco a year ago, and they were talking about their collaborative models. They were talking, in one area, about psychiatry and how there’s a shortage of psychiatrists. What they’ve done down there is made the psychiatrist the team leader. He would have a team of physicians who are interested in psychiatry — RNs, psychiatric nurses, social workers. He basically was the team leader, and they were all on salary.

I’m just thinking that maybe this is the way that we need to think instead of this fee-for-service model and people having to work to pay their overheads, this sort of thing. They know exactly what it is they’re getting for that job. What do you think of that?

B. Cavers: I’ve got a committee for you when you finish doing the first month’s work that we’ve got.

In B.C. this is called conversion to evolution. In British Columbia the GP Services Committee has developed practice modules on adult mental health issues, and now the most recent collaborative is on child and youth mental health and substance abuse.

Those collaborative systems are getting together to remove these artificial barriers in payment modalities in the Ministry of Health, Ministry of Children and Family Development and Ministry of Education. They’re trying to orient the care around the patient to what makes sense.

A few things. You can have a distributive model. So you have physicians, you have psychiatric nurses, you have social workers with enhanced skills, and you have one person who’s a touchstone. That’s, I think, what you’re referring to — how a person can distribute his or her knowledge to the rest of the team, have them do work and know when to come back and say: “Okay, I’m running across a problem here.”

We’re doing that here in B.C. We’re a little bit behind California, but we’re going to catch up and pass them soon.

B. Routley: In the discussion about multidisciplinary teams you mentioned that some divisions have already partnered with community pharmacists, and I think you said paramedics. I know paramedics and pharmacists that have said they could be a lot more useful to the medical system than they are currently — that there are things that happen in transition to the hospital, where they’re going to see a doctor and get the ultimate care.

They feel frustrated that they’re not able to do what they could possibly do to enhance a patient’s life, which is really, I think, what the whole thing is all about. I just wondered what your comments were about including both pharmacists and paramedics and doing a lot more that could be shared throughout the medical system.

B. Cavers: So the pharmacists. A few years ago there was an initiative called medication management review that was brought out by pharmaceutical services division. It was well-intentioned, but there was a lack of that word I want you to remember: collaboration.

What happened was it was rolled out to pharmacists, and pharmacists unilaterally, without a physician’s know-
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ledge, started doing medication reviews on patients. Doctors started getting faxes saying: “We’ve talked to the patient. We think you should change these medications.” Well, that doesn’t work.

The game afoot right now is meeting with pharmaceutical services division, which is very open to the idea of having a collaborative, cooperative engagement between physicians and pharmacists to do medication reviews on the patients that are on multiple medications or are high-risk patients. You would be impressed, but not favourably impressed, with the number of older people who are on more than six medications. Invariably, there are going to be side effects.

Can we use pharmacists to a better scope of practice? You’re darn right we can. But it needs to be in a process…. In the best-case scenario, bring the pharmacists doing those processes and the physicians on the other end into the same room — the eyeball test, the developing of relationships and trust — and it’ll happen.

The community paramedics had a contract signed in 2014 providing funding for the community paramedics program. Excellent idea. There was no linkage built in under that contract for how they’re going to interact with physicians.

To give them credit, the B.C. Ambulance Paramedics came to the Doctors of B.C. and asked for a meeting with us. On Friday, I think it’s at 11:30, we are meeting with members of their executive and the co-chair of the Joint Standing Committee on Rural Issues to say: these guys have skills, the other guys have a need, and the patients certainly have a need, so how do you actually bring those two together in a system that works well for the patient without internecine rivalry and without undue consequences? We’re working on that.

While it is a very challenging time in medicine right now, it’s really exciting.

J. Rice: I know we’re over time. I live in a rural area where recruitment and retention is an issue. I was looking at the two non-financial factors that you say are challenges — the fear factor about all the things you’re going to have to do and, too, about the community. I know, for example, in one community right now there’s a challenge, the school board between the physicians, because there’s a criticism of the quality of education provided in some of the rural communities.

I guess my question is: do you feel that there’s a role municipalities or districts have to play in the recruitment and retention of physicians? How do you see overcoming those obstacles? It’s not uncommon that the resources or the recreational opportunities or the educational opportunities are often lacking in faraway places.

B. Cavers: Communities participating in the recruitment? Absolutely. Municipal governments? Absolutely, they’re a player. In real life, I spend part of my time not being a doctor, and I want to know that my community is safe, is supporting me and has access to the things that I need and love. And can they play a part? Absolutely.

To give you some good news, the municipalities are already playing a part. Health Match B.C. has engaged with them. There was a summit about a month ago on recruitment and retention. It was held just around the airport, near YVR. Multiple players were there, including members from UBCM.

J. Rice: One last question to follow up. In some of these communities, though, the educational opportunities for physicians’ children are lacking or employment opportunities for spouses are lacking. Yet I find that those communities are the communities that actually have greater need — high diabetes, the social determinants of health issues. So how do we address the fact that these places are unattractive to physicians but yet are the places that have the greatest need for improved medical services?

B. Cavers: Yeah, that’s a tough nut to crack. One of the models that has been thrown out now in some of these communities is the one I refer to as the rotating doctor idea. Perhaps you’ve got four doctors that live in a different place that they prefer to inhabit for their families. Every four weeks a doctor goes in and provides face-to-face services, and the other three doctors can provide non-face-to-face services and follow-up to their patients. “How’s your blood pressure? How’s the medication working?” etc. Or “Sorry, John. I think you need to be seen. Would you please go in and see Dr. Stilwell.” That sort of thing.

B. Cavers: Not enough. It also addresses the issue that some of the younger physicians don’t necessarily want to be in a rural community because they’re afraid of being tapped on the shoulder 60 hours a week. We have to be aware of what the younger generation is wanting and wanting to provide, and we have to work with that.

L. Larson (Chair): Thank you very much, Dr. Cavers. That’s fascinating to listen to, interesting. You’ve given us so much work. I don’t think we’re ever going to get through it, so we may have to have you back to see how we’re doing with the workload that you’ve given us.

L. Larson (Chair): And the committee appointments that you’ve identified as well, which are absolutely crucial.

Very good to see there is such a lot of enthusiasm and willingness on the part of doctors to make changes, to move forward, to do things. I guess if we can get the IT thing sorted out, that might help considerably too. Certainly, when you were talking about rotating doctors, I think the IT would play a huge role in that, in that there’s a way to communicate with those people when the doctor is no longer there that is more of a face-to-face type of idea as well.

B. Cavers: There is an approach by the Institute for Healthcare Improvement called the Triple Aim that I referenced in the papers. If you’re not aware of it, it addresses three aspects of care. One is the per-capita cost of care, one is the population health, and the third aspect is the experience of care by the patient. British Columbia adopted that but did a B.C. modification so that it’s the experience of care by both the patient and the provider.

The Triple Aim has been officially adopted by our collaborative committees and by our association as a lens for forming initiatives and also as a framework for evaluation, because evaluation is absolutely part and parcel of what we’re doing now.

L. Larson (Chair): We will take a two-minute break to allow our guests to leave, and then we will wrap up the committee.

L. Larson (Chair): All right. We’re back for just a few minutes. I just wanted to touch base with everybody about Friday morning to make sure that as many of you as…. We need a quorum, obviously. We have a full morning in Vancouver. Are there any questions about that at all or anyone that has any serious issues?

M. Stilwell: I will have to go a little bit in and out, but I will be there at 8:30 and 1.

D. Plecas: I have a thing to do on health at SFU in the same building. I need a break in there for an hour. So I will have to go and come back.

S. Hammell: Has anyone kind of computed the amount of time? For me, I don’t stay down in Vancouver. That’s leaving at least at quarter after seven, which means getting up pretty close to….

L. Larson (Chair): I understand. It does the same for…. But don’t forget there are some of us who don’t even live down here. I have to go to Vancouver. I have to stay overnight. I have to get up at 6 a.m. and ride a train downtown in order to get to this meeting too. I don’t even get to go home until Friday night. I think there are a lot of people that….

It is a stretch, and we won’t do it too often if we can help it. But we really need to do it this time. There are a lot of us that aren’t even living on the Lower Mainland, let alone close enough to get to it.

J. Darcy (Deputy Chair): Do we have a confirmed list of presenters for Friday morning?

L. Larson (Chair): Yes, we do. I think Susan has sent out the agenda to everybody.

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Chair:	Linda Larson (Boundary-Similkameen 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)
	Sue Hammell (Surrey–Green Timbers NDP)
	Richard T. Lee (Burnaby North BC Liberal)
	Dr. Darryl Plecas (Abbotsford South BC Liberal)
	Jennifer Rice (North Coast NDP)
	Bill Routley (Cowichan Valley NDP)
	Dr. Moira Stilwell (Vancouver-Langara BC Liberal)
Clerk:	Susan Sourial

REPORT OF PROCEEDINGS(Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH