Health — Issue No. 26 — Tuesday, July 5, 2016 (HTML)

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

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

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
Presentations	383
E. Palmantier
D. McLeod
S. Maurice
S. Kupka
K. Evans
H. Crowley
J. Hogan
M. MacLeod
L. Zimmer
M. Krause

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

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

This summer, we launched an additional call for submissions, and we are looking for new or updated information on the following three questions: how can we improve health and health care services in rural British Columbia, what long-term solutions can address the challenges of recruitment and retention of health care professionals in rural British Columbia, how can we create a cost-effective system of primary and community care built around interdisciplinary teams, and how can we enhance the effectiveness of addiction recovery programs?

As part of its consultation, the committee is holding public hearings in Victoria, Prince George, Kamloops and Vancouver.

British Columbians are also invited to participate by sending a written audio or video submission. You can make a submission or learn more about the consultation or the committee by visiting the website at www.leg.bc.ca/cmt/health. The deadline for submissions is Friday, July 29, 2016.

Thank you to those in attendance today for participating in our consultation. All the input we receive will be carefully considered by the committee as it prepares a final report to the Legislative Assembly.

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

I’d like to ask the members of the committee to introduce themselves, starting with our Deputy Chair, to my left.

J. Darcy (Deputy Chair): Judy Darcy, Deputy Chair of the committee and MLA for New Westminster.

S. Hammell: Sue Hammell. I’m the MLA for Surrey–Green Timbers and the critic for mental health and addictions.

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

D. Plecas: Hi. I’m Darryl Plecas. I’m the MLA for Abbotsford South and the parliamentary secretary responsible for seniors and the parliamentary secretary responsible for access.

M. Dalton: Good morning. I’m Marc Dalton. I’m the MLA for Maple Ridge–Mission.

D. Barnett: I’m Donna Barnett. I’m the MLA for the Cariboo-Chilcotin and Parliamentary Secretary to the Minister of Forests, Lands and Natural Resources for Rural Development.

L. Larson (Chair): Also assisting the committee today are Susan and Stephanie, who are making all the noise at the back, from the Parliamentary Committees Office. Mike and Alexandrea from Hansard Services are here to record the proceedings, as mentioned.

With that, I’d like to turn our floor over to our first presenters. You have 15 minutes to kind of give us an overview of what you do and then 15 minutes for us to ask you some questions. And if you would introduce who you have with you, too, Emma. Thank you.

E. Palmantier: Good morning, everyone. First of all, I would like to acknowledge the Lheidli territory where we’re conducting our business.

My name is Emma Palmantier. I’m the chair of the Northern B.C. HIV coalition. Beside me is Lisa Alec. She is the admin assistant/educator.

I’m very pleased that I got invited to present this morning. I’ve been really, seriously thinking about my presentation, because I represent those that do not have a voice and that are silenced.

I’m just going to give a brief overview of who we are and then go into our presentation. I have a PowerPoint that will introduce who we are.

How did we get here? Sixty chiefs and health leads, HIV organizations and health professionals met for two
[ Page 384 ]
days in the spring of 2005, in June, to discuss the rising number of HIV/AIDS cases in aboriginal communities. The chiefs signed a declaration for action on HIV/AIDS, which created the Aboriginal HIV Task Force, with specific inclusion of youth representation.

This was when the task force was established. A strategic plan was developed and discussed with communities during the regional consultation. Later the chiefs endorsed our workplan and changed our name to the Northern B.C. First Nations HIV Coalition in 2012. Our mandate came from the 60 chiefs in the north.

As I mentioned, I am the chair of the coalition. I’m the key negotiator and manager, and I’ve been with the coalition for ten years. I have been a politician, I was the Chief for Lake Babine for three terms, and I was also Vice-Chief of the Carrier-Sekani Tribal Council back in the days. I sit on various provincial and regional HIV/AIDS committees. I am president of the Prince George Native Friendship Centre, and I’m the chair and also the B.C. representative of the national organization, which is the Canadian Aboriginal AIDS Network. So I represent the national too.

The staff that we have. There are just three of us. Colette Plasway is the program coordinator, and she assists me with the overall program management, including planning, development of budgets, reports, publications and contracts. She has worked with us for eight years. She previously sat on Renewing Our Response. She completed part of her BCom degree at the University of Northern B.C., and she’s worked with Northern Health for five years.

Then Lisa is the assistant educator trainee. She completed a course in business technology, has her administrative assistant certificate, and brings with her many years of experience in the areas of administration and finance. She is currently training and working alongside the educator to provide culture-specific HIV education to the communities. She’s also got her culinary arts — a chef and a food enthusiast. She provides valuable information on healthy cooking, eating and nutrition.

Our vision is that the aboriginal people of B.C. will achieve and maintain strong, healthy, fulfilling lives free of HIV/AIDS and related issues. Our mission is that the coalition will support meaningful, lasting efforts for aboriginal communities in northern B.C. to address HIV/AIDS and related issues in a culturally relevant manner. The strategic directions are leadership and political action; education and awareness; prevention and harm reduction; treatment and palliative care. These are the three strategic directions.

With leadership and political action, we get ongoing support by elected and traditional community leaders. Elders and youth will encourage a strong political voice that will move all levels of government to support HIV programs, to ensure that networks and partnerships are maintained and to bring local and northern issues into the northern and national efforts that address HIV and related issues.

As the chair, I always provide updated reports to the chiefs and health directors at the regional caucus and northern chiefs meeting on an annual basis. So the chiefs do get updates on the work that we do, and they are given a chance to give us any directions or resolutions on the work that we do.

Part of our mandate is the education and awareness. We provide awareness of HIV risk prevention and treatment across all aboriginal communities to support and collaborate with current education and prevention programs, such as Chee Mamuk, which is a provincial organization that has a mandate at the provincial level.

Prevention, harm reduction, treatment and palliative; to collaborate and support existing harm-reduction organization services that acknowledge and respect the vibrant culture of aboriginal people; to identify gaps in harm-reduction services.

Prevention, harm reduction, treatment and palliative care: to ensure there’s adequate, accessible and safe services for individuals and their families despite the geographical, economic and other barriers.

This is the region that we cover. As you can see, the north is such a big, vast geographical area. We go as far as Quesnel and to the Treaty 8 area — Fort St. John, Fort Nelson — to the border of Yukon and as far as Haida Gwaii. We cover 54 First Nations communities. There are fly-in communities, isolated, rural. These are all the different communities that we work with and represent.

These are the coalition members. We’re unique in B.C. and across Canada, I’m told. The coalition members consist of leaders, elders, youth and people that are living with HIV and AIDS, representation from agency and health service providers. We have federal, provincial, regional, local government members that are on the committee. We have reps from Northern Health, representation from the First Nations Health Authority. We have RCMP, and we have Ministry of Children and Family Development and other health professionals. We meet twice a year.

These are the people that are living with HIV that are in the coalition. They’re from the different communities in the north. They provide directions to us, and really, they are the reasons why the chiefs mandate us to do this work. There are many out in the communities that have been diagnosed, and we’re reaching out to them.

What we do. We provide education through workshops, information booths. When the communities invite us to health fairs, the staff attend and provide information booths, which is really successful. A lot of the members, the young people, attend. Our booth seems to be the most popular, because the staff really network with the communities. At these booths, the people feel so comfortable in sharing their challenges — what they face, their
[ Page 385 ]
relatives, people that are diagnosed with hep C and HIV. It’s really one of the most successful works that we do — providing a booth there.

Then we did a community readiness assessment. I’ve provided a copy of the report. This is the voice of our people, which identifies the gaps and barriers. I’ve really condensed it, trying to put it into this 15-minute presentation, but I hope you will have a chance to review the report.

Provide assistance to health care workers, our front-line workers. As the chair, I’m always contacted by people that are afraid to network with their own people in the communities because of confidentiality. A lot of people are really afraid right now to disclose. I’m the key person, so I advocate for them, and we have Dr. Hamour, who is a specialized doctor here in Prince George that I collaborate with.

I mentioned that the coalition meets twice a year. We get input from the province. This is our current project. We do community training, as I mentioned. We just finished the healthy sexuality toolkit. It took a year to do this. We did 54 kits. The next step will be to provide training — train-the-trainers for the health directors and front-line workers to provide workshops in their own communities. This was a very expensive toolkit that we did.

Then we did the community readiness assessment. I mentioned the information booth. We also launched a youth video project. We’re working with CKPG, and the video should be finished by the end of August.

Our valued partners are…. Carrier-Sekani is our host agency. Northern Health, First Nations Health Authority, the Ministry of Health, Chee Mamuk, the Red Road society, the friendship centre, Public Health Agency, Positive Living North, RCMP, Trans Canada and the national organizations. These are the people that we access funding from or work in partnership with. That kind of gives you an overview.

Going to my presentation, I gave you five questions. The first one: “How can we improve health care services in rural British Columbia?” Going back to the community assessment we did, what the people told us is: “To plan and build three treatment services and care facilities in the north.” The locations identified were in Terrace, Prince George and Fort St. John. They can be for general treatment, palliative care and include HIV services as part of their program. This would increase access to service and community support for aboriginal people.

The response from the citizens of the north is that too often their loved ones are forced to move to Vancouver for quality health care services and treatment for those that are diagnosed with HIV and AIDS. This has really been identified as a need, because a lot of the people, as I mentioned, have to move to Vancouver, because that’s the nearest treatment service, like the Dr. Peter Centre. We don’t really have any in the north, so this was really identified: “To provide more physicians and nurses specialized in HIV care.”

There were some communities that identified racism and discrimination from local health units for HIV services. Again, this would increase access to services. As mentioned, the only doctor that we have in Prince George is Dr. Hamour. In Smithers, it was Dr. Daphne. But I understand there are two more doctors. There are just only three specialized doctors.

“To make culturally sensitive training mandatory for northern health professionals.” There’s still racism, discrimination and lack of understanding experienced by community members by the northern health professionals.

“To provide harm reduction programs for youth.” There is an increase in drugs and alcohol abuse, sexual abuse, overall abuse including gang rapes, gang rapes as bully tools, girls getting drugged and raped, teen pregnancies and youth suicide. This was really identified because, as you know, the youth population is a rapid-growing population in the First Nations community. As you’ve heard many times, there have been suicides amongst our communities.

There are also issues around mental health, disabilities such as deafness or a wide range of developmental learning issues such as fetal alcohol syndrome disorder, attention deficit disorder or attention deficit hyperactivity disorder. New policies need to be developed in some cases. Support to implement them properly is also important.

It was emphasized in our visit that they would like simplified language, such as medications, so that it is clearly understood.

Efforts to support compassionate leave, so that a caregiver can support an ailing partner or family members, are also needed.

The second question: What long-term solution can address the challenges of recruitment and retention of health care professionals in rural B.C.?

L. Larson (Chair): Excuse me, Emma. We’ve actually gone past the 15 minutes that we gave you, but we certainly want to hear what you have to say. It just means that we can’t ask you questions because there’s no time to ask you questions. So it’s up to you.

Draft and develop an orientation and training tool for health care professionals that is developed, driven and taught by knowledge care holders of the land, culture and language from the traditional territory of where health care professionals are going to be working. Work in collaboration with the First Nations education department to recruit local First Nations students in post-secondary that can further their careers in nursing and physician.
[ Page 386 ]

How can we create a cost-effective system of primary and community care built around an interdisciplinary team, to work in collaboration with First Nations health care professionals, to gain knowledge of individual clients’ needs and health services’ language barriers? Some have very little knowledge of managing their medicine or how it will cure and heal their symptoms.

The addiction recovery. Work in collaboration with First Nations counsellors and elders that have knowledge of how they work with those that have problems with substance abuse and other addictions. Work in collaboration with First Nations health professionals, youth and elders to design and draft a health care plan as aftercare and support for those that have completed a recovery program. Establish a local support group that can meet and work with local First Nations leaders and staff to work and collaborate with youth, elders and citizens that have problems.

I just added homelessness because, as you know, there have been a lot of homeless issues. We have people that are diagnosed with HIV. I just added it this morning. So my recommendation is to establish a housing and homelessness secretary devoted to reserve and urban aboriginal housing and homelessness issues. Reinstate and increase funding for new social housing, mortgage subsidy and the CMHC aboriginal officer programs.

L. Larson (Chair): Thank you very much. I realize it’s very difficult to get into such a short space of time the amount of work that you do. I’m going to go to Sam first and see if he has a question. Then mindful of the time, I will cut off this committee at the appropriate time.

S. Robinson: Thank you, Emma, for your very condensed presentation. I did have a chance to take a quick look at your executive summary from your project. It sounds like it was very thorough.

One of the things that you mention in the executive summary is concern about funding based on population and not on needs or remoteness. I’m just wondering if you could speak to some of the challenges of some of the communities in terms of their remoteness — what that looks like and the kinds of things that we ought to be paying attention to when we take a look at how to provide health support to remote communities in particular.

E. Palmantier: That has really been a key theme that was identified. The First Nations communities, based on population from Health Canada at the time…. Now it’s the First Nations Health Authority. Their funding formula was based on population. So no matter where the communities lived — whether it’s remote or big or large — it’s based on population.

Small communities such as…. One example is Good Hope Lake. They would only get $149 annually on HIV and AIDS program services. So what they have really recommended is to review and revise the policy based on the needs of the people, especially in an isolated community. Some, like Hartley Bay, are fly-in communities, and it’s really hard for people to provide any community-based services and programs on health issues.

S. Robinson: So there needs to be some sort of weighting or some sort of formula that takes a look at how remote you are, and there needs to be some added component to that?

E. Palmantier: Yes. We’ve brought this up with Northern Health and the First Nations Health Authority.

Certainly, there are provisions — not used very much — in the Ministry of Health funding for population needs funding.

One of the themes that you touch on in many different ways is the lack of cultural sensitivity, the need for greater education and orientation of health care professionals that are working with aboriginal communities, as well as more training in aboriginal communities for people who provide service and care.

Can you talk a little bit about: are there any such programs now? What exists now? What isn’t working? What do you think that looks like?

E. Palmantier: There is a cultural sensitivity program by Northern Health. But it’s designed by someone down south. I feel that it should be more to the north and have people that have knowledge of the territory to redesign the program, where it will be more for northern people.

Between south and north, there are a lot of different issues. My recommendation would be to review the current program and establish a committee that could — with several knowledgable people, First Nations people — design a program according to our territories.

In B.C., we have various different languages and cultures, especially in the north. I find that our language…. I’m First Nations, but when I go to communities like Haida Gwaii and Nisga’a and Tsimshian, their language is different. But our traditional practice is almost similar.

J. Darcy (Deputy Chair): Do the aboriginal support workers who are employed by Northern Health speak a variety of languages or not?
[ Page 387 ]

E. Palmantier: Some do. Some of the aboriginal liaison that I know do speak their language. We had one here that was really good. She did speak our language. She advocated for our people. She was very knowledgable. I haven’t met the new person yet.

You spoke about three facilities that you had…. Have you put in a proposal to the federal government for these three facilities — the ones in Terrace, Fort St. John and Prince George? Or are you just at the planning stage?

E. Palmantier: I was really advocating for the facility. But I am told by Northern Health that they would like me to work with the different departments that we can work in partnership with. There is a committee that has been formed, but I haven’t been contacted to work with them. I told Vanessa that I really want to work with the Northern Health staff to proceed with the facility, even the current facility — I know there’s a hospice here that our people are going to right now — to work with them.

In Terrace and Fort St. John, people keep telling me: “Emma, don’t think Prince George is the north.” Fort St. James tells me: “We’re the further north.” And then Terrace people tell me: “We’re the further north.” You have to represent the people in all these regions. I make sure that I do bring that up all the time.

D. Barnett: Would the facilities be under Northern Health? Or would they be under the First Nations Health Authority or some other department?

E. Palmantier: It is something that we will have to explore. I brought this up many times with Northern Health and the First Nations Health Authority. It’s a matter of getting everybody together to seriously look at what the people want.

L. Larson (Chair): I noticed you have a youth program where you’re trying to get a youth person in each of these communities that can make contact with people as part of your education. Are you making any progress getting youth? I know you’ve got — was it? — 54 nations out there. How many youth coordinators do you have?

Also, the other thing I was interested in is how many of your HIV/AIDS people are in the palliative stage?

E. Palmantier: There has been a number of them that are transferred to Vancouver. This past year, unfortunately, we lost two that came back from Vancouver. I know there is one in the northwest. I had worked with the community to put him into a facility. He’s somewhere in Terrace right now, I believe.

L. Larson (Chair): And the youth? How many youth have you managed to get involved in the education process?

E. Palmantier: The youth. We have youth train-the-trainers, but because of funding this past year, we had a decrease in our budget. We only had $180,000 from Northern Health, so we really had to, kind of, try and do the best we could. The youth coalition, who are representatives of the four regions in the north, really want to see youth train the trainers. We’re working on negotiating for funding for youth to train the trainers in the four regions in the north.

In the past, it has been successful. We had one in the northwest, and the outcome of that train-the-trainers Nisga’a…. The two youths that got trained planned and hosted a youth conference on HIV. We were invited, and it was very successful.

S. Hammell: Just quickly. You talk about, in particular, the kids. There’s an increase in drug and alcohol abuse. I would assume alcohol is a fairly common drug, but what are the other drugs you’re seeing?

E. Palmantier: A lot of it is marijuana and the injection drug use. There was a study that was conducted with us with the Public Health Agency — I forgot to bring that report — in cocaine and crack.

L. Larson (Chair): Thank you very much, Emma, for being here this morning. We really appreciate you. You do wonderful work with very little money, which seems to be the way of it. The less money, the more work sometimes seems to happen, but you certainly have some wonderful plans and ideas, and I hope the health authorities are listening to that and that you did get together with the First Nations Health Authority and Northern Health to move some of these projects forward.

Good morning. Welcome, Denise McLeod. We have no background information on you whatsoever, so I’d really appreciate it if you would introduce yourself and explain what your interest is here, and then move right into your presentation. I can give you a warning when you’re getting close to the 15-minute mark if you like. Welcome, and go ahead.

D. McLeod: My name is Denise McLeod, and I’m a family practitioner here in Prince George. If I can read this, it kind of tells you my background.

D. McLeod: Thank you very much for giving me this opportunity to speak at this hearing. When I initially got the invitation to talk to this committee, I thought it was a full-day event and we were just going to hobnob and have great ideas. I’m great at talking, but when you condense me down to a little 15-minute spiel it’s a little harder.

So I didn’t get any facts down. I didn’t do any major researching and presentation kind of stuff. I thought: “Well, I don’t know if that’s going to be good enough for you guys.” And then I thought: “No, maybe just the anecdotal daily life of a family doctor here with my experience would be something that might be of some interest to you.”

You see, I’m one of the foot soldiers of health care. I graduated in ’77 as a registered nurse. I practised for 12 years. I did psychiatry, surgery, burn care, critical care. And then I graduated from UBC medical school in 1991 and proceeded to do extra rural medicine training when it wasn’t necessary. I did some surgical training to prepare me to work in the north.

I practise as far as Hay River, Northwest Territories, and as far south as Revelstoke. The majority of my practice as a GP surgeon was in Burns Lake in my early days and as a family doctor in Prince George for the last 12 years. I was assistant dean of student affairs for the first five years of the northern medical program when it opened, and I presently practise as a full-service family practitioner, minus the obstetrics, here in Prince George. I am active in clinical teaching, and I am on various committees.

I’d like to start off with the second question that you posed: how to create a cost-effective system of primary care and community care built around interdisciplinary teams. I think we’re on the right track here. There’s a coalition between family doctors and the government at various levels in developing primary care homes here in Prince George. I can’t list all the studies, but we know that people with primary care physicians in a primary care home reliably fare better in health. Hospital use is down. Health outcomes are better. There’s less duplication of things like lab work and X-rays, etc.

In PG, I’m part of a pilot program for primary care homes. I work under an umbrella with designated RNs, a social worker, a mental health worker, an OT/PT and the odd dietitian if I can get her once in a while. It’s a great concept, but trying to get this off efficiently and effectively has been difficult. I see the benefits that some patients have, but the transition is slow. They are trying to do this project keeping the same budget that they have, reorganizing community care with primary care, and it’s working, but very slowly.

If we’re going to try and keep our frail and elderly people in the community, they need more support, more aides to go into the home, more OT and PT to assess to keep them out of the hospital.

I also believe the system is top-heavy in administration. This may be necessary for now as we move forward, but we should have a plan to actually have more foot soldiers than administrators drawing from the public purse.

We also need to think a bit outside the box. Can we add pharmacists to the team instead of pharmacists independently altering medications and advising individual patients on medication management? I feel this will start siloing care once again, which is what we want to get out of, and may contribute to polypharmacy, patient confusion.

The role of the nurse practitioner in the team could also be reviewed. They have valuable training. Most work as clinical specialists in hospitals or clinics. They do not practise a full scope of care unless they work in remote areas, where prescribing, assessing, diagnosing, suturing and all those things are needed. We need to review their place in the primary care home in larger communities. A team approach is always better.

If I could choose a demographic to focus health issues for long-term effects, I think I’d choose our youth. The health of our youth not only has physical implications — like their immunizations, their growth and development — but it also has social and mental implications. If we invest in our youth with health, education and opportunity, we invest in the health of our future health care users and have long-term gain.

Investment, in my eyes, isn’t just towards the children, but it’s also investing in their families — providing families the opportunity for affordable daycare so parents can work and be role models for their children. That would be inspirational.

The working poor struggle to pay for medications, rent and food while trying to build and move forward for a better life. There’s a need to promote good work ethics by example and provide opportunities. Maybe we can engage private enterprise. We need to think outside the box on this. People need jobs, they need to be
[ Page 389 ]
able to move to them, and they need to have sustainable jobs that they can count on so that they can build their family and be role models. Maybe we need to get private enterprise involved. I don’t know if that’s health care or not, but I think it is.

The second question I want to address is: how do we improve health care and health care services in rural B.C.? And what long-term solutions can address the challenges of recruitment and retention of health care professionals in rural B.C.? Again, I must say that we’re on the right track in the north. This government is starting to get it.

One of the best ways to improve health care in rural B.C. is making it accessible in rural B.C. This is being done already with the cancer treatment care for the northern people with our new B.C. Cancer Agency. We need to expand that so that cardiac care, maternity and pediatric care are available and accessible in the northern communities.

I’ve given you all a copy of the Northern Health Authority — that big yellow dot versus that little orange dot. This is what we need to take care of, and this is, I think, what you’re asking. It’s interesting that Emma also brought up the expansion and the diversity of this health authority. The Northern Health Authority is responsible for over half the geographic area of British Columbia but relies on southern B.C. and Lower Mainland for basic cardiac care management, neurological services and such.

Rural citizens should be able to access health care in the north for several reasons. There is connectivity in the north with other northern communities. Family practitioners and specialists alike appreciate the diversity in each community. There is a connection and a relationship one does not have with the Lower Mainland, although I can’t criticize the Lower Mainland. When I get my patients back, they’re awesome. They got good communication, but they just don’t get the challenges that our patients have in the north.

Travel, housing and support at local areas for a family in the north is less expensive than having to stay in the Lower Mainland or in the Interior. Transportation via air ambulance is costly and time-consuming. People are waiting two to nine days in hospital for cardiac assessment, only to be discharged after a simple angiogram or stent and sent home at the patient’s expense. It’s a very expensive trip down, and it’s an expensive and stressful trip up for the patient.

Resources for patients in the Lower Mainland are being used for patients outside the health authority. We’re not a priority for the Lower Mainland. I feel like they’re second cousins sometimes. Sometimes patients wait years for consultations for pain management, bariatric medicine and other medical services.

Do you know that our regional health hospital doesn’t have the electrical capacity to actually upgrade our operating room? We had to close down the operating room twice this year because we couldn’t have the electricity going or there was the risk of it. We need to be able to provide the same calibre of surgical interventions as the other health authorities.

As far as recruitment and retention in the north, I believe we need to focus on the generalist. The family doctor is the true generalist of medicine. In the north, I believe we are the only standing, full-practice service practitioners in B.C. We provide in-patient hospital care, maternity, palliative — to name but a few. We need to nurture that, promote that and fund that. To a large degree, this is being recognized. Family doctors in the north are proud of this, and it’s what we do best.

We continue to need to support our specialists, and I believe we need to encourage general specialists. You know, if we were going to keep a gastroenterologist, a cardiologist, a nephrologist and pay them all MOCAPs and stuff like that to be on call, that’s expensive. When I’ve got a generalist who’s actually a GI specialist with a cardiac patient…. I’m kind of in a hoop. So we need to really encourage the specialist-internist-generalist too.

Of course, I can’t take care of my patients without the paramedical professionals — the nurses, the OTs, PTs and X-ray technicians. Again, we kind of get it up here. We have done a great job at CNC with our radiology course. But to keep people here that we train in the north, we need to provide them with reliable jobs. We lost a great technician to Calgary with a full-time job and benefits. We train them; you take them.

I really think we need to look at the money spent on administration versus services at the patient level.

Finally, my personal thought on nurse practitioners. I was very excited when the nurse practitioners came to B.C. I was involved initially in their training in my office, hoping that I’d actually get one. It wasn’t a good business model for me.

I taught them to do biopsies, IUDs and more. But why would I have a nurse practitioner in my office if I have to pay for her or his administrative expenses? The nurses I trained were great. They would have done well in a practice. Now they either have to work in remote areas or work in a clinic, like a cardiac or GI, and be GI specialist nurses. Personally, having been a nurse in the past, I think that would be a waste of my time, but that’s just my personal thing — working in a clinic.

I think considering nurse practitioners to run walk-in clinics would encourage doctors to actually practise family medicine. Nurse practitioners as locums would give family doctors a break so that there’s someone who can take care of my patients when I leave instead of me leaving and putting a burden on my practice and the other people. And it’s stressful on the patients.

There’s nothing I would like more than a reliable holiday in the north when I can take a break and not be a burden. You underestimate the power of the nurse
[ Page 390 ]
practitioner as a team member in the health care delivery system.

Finally, how can we enhance the effectiveness of addiction and recovery programs? I may have a few words to say about this, but I’m less qualified. This isn’t a 12-step program or a three- to ten-month program. It’s multifactorial and very personal for the addicted person.

Prevention is always the best way of actually developing our healthy youth programs and opportunities. But you can’t dry out and then turn back to your old previous situation. Social services, mental health and community opportunities to change will promote long-term recovery and success. Successful addiction recovery is tightly knit with housing, education and opportunities for jobs.

Community support for the mentally ill plays an important role too. Again, health services integrated with social services is imperative. A person’s primary home, in health care, should include social workers, addiction management and counselling at the health care level. This is somewhat seen in my practice with the primary care team pilot project. We just need more of these resources and more available to them.

My patients are usually discharged prematurely, because they have to move on to the next kind of crisis. But if there was some sort of follow-through with a few more supports, I think that would be great.

Thank you for allowing me to speak. I’d be happy to discuss anything you have in mind.

L. Larson (Chair): Thank you, Dr. McLeod. You did a great job putting it all on the table in a very succinct manner. Thank you very much. Much of what you’ve said we have encountered through others — very valuable information that you bring to this committee.

I wanted to just explore…. I know that there’s this pilot project happening, but I wonder if you could talk a little bit more about it and about the funding issues, and if you could talk a little bit more about the team that is included.

I know you were talking fast in order to get inside your time. You said OT, PT, care aides, and you mentioned others. This is the pilot project to integrate primary care and community care under the auspices of Northern Health, I believe. I may be wrong. I know that there is a push towards that. If you could describe it and if you could describe the barriers to it working to its maximum capacity.

D. McLeod: I think this is part of the GPSA, BCMA — government levels — but I don’t know all the partners that are involved in this. I was invited to be part of it. I have a great clinic. It’s already got EMR’d. I don’t have a paper chart anywhere. I think that’s one of the things that make me a candidate for it. It really does rely a lot on our electronic medical records and sharing information.

There is a team nurse or a team person who helps me monitor and helps me identify — or I send my request to, and she’ll give me a mental health worker, a nurse, OT and PT. But my OT…. There’s one, and she takes all four of the teams. There are four teams. I’m team No. 3. So there are four practices. My practice has three doctors in it. They take care of, probably, I’d say, 5,000 patients. Team 3 also has a few other doctor practices to take of.

D. McLeod: I believe so. What they’ve done, I think, in Northern Health, if I remember all the semantics of it, was he started taking some of the community health nurses and putting them in teams. That was a big job, because you’ve got all of your union things to deal with and how you are going to change this job. Someone who is sitting at a desk answering a phone and maybe giving immunizations…. Patient care…. Everybody is worried about losing jobs.

It was a big thing — so that people felt comfortable with the change. I think the change is the biggest thing — big thing for doctors. All of a sudden, you’re used to just kind of writing something. You might go there on your own, and you might not, depending on what kind of physician you are. We’ve got elderly doctors here who are set in their ways, and we’re trying to make it a beneficial thing for them.

There are barriers with change on all sides of the table. There are barriers about compensation for being there and for doing your thing. I think for nursing….

For my team approach, I can tell you how I struggle. I’ll go up and pick up a patient if I have to. I don’t have to do that anymore. But we do struggle, because I could have a few more patients being picked up to make sure that they come to the home, come to the clinic or they get met. My clinic is very comfortable. My patients are happy there. My dog runs around, and everybody feeds him. We have couches instead of chairs.

If people can actually start developing that relationship and realize that they can make their appointment and be there, that’s one thing. If you want to take people who are a little bit on the outskirts of health care, the ones that are the more challenging, that don’t show up, those are the ones that really do need you. So we need someone to go pick them up and take them.
[ Page 391 ]
I don’t have enough people to pick them up and take them.

My receptionist will phone and make sure that that’s all done, and that takes extra time for me to coordinate. I don’t mind, because I was doing that on my own before. But if we want to get everybody involved in that, I think we need a little bit more of a steward to kind of help with that, and we need more people to do the picking up.

We need more people to go and do the in-house visits and just the checkups. As soon as my patient is fixed — dropped, until they need me again. Well, I think we need to have them seen every two weeks by somebody else. They don’t have to come and see me. Just drop in, see how you’re doing, check up on you once a month. But we don’t have the manpower for that.

The concept is great. Having the occupational therapist go in there instead of them having to go into the hospital, park or take the bus, into a big maze of things where people are confused…. It’s scary sometimes. That would be, I think, a helpful thing.

S. Robinson: It’s a similar sort of question about the barriers that you mentioned.

Right now, you’re located in Prince George, which is great, but it sounds like you have much more rural experience. How do you imagine this playing out in other places — for example, like Burns Lake and others, if you could replicate this?

D. McLeod: I think there’s no cookie-cutter. We’re very different from Burns Lake. But I think that we could actually use some more….

When I moved back here, I had a lot of patients want to come and see my practice or see me do some remote medicine. I said: “That’s not good.” But when I do have patients who are admitted here from Burns Lake, I might take care of them and be their GP in hospital, which is, I think, a really important thing to be — a representative and an advocate for them.

When I send them back to Burns Lake, it’s horrible. They’re promised…. “Oh yes, you’ve got a broken hip.” Demented people? That’s a whole other issue. We might talk about that.

I send them back to Burns Lake and say: “Oh yeah, you’ll get physio there.” They don’t have a physio there. They have one physio that goes in there and tells the nurses what to do.

So if we’re going to keep our hospital moving, we need to be able to provide. I want my Northern Health Authority to have the same things that the Lower Mainland has. I want a cardiac suite. I want a better surgical suite. I want better orthopedic management and surgical centers and stuff like that.

That has to transition down from Burns Lake as well. They don’t need open heart, but they do need physio, OT. They did have a social worker when I was there, but I think it’s hit and miss. But if you have all of those people working together, they all have such a better time because they’ve got a team there.

Nurse practitioners in Burns Lake working with the doctors — I think that would be great. The only problem with that is that they don’t do call. So it would be a difficult thing to say: “You’ve got nurse practitioners, so you need less doctors, because those doctors are going to burn out.”

Call in Burns Lake is hit and miss. I could be on one in three calls, and the nurses there are great. I wouldn’t get called in for sore throats or anything, but I might get called in for a gunshot wound and someone’s heart pumping in front of me, and I’m just a GP working the north. It can be a very stressful call, so you still don’t want to do one in three calls. You want to do one in five calls. You want to be able to take time off. It would be nice to be able to back off on the actual patient load but not lose money on that.

I kind of found that the rural areas either had really good doctors or had money-grabbers. I don’t know how to protect against that, but you have to encourage them.

Burns Lake and those areas…. Emma, you had asked about the biggest addictions. Pharmaceuticals — Tylenol 3, benzodiazepines. The college is getting really good and heavy — giving me directions to say: “Look. I’ve got to get you off this, because I’ll lose my licence.” But it’s a very difficult thing to do in the smaller communities, especially the ones that are heavily laden with aboriginal people.

So really good addiction medicine and really taking heed to the request that Emma takes…. I think, in not wanting to silo and…. The aboriginals want all these things, and they need an extra amount of stuff for that. But we have to somehow include a blend, or we’re just doing the same thing we’ve always done: silo all these different people in there.

We have to sit down at a table, like with Northern Health and aboriginal health and say: “How can we use all this money?” Most of it might go, but we’ve got to get the people together, you guys — and in a way that they all feel like they’re working for the same cause, excepting that some people have more need, because they started ten steps behind us.

I’ve got to say: the people who have addictions are all ten steps behind us, right?

D. Plecas: Thank you, Doctor. I could listen to you all day. Thank you very much for that very thorough presentation.

D. Plecas: I really think it would be very worthwhile to do that. I love your perspective about having more
[ Page 392 ]
generalists, people who could do more. Make more use of people’s skills. It just made so much sense and could probably save us a lot of money and give us a greater ability to provide service overall.

One thing…. I actually have a zillion questions, but I don’t have time to ask them. I’m only allowed one. The one that I would like, if you could talk about it, is your concern about the health authority being top-heavy. That’s not the first time I’ve heard that about health authorities. I’m just thinking about…. Like, I’m listening to you and thinking that you don’t need any lessons on what to do, and I’m sure your colleagues don’t need any lessons on what to do.

That thought had come to my mind when I talked to Dr. Konkal, one of our really aging ophthalmologists, and he said that when he started in Prince George, there was one floor of administration and 400 beds for patient care.

Now, patient management has been very different. We don’t bring in kids with tonsillitis or otitis media any more. But now we have buildings of administrators and only 200 beds. I don’t know if that’s the right number, but it reflects kind of the same thing.

You know, I’m thinking about this, and it’s not all misuse, because Northern Health is now Northern Health, right? A lot of Prince George takes care with that whole area. But that whole area also has other administrations helping them.

I just think that a review of…. I was talking to Mike Morris about this. He was at my house. We had a doctor meeting. This was when he first started. He thought of maybe doing…. I don’t know what he called it, but it’s to see how all the administrations are working. He did it at the RCMP, and he knew exactly what I meant. I thought that would be kind of interesting.

I think there are a lot of people who have a job who don’t do the job. I think there’s a lot of redundancy, and then I think there’s a lot of places that are lacking. Maybe we have the same amount of people. But please, let’s get coordinated so that we keep jobs in all these areas, because we need to have people there.

These people in these small communities need to be employed as well. So if someone from Prince George wants to move out there and keep their job — because we can do everything remotely now — I think that’s important.

I don’t want to take away jobs from Hazelton and Terrace and all those places and put them all in Prince George. I think we actually need to decentralize some of this stuff, and a lot of stuff could be done through communications, and our health care could be done through that.

We are doing some excellent work with trying to do some remote medicine, so that you can actually do some management and some basic stuff and do all the previews before they actually get shipped into here.

I was interested in what you were saying about how the GPs practise here and how they do everything — hospital admissions, emergency, everything. It sort of seems like a throwback to the pre–walk-in clinic days in the Lower Mainland, when you actually did go into family practice, general practice.

Is that the case? Or is there more of this development of the walk-in clinics and things like that?

D. McLeod: Well, we’ve got an extra walk-in clinic here, but Prince George has always been very adamant and a very tight community about not having walk-in clinics. So up until about two years ago, you could not work at an after-service clinic. It wasn’t walk-in. You had to have a family practice to work there after hours. So between four and nine, you provided services for the community, for people who couldn’t go in to see their doctors and stuff like that.

Dr. Leiski, one of the emerg doctors, set up a walk-in clinic at the Superstore. As much as there was a lot of resistance about it, they provide really good service. Again, they’re EMR. Everybody gets an idea of where their patients have been. I get a note saying what they did, what they treated, what they prescribed. It’s fantastic, but it’s still not what we really want.

They’re talking about…. I know this because my husband’s in real estate, so he knows who’s looking at property. He says: “You know, they’re looking at another walk-in clinic here in town.” I’m going: “Holy crap.” Now our new graduates are coming along, and now they’re going to be doing walk-in clinics because it’s easy.

I don’t know why we don’t have nurse practitioners doing walk-in clinics. They could do a great job, and they could be nine to five. They’d be cost-efficient. They could be cheaper and better to access. Like, just load ’em up. Then they won’t be seeing the doctors at the walk-in clinic, and the doctors will just have to practise medicine. Go figure.

L. Larson (Chair): This was sponsored by the Joint Standing Committee on Rural Issues, by the Doctors of B.C., and I just wondered if you had participated at all. It’s actually A Guide to the Rural Physician Programs
[ Page 393 ]
in British Columbia — strictly rural ones. But I didn’t know….

D. McLeod: Oh, I’ve been on the college and all those kinds of…. I don’t know what I’ve done anymore. But mostly, I know that I like to practise medicine.

L. Larson (Chair): Okay. You could have had input on this. This came out last spring, so I just wondered whether or not you had had any input.

Thank you so much, Dr. McLeod. We’ll let you go back to your very busy practice. Thank you for being here.

Our next presenter this morning is somebody that I am familiar with, and that’s Dr. Sean Maurice. I met him in Keremeos on a travelling road show for medical professionals. It was incredibly interesting.

We did have Ed from the Princeton health group. He was at our meeting yesterday. He touched on what you’re doing a little bit, but it’s wonderful that you’re here and that we can hear it from you. We did allow about 15 minutes for the presentation and then 15 minutes for us to ask questions. I’ll turn it over to you, Sean.

S. Maurice: Thanks very much, Linda. Thanks for the introduction and for the opportunity to be here. Thank you all. I’m sorry that it’s so cold here. It’s not always cold here, but sometimes.

I have no disclosures aside from saying that I’m not from northern, rural or remote B.C. I’m actually from Vancouver. And this wasn’t my idea, but I’ve been here for almost a decade, and I’m proud to be here. It’s a great community. It’s a community that fought for the university a quarter of a century ago and fought for the medical school about 15 years ago. I’ll just try and tell you briefly some of that story.

I wasn’t here for this, but in 2000, there was this famous rally — 6,000 or 7,000 people. I think you have this electronically but don’t have handouts. So 6,000 or 7,000 people came out and expressed their frustration with the state of the health care services available in the north. There’s a longer story, which I don’t know well, about some physicians walking off the job, and this was sort of the culmination of that.

One of the ideas put forward at this meeting was the creation of the northern medical program. A lot of people in town now…. Physicians will tell you that it’s hard to appreciate how ambitious that sounded at the time now that we have a functioning medical school as part of the distribution of UBC medicine. But it was quite ambitious and took a lot of vision and a lot of people working hard on the ground to make it happen.

I’m proud to be part of that medical program. We have had quite a few graduating classes now. We’ve had a lot of physicians returning to community. Recently we’re starting to get back some of the specialists who’ve gone and done five-year residencies to community.

So it’s still actually pretty early years, despite being in our 12th year since we started. I’ve been here since the first graduating class. One of the things I’ve been wondering…. In addition to all the physicians coming back, all of the specialist physicians that have come to help teach in the program…. When I came, there was no gastroenterologist in town, and now there are four. So some of these successes, from a Prince George perspective, are pretty clear. I’ve been wondering how much of that effect is seen across the north.

The north is a big place. How many of these physicians are going to those communities? How much are they aware of what we are doing?

I fairly naively signed up for this conference in this building in 2009 as a basic scientist from Vancouver who likes the outdoors but doesn’t really know much about the issues of getting a family doc in Fort Nelson or Princeton. And I didn’t pay much attention to this word “action” here on this conference — the rural health workforce’s commitment to action.

At the end, we were asked to come up with something we can do in the next year to help address the problem. The group I was with didn’t have anything that I can remember, but there was a table that had a really good idea, which was the road show. My dean was at that table, and afterwards, I went to him, and I said: “Dave, that sounds like a really good idea. If there’s any way I can help, could you let me know?” He said: “Sean, you can have it.” So that’s how I came to be the academic champion for the health care travelling road show.

The goals of this road show are to provide health care professional exposure to rural youth, to provide rural exposure to health care professional students and to provide an interprofessional experience for the health care students.

I imagine you’ve all heard of interprofessional education as a thing that we’re trying to do a better job of. If you haven’t, basically, it’s because we teach our doctors and nurses and physiotherapists and all of the different health care professionals in silos. They have to work together in teams when they get into practice, so the earlier we can get them thinking about working in teams, the better. We’re all trying to do it. We just don’t really know how to do it, because our programs are all quite packed and independent. So this is one of the ways.

The format involves us going into schools as this interprofessional team. Over the past six road shows, we’ve had students from medicine; nursing; physiotherapy;
[ Page 394 ]
occupational therapy; medical lab technology; medical radiography technology, or X-ray; audiology; speech language pathology; midwifery; biomedical engineering; dentistry; and dental hygiene. Not all of those at once, but we’ve had nine at once this year on one of the trips.

They give short formal presentations to a group. This is me just doing an introduction to the group in the bleachers, and then they do hands-on, interactive small group sessions.

This is a male nurse talking to a small group at a table. There are eight other tables, and the students, after the formal presentation, will rotate through the room, go to all of these different stations, see some of these students who are still in their training, get to interact with….

Here is an intubation dummy. There’s all sorts of equipment, truckloads of stuff, microscopes, skeletons, stuff they can get their hands on, which can help them to really visualize some aspect of training for that job from the perspective of these students who are learning things quite freshly. Often they tell a story in a different way from somebody who has been practising in the field for ten or 20 years.

Then we go and do tours of local health care facilities. It’s, this summer, in Princeton. Meet local leaders — mayor and council and sometimes even MLAs, like Linda, in Keremeos. This is the mayor of Merritt. This is Ed, who was just mentioned — part of the Princeton….

Nienke is taking the picture, I think. That’s why she is not there. I’m in the back there. This is the manager of the Douglas Lake Ranch, outside Merritt, so a pretty neat bit of local history. He came out and spoke to us. We’re at this Quilchena Hotel on Nicola Lake. It was gorgeous. A bit of local flavour, something that I didn’t know existed and couldn’t have come up with myself. This is something they put together to allow us to meet some people and get a bit of the flavour of the region.

This is in Haida Gwaii, actually at Old Massett, which is kind of the far end of the road. You really feel like you’re in the middle of nowhere. We’re on reserve. And this guy, Jim Hart, is a well-known carver and somebody who sort of embraces a bit of a hybrid worldview and has a lot of space for talking to tourists who come in and ask naive questions about totem pole carving.

They’re actually working on a very large totem, which is going to be set up at UBC as part of truth and reconciliation in September. So it was pretty cool to see it on site, being carved there, hear the story of finding the right tree and deciding what goes onto that.

So the idea is that we’re giving these students — half of that group is health care professional students from across the province — an idea of some of the highlights of that local community if they were to move there, the types of people, the types of things that happen there that they might have in their off time.

Why are we doing this? Research tells us that there’s a physician maldistribution. Depending on the sources, the numbers are different, but typically, more than twice as much of the population is rural versus, in this case, 9 percent of physicians. I’m sorry that I have a physician bias because I teach in the medical program, but similar things are true for other health care professions. In fact, a lot of small towns simply don’t have a physiotherapist or a midwife or a lot of the professions. You could say that there should be an urban bias because that’s where the tertiary care centres are, and that’s true, but it shouldn’t be this much.

Rural youth are less likely to have the confidence that they can get into medical school, and they face greater barriers. If you’re in Fort Nelson, it feels really far from family support and costs a lot, or it feels like it costs a lot, to get down to Vancouver to go into training. So it’s worth making the effort to reach out to them because they’re more likely to return to rural practice if you can get the student who’s grown up on a farm, who’s grown up in a small community. They’re more likely to feel comfortable there, even if they don’t go back to the same community they came from.

It’s also really important that we engage the community in health care recruiting and retention. That part of the road show is community engagement.

This is a map I had made for a publication last year that summarized the trips to date. Then if we add on this year’s trips…. I think you’re probably all from B.C. and know the size of our province. When we’re speaking to people who don’t know, somewhere around here is the start of the Northern Health Authority, and from there up, that’s the size of France. It’s a big area, with some 300,000 people. It’s a very sparse population by world standards.

We’ve also done a couple of trips into Interior Health, and there has been good justification for that. I hope it continues to be a provincial initiative, even though some of our funding is really focused on the north.

We’ve seen quite a few students, and I’ll tell you in a minute that we don’t actually want to expand beyond 1,000. That’s probably too many in a week, and we’ve been continually increasing the number of health care students involved.

This is just pilot data from the Clearwater trip on this slide. We asked people how successful they thought the project was in general. You can see, overall, 4.6 out of the five. It’s quite a strong response to that. “Do you think this project will encourage health care students to consider settling in Clearwater or other rural communities?” It’s still pretty strong — four out of five for that. And: “Do you think this project has encouraged local high school students to consider careers in health care?”
[ Page 395 ]
And 4½ out of five on that. The health care students all thought, “Absolutely”; everybody else, maybe a little bit more across the board.

Some of the responses we got to longer questions focused around a theme of engaging youth in health care career options. From a secondary student perspective: “I like that everything was hands-on and that we got to learn a bit about all the different professions.” From a teacher perspective: “I think the personal stories were encouraging, especially for our ‘average’ students.”

There are other initiatives that target keen students and kind of give them some of the bits and pieces they need to know to apply to medicine — what salaries are and different details. This is really more of a grassroots and earlier seed-planting mission. We want people to think about things they haven’t thought about before. For the students who might be, maybe, a little bit disengaged and don’t have a reason to focus on biology or classes in general, there’s hopefully an opportunity to inspire something there, to light a bit of a lightbulb in their minds.

And then, from a student perspective again: “I like the connection obtained by talking to the people who had come for my sake.” It’s somebody, they’re recognizing, that is coming for them.

Another theme that emerged: “Opening my eyes to rural communities.” These are from the health care student perspective. “Seeing what else rural towns had to offer. Listening to the adult community members express their hope for their children and this town. Talking to the kids, realizing it’s all come full circle.”

And then this one there are kind of two interpretations to. “I found it very interesting to see the discrepancy between the amount of available health care resources in Fort Nelson versus Vancouver, as well as all the things they were able to do with the minimal resources.” We have had students come from the city and say: “Gosh, I don’t want to ever go rural. I never did, and now I want to even less so, but I appreciate the challenges.” I think that’s actually a success, because if you’re getting somebody referred from a small town to a tertiary centre in Vancouver, you know where they’re coming from and you know what you’re sending them back to.

But I think it’s also neat, this last bit — being able to see what they can do with minimal resources. Some of the students are really impressed. When we’re looking for rural generalists, we’re not looking for cowboys, but we’re looking for…. One of the phrases in this field is “rational risk-takers” — people who have a sense of adventure, people who like to go…. There are some similarities with people who might like to go for long backpacking trips and realize they don’t have all the amenities, but they are willing to accept that adventure.

There’s a lot of benefit to being a generalist and not having all the specialists at your fingertips, knowing the limits of what you can do and how you can help somebody when you aren’t able to evacuate them. It takes a special person to want to do that, but some people are actually attracted to that kind of practice, and we want to find those people.

This speaks to the interprofessional aspect — learning with, from and about. I learned a little bit more about what’s involved in different professions, which makes it easier for me to understand how I can incorporate partnerships later on, when I’m in practice. It’s very easy for them to ask each other naive questions at this point. Once they’re in practice and egos kick in, it’s a little harder.

When we set up our presentations and all the equipment is around a gymnasium, sometimes, later in the trip, when we get fast at that, we have ten minutes before the students come. The health care students will go around to each other’s tables and say: “Teach me how to read a blood smear. Teach me how to birth a baby. Teach me how to size crutches properly.” It’s neat. They get to learn a lot about what each other do. I’ve learned a lot over the years.

From more of an operational perspective, some of the lessons that I’ve learned. It’s really important to represent a diversity of health care careers. This requires provincial recruitment. For the last two years, we’ve been doing that. If you go back to that map, you’ll see our numbers have gone up a lot since we started doing that. It’s a more powerful message, when you’re presenting to the school, when you have nine careers instead of just three, maybe, which has sometimes happened before. I mean, three is still better than one, but part of the message is that there are lots of options. It’s not just doctors and nurses, which is what most people know. Those are very important, and we need more of both of those. But all of the fields are important.

Some students will find intubating a dummy absolutely fascinating, and some will think it’s the most boring thing or the most gross thing. We’ve had students faint at that. But then they’ll look at an X-ray, or they’ll look at a blood smear or something else, and they’ll think: “Oh, that’s cool. I can relate to doing that.” Health care is diverse, so we want to represent that.

I mentioned briefly before that we’ve learned that we don’t want the sessions to be too big. Our cap used to be 100 in an hour or 150 in an hour and a half. Now we’re saying: “You know what? If we do 60 in an hour and a half, those students are having a better experience.” It’s always a balance. There’s a lot of effort involved in planning. If you get to a small town, you don’t want to be turning away a lot of kids, but you also can’t see everybody and make it a meaningless experience either. Nobody can get to the front of the line to see what’s happening. That doesn’t work either.

When we went to Fort St. John last year…. There are a lot of kids in that town. It’s a pretty big town by northern standards. We saw the grade 10s, and that was it. That seemed like the highest impact.
[ Page 396 ]

Engaging stakeholders is actually complicated. That probably doesn’t surprise any of you, but as something that was meant to be a pretty simple initiative…. Initially, I’ve learned that we need to start early in the year and try and make sure everybody is on board — from the health authority to the school district, the principals and teachers, the local health care practitioners, if they’re available, the mayor and council. It’s a better experience if everybody is engaged. That includes communicating the vision.

We’re working on streamlining the process and writing down things so it’s easier for expansion. You saw this here. We did two trips for the first time, and the hope is that we do two or three next year.

There’s a necessity for ongoing dialogue with the health care professional programs provincewide. We have had a communications person in the northern medical program for the last two years who has helped with this piece, and that’s part of how we’ve been able to do provincial recruitment — sending out posters and getting applications from all over the province.

That’s worked well. We had 69 applications this year for 18 spots. It’s good to have more than we can fill. Still, there are some programs that got the flyer, didn’t know what it was and didn’t send it off until a couple of weeks in or didn’t send it off at all. Then, later, they’re saying: “How come our students weren’t involved?” It’s just another relationship that requires time and being on our radar continually.

I’m not completely sure why I’m here, but I’m thinking part of the reason is that you’re thinking about initiatives to suggest to someone else to support. So if this program had greater support — I think that would be a good thing — what that could look like.

Secure funding for annual operating costs — transportation, accommodation and food. Currently, that’s a year-by-year basis. We’ve had great ongoing support from the Northern Medical Programs Trust and from REAP. Kelowna is looking to start this program next year. They don’t have a Northern Medical Programs Trust, so they’re trying to figure out where they’re going to get money from.

It would be really helpful, if we were going to expand, to have a staff person whose job it was to actually maintain relationships with the health care professional programs and the communities and the community champions, to standardize some of the materials we send out — the application forms and the information forms for students who are accepted and those sorts of things, which are done off the side of the desk right now — and to maintain program evaluation databases and things.

One of the things I’ve thought of before is the ability to actually purchase equipment. As to what’s available in different places, I’m not entirely sure. Here we operate on the generosity of the medical program, the health sciences program, the lab tech program, the hospital. I’m not sure if you’d find that same generosity in Vancouver, or in Kelowna even. We haven’t broken anything yet, thankfully, but I always do wonder a little bit, when we’re loading up microscopes and things into the truck, where we’d find the money if something were to go awry. It would be nice to have a bit of a backup for that.

Ideally, it would be nice to be able to expand so that we’re doing more trips annually. We do have more than enough applicants in the current model. Medical students, in their new curriculum, do have time to plan projects as part of curriculum. So I can ask them to do this, but it still requires a lot of my support.

Those are just a few thoughts, and I welcome questions. I’ve got a couple of “Thanks” pages. The first here is just to acknowledge our funders, the university and the college, who have provided the materials that we’ve used.

I’ll just point out that this is the northern medical program building. In this little DNA strand on the wall here, the big ones are the towns that have contributed to the trust, and the little ones are individual donors and companies. This is sort of meant to represent the lifeblood, as it were, of the program. They’ve contributed to the Northern Medical Programs Trust, which is an endowment that supports initiatives like this for the north, and these are just communities, health authorities, funders and school districts that we’ve visited over the last six years.

L. Larson (Chair): Thank you. It’s a wonderful program. That’s why you’re here, because it is a wonderful program.

D. Plecas: Thanks very much, Sean. I’m only supposed to be asking one question, but I’m going to ask two very quickly — related. Have you done anything to tell you the extent to which your efforts compare, better or worse, to what’s happening elsewhere around the province? The whole idea is to draw people, students into health care. How do I know that there are not five times as many interested in health care in the Fraser Valley? That’s one.

Secondly, what else do you think we could be doing to incentivize the whole matter of retention? It seems to me, when I think you have a medical school here, like there should be throngs of people who are interested in being part of all of that, yet we’re still hearing that there’s this significant problem with recruitment and retention. What’s missing? Is it really any better than it was five years ago?

S. Maurice: Well, for the second question on the recruitment and retention, it’s sort of not my field, but I think the answer really is about finding the right people, which is part of why we’re doing this road show. Throwing money at the problem can help, but it definitely has limits. If people are coming in for a two-year incen-
[ Page 397 ]
tive, then they might just be coming for two years. It’s really a matter of finding the right people.

It’s not only people from rural origins, although the percentages of them who are going to be happy in a rural setting are higher. There’s also sort of a rural…. I’m forgetting the word they’re using now, but very recently the former dean of our program has come up with a new descriptive for people who have an attraction to the benefits of rural living.

I guess I would be one of those. I came with a young family to Prince George, where I could afford a house, when I would never be able to in Vancouver. I’m relatively uncommon, I guess, coming from Vancouver. But the combination of access to the outdoors, affordability of housing…. I don’t need Robson Street all that badly; I prefer to be in the mountains.

That sort of rural leaning we’re not that good at detecting, but we’re working on it. In the admissions process for the medical program, we do have a rural and remote suitability analysis, and they’re working on refining that. All 32 spots in the Prince George northern medical program have a component of the acceptance criteria that uses that rural and remote suitability analysis; ten of the spots in Kelowna do. But we do struggle to get enough students. So having it on students’ radar through initiatives like this is important.

D. Plecas: I know that for attracting people to post-secondary, at least I think if you look provincewide, there’s less interest in post-secondary from the north, in high schools from the north. So that’s a problem. Then, along with that, what is the likelihood that students coming out of high school would have an interest in health care, relative to the percentages which would have an interest in health care in the Lower Mainland, for example? Are you finding that as well? I guess that’s what I’m saying.

S. Maurice: Well, if they have an interest in health care, they’re less likely to think that they can make it, even if they have the same grades. The barriers are greater, including the psychological barriers, thinking: “Oh, I’m just from Fort Nelson. I can’t get in.”

There are also other problems, like in…. I mean, maybe the markets have changed enough that’s it’s not such an issue, but when we were at high schools in Fort St. John, they said: “It’s hard enough to get boys to graduate high school, because at 16, they can go off and work on the rigs and make $60,000 to $80,000 a year in their first year.” I thought: “Gosh, if I had that problem when I was straight out of high school, it might have affected my career decisions too.” I mean, there are some of those local factors.

D. Plecas: Do you actually have a sense of that right now — what the difference is in the participation rate with an interest in health care fields here, relative to what it is in the rest of the province?

First, I know you talked about the screening for the medical school here, but I’m just wondering about even this program here for the road show. There are quite a few applications. Do they screen those that come on to see who’s most likely, maybe, to have a real interest in getting employment up here? That would be the first question.

Secondly, just from your perspective, outside of, say, Prince George — how about just in the north in general — would you say that the level of medical services…? Do you feel that that’s a steady improvement? Is it status quo? Is it declining? What’s your perspective?

S. Maurice: As to the first, in terms of dealing with the applications, the process has changed a bit year by year. This year we had nine people, including four medical students and faculty, from Prince George, from Kelowna and from Selkirk College involved.

We went through a process of ranking the applications essentially based on their sincerity. How much did the students who were applying understand the mission of the road show? How much were they going to be able to inspire the youth? That was the first priority. It was not about whether they are likely to be recruited to those towns. That was sort of secondary.

Then after we do that, we have to go through…. We didn’t have a length requirement on these applications. It’s really interesting. You can see who’s at what stage of their post-secondary education, just based on how much they have to say. If they say a whole lot and it’s kind of meaningless, well, that doesn’t help them. The midwives in particular seemed to be the most verbose but articulate. They wrote long and comprehensively, with many different, well-emphasized points in their applications, so a lot of them scored very high on understanding the education piece.

We didn’t want to go with all midwives, so we went through and ranked and then looked at preference of different road shows, because we had the two this year. Then we looked for the diversity piece, and so we picked the top one or two midwives and the top one or two nurses and then went through and made a decision. “Okay, this applicant is not ranking very high, but we really need a lab tech. I really feel like having a lab tech.”

Having some of the technical programs is important. Those are much shorter training programs. You get in
[ Page 398 ]
straight out of high school. You do 2½ years, and you’re done. They’re sciency. They’re not patient contact. That fills a niche that the others don’t. “Let’s talk about whether we can let this person in, because we’d really like to have a lab tech on this show.” That’s kind of the process for that.

M. Dalton: What about health services in general, in the north, outside of, say, Prince George?

S. Maurice: I would say, in terms of the northern medical program, the stories that we have are…. It depends on where you go.

Mackenzie is one of our great success stories. We had one of our grads from, I think, the class of 2009. James Card went up there. I think he went for a locum for a year. Maybe he was covering mat leave. I don’t know. He went with a wife who had just delivered a baby. The community wrapped around them. The ladies brought quilts over, and there were freezer meals brought over to them. People just checked in on them. They made sure that his workload was reasonable, and they made sure that his family felt safe and supported and had a community.

He’s quoted for saying something to the effect of, “After a year, we had no choice but to stay,” because the community just wrapped around them.

Fort St. James is a little bit the opposite. I’ve heard people say, off the record: “You know, that place will just chew you up and spit you out. If you show up there with a young family, they’ll work you too hard. Your family won’t feel safe, and you won’t stay.”

When we were in Fort Nelson, they had a student who had been admitted to the medical program. That was their big hooray. Jen got into the northern medical program, but then she didn’t come home. I thought, “Oh, that’s so sad that you see that as a failure,” because on a provincial basis, that’s a success. So (a), she got in — she has career options; that helped her develop her career options — and (b), she went back to Fort St. John. That’s a recruitment gain for the province, but it didn’t meet Fort Nelson’s needs.

So the answer to that question is very local. I think, provincially, we’re moving in the right direction, without question. It just depends who you ask.

D. Barnett: On your recruitment for the university, do you have many First Nations apply?

S. Maurice: We do. We have targets, and we have a First Nations admissions officer at UBC. I think our goal was that we were going to graduate…. From the start of the distribution and the expanded medical program in 2004, the goal was that by 2020, we’d have 50 First Nations MD graduates. We already have that. Last year, we passed that. So yeah, that’s working.

S. Robinson: Thank you very much for your presentation. I’m very interested in — and I think Darryl was trying to get at — what the performance indicators were. In terms of actual numbers, I’m assuming that you’re tracking how many actually do go to medical school, how many actually come and practice rural…. What are you expecting to publish or, at least, advise on how…?

S. Maurice: Those things are not easy to measure. It’s not actually my main area of research. We’ve done the surveys as part of the pilot project. We do ongoing program evaluation to get people’s perspectives immediately after. We have not done long-term follow-up.

A physician in Clearwater who’s now the head of the Society for Rural Physicians, John Soles, helped us run the first one in Clearwater. I’ve run into him a few times recently, and he says, anecdotally, that there’s absolutely no question that the conversations around health care careers increased dramatically after we came — conversations with school counsellors, people who talked about that at their graduation as something they’re thinking of going into.

Physicians, in particular — it’s a long training path. So if you convince someone in grade 10, if you plant the seed…. I mean, some people will graduate high school, go do something else for a bit, and then decide to come back to university. Even if they go straight to university — four years of university, four years of medical school, a couple of years of residency — that’s over a decade. So it’s hard to measure those things. And then some of them locum, and all the rest of it.

A few of our concrete success stories are just sort of people that I happen to know. We had a physiotherapy student who was looking for a position. Her husband was in forestry, so they were looking for small-town B.C. somewhere. She came on the road show in 2013. We went to Vanderhoof and also went to Burns Lake, which the previous person was speaking about. She fell in love with Vanderhoof and sort of got recruited on the road show. She attributes that to providing that opportunity.

We have somebody from Fort Nelson. In fact, she was in that picture here. This girl was in grade 11 when we came to Fort Nelson in 2012, and she didn’t know what she wanted to do. Two years later, she was in the lab tech program at CNC. In 2014 and 2015, she came and represented lab techs on the road show. This winter, I ran into
[ Page 399 ]
her at Powder King. She just took a job in Fort Nelson as a lab tech at the hospital. So that’s our first story, that I’m aware of, that’s full circle back to the hospital.

It would be great to do a long-term study. It wouldn’t be easy. I would certainly need some epidemiology experts that kind of know how to do that work.

S. Maurice: It would be the absolute proof. But then you could ask Linda Larson what that conversation was like in Keremeos after we left, in the high school.

S. Robinson: I’m sure. But it’s follow-through right through to the end. It’s hard to sustain that.

L. Larson (Chair): Very difficult, too, because if he’s presenting to a bunch of grade 10 students, who’s going to track them to see how many of them actually go into the medical professional field? You have to get the school on board. A lot of those things we don’t have access to. But it would be really neat.

Thank you so much for coming and talking about your program. I think it’s fabulous. Thank you for being here this morning.

We’re going to do a quick turnaround. My apologies to the next group, because we’re running a bit late. We won’t cut you off short. We’ll just have less lunch, which won’t hurt any of us. Just give us a minute here to turn over.

Our next presenters are Dietitians of Canada, B.C. region. I’d like to welcome Marianne and Sonya and Courtenay. We may have even crossed paths before. Sometimes the faces are familiar.

Welcome, and please proceed. We certainly will give you the full 15 minutes to do your presentation, and we will allow enough time for questions afterwards. So go right ahead, Sonya.

S. Kupka: Thank you for the welcome. Yes, we did have the opportunity to present to the previous Select Standing Committee on Health and really appreciated that. We also had the privilege of hosting a couple of MLA events in the Legislature around Dietitians Day. Thanks to all of you that were able to welcome us there and make it a great opportunity. I know that I’m having the opportunity to speak with an audience that’s a little bit familiar with the kind of work that we do, so I’ll try to stay focused specifically on the questions that you’ve been charged with.

I’m so pleased to have arrived a little bit earlier to hear the previous presentation, because I can really hear some congruency and some consistency. I used the opportunity to slip in my card. So the next time they present, you’ll see dietitians on that list, being part of the team.

S. Kupka: Yes, absolutely. Well, there are many professions, so I can totally understand that. But it did sound like a great program.

I’m so pleased to be here with my colleagues today. I’m Sonya Kupka, the executive director with Dietitians of Canada. In your portfolio, which has been distributed, on the left-hand side — I won’t go through it — you’ll see our corporate profile. That will tell you a little bit about the organization of Dietitians of Canada and how we represent dietitians and the work that we do across…. It does have a national focus.

I’m here today and, even though I have a provincial mandate, chose specifically to come to the north because of seeing that that is such a key issue. And I wanted to have my dietitian colleagues join me.

Marianne is a dietitian who works with Northern Health in population health. As well, she has a blog and is an author of French Fries to Flax Seeds — a great website. I encourage you to have a peek at it. It just is reflective of us as a profession — that we do the full gamut.

Then on my left, I have Courtenay. Courtenay is the chief clinical dietitian with the University Hospital of Northern British Columbia and so has a strong clinical focus. Again, that’s reflective of our profession — looking population-wide and doing population interventions and then very specific clinical interventions as well.

The United Nations just declared 2016 to 2025 the decade of action on nutrition. As a profession, that’s very, very exciting for us. That’s where I can come here quite confidently and say that nutrition is a primary contributor to improving health.

As part of that declaration, the United Nations ratified a document called the Rome declaration on nutrition. It goes through a number of actions that they’re encouraging countries around the world to take on and certainly acknowledges that the issues they’re facing in some countries are very different — in the more developed countries than, perhaps, in the undeveloped countries. But across the board, we’re struggling with common issues. There are some good strategies there. Certainly, our submission is aligned with that.

Dietitians do have a unique body of knowledge and expertise. We provide an integral contribution to the health of the population and, also, are very aware of the need for the stewardship of public funds and, through our roles within government, support that. Dietitians of Canada has a long reputation and relationship with the governments of British Columbia, working together collaboratively and being solutions-focused. And that’s what brings us here, today.
[ Page 400 ]

As dietitians, we’re very passionate about food and nutrition and eating and the contributions that can make. Also, we’re absolutely committed to accountability. As a regulated health professional, there’s that accountability mechanism that goes with it. We are the only regulated nutrition health professional that’s covered by the B.C. Health Professions Act. We do work to the highest standard around evidence-based nutrition.

I did mention that I was here before, and we did do a previous submission. I would encourage you to have a peek back at that. It certainly is still relevant. You’ll see the focus has shifted a little bit, just with some current trends that have come up. We’ve become a little bit more focused on the workforce in this submission. But certainly, the other recommendations are still valid.

We’re presenting three strategic recommendations for your consideration. The first two are very much focused on health services. Then the third and fourth are more health and human resources types of issues. Then the last is looking at policy and government oversight.

The first recommendation: investing in evidence-based nutrition interventions within primary care. There have been some very exciting things happening in primary care in B.C. There has been some excellent progress around the GP for Me program and the divisions of family practice, and there’s been a lot of talk about interdisciplinary teams — intentions moving towards interdisciplinary teams. That’s very, very exciting. As a profession, we’re not yet seeing dietitians being part of those interdisciplinary teams.

We did a workforce survey. The executive summary is in your report, and then the full report is available on line.

So 3 percent of B.C. dietitians indicated that they were working in primary care in B.C. In comparison to Ontario, about 13 percent of dietitians are working in primary care. It’s a very untapped area in terms of potential, and dietitians can play a key role.

In the report, there’s a bit of information about cost-effectiveness. There’s really good, solid data and evidence around nutrition interventions and counselling and the difference that makes, especially with many of the chronic diseases that were faced. When we look at the teams, and especially physicians being pretty tapped on those teams, generally, once you do get a dietitian being part of a primary health care team, the team is really pleased with that, and the physicians in particular — having that backup.

There are pockets of excellence, I’ll call them, and opportunities that we can learn from. Our recommendation and our ask around that is really to make explicit reference. We talk about an interdisciplinary team. It’s more than having physicians and nurses and midwives. We really need to look broader. I’m sure you’ll hear that from some other professional groups. But even in the north, we’ve had some conversations, and that seems to be a gap where the profession isn’t listed yet.

We’ve heard mention about a Kamloops model going forward in terms of having an interdisciplinary team, and we really look forward to trying to be a part of that and then further demonstrating the value that dietitians have. Alberta is another really excellent area to look at in terms of models of including dietitians on the team and the difference that makes in health outcomes.

Related to that, what we have seen on some of the teams that moved forward is that there may be talk about the interdisciplinary team, but there’s that challenge in terms of co-location and the benefits that come. Every team member — for example, every dietitian — may not see every patient, but if you have that opportunity for co-location, it gives the opportunity just to pass on a few hints and move it forward more effectively. We certainly hope that, moving forward, there will be more of an opportunity for dietitians to be able to contribute and help out the teams in primary care.

Related to that, or perhaps independently, is the need for home-based nutrition services to reduce the demand on hospital-based services. That’s the second recommendation. It depends what area of the province and what health region you go to. In the Lower Mainland, they’ve got very established home health programs that are fairly stand-alone in terms of the stream. Again, the whole area of nutrition services in those is next to nothing.

Fraser Health — which has a very robust home health team of nurses down there and a couple of other paraprofessionals, albeit in smaller quantities — serves a population of 1.6 million and has about 1½ dietitians serving that population. That’s one full-time dietitian.

As you can imagine, at this point, the nurses don’t even refer to that dietitian anymore. There’s no point. So we don’t have wait-lists. In terms of being able to demonstrate the need through a wait-list, I would suggest that that’s perhaps not the most effective mechanism, because if the service is not there, the referrals are just going to stop.

The dietitians then do end up really needing to focus on some of the most critical stuff and then the more critical of the critical. If we take a look at home tube feeds, for example, where individuals cannot meet their nutritional needs through oral intake — it might be post-surgical; it might be as a result of strokes, ALS, developmental disabilities. In those cases where there’s somebody who goes home on a tube feed, they understandably feel quite vulnerable. Even there, there’s very little support. It’s very hard on the few staff that are there to be able to not provide the service that’s needed to be able to provide that real quality care.

Whether it be an independent, stand-alone…. Whether it be part of the home health program or linked to the primary care, the whole notion of some kind of an outreach to the community to help people stay at home would be really key to be able to successfully manage
[ Page 401 ]
the chronic conditions and then to have the best of their health possible to be able to be maintained independent in the community.

The third area that we wanted to flag was around the rural and remote communities. We probably had the most conversations as a team of dietitians around the province. I should have mentioned at the beginning that in preparing this submission, I did reach out to members in the north — part of Northern Health as well as the north Island — to get some feedback. From that, there were certainly some themes that came up. Also, our workforce survey helped to inform the presentation a bit — that most dietitians work in larger centres. The further you get from the larger centres, the fewer services are there.

Across the board, one of the key things that was mentioned was the need to have adequate staffing levels. At first, it seems odd to have that as part of recruitment and retention. But it’s really hard to hang on to the staff when they’re run off their feet. I think you just heard that from the previous presenters, in terms of some of the communities.

If the demands are too high, then you start to not feel that safe. You don’t start to feel safe as a practitioner. As a regulated health professional, there’s a certain standard that you’re expected to uphold. If the caseload is too high and you’re not able to provide those kinds of services, it’s really not a good feeling.

I spoke with one dietitian, and her quote, I think, captured it very well. She said: “It’s difficult to go home at the end of the day completing the bare minimum, and sometimes not even, for your priority patients.” This isn’t even talking about all the patients. It’s not even talking about all screening. This is talking about, “Okay, today” — I’ll use this example — “we’re going to do the TPN program,” people on total parenteral nutrition, and the others don’t even get on the shortlist. Staffing level really is a critical component around retention.

A couple of stats to throw at you. I did mention the 54 percent that didn’t have relief coverage, especially in the north. It’s down south as well, where we just don’t have the casual pool.

But the other piece that came out of the workforce survey is that 57 percent of dietitians worked more than they were paid. The interesting piece of that is that in 2008, it was 18 percent. It’s gone from 18 percent to 57 percent. There has been a shift, and I’m sure it’s not just dietitians. I’m sure you’d hear that from other professional groups. But as far as retention, that’s a key point.

The other point that was most frequently mentioned as the limiting factor was insufficient work to sustain a living. A lot of the positions that are created are tiny fractions.

There might be a 0.2. Great, there’s a 0.2 up in Masset. I’m making that up. I don’t know if there really is. But that’s an example of a community where there might be just a small portion of a position. To have somebody move up for the 0.2, they’re not going to be able to do that because they can’t sustain a living. Then there’s also the need to find their partner, if they have one, or their family a job. It’s a really tricky aspect.

We were thinking: “Okay, well what’s the solution for that?” Sometimes it’s just hard to justify more of a position if the population isn’t there.

One thing around dietitians is that dietitians have a very broad base. We do have undergraduate and then practicum training on that. That does position dietitians very well to assume leadership positions.

Certainly, that does happen. Primary care is a really good example where we’ve had a number of dietitians who are working in a leadership position — managerial, not specific to dietetic services, in addition to providing specific dietetic services. So really looking towards dietitians in that kind of a leadership role.

It also then becomes a retention piece, because it provides a career laddering opportunity. That, for longer-term retention, can be really important for those individuals who want to expand their work and their career.

The new graduates are a bit of a challenge. Often we’ll get new graduates, and they’re recruited up here, and they stay. But to stay here is really hard, unless they have a really strong sense of community.

I love the term and the description of “having the community wrap around them.” That sometimes happens by accident if you have a very strong community. Sometimes it needs a little bit of help. Sometimes that wrapping around needs to come from outside of the community. If there was some way, even, of extending some of the orientation periods and building in some travel for that….

Going back to the north Island, there’s a new dietitian there. She’s working up in Alert Bay, in a couple of the areas up there — quite isolated and quite new. What she could really use is just some more support and mentorship from her dietitian colleagues. To be able to do that, you have to have some face time. Once there’s a bit of face time, a bit of a relationship, then it’s easier to pick up the phone and the email and ask the questions. But a little bit more of an investment, I think, in travel at those early points would be really helpful in terms of helping them feel comfortable — that continuity.

I’ll use the term “professional isolation,” which is similar, I think, for the new graduates. But it also goes beyond that. As we get further in our career, often we want to be able to explore different areas of practice. We want to be able to connect with our colleagues and, again, create that expanded sense of community.

At the bottom of page 3, I included a quote from another dietitian, who described: “Most of our interactions are done through email, over the phone. The odd time I
[ Page 402 ]
get to travel to an Islandwide meeting with dietitians is amazing. I always come away feeling like I’m not the only one who’s facing the many challenges I come across. I always learn something new, often more than one, and I’m able to build new relationships.”

There’s certainly a lot towards that that can happen through distance learning. As a professional association, we provide a lot of distance learning, but it doesn’t replace the need for having, on some occasions, some face time. So really taking a look at the unique challenges faced in the north around professional development.

It often takes longer to travel to places, so you end up taking more time, and then the travel costs are a little bit higher. I think it’s a little bit unique compared to some areas of the Lower Mainland.

In Vancouver Coastal, for example, they have a terrific day called Dietetics in Action. They’ve got such a huge pool of dietitians — about 150 dietitians who come together — and there’s a lot of expertise. There are dietitians who specifically go into HIV, and they can share their expertise with their colleagues. Because they have the numbers, they’re able to do that. It’s a little bit different in some other areas, so extending those opportunities would be helpful.

Around the monetary incentives, they’re absolutely helpful. What’s interesting is that when we surveyed dietitians as to filling difficult-to-fill positions, the top thing that came up was being able to earn a living. That was not talking about the salary. It was talking about full-time employment; 45 percent cited that, compared to increased salary — 19 percent mentioned it. While it’s important, there are many other pieces around it that seemed to come up as a bit more of a priority.

S. Kupka: Okay. I’ll just say one thing about No. 4. That’s just the piece around the dietetic training.

We have 36 spots for dietitians, so we don’t have a whole lot of dietitians coming into the system, which is problematic. A lot of people spend two, three years just getting into the dietetics program. So we look forward to working with the Ministry of Advanced Education on that, in terms of seeing what kinds of solutions….

We import about 40 percent of the dietitians to the province, a lot of them from Atlantic Canada. Particularly in the north, a lot of them come from Atlantic Canada up here, which is great. We just need to be able to hang on to them.

The last piece I’d like to bring to your attention is just the whole notion about unregulated nutrition practitioners. There are 36 seats at UBC, 36 new dietitians a year — 1,000 unregulated nutrition practitioners every year. The challenge in that is that there really isn’t an accountability system that goes with it. We have a common passion for health and nutrition, which is wonderful, and then it starts to diverge.

Because we’re a regulated profession, we would never call our tap water toxic. Yet, in some of the other…. It’s fair game. A lot of the recommendations may be somewhat fearmongering. They may be downright inaccurate. We’ve been working with the Ministry of Health on this.

There was a program on Vancouver Island that had hired, for high-risk pregnant women, an unregulated nutrition practitioner. They, understandably, recommended vitamin D, which is great. We do recommend that for babies. Where we diverged was based on evidence. They were insisting on cod-liver oil being a natural source. What they didn’t know is that it’s also high in vitamin A, which causes toxicity. That could have ended really badly.

Again, we’ve got a number of those examples. So the whole notion of taking a look at the unregulated nutrition practitioners is a health issue. I do understand that the solution likely lies more within the Ministry of Advanced Education, aside from policy development. But we’d like to bring that to your attention.

J. Darcy (Deputy Chair): Thank you so much for a wonderful presentation. The contribution that you can make to improving primary care — which, of course, needs to be a major, major focus in the province — I think is quite remarkable, and you’ve demonstrated that very well.

One of the examples that you touched on really touched me as well. I visited some of them, the CHCs — community health centres — in Ontario, where you can see physically, as part of the community health centre, the entire team, including dietitians who do group education with patients with diabetes and who also do teaching of young mothers and families about nutrition and so on and who are, as you said, very much integrated into those teams.

Three percent is a very low figure for primary care. Are there examples or pilot projects — since we’re great at pilot projects, not so good at scaling them up…? Are there good models, good examples that you can point to in primary care of integrating dietitians into the interdisciplinary team?

S. Kupka: Yeah, there certainly are, including in B.C. There’s a pilot project right now in Abbotsford, a partnership with Fraser Health and the division of family practice there. They’re looking at trialing and collecting some good data on that, so we’ll look forward to see what comes out of that. There’s also another example….

J. Darcy (Deputy Chair): You said part of family practice. Is it a primary care team?
[ Page 403 ]

S. Kupka: Yes, through the division…. I’m not sure who else is on the team, but it’s part of the division of family practice. The health authority has essentially loaned this group of physicians some dietitian time to be able to see what it’s like and to be able to get some data on how that works and what would be…. They’ve certainly had their challenges, particularly around the payment and the compensation, just how to work through that logistically. But they just worked through that and over it and are proceeding. I think they’re about six months into it, but I could be wrong.

There’s another example, which is probably a little bit more controversial. It’s in some of the private areas — the Copeman clinic, for example. They have a large team of dietitians. Part of the learning, I think, from that is that they realize it’s good business — that the dietitians can actually spend time and get some outcomes and then save some of the more expensive physician time.

There’s also a clinic, I believe, in Coquitlam. It’s primarily a weight management clinic for very, very morbidly obese people. Again, they’ve got a really strong team, including the dietitian. They do massive group visits where they’ll do presentations to 70 of their clients at once. They’ve come up with a pretty efficient model to be able to make the best use of that dietitian’s time.

There are, both within the public and the fragments of the private system that we have, some examples of how it’s worked in B.C., and then, certainly, going in Alberta and Ontario and Quebec.

S. Kupka: Oh, with diabetics. I would think that in the Abbotsford group, part of the client population would be. There are often dietitians who are part of diabetes education centres, even though they wouldn’t be called necessarily, I think, a primary care clinic. Around diabetes education, that would be something that would typically be prioritized, and dietitians would be more likely to be involved.

L. Larson (Chair): I can speak to that. I have a grandson who has diabetes, and his team does consist of a dietitian. When he goes to the centre, all of his team is there, including a dietitian. I think the diabetes group has done a fairly good job of making sure that they’re part, certainly, of the diabetic education.

D. Plecas: Love what you do. I think it’s too bad that we don’t have more of you and see more of you in more situations, particularly in primary care. With our initiative on Better at Home, one could see that, certainly, there’s an important role for you to play there.

It’s ironic that you mentioned that this program was started in Abbotsford, when Fraser Health has, I think you said, 1.3 dietitians.

D. Plecas: Which seems to be an unbelievably low number. Anyway, I think we could certainly work to do more there.

The one question I have relates to these nutrition practitioners. Can you tell us more about what that’s all about?

S. Kupka: It’s a trend that has been getting momentum probably over the past five years. There have always been many people practising nutrition with various backgrounds. I think with the increased interest in nutrition, there has been a response in the marketplace.

A lot of the private colleges have started offering courses, graduating nutritionists — we’ll call them — under various, whether it be certified nutrition consultant, whether it be clinical nutrition practitioner…. But all of them have something in common. They’re not regulated. The programs that they’re in don’t have any oversight.

There are transitions now, which I’m sure you would know better that I, around the Ministry of Advanced Education and the private career colleges, where they’re going to be having a different level of scrutiny. It’s still not looking at the curriculums, and it’s still not looking at the training.

The training of the nutrition practitioners is typically not dietitians. It wouldn’t typically be physicians. It would be people who are interested and passionate about food and coming with their own beliefs, as opposed to necessarily coming from an evidence-based background.

Because the employment prospects aren’t that great so far, there have been fewer — I wouldn’t say none — incidences where these unregulated nutrition practitioners have been hired by health authorities. They typically would go into private practice or, for example, in areas such as InspireHealth, where there’s a strong passion towards holistic practice. I mean, dietitians practise holistically too. We look at the whole person in terms of including the socioeconomic status and family status.

They are working around the health system as opposed to directly in health authorities. We have had instances, though, where we’ve had nutrition practitioners coming in and speaking to a group of mental health clients. There were some presentations in the community around Crohn’s and colitis — large audiences, 100 or 200 people, living with Crohn’s and colitis and receiving information from the unregulated nutrition practitioners that was just inaccurate.

The difficulty is that there isn’t…. Through their training, I don’t think that they’re given a very good, solid understanding as to their scope of practice and when to
[ Page 404 ]
stop. Using the water example, it starts great. Absolutely, drink more water. I think we would all agree with that. Where it diverges is suggesting that we should only be drinking filtered tap water and that our tap water is not safe to drink.

I think that’s where it starts to become challenging. There aren’t limits around the scope of practice, and there’s no recourse. There’s no recourse. If I were to diverge, go far away from the evidence, my college would come back and speak to me. There would be a formal investigation, and I could lose my licence to practise. So there’s a very clear accountability and recourse.

They’re trying to set up some self-accountability and regulation through the colleges that graduate them. That may be something that’s promising. I’m not sure how well self-regulation works.

D. Plecas: Why would it be that this would have evolved, given that you’re there? How did it get to a place where somebody had the notion that we would even do this?

S. Kupka: I think that’s an excellent question. I mean, a couple of things that come to mind are, one, 36 graduates a year. We have the smallest number of dietitians per capita in the country. Ontario just has a few more, but they’re pretty low per capita. There just are not enough dietitians, so we’re not able to be that accessible.

A lot of the positions where dietitians used to be — for example, in public health…. There used to be a lot more public health dietitians. I used to be a public health dietitian in northwestern B.C. When I was in that role, I was able to go to some of the health fairs and do the outreach. I was the main media contact. I was able to fill that gap in the community.

As those services were either becoming more generalist, to health promotion positions, or the staffing levels were capped, there started to be a gap, and where there’s a gap, then it starts to get filled.

I had a question about what you’re saying about the high demand for dietitians, and yet there are no resources to increase the program. Is that a university problem? I just don’t understand that. Yet you’ve got a thousand unregulated nutritionists. It seems to be a very serious imbalance between the numbers of dietitians — professional ones — and these unregulated ones.

Is there something that the government should be doing to…? I mean, I don’t understand: why is it so expensive to train a dietitian? Why can’t they just double the program? I don’t see that.

S. Kupka: There’s one program in B.C., and it’s within the land and food systems. It’s not within the traditional health programs. Around the budget letters that go out to the universities, dietitians are not included in that.

One of the asks that we had in our previous submission was to have dietitians included in that budget letter, so that the Ministry of Health would specifically ask the Ministry of Advanced Education to help to fill the supply of dietitians.

Since we first made that ask, it’s starting to become a little bit more complicated, and it goes back to some of the workforce. There’s a ten-month practicum that goes with being a dietitian, and it’s done through preceptors. As the coordinators and the staff out in the community become more stretched, it gets a little harder to absorb that. Now we’re starting to have conversations whether or not we need to change that aspect of the training model.

It’s twofold. It’s the number of seats that could be addressed through the budget levels, and then it’s support and coordination through the health authorities — and maybe another completely creative approach that may come from those discussions.

S. Robinson: This is all a very, I think, important discussion. I would just want to expand it a little bit.

What caught my eye under your proposed actions, under number 2, was that in B.C., 55 percent of older adults moved to hospital, medical and surgical units are malnourished, and the impact that happens. Fifty-five percent seems ridiculous. These are people who have come into care. So they are likely seen by a physician before.

I’m very interested in…. I mean, it certainly has impacts. So is it the physician not picking up on it? It certainly speaks to broadening a team-based approach. But clearly, there’s a gap.

I wonder if you can just speak to that number and what your thoughts are about why it’s so high.

S. Kupka: Thank you for highlighting that number, because it’s astounding how high it is — and the impact in terms of surgical time, recovery, wound healing and all the rest of it.

As to why it’s so high, it’s a little bit more complicated. Is it that the physicians don’t pick up on it? Perhaps. It could well be that they’re pressed, and the time is pretty short as well. Although, if there’s large…. It’s not always wait associated. Sometimes it’s not that evident. Unless you do a nutrition screening, which is possible to do in primary care as well, and would be a great thing to implement.

The other piece might be: what are they going to do about it? Is the physician, perhaps, aware that: “Wow, gee. I’ve got this frail senior. This senior has been losing weight”? Chances are they’re not in that great shape. Their skin integrity isn’t that great. But what do they do? How likely is it going to be that that frail senior is going
[ Page 405 ]
to pick up the phone and call Dial-a-Dietician, which is now HealthLink B.C.? There are dietitians there on the end of the phone, but they’re not going to be generally somebody’s first entry in terms of talking to a dietitian.

Coming back to the primary care model or the home health model, if there was an opportunity to be able to have more of a contact, if the dietitian was there co-located, the physician would think: “Wow. I should be thinking of this.” The dietitian would probably implement a screening program to help to prioritize the referrals. Then there could actually be some intervention and then closer connection to find out why the level of malnourishment is so high.

Is it lack of income? Is it the ability to be able to connect with the many excellent community programs out there? Is it lack of skill? Perhaps it’s a gentleman who has lost his wife and has no food skills. There could be a number…. That’s where having a little bit more of a detailed assessment would be very helpful. But for that, you have to be willing to identify the problem.

L. Larson (Chair): Thank you so much, to you, Sonya, and to your team that you brought with you today. I’m sure they’ve heard you speak many times, so they’re a very patient team. Obviously, in our discussions of team-based care, dietitians should be part of that team.

S. Kupka: Thank you. I’ll look forward to that, and you know where to find me.

L. Larson (Chair): Good afternoon. We are back on air with our next presenter, which is, according to my list, the Physiotherapy Association of British Columbia.

Welcome, Kevin. It’s nice to see you again. Most of us have a previous history with you over the years and have worked with you on many other things. I gather you have Jenny and Hilary with you today. The format is 15 minutes for you to talk to us and 15 minutes for us to talk to you. So leap in.

I’m the CEO of the Physiotherapy Association of British Columbia, and I’m here as a last-minute replacement, actually, for Bryce Kelly, who is a physiotherapist from Fort St. John and chair of our rural and remote committee of the Physiotherapy Association of B.C.

I think indicative or illustrative of the challenges of working in northern British Columbia, Bryce tried to take a private plane from Fort St. John to Prince George this morning, but if you looked outside, you would have seen that it was a little soupy out there. So he sends his regrets, but they weren’t able to land. Fortunately, he was able to return to Fort St. John.

With me are Jenny Hogan, a physiotherapist here in Prince George and northern representative on the PABC board of directors, and Hilary Crowley, who is a Prince George–based physiotherapist since 1971 and currently a member of PABC’s rural and remote committee.

The formation of this committee two years ago reflects the urgent need to address access to physiotherapy for rural residents and the challenges that rural practitioners face in meeting the needs of this population. Volunteers on this committee are very actively involved researching rural issues, including the implementation of telephysiotherapy, and are developing a rural physiotherapy recruitment toolkit.

The challenges faced by residents of rural communities when it comes to health and accessing equitable health care are well known and exhaustively documented. Given the abundance of evidence that this committee has already heard, who would blame any of you for feeling a little bit overwhelmed? But our presentation is going to focus on opportunity, specifically the opportunities that arise from optimizing the role of physiotherapy in rural and remote health care.

Physiotherapy is a well-established, evidence-based profession that has proven to be effective in assessing and treating a wide range of conditions, yet the rub is that it’s underutilized as a cost-efficient means of improving patient outcomes and health care system performance. We believe it’s time to take a fresh look at physiotherapy.

Hilary is going to provide you with a bit of an overview on physiotherapy, and as you’re going to hear, it’s a lot more than just twisted ankles and sore backs.

H. Crowley: Physiotherapists have a master’s degree as an entry to practice, supported by continuing professional development that provides a solid foundation of modern science for their profession. Evidence shows that physiotherapy positively affects the clinical outcome in treating both chronic and acute conditions and costs less when provided in community versus in-patient settings.

Physiotherapy has proven to be highly effective in the management of many health conditions, including arthritis, obesity, cardiovascular disease, cancer, stroke and
[ Page 406 ]
musculoskeletal disorders. Physiotherapists work with patients to identify and target modifiable risk factors to prevent onset or progression of chronic diseases, such as diabetes and cardiovascular conditions, and their related symptoms, thereby reducing costs associated with the long-term management of these conditions.

Physiotherapy can decrease medication use for chronic pain, diabetes, hypertension and chronic lung disease. Physiotherapy programs focused on strength and balance have been shown to lower mortality rates related to falls and the risk and rate of falls in older adults. Incidentally, the estimated cost of treating patients after a fall is 1.85 times higher than implementing a physiotherapy fall prevention program.

Physiotherapists can accurately assess, triage and treat patients, reducing patient treatment costs and significantly impacting surgical wait times by reducing or delaying the need for surgery.

J. Hogan: There are many opportunities where physiotherapists can play a greater role in rural and remote health care and have a significant impact. Here are two examples: hospital stays and chronic pain.

Example 1. It costs around $1,500 a day to keep someone in hospital in the Northern Health region. Community physiotherapists can keep people out of hospital through preventative programs and community-based treatment that keeps clients mobile and living independently. For people who are admitted to hospital, we reduce the length of stay by mobilizing clients at their earliest opportunity and through our expertise in discharge planning.

Example 2: pain. Pain is the number one reason people seek health care treatment, accounting for about half of all physician visits. The Northern Health Authority estimates that 60,000 adults in the region experience chronic pain. In 2012-2013, chronic pain accounted for approximately 372,000 additional physician visits across Northern Health and over 73,000 unscheduled emergency department visits. Physios could be employed in emergency departments to triage these clients.

We can also prevent many of these emergency visits by early intervention. There is unequivocal evidence that physiotherapy can prevent chronic pain where there is early intervention in the acute phase.

These are just two examples that we raise to illustrate the deep and still largely untapped potential of physiotherapy to provide high-impact, low-cost initiatives that can improve health and health care services in rural B.C.

K. Evans: The vision of the Physiotherapy Association of B.C. is that British Columbians are moving for life, with the help of physiotherapy. Our concern is that rural British Columbians have particularly limited access to physiotherapy care.

For example, only 86 of the 3,337 physiotherapists in the entire province of British Columbia are located in the Northern Health region. That works out to one physiotherapist per 3,488 people, compared to one per 1,447 in the rest of B.C. This represents more than a threefold difference in availability of physiotherapists to the population, without considering the patient access challenges associated with serving a sparsely distributed population.

Now, how that plays out for individual communities is outlined in appendix 1 of your handout. You’ll see that in nine towns there is no publicly funded physiotherapy access because there are no positions. Some communities have positions, but they’re vacant. In others, where there are physiotherapists, they are stretched to the limit. The physio in McBride, for example, covers the entire Robson Valley, including Valemount, where the nearest option is a two-hour drive here to Prince George.

We invite you to frame this not as a question of shortages and vacancies but as lost opportunity costs — services that could enhance residents’ health and reduce system costs and that are not there.

Another area where physiotherapy provides tremendous opportunity to improve health and health care services in rural B.C. is with our elders.

Here’s a quote from a report last year from B.C.’s seniors advocate. “The importance of physiotherapy cannot be minimized. They work with seniors to improve strength, motor function and balance. Simple things, like being able to transfer in and out of bed safely and frequently, can easily become impossible” with the deconditioning that happens when frail seniors are bedbound from flu or a fracture.

The seniors advocate report noted that in Ontario, 58 percent of residential care clients receive weekly physiotherapy, compared to 25 percent in Alberta and just 11.6 percent in B.C. — the worst in the country. There’s even less access if you live in rural B.C. Appendix 2 of your handout provides some specific examples from the Northern Health Authority. In Houston, Kitimat, McBride and Chetwynd, the number of residential care residents who receive weekly physiotherapy is zero. The three residential care facilities here in Prince George range from 0.9 to 2.4 percent.

Now, on the other end of life’s spectrum, it is well recognized that early intervention services are critical for good outcomes for children with delayed development. However, again there is a chronic shortage of physiotherapists to be part of the interdisciplinary teams providing these services to kids in rural B.C.

In 2015, the Ministry of Health released Rural Health Services in B.C.: A Policy Framework to Provide a System of Quality Care — a document that provides a solid foundation and action framework. It identified that the
[ Page 407 ]
immediate goal for rural health is to build integrated interprofessional primary care teams, and it identifies physiotherapists as an essential member of those teams.

However, with the chronic shortages in the current system, it’s going to be a challenge to find enough physiotherapists to populate those new teams, which is yet another manifestation of how the opportunity of physiotherapy to improve health care in rural B.C. is being limited by a lack of physiotherapists supply.

We invite you to view the tackling of the shortage of physios in rural B.C. as an opportunity — a sound, evidence-based and cost-effective business decision.

H. Crowley: This leads us to our first recommendation. British Columbia has fewer physiotherapy training seats per capita than any province in Canada. One in three B.C. physiotherapists are over the age of 50. A wave of rural physios is retiring and not being replaced as new graduates flock to the Lower Mainland and private practice.

The Physiotherapy Association of B.C. recommends that the Ministry of Advanced Education expand UBC’s master of physical therapy program from 80 seats to 100 seats and designate 20 of those as a fully distributed cohort — the northern physical therapy program, situated at UNBC. If we’ve learned one thing about health care recruitment, it’s this axiom: “Train in the north; treat in the north.”

Beginning in 2012, the provincial government funded 20 UBC master of physical therapy students annually to complete the majority of their clinical training in the north, but their academic training, which forms the bulk of the program, remains in Vancouver. Locating the full program in the north enables students to live, work and form ties and bonds in northern and rural communities. The northern medical program, which trains physicians at UNBC, is evidence of the effectiveness of this approach.

A 2015 survey of physiotherapists by the Canadian Physiotherapy Association asked rural physiotherapists about their decision to work rurally. The top response, at 45 percent, was the physiotherapists who grew up in a rural community. An attractive signing bonus applied to only 13.3 percent, suggesting that experience or connection to a community is a stronger influence than monetary reward, for recruitment. This is consistent with research regarding physiotherapists in northern Ontario, as well as rural Australia.

A training program based in the north that targets rural entrants is a well-proven strategy to assist with recruitment and the supply of physiotherapists in northern and rural regions.

Retention is as critical and as complex as recruitment. Research shows that continuing professional support is one of the key factors. The rural physicians program, initiated through a partnership between health authorities, the Ministry of Health and Doctors of B.C., has 11 separate programs to support physicians practising in rural B.C., including continuing education funding.

There is nothing comparable available to physiotherapists and other allied health professionals, who are key members of the interdisciplinary primary and community health care teams now being established to meet the needs of rural residents. A lack of continuing professional development opportunities is cited by physiotherapists as a key factor contributing to high turnover in rural B.C.

PABC recommends that the Ministry of Health partner with rural health authorities to establish a process and funding for continuing professional development for physiotherapists practicing in rural B.C.

J. Hogan: Effective health care is not just about the numbers on the ground but also about how they are deployed. PABC fully supports the move towards integrated interdisciplinary primary and community care health teams, particularly in the context of challenges of rural health care.

We encourage continued exploration of a variety of population-based models of interprofessional health care service delivery in northern B.C., such as the current trials involving itinerant physiotherapists that accompany primary care teams travelling to remote communities to provide care, and the use of telehealth to support patients and teams.

We would be remiss if we did not, in our remaining time, touch on how technology can contribute to the effective deployment of physiotherapy resources in rural health care, particularly telehealth. Telehealth holds enormous promise for increasing access to services and supporting rural practitioners who are generalists. It is critical that this be developed within a framework that supports the building and maintenance of in-person relationships and in-person care.

Having access to telehealth can mitigate the burden of the costs associated with travel, harsh weather conditions and geography, because both patients and physiotherapists can avoid travelling great distances. Telehealth also supports practitioners by facilitating interprofessional team-based care, increasing access to specialists and shared care.

We recommend that the Ministry of Health develop funding models and compensation systems that support physiotherapists to engage in telehealth. We further recommend that the Ministry of Health, in partnership with a rural health authority, initiate a pilot project to examine outcome and cost savings of telehealth in the post-surgical rehabilitation of patients with joint replacements living in a rural community.

Still with technology, allow us to add our voice to the loud chorus calling for the creation and management of an electronic medical records system, which is an imperative prerequisite to the realization of the integrated,
[ Page 408 ]
interdisciplinary health care delivery system envisioned by the ministry.

K. Evans: Thanks again for this opportunity and your attention. We would be pleased to answer any questions you have and even more pleased that we came in a minute ahead of time.

S. Robinson: Thank you for the presentation. As I was listening to you speak, of course, I’m thinking of my own experience with physiotherapists. Thankfully, it hasn’t been much, but there’s been some. I’m interested in using the technology in physiotherapy, because any time I’ve been to a physiotherapist, it’s been hands-on and making sure that I’m doing the exercise correctly and helping me feel exactly which muscle I’m trying to engage and holding me down in a certain way or taping me up in a certain way.

Can you explain just a bit about how physiotherapy works with a telehealth model?

K. Evans: Well, actually, no. I’ll defer to the physiotherapist here, because I’m not.

H. Crowley: We would do the initial assessments ourselves. We’re already using telehealth in some communities like Yekooche and Takla, north of Fort St. James. The physiotherapist goes in and assesses the clients and then works through somebody in the community, identified, that will be a caregiver to that client. Then, after the physio comes back to Prince George, they provide ongoing follow-up through the telehealth.

They’ve already given hands-on skills to a caregiver in the community. Then they go back every month. Monthly they can upgrade the skills that need to be done. But in the intervening time, the client’s receiving therapy from an identified caregiver in the….

S. Robinson: So it’s a monitoring role that you play during the telehealth portion of care?

H. Crowley: Monitoring, and you may still advance it from the telehealth perspective.

K. Evans: If I may just quickly add to that. I’m sure, Selina, that you probably saw this too when you were….

K. Evans: Yeah. I mean, that’s typically what you’ll get in a physiotherapist’s office to give you exercise prescription. Technology has advanced to a point now where, in fact, the physiotherapist can give you an app that’s on your phone that you can download specific exercises to you, including the video instruction, and you will actually then put in your compliance as you do those exercises. The physiotherapist loops back on their unit and can see how you are complying, and also whether there is any pain or complications, because you will be registering your pain as well.

Just one example of how, actually, the answer to your question today will be different from the answer six months from now because of how technology is moving. The point is that physiotherapy and the healthcare system needs to get on this train, because we are behind.

L. Larson (Chair): Okay. I’m just going to check with Sam. Sam, do you any questions?

J. Darcy (Deputy Chair): Thank you very much for your presentation. So many things I’d love to pursue, but we get one question each — or one and half, if we’re smart.

The figures about seniors were very compelling from the seniors advocate — the number of seniors who have access to physiotherapy or occupational therapy, compared to Alberta or Ontario, as you’ve mentioned.

I’m trying to wrap my mind around…. I know what the barriers are in the Lower Mainland, and we know that for joint replacements, for instance, if you don’t have an active physiotherapy regime for several months afterwards, you don’t get the benefit of that surgery, right? I’m sure that there is evidence that indicates that.

Aside from not having enough physiotherapists in the north, there’s also the financial barrier, right? Because physiotherapy was once covered and is not now.

J. Darcy (Deputy Chair): It was delisted. So even when there are more physiotherapists around in the Lower Mainland, I’ve seen — people come to my office — a huge barrier to be able to access physiotherapy services, right?

I guess my question is: do we have…? It would be wonderful, in making this case, because I think we’re all on the same page. Do you have studies, research, about the impact? For instance, we do, I don’t know, 80,000 hip and knee replacements, joint replacements, in the province every year. I’m sure that somewhere there must have been research done about what the health outcomes are when you do have access to the full physiotherapy sup-
[ Page 409 ]
port that you need, compared to not. Do you have any access to that?

K. Evans: We certainly do. It’s not at our fingertips. I’d be happy to provide that to the Clerk and to the committee.

K. Evans: Absolutely. Because it is unequivocal. There’s no question about that. You can tie health care costs to that decreased recovery as well — or extended duration of stay in hospital.

J. Darcy (Deputy Chair): Absolutely. Because routinely, you get three coupons for physiotherapy, and then you’re on your own. So if you can afford to pay for the rest, you benefit from it. If you can’t…. Here you have the issue of not having the physiotherapists either.

K. Evans: If I may, just another comment in terms of the access. There’s the private physiotherapy sector, but there’s also the public physiotherapy sector, which is, obviously, funded and available to all British Columbians regardless of their financial status. In the north, I think what we’re looking at is strengthening and fortifying the public system.

The public and private do work together, because when you are discharged from hospital, there are times when you will maybe go into the private sector. But I think oftentimes, at least in the Lower Mainland, the conversation about physiotherapy is focused on the private sector.

H. Crowley: Can I just give a short answer too? At the moment, there’s a six-week post-op program for total hips and knees at the hospital. Just one day a week, but for six weeks. But it’s had to drop, because they’re short of staff. So when they get more staff, it’ll carry on again. That’s one way it impacts. But also in the residential care, where we have no physiotherapists working, that would be publicly funded. It’s just that we need a position created, and then the physios would apply.

D. Bing: Thank you for your presentation. Just a little earlier this morning we had the dietitians come in. They were telling us how there’s a huge demand for more dietitians, but they’re restricted to 36 to be trained at UBC, and they can’t get, I guess, the education people to increase the size of their numbers.

When I went to dental school 43 years ago, there were 40 dentists in the program. Today, they still graduate 40 dentists. Is that a similar situation to physiotherapists? Are you restricted in the numbers because of education funding and other inertia in the system?

H. Crowley: It’s restricted by funding for sure. It started off as being a combined program, physio and OT, and there were 20 of each. Then it got split into physiotherapy and occupational therapy. Then physiotherapy went to 40 seats and to 80 seats. But everybody just stays down where their training program is. That’s why we’re really…. And they’re stuck at 80. They can’t get funding for more at the moment. We keep trying. But even UBC wants to place the extra 20 up here, because they see the need up here.

D. Bing: One of the arguments we had for restricting the numbers of dentists, anyways, was that they always would get 60 to 100 come from other provinces. Does that happen with physio? Do they come from other provinces?

H. Crowley: No. They apply, but preference is given to British Columbians. For instance, there were 200, I think it was, applicants last….

H. Crowley: Oh yeah. Graduates come from all over the place. We get a lot foreign-trained people because we can’t find enough Canadian-trained.

D. Barnett: That’s a good topic: the foreign-trained. They have to come into Canada as foreigners, but they still have to go and take some more education.

I live in rural British Columbia, and I have two very qualified people who came here because they found an ad via the federal government. They came here to do their profession. When they got here, they found they had to go back to school for a couple of years. So they just said: “Well, we’re not doing that.” They do it on the sideline, and they take care of an awful lot of people but not through the medical system.

Is there something that you could suggest in order for these foreigners to come in, that they could be able to work without taking so much training in Canada to be able to get into our health care system? Would that help?

H. Crowley: We have a national exam that every physiotherapist has to pass. There’s an interim licensing that one can get, as long as they’re being mentored in a facility while they’re getting ready to take that national exam.
[ Page 410 ]

D. Barnett: The problem is in rural British Columbia, there’s no facility for them and no mentor.

H. Crowley: Right. It would be a challenge. We do have some that manage, but they have to come to Prince George for their mentorship time.

K. Evans: As a matter of policy, the Canadian Physiotherapy Association and the Physiotherapy Association of B.C. support the structure that’s in place by the alliance, which are the regulatory bodies from each jurisdiction, nationally. Our role is to ensure that those foreign-trained physios have the support that they need to write that exam as soon as possible and to pass that exam. We do that through our continuing professional development programming.

I don’t think any British Columbian wants to see the standards lowered as a result of our feeling the pressure of needing more physiotherapists. I think we can have it both ways.

K. Evans: It’s an informal mentorship program. The continuing professional development office at UBC is now looking at whether there’s a demand in rural B.C. for a more formal mentorship program. Jan Lowcock is actually doing some work into that right now.

D. Plecas: Thank you very much for your great presentation. The first thing I want to do is echo my friend Judy Darcy’s point about wishing that we could have some outcome data. I think that would be extremely helpful to us, health outcomes.

My question relates to the whole business which, I guess, in a nutshell, seems to be that there is this very noticeable shortage of physiotherapists relative to other provinces, and particularly so when we think of seniors.

I guess my question is: is this something that has always been that way? Or has this become an increasing problem? More importantly, can you tell us why you think it got to that point? Like, somebody must not be making decisions.

H. Crowley: I’ll just put in my two-bits worth. I think somebody has got a really, really tight hold on the finances in the province, because the need is identified and yet there are no more seats being offered.

K. Evans: I think what we hear from our members…. I’m fairly new to the physiotherapy association — all of five months — but with my former background, I do ask a lot of questions. I’m a bit of an information sponge. Clearly, what I’m hearing is that there’s a need for somewhat of a de-medicalization of the health care system in British Columbia.

In terms of a lot of the power, in terms of decision-making and dollars, it’s nurses and doctors that are highly influencing those decisions. Other allied health professionals, including PTs, OTs, speech pathologists, offer value but really don’t have much influence at the table where some of these policy decisions are made.

Darryl, with respect to your specific question: has it always been this way? You take a look at, first of all, the demographics. The need for physiotherapy, because of the aging population, has never been greater.

The other aspect is that we now, because of the tremendous sums of money we’re spending on health care, need to be looking more at a preventative approach to health care. A very slow ship to turn around, but as we do, the utility of physiotherapists becomes more and more apparent — and so does the shortage.

M. Dalton: I’m just noticing that you have a number of positions that are not filled — that are approved, but not filled. If we could disperse all the new physiotherapists that are being trained for the positions that are available, would that fulfil the official need or not? Or do we still find the problem of physiotherapists remaining in the Lower Mainland and maybe the Okanagan?

K. Evans: I’ll give you an example. The northern cohort so far…. Even though the academic is not based up here in Prince George, 47 percent of the 20 students who were in that first cohort are now practising in the north. Fifty percent of the second cohort are now practising in the north. If they actually had their academic training up here as well, so they could develop those emotional ties and bonds to rural British Columbia, we believe that number would increase significantly.

I was at the UBC school of physiotherapy recently, and I asked the soon-to-be graduates in October: “How many of you are going into private practice?” Most of the hands went up. “How many of you are going to practise in the Lower Mainland?” Most of the hands went up. So a program like the UNBC program, the UBC program situated at UNBC, we believe, is going to go a very, very long way in addressing a large part of this problem.

As far as the number of seats that are made available, say, at UNBC for physiotherapy or for other programs, is that designated by the province or by the university? Who has the decisions? Are the numbers allocated by the
[ Page 411 ]
Ministry of Advanced Education, or is there a lot of flexibility for the university?

K. Evans: AVED has looked at this in the past, and we hope they’ll look at it again.

H. Crowley: I just want to add something. Kevin mentioned the north. It’s north and rural. So those 50 percent weren’t all in the north. They were northern and rural.

L. Larson (Chair): Thank you very much. We even finished on time, which is practically the first time we’ve done this today — that we finished on time.

Thank you so much, all of you, for being here. What you’re saying is what we’ve been hearing. The message is very strong: in lots of areas, we don’t train enough people, and in other areas, we don’t include them in the team that actually provides whole holistic health care. That has come through very clearly. Thank you very much. Thanks for taking the time.

Our next presenter in Martha MacLeod from the University of Northern British Columbia, School of Health Sciences. As you’ve heard from the previous speakers, there is a shortage of seats for people in the health care services. We’ve given you 15 minutes for your presentation and then 15 minutes for us to ask questions.

M. MacLeod: Thanks very, very much. As you see, I’m going to make two presentations today. The reason for that is I’m a professor in two schools at the University of Northern B.C. I happen, also, to be on the advisory committee for the physiotherapy, so I was very pleased to hear their presentation. We hold many generalist hats in the north. I’m at the School of Nursing and at the School of Health Sciences.

I’m speaking right now from my place in the School of Health Sciences and from my vantage point as a researcher in rural and northern practice and its development.

Now, I’m a qualitative researcher; and that is, I work with teams to study in depth the processes and practices which health professionals and organizations work to develop better working systems and structures. That’s what I’m going to talk about today.

Notably, I’m leading a research project entitled partnering for change — understanding the process of primary health care transformation, which is a longitudinal qualitative study funded by the Canadian Institutes of Health Research. My co-principal investigators are Drs. Neil Hanlon and Margo Greenwood of UNBC, Trish Reay, in Business at the University of Alberta, and Dr. Dave Snadden from the University of British Columbia faculty of medicine.

Now, the purpose of this research is to examine how a large rural health authority — Northern Health — is accomplishing whole-system change as it shifts its primary attention from the acute care system to a much greater focus on meeting the health needs of the population. This whole-system change is moving the organization in ways that more consistently and coherently put the patient and those living in the community at the centre of care.

This presentation addresses the second question of concern to the committee: how can we create a cost-effective system of primary and community care?

Now, unfortunately, I won’t be talking about cost-effectiveness. What I’ve learned in the process of doing this study — and I know you’re looking at outcomes — is that…. We’ve worked with a health economist, and we were hoping that we could do an economic analysis in the process of this research. But we realized that economists deal with questions of what and, once you have it, what’s happened.

What this research deals with is the question of how: how can you make these changes actually happen? So I’ll be talking today about how we’ve been studying the changes actually happening for whole-system change.

I’ll talk a little bit…. I’ll start with what Northern Health is actually doing and what’s different in the way in which Northern Health is working. What I’ve found in my work with research teams across this country is different. What Northern Health is doing is working with partners — physicians and communities — to make transformational change. That’s not just rearranging things, not trying another pilot project, but rather shifting its entire health system in order to work together.

What it means is a commitment, through a continuum of consultations, through collaborations, to partnerships. So there’s a sharing of goals, commitment to others and planned steps to make change.

Now, where the goal is, is to create a system of integrated health services built on a foundation of primary care in this large northern geographic health authority, which you know is two-thirds of the size of the province and has a population of under 300,000. Less than Iceland is where we are.

What does this whole-system change look like? It’s got physicians, health authority and communities. Northern Health is leading this by influencing changes in its partners that are external, that are linked to the work of the health authority. The view is to work for the patient and the community through what they’ve been calling a
[ Page 412 ]
Northern way of caring, which is the way in which things are done in the north, usually by partnering.

First of all, through primary care homes, people can establish a long-term relationship with a multidisciplinary team that provides them with health care and supports them in managing their own health.

Third is moving, efficiently as some people need to, towards tertiary care — which is the highly specialized, in Vancouver. Then community services focused on population health.

The way in which Northern Health started to work with primary care homes is clearly identified in the vision for it. Make sure that the language, over time, began. This has been going on quite consciously since 2009. We started our research in 2011, and started to chart with that.

The care is accessible, continuous, coordinated and comprehensive. Patients then have access to that broader interdisciplinary team, which includes the physiotherapist and others, and also uses well-supported information technology, including an electronic medical record.

Here, in northern B.C., there’s a system that many of the physicians use called MOIS. It then has been linked through Northern Health so other disciplines can work on it. Northern Health is doing an awful lot in order to make it so that the practitioners all can chart in one place and then have the databases that are necessary for provincial reporting linked through that.

In the primary care home, there’s assessment, shared-care planning, caregiver support, coordination of care, ongoing quality improvement and the idea that there is the focus on population health as well.

A key piece of this is alignment of services. What’s happened in Northern Health, different than other places in the country, is that there have been various forms of primary care clinics or services created across this country. Many of them have been added onto the systems. Many of them have provided more funding for physicians — many of them where physicians actually hire staff to have this more coordinated care.

In Northern Health, there’s been an active process whereby they are changing the services. Particularly, the services that are changing are home and community care, public health, and mental health and addictions, all of which were provincial services at some point, then moved to the regions and now worked in a more integrated way, because they have been in a very siloed process.

Early in this process, Northern Health traced the patient journey. They identified that one older person may have 13 intakes done — 13 different people they need to tell their story to and move through. So what they’ve done as part of that is to cut down those different intakes, get people working together, charting together and moving that way.

Okay. So what have we found? We’ve found that there are very few road maps to guide this. Indeed, what Northern Health is finding is that there is not a map. One needs to create that vision and then take the steps as the way to go.

What have they done? I’ll tell you a little bit about this research so you can see the context of it. It’s a multiple-case study over four years, 2011 to 2015, and we’re just finishing up in 2016. Seven communities — Prince Rupert, Burns Lake, Fraser Lake, Valemount, Prince George and Fort St. John — some larger ones in the north and some very small ones. In-depth interviews were conducted each year in each community and regionally — a total of 21 to 28 each year at the regional and 50 to 58 at the community level — including community leaders, physicians, Northern Health staff and care providers and the executive and board of Northern Health. We kept documents on all of these.

What did we find? We found that a key component of this is that Northern Health has worked from a strategic plan. That plan has been developed with the partners, it clearly articulates directions for action, and it serves as a touchstone. They’ve just renewed it. It’s really quite something, the number of people we interviewed that said: “That strategic plan is something that we use and we see as we go forward.”

Now, one of the things that a general practitioner said early on was: “It’s a learning process for all of us, and I think it’s also a learning process for Northern Health. I really like the way that they engage with the people on the ground level. It’s different in every practice, different in every town, and the needs of those communities are different.”

That’s a key piece — that Northern Health actively engaged municipal partners. In 2009, they did a series right across the north, listening to and recording participants’ health concerns — a structure of group conversations across that period of time. They then identified from that that there was a need for a primary care home for every northerner and for accelerated primary care innovation. Leadership and community engagement was key.

The idea was that more people than they thought said they needed to get involved in preventing illness and promoting health, and fewer than they thought said: “We really need doctors here.”

Over time, they’ve involved people, and Northern Health has advised. How did they determined what municipal leaders? What they said was: “People who can move a community in a direction.” So the involvement of municipal politicians has been key with that.

Municipal politicians themselves have said that this partnership has been not without its challenges. As one said: “We’re firefighters. We respond to small firestorms versus the larger ones that are necessary for the planning for health.” I think that’s a key point for this committee.
[ Page 413 ]

They’ve been opportunistic — strategic yet opportunistic. What are the opportunities, funding available from various pots? How can they move forward?

What I’ve experienced is that the Northern Health executive and many people in Northern Health have had to work with the ministry in saying: “Okay. Here’s your goal.” What the ministry is saying is that you must accomplish that goal in a particular way, and what Northern Health is trying to say is: “We will get to your goal, but we need to get to it in a slightly different manner.”

Keeping that communication open between the health authority and the ministry has been key. Part of what has helped with that is Northern Health’s activities that they’ve had with their politicians and community partners at the municipal level. And the regional MLAs, as well, have certainly been there.

The physicians. What has got the physicians on board? The physicians on board have come there because, as one said: “It made me pay attention.” It’s about participating in a system change, and that was attractive.

The other approach that Northern Health has taken, which is part of the how, is that the people that were making improvements did not have a preset agenda. They were willing to think about things in a new way, willing to listen, admitted they didn’t have the answer. The only thing was a requirement that it would be best for the patient — and to improve the quality of life for providers and be a suitable effort.

They created space for taking risks. They’ve focused on it. It’s not without its rockiness right now. They took a long time, and they have been taking a long time to work with the unions. They’re in the process now of making new positions for primary care nurses with primary care teams and starting to move those positions into that integrated team.

What we’ve learned from this is that this kind of major system change is long term. It cannot be done within a time frame between elections, unfortunately. It needs to have the vision, the view, on the long term. It needs to have leadership that is extended over time.

I’m going to quote from the CEO at one point in time. She said: “Do not underestimate the magnitude of change and the continuous effort required over time. Do not be afraid to allow and acknowledge failure and to try again. Keep your eye on the ball, stay focused and avoid distractions.”

From our perspective, you need consistency over time and leadership not only within the health authority but also with the community and with government and the communities — and then watch for distractions from this.

L. Larson (Chair): Thank you very much. I have one question. Obviously, you’re talking about a team. Are you including in that team the dietitians, the physiotherapists?

M. MacLeod: Yes. The dietitians and the physiotherapists are all part of that interprofessional team.

D. Plecas: Thank you, Martha. I’m listening to you, and I’m thinking it’s almost like you’re a spokesperson for Northern Health. I’m just getting a sense that…. I know you’re not, of course. But you’re not saying things to us which are negative, if you will, and that’s not quite what we’ve been hearing since we began today. It’s a very different flavour.

It sounds to me like you’re saying: “Look. We’ve looked at all of the issues. We’ve got a plan in place.” You refer to the strategic plan for Northern Health almost as though things are well in hand, and I’ve got to believe that you don’t really believe that’s totally the case.

D. Plecas: Yeah. So I guess if you could say something about what challenges you expect along the way. That’s one thing.

I don’t know why I’ve missed this along the way today and yesterday — the notion of a primary care home. What exactly do you mean by that?

M. MacLeod: Primary care. Let me just go to the primary care home, because they’re figuring out what it is, all right? They’ve got a vision.

Okay. Let me take your first part of it first. What I’ve seen is really amazing change as a researcher, and I think that’s probably what I’m focusing on.

There have been challenges, and there are huge challenges right now. You can imagine moving a great…. What they’re trying to do is build the airplane while it’s in the air. They’re trying to work on a system where people say: “I want to have an absolute road map. I want to know what I’m getting into. Give me that clear direction.” And they’re saying: “We don’t have that. We have the end in view. We know where this needs to go to, and it might be a little different each time it gets there. Fort St. John might take it quite differently than Fort St. James.”

Nevertheless, there are some principles and practices. It is both top-down and bottom-up. It can’t be both of them. You get problems when it’s top-down and problems when it’s bottom-up. The communication systems are tremendously complex, and moving the system is tremendously complex. There are lots and lots of challenges. I don’t want to minimize that.

M. MacLeod: What’s a primary care home? All right. What happens in it…. The primary care homes have been working out…. We’re trying to figure them out and the primary place for them. It’s worked into primary care, which has been the physician and nurse practitioners, primarily, but the divisions of family practice have been some of the key components with that. So it’s the physician, it’s the nurse practitioner, and then it’s an interdisciplinary team, including the physios, the mental health workers, the nurses and others working with that group for the patients.

Now, many people, many of us, go for episodic care. You make an appointment with your physician. You get something. Those ten minutes are all you need, and you move. However, part of what one of the researchers who is working with me is saying is: “Who needs a team?” Not all of us need that team, but we want to go into a primary care home. If we need that team, then it’s there. Then there’s an easy referral. There’s an easy intercollaboration. It isn’t just a referral and then you’ve got to move to somewhere else.

M. MacLeod: They can be. It can be, also, in fee-for-service practices. In fact, they’re working on how you can have a virtual community health centre with practices.

M. MacLeod: I think one of the things…. I don’t have this exactly. You’ll have to ask Northern Health for that. But what they have is a mix…. What they look at is the patient population. So if you’ve got a large number of child-bearing women, such as up in Fort St. John, you’ll have a different mix of professionals than you will in a place where there are a lot of older people or where you’ve got a group that work with frail elderly.

S. Robinson: Thank you very much for the presentation. I really appreciated you starting it off by qualifying that you’re looking at how the change happens, not why it happens.

Through the presentation, you commented…. It seemed that it’s organic, that the change needs to come from within the community, and it needs to have all these champions who are continually moving a very difficult system in a particular direction.

I’m wondering…. It sounds like what you’re doing is documenting the change as it’s evolving. This is a documentation of a whole system shift. Based on what you’ve witnessed and what you’ve documented, can you advise us as a committee on some of the recommendations we ought to be making going forward and looking at these particular issues, about what we ought to recommend based on what you’ve been witnessing and documenting?

M. MacLeod: I think the recommendation I have I said at the end, which was to allow for consistency of vision. One of the things that Northern Health is doing is achieving provincial goals but in a slightly different manner.

That notion of provincial goals that are suited…. They have to be suited to the particular context. The goals for the province may not be exactly what the goals for the north need to be because of the different numbers and the amount of resources that need to be there. For instance, the surgical services goal is a less important one than some of the population health goals in the north. Nevertheless, consistent goals are quite okay. But there need to be opportunities for meeting those goals in different ways in different parts of the province.

One of my recommendations is, because you hear things coming out: please don’t go the route of Alberta with one health authority. What I’ve seen the health authority, Northern Health, being able to do is be responsive to the people of the north in a way that my colleagues in Alberta are not seeing in the rural areas.

The idea of promoting ways to keep stability in the executives and the board of those health authorities, I think, is an important thing to consider from a provincial perspective. And allowing and understanding that if there is going to be whole-system change, it will happen over time, and it will not always be comfortable.

S. Hammell: Thanks, also, for your presentation. It’s not clear, but it is clear. I think in many ways, you’ve accomplished what you needed to.

My interest is, in particular, with mental health and addictions. How has that fit into this new and different way of working?

M. MacLeod: What I understand…. Remember, I’m looking at the change. You’re asking a bit of a “what” question. What I can say is that the mental health and addictions teams are being integrated into the interprofessional teams around the primary care home.

I’m going to give you an example of something that I think is happening. That is that within a primary care home, there may be a primary care nurse. That is what they are looking at — a primary care nurse. That primary care nurse, in some practices, may have a background in mental health and addictions. She would pick up the mental health aspects of it, of some patients’ concerns, and be attuned to them differently and then communicate that within the team differently and assist in the connection of that client with the more specialized mental health team.

There will still be that specialized mental health team at the specialist level. But at the primary care home, there
[ Page 415 ]
will be more attunement to mental health and addiction issues.

J. Darcy (Deputy Chair): Thank you so much for your presentation. I think questions will spill over into the second part, I’m sure.

From everything I know about Northern Health and have seen, it is the health authority that is undertaking not just pilot projects but system change, which also does mean that you break a bunch of eggs when you have to make an omelet. It isn’t always perfect.

The integration of primary care and community care. I wonder if you can talk a little bit more about that because that also affects who the team is. In community care, it’s care aides. It’s health care assistants. It’s LPNs.

Maybe we can get into this more in your second question. I know that the primary care home could be a CHC. It could be the equivalent of a family health team — FHTs, as they call them in Ontario. There are a lot of different models that still meet that.

I’m interested, in particular, in the integration of primary care and community care — what that looks like and who the team looks like.

M. MacLeod: Again, the team could be a public health nurse plus home and community care, a nurse, maybe a case manager. I’m not sure exactly what they’re doing with the case management notion, but the case manager could be, for the patient population…. Remember that they’ve got a patient population. So for that particular patient population, they may also have a care aide or an LPN working with them. They may have an LPN, depending on the patient population, in the primary care home or in the team.

Each team is going to be slightly different, and that’s what they are in the process of looking at now. What do those teams actually look like? When you say “community care” and “community services,” those are the people that are being redeployed into these interprofessional teams around a primary care home.

J. Darcy (Deputy Chair): Does that include the home support and home care program?

Now, at the same point, there’s the interface with the specialized. I’m not exactly sure how…. For instance, I know public health more than I know exactly what that…. What they’re doing is keeping a smaller communicable disease group for the region because they know there needs to be rapid response.

The group that does the well-baby, the mom and babe, services is going into the primary care home — the interprofessional team around the primary care home. So I would expect that when they work alongside the mental health and addictions people, you might get a picking up of postpartum depression quicker and moving in on that. Same thing with the home and community care and linking that in with the OT services. What I’ve heard from one of the researchers is how OT is really connected in better and differently than before.

I can’t describe it. The Northern Health people can. Perhaps that might be something that this committee might want to hear directly from them.

We’ll let you shuffle your paperwork and begin your next presentation. Welcome, again.

L. Larson (Chair): Also, welcome to Dr. Lela Zimmer. Thank you so much for coming this afternoon to join Martha.

L. Larson (Chair): I’ll let you just leap into your presentation — again, 15 minutes, and then some time for us to ask questions.

M. MacLeod: Okay. As I said, I was a professor in two schools. I’m talking from my place in the School of Nursing. As of yesterday, I am no longer head of the School of Nursing. Dr. Zimmer is head of the School of Nursing. That’s why we’re in a bit of a transition here. I’ll do the talking. Lela just got back from sabbatical, and I’m just heading on to sabbatical. Lela is also the interim chair of the school and the undergraduate programs coordinator.

I’m speaking from two vantage points here — again, as the former head of the school. UNBC is one of the very, very few universities in Canada that specifically focuses on the preparation of registered nurses and nurse practitioners for rural, remote and First Nations communities.

The second vantage point arises from research. My second-largest piece of research is on a nationwide study called Nursing Practice in Rural and Remote Canada. It, too, is funded by the Canadian Institutes of Health Research. With a group of researchers, including Dr. Zimmer, and an advisory team of nursing leaders from every province and territory in the country, we’ve surveyed registered nurses, nurse practitioners, licensed practical nurses and registered psych nurses in the western provinces to find out what contributes to recruiting and retaining them in rural and remote communities.

Now, we did a study a dozen years ago. It was the first time that rural and remote nursing was described and charted in Canada. We only studied registered nurses at
[ Page 416 ]
the time. With the changes in primary health care, we were asked whether or not we would consider redoing this study ten years later, at the time, and then include the larger family of nurses, which includes the nurse practitioners, LPNs and whatever.

I’m going to respond to the first concern of the committee in this presentation: how we can improve the health and health care services, and long-term solutions to the recruitment and retention.

A dozen years ago, our main findings about recruiting and retaining nurses were three things. Partnerships between communities and health authorities are needed to successfully recruit and retain nurses. Workplace supports in health authorities and agencies enhance the retention of rural nurses, and better supports are required for nursing education programs that specifically target rural and remote.

Now, we’re still in the early stages of data analysis and writing on this project, so I can only give you some early responses to this. But essentially, what we’re thinking we’re finding is about the same. In this national study, 3,822 nurses have participated — a return rate of 40 percent. In B.C., we’ve got 292, with a return rate of 38 percent. We’ve also analyzed the Canadian Institute for Health Information nurses database, and a policy document analysis is part of this.

What we find is that in B.C., about 12 percent of people live in rural communities. That you know. Our definition of rural is Stats Canada’s: under 10,000 living outside of the commuting distance of a large urban centre. About 7 percent of nurses in B.C. serve the 12 percent of those B.C. residents. The numbers of rural residents in B.C. is going down — the percentage — as is the percentage of rural nurses in B.C. There are about 2,800 rural nurses in B.C., including NPs, RNs, RPNs and LPNs.

We know that there are a few things. They mentioned it in the physiotherapist…. We know that one of the best ways to recruit and retain health professionals is to capture those who grow up in rural communities. Now, that data is available on physicians around the world, for sure. Our study shows it’s the case for nurses as well.

Having said that, there’s a little bit of cause for concern in B.C. Fewer nurses in B.C. than in other provinces and territories across Canada have grown up in rural areas. So we’re not capturing those people who are wanting to be educated as nurses and keeping them in rural B.C. About half of the rural nurses grew up in a community with a population over 10,000. That’s a little different than in others.

Now, men. People often ask: are there very many men in rural B.C. in nursing? About 6 percent of nurses are men in rural B.C. That’s not a huge difference than across the other….

The regulated nursing workforce in rural B.C. is older and aging faster than in urban parts of the province. Apparently, approximately one-third of all rural nurses are older than 55, and nurses under the age of 35 represent only about 1/5 of the population. This is particularly evident for RNs, where 75 percent are older than 45, compared to a national average of 62 percent. So we’ve got an aging population in the rural areas.

It turns out that the education…. One of the things that has happened over the last two decades — not quite two decades — is a baccalaureate is entering into practice. Indeed, we’re seeing the effect in rural B.C. Where there used to be an education gap in rural B.C., that’s catching up.

Fewer rural nurses in B.C. are employed in permanent full-time, compared to across the country. The proportion of RNs in B.C. working full-time has decreased in both urban and rural locations, and that certainly is there in the rural areas.

Now, the number of RNs…. When you talked about the questions about the proportion of LPNs and others working in community settings, what we’ve noticed is that in rural settings, the proportion of LPNs is increasing, and the proportion of RNs is decreasing in the community settings. We don’t have…. I can’t tell you exact numbers with that, but we’re noticing that trend.

Most of the LPNs, rural LPNs in B.C., work mainly in long-term care settings — about 71 percent — which is higher than it is in the national average. Just a third of them work in acute care, the rural LPNs — lower than the national average. NPs in B.C. have a broader scope of practice, and most work in primary care environments.

The kinds of things that we have in terms of accessibility…. We asked a number of questions about primary health care and: “Do you” — rural nurses — “think that patients have accessibility to health care services?” In general, rural nurses in B.C. felt positively that patients did have accessibility to primary health care services, but the numbers are slightly lower compared with the national average. So that’s sort of interesting.

Most patients that needed urgent care can meet a health care provider within the day of opening hours; 86 percent said they could. Patients are treated with respect and dignity — 89 percent. And concern for maintaining patient confidentiality is strong — 80 percent. You know that in small communities, that’s a challenge. And nurses normally consider their workplace safe for patients to receive health care services — 91 percent.

The major concern was the population health orientation of the health services, and only 37 percent said that the workplace took part in a needs assessment, and they thought they responded slowly to the health needs of the community they serve. So that’s something that we think needs to be changed in B.C.

Half of people thought that there was a poor fit between services and the community’s health care needs, and those who thought that patient outcomes were monitored was lower — 51 percent — than average. The average across the country was about 61 percent.
[ Page 417 ]

There are good processes for critical incidents across the province, and that’s about 82 percent. And they think that patients’ charts are kept current — about 85 percent.

However, only 46 percent of B.C. nurses thought that their workplace regularly measured quality improvements, compared to 61 percent at the national average. So there’s a difference in perspective here.

The collaboration. One of the things we ask about is collaboration and: is there good collaboration, and is there not? There is collaboration — 82 percent — with other disciplines.

What about that in the nursing education of northern B.C.? In northern B.C., we have four programs, several programs. One is the undergraduate. We prepare nurses with bachelor’s degrees in Prince George, Terrace and Quesnel. We know that 70 percent of our graduates are employed by Northern Health.

We have entered into a partnership with Northern Health, where our graduates…. We work with them so they can track our graduates through. We can get an idea of how many are educated in the north and stay in the north, and we’re just beginning to get that data with sharing with that.

We produce anywhere from about 106 to 120 graduates of that program every year. We’ve found that over the years since 2005…. So 2009 were the first graduates from Terrace, and they have found that there is stability in the workforce now in Terrace and in the northwest, the whole northwest.

We do not have any education in the northeast. There have certainly been requests for it in the northeast. We’ve not been able to get funding for that, and the turnover is the highest there.

Like most education programs, we overproduce in the areas that are around the areas of the school, and the distribution is sometimes a challenge. We’re trying to overcome that through clinical placements, but the argument that the physiotherapists made was a very good argument, we’ve found, and both the UNBC program and the Terrace area show it.

Our nurse practitioners. We are producing around seven or eight. Now we’re up to ten this coming year. All of our nurse practitioners are getting jobs. There are job openings for nurse practitioners in the north. I believe there’s a saturation in the south. We increasingly are getting people wanting to live and work in northern B.C. or in rural B.C. Therefore, that’s what we have with our nurse practitioners.

The kinds of things, then, that our study is showing: workplace supports, growing people, educating people in the rural areas and supports for nursing education. Our rural nursing certificate program goes across the province. It is for registered nurses and is a well-regarded program helping registered nurses to become focused in rural nursing.

Just a couple of questions on the part-time and full-time nurses. Are we finding that nurses, when they are getting to 65, are retiring, or are they continuing? Also, the next question is: as far as the actual costs of having part-time versus full-time nurses…. Is it actually more expensive on the system — more part-time? Is it more affordable? Maybe some comments on that.

M. MacLeod: I’m afraid I can’t comment on that affordability within the system. A lot of it has to do with the collective agreements. At what point does a full-time or part-time become more cost-effective? You’re talking about a portion. Like a 0.7 or 0.6 — at what point does that come? I’m not sure where that is.

In terms of nurses wanting to work full-time, there are more people wanting to work full-time than there are full-time jobs available.

S. Robinson: Thank you for another great presentation and having some really good data for us. Part of what we’re doing is listening to many different groups and trying to integrate it into a whole and create some recommendations.

The very first presentation we had this morning was from the Northern B.C. First Nations HIV/AIDS Coalition, and one of the issues they talked about was discrimination, racism and lack of understanding experienced by community members, by northern health professionals. I’m wondering if you might be able to provide us some comment about the programs that you have. What are some of the gaps around making sure, when we’re serving First Nations communities, how we’re paying attention or where we ought to be paying attention in order to ensure that we’re providing the resources and services that they need?

L. Zimmer: As part of our curriculum, we have a course in second year. This is the undergraduate program on First Nations health and wellness. We also require all students to take at least one First Nations studies elective. So they do have that exposure.

We thread population health issues and the health and wellness of aboriginal people throughout the curriculum in all subject areas. Certainly, our students work with First Nations populations in the clinical setting. Because they are sent out all over Northern Health for their clinical experience, depending on the community, they will have more or less exposure.

In our fourth year, students choose a sort of focus area for a final practicum. One of those areas is nursing in a First Nations community. So they actually take on the community health nurse role.

That said, for many of the students, as they come into the program, they have not had much interaction with
[ Page 418 ]
aboriginal people and may not have much understanding. Our hope is, and I think the fact is, that that understanding grows and that comfort grows over the four years.

But we could be doing more, and we intend to do more, with the report that’s come out and the request that universities indigenize their curricula. We take that very seriously, and we are looking at that.

In terms of nurse practitioners, many of their practicums are in areas where…. Well, they’re primary health care providers, so they’re in areas where they’re working largely with aboriginal people.

M. MacLeod: Indeed, they have a course, a required course in our graduate program that all of our graduate students need to take, whether or not they’re taking a thesis stream or the nurse practitioner stream.

D. Barnett: Thank you very much for your presentation. Do you have many First Nations students?

L. Zimmer: Not as many as we would like. In our undergraduate program, we have set aside 20 percent of our admission seats for self-declared aboriginal students — obviously, who meet the entrance requirements. We have more than we used to but not as many as we would like, and recruitment in aboriginal communities is certainly something we’re going to be developing.

D. Barnett: Back to the part-time versus full-time for your nurses. I live in rural British Columbia, and where I live, it is a big issue. We lose our young people who go and take nursing courses, become full-fledged RNs, come back to our communities and are part-time nurses when they need full-time work. We lose them to the urban centres, and I think that’s something that we need to take a good look at, at the committee level. Because the other ones retire, and then we’ve got a really serious issue.

M. MacLeod: I think it’s funding, and it definitely is cost. I think. And it also is the creation of positions that require that joint work between union and the health authorities.

D. Plecas: Thanks again for your presentation. Again, I’m having a positive vibe here. I’m not having a sense of urgency about something.

In fact, I’m looking at 70 percent of your grads that actually end up being employed by Northern Health, and I’m thinking to myself, when you think about university grads in general, that this is a pretty impressive number.

I’m just thinking, surely there’s a percentage that would have come from outside of B.C. and heading back and wherever. You must have some sense of where that relates to. I’m thinking: how is it going to get any higher? That’s one question.

The second question relates back to the full or part time. I’m wondering. The increase in part time — has that actually been coupled with a decrease in full time, or is it an add-on to full time? Obviously, that would be a very different situation.

M. MacLeod: I shouldn’t start with the back one first. What was your first question?

D. Plecas: I know that part of that is a consequence of the great work you do in your department.

M. MacLeod: The full time and part time — I cannot tell you what the breakdown is. That’s the kind of thing that health authorities would be able to tell you, and what that movement is. Or the Health Employers Association of B.C. will certainly be able to give you that information quite accurately.

In terms of the 70 percent, where our challenges are in northern B.C. is that…. It’s distribution across the north. It’s whether or not they will go to…. I’m talking about the north, although our students from Quesnel take experience in 100 Mile. And so we do, then, go to 100 Mile and places like that. But will they go there and stay?

That notion of churn is something that I think merits some attention. That’s the retention.

When you want to leave a job in a large urban hospital, you decide: “I want to leave medicine, and I’m going to go to surgery,” or “I want to go to a specialty unit.” You stay within the organization, or at least, you stay within the city. In a small community, you can’t do that. You’ve got to move out of the community if you want that.

Our 70 percent we’re really delighted with. What we need to make sure is that our numbers will stay up so that our production numbers with that 70 percent will stay fairly even with Northern Health’s needs over time.

Of the people who stay, they may go on to specialty education and stay within the organization — or go away and then come back, as normally. We need to make sure that there are opportunities for people — both to come from a place and get educated and, then, perhaps, to go back to that place.

What we haven’t mentioned is that our undergraduate program is in collaboration with Northwest Community College, in Terrace, and CNC — College of New Caledonia — in both Prince George and Quesnel.

D. Bing: Thank you for both presentations. I had a couple of questions about nurse practitioners. We’ve heard a lot of very positive things about how valuable
[ Page 419 ]
and useful nurse practitioners are. Yet I’m a little concerned. Your numbers are like seven to ten graduates per year. Do you know how many graduate in the province as a whole, for example?

M. MacLeod: I’m not sure how many graduates there. We are funded for 15 per year, so we’ve got.… We’re funded for 15 FTEs over two years, so that’s 30 FTEs is what we’re funded for.

UVic and UBC also take in 15 a year. I’m not sure what the overall employment pattern is for nurse practitioners across the province now. At one point in time, there were not enough jobs for them in primary care in the Lower Mainland. I do know that we continue to have openings in the north.

We can’t take anymore in. The funding that MAVED provides for nurse practitioners makes it…. The university has to spend more money on it than is available. The amount of money that the med school gets per physician is upwards of $60,000 per FTE. Nurse practitioners — the university gets $18,500 for that.

Now we’re having physicians saying: “I’m sorry, I can’t precept.” Primary care places are saying: “We can’t precept unless we get money for it.” We have no money. We can’t pay our preceptors. Physicians pay preceptors. It’s really challenging. It’s increasingly challenging to mount nursing education programs in interdisciplinary environments.

J. Darcy (Deputy Chair): Thank you very much for your second presentation. It’s hard to separate many of the issues, of course.

We heard a wonderful presentation yesterday, one of our first ones, from the Cowichan health centre, an aboriginal health centre that was using a really interesting model. It is a pilot project. It isn’t system change; it is a pilot project.

They talked about…. This is related to the question I asked earlier about LPNs. They have, in their interdisciplinary team, health care coaches who could be medical office assistants but, in their case, are LPNs working to full scope, which seemed to make the most sense. Those LPNs, then, also played some role in triage or assisting in the patient journey with various other health care providers.

That included the doctor who made the presentation to us — Daniele Behn Smith. It included dietitians, registered nurses and so on. They said it was based on a model in Alaska.

In this case, all of the health care coaches…. They do western medicine as well as well as traditional indigenous medicine. I’m not sure of the whole staff, but the health care coaches were all First Nations people.

Is that a model you’re familiar with? I’m now talking system change in Northern Health, as well as the role of various types of nurses within the nursing team.

M. MacLeod: Now, I do know that that’s Southcentral, in Alaska. I do know that Northern Health looked at Southcentral as to what they could glean from that with regard to what kinds of models they could put forward and create. I know there are primary care coaches. I don’t know if those coaches are playing those same roles as in Cowichan. I couldn’t tell you that.

One thing, as well, that Northern Health is doing that I’m certainly aware of is the kind of work it’s doing with the First Nations Health Authority in trying to come together with kinds of models for primary health care with that. I don’t know where that is at this point. You’ll have to ask them.

L. Larson (Chair): Thank you very much. We’ve finished almost on time, which is wonderful. The information was amazing and very thoughtful, and we’re very pleased that you were able to be here today.

Welcome, Murry. You’re with the Central Interior Native Health Society, I gather.

L. Larson (Chair): Thank you for being here today. As you see, we have 15 minutes to hear from you and what you do and recommendations for us, and then we will ask you questions.

M. Krause: Okay. Thank you for providing us with this opportunity. I’ve made some notes because I don’t want to stray from that. I only have 15 minutes, so I want to make sure I use the time wisely.

The Central Interior Native Health Society came about as a result of a royal commission on health, way back in 1991, which acknowledged the disparity in health between aboriginal people…. Well, one of the outcomes was acknowledging the disparity in health between aboriginal people and the rest of the population.

Aboriginal leaders in Prince George came together and said: “We need to do something. We can’t just let this go by.” In their wisdom — I think it was well thought through — the society undertook at least three things in our work.

They looked at, of course, a friendlier access to health care because, from their experience, they knew the challenges in accessing the health care system. They believed it should be based on the social justice foundation that
[ Page 420 ]
everybody deserves good-quality care; that there are other things that affect health, like poverty and those kinds of things; and that, from their experience, we should be involved in the training of health care professionals so that, indeed, those people who provided health care had more understanding about what First Nations people face in British Columbia.

The clinic opened in 1993 with a really small team — one part-time doctor, one nurse, one social worker, one MOA, a bookkeeper and an executive director, so a really small team. But right from the beginning they were really committed to a holistic approach. Those leaders in those days saw that as a holistic approach, rather than just more docs and more MOAs or something. It was really about a team approach and, again, all the time thinking that there should be a cultural overlay on the service and how it unfolded.

I came on two years later, and luckily enough, right away we got some more physician time. At that time, it was pretty much still the traditional model. Despite having the other team members in the room, it really was around that the physicians tended to be the gatekeepers and other people assisted in that work. To provide more service, we knew that we needed to have more physician time, and luckily, we got that.

At that time, we were also asked to serve on the Provincial Coordinating Committee for Remote and Rural Health Services. It was in the late ’90s. That was where I first heard about EMRs and first really started hearing the conversation about primary health care.

Of course, we started to explore all of these things too, and immediately embarked on having an EMR in our clinic. We were wise enough to go with a local and have Bill Clifford’s MOIS program. It was what we used. Actually, we helped Bill evolve it so it could be used in a team approach rather than in a solo doctor’s office. We’re pleased to have done that, but we’re also very thankful for the support we got from Bill.

We were actually, at that time, also asked to be involved in a research project with the School of Nursing at UVic looking at the implementation and the evolution of primary health care. I think it was quite aptly called, at that time, primary health care from rhetoric to practice, because lots of community health centres were saying they were doing primary health care but it still, really, was pretty much the old model.

Around that time, also, we were lucky enough that…. You know, things happen in a good way. The Romanow report was tabled in Ottawa, and primary health care became the order of the day and conversation of the day. Funds were allocated from the feds to the province and out to the communities. I was approached by Cathy Ulrich, who was then the VP of clinical services at Northern Health, and asked if we’d like to become an urban primary health care site.

Having been there long enough and knowing what the challenges were, I was a little cautious. Although it meant a huge increase in the number of staff we would have and the resources we would have, I asked if part of the resources could be used to hire what you might call a change manager. She agreed, having been a nurse in the system as well. We really knew that we needed somebody who was boots-on-the-ground and really was acknowledging every day what needed to happen to make it different. Also, that came with a researcher to document the changes and how the implementation took place.

At that time, too, we changed our patient criteria from an aboriginal person of any socioeconomic background and people living on or close to the street. At that time, and probably to this day, we have about 80% aboriginal patients and 20% people who are street-involved.

At that time, one of the things we realized with our change manager — which we called the primary health care coordinator because that sounded much more positive than change manager…. We had weekly team meetings, because we were all very committed, the change manager and myself, to a really non-hierarchal approach to change and how change might get implemented. So we had the whole team engaged in how we might do things differently — the physicians and everybody that was now working at the health centre.

It really was about the whole concept — of course, putting the patients in the middle and how we could wrap services around that person to really make a difference and then starting to fully utilize the EMR in terms of everybody entering into the same file. Everybody knew what was going on for that patient. If a physician had just seen somebody, then the nurse would know what had happened. So would the social worker, and other people in the team would know exactly what had happened in that process.

Also, bringing on new patients — a really good process of taking on new patients was used. What we’ve learned from First Nations people is their tiredness of having to repeat their story, especially people who have been really severely traumatized. It was about having to, hopefully, only tell that story once, and there was their story on their file so that each successive service provider didn’t have to ask the same thing over and over.

At that time, as this evolved, we also realized the merits of having weekly clinical meetings as well, especially for those people that were currently experiencing a new diagnosis or a real crisis in their lives, who might be hospitalized or something might be going on for them.

That was where the rubber really hit the road in terms of people stepping up and saying, “Maybe it would be best if the nurse took this on,” or, “Maybe it would be best if the addictions counsellor or the elder would take this on,” in terms of sitting with that patient and making sure they felt that they were cared for and they were getting all the information they needed and all of those kinds of things.
[ Page 421 ]

Again, we do that to this day. Even the northern medical program, who has been in the room and has seen the process in action, has indicated that this is the way it needs to be. It needs to be this kind of engagement, and it needs to be about this kind of buy-in and this kind of energy towards really making a difference for the life of that patient.

I think that one of the things we also realized over that time was building a culture of trust. We realized that, in working with even new physicians and new nurse practitioners, don’t ask people to do things they’re incapable of doing or don’t have the resources to do. We really realized that if we could provide as many services as possible within the four walls of our clinic, we’d be much more successful.

We’ve heard time and time again that the patients were wary of the hospital, the health unit, the medical buildings and all those kinds of things. We were making referrals, and those referrals weren’t being followed through on. Of course, it’s difficult to maintain a good relationship with a specialist if the people you’re referring habitually don’t show up. It really was trying to find a way to make sure that those connections were successful.

Right now we have within the clinic…. I’m sort of jumping forward a bit. Again, concerning who we serve, the clinic has a methadone clinic. We have a medication adherence program for HIV patients. We have a pediatrics program for the large increase we’ve had in the number of children. The Healthy Babies programs we now have at the clinic, and we have the physiotherapy program.

We jumped at the chance to have the physiotherapy program come into the clinic, and we have a great physiotherapist, who’s a teacher. We have the students there, and we’re starting to realize just the merits of that program in terms of using physiotherapy and those kinds of things, as opposed to pharmaceuticals, to help people deal with their chronic pain and other issues.

We also know that the people we serve don’t very often have people touching them in a good way, so it really is about having that caring touch that helps people get through their pain and get through what they need for the day.

Our current team is part-time physicians, nurse practitioners, RNs, social workers, an addictions counsellor, several outreach workers, a part-time elder and the physiotherapy. We’re currently working full bore on the whole issue around cultural and trauma competencies. We’ve been engaged in a number of research projects that indicated we can do all of these things and probably do them very well, but unless we were as cultural- and trauma-competent as we needed to be, we would not be as successful as we wanted to be with our patients.

We continue to work very diligently around the issues of social justice. We acknowledge that it’s hard to get people healthy and keep them healthy if the world doesn’t become a different place, because the people return to places where they’re living in poverty, lots of homelessness. We’ve been engaged a lot in child exploitation. Of course, racism exists, alive and well, in our communities and also, unfortunately, in the health care system.

Again, we are involved currently on training. We have the northern medical program. Residents now spend a month at the clinic. It started out as two weeks, and the residents and the program realized that wasn’t long enough for the residents to get the experience that they probably could have from being in the clinic. We’re very pleased to do that. We’ve been doing that for a very long time. Right from the beginning, we were taking social workers, social work students and nursing students into the program and trying to give them some background on culture and how that impacts on people’s lives and what their lives are about. We take nurse practitioners and now physiotherapists.

Again, it’s a very active place as far as learners are concerned, but we only feel that we benefit, because we have all these great, usually young people coming in really committed and really enthusiastic. It just only adds to the vibrancy of what we do at the clinic.

Our big dream is to add dentistry at some time. Cool Aid in Victoria has a dental clinic, and that’s what we would like to have too. Unfortunately, there’s no real good mechanism for funding dental clinics in an environment such as ours. We’ve certainly had the dental community come to us and want to set up a clinic within Central Interior Native Health Society. Not only do we not have the room, there’s no way to sustain it funding-wise. Again, that still is a dream, because as you might imagine, every day we see people with really poor oral health. That’s a really major factor for us.

What some dentists have done is open up a free clinic at the friendship centre, where unfortunately — well, fortunately — it’s for pain management. But it’s all extractions. There’s no prevention. There are none of those kinds of things. It really is relieving the pain for that individual.

We have monthly talking circles, which involve everybody, all of the staff. We use it to plan. We use it to debrief from challenging events. We use it to debrief from the death of a patient that we’ve known for a very long time, that everybody’s really well connected with. We use it for all kinds of things, but it really is a way to, I guess, make sure culture is embedded in what we do and that we honour that each and every day.

Again, the whole goal is to focus on respect and equity. We really believe that the essence of teams really is equity, that everybody feels like they’re part of it. We see it in practice in every day. The MOAs have as much to offer to the conversation about what’s happening or needs to happen within a clinic as the nurses or social workers do — or the physicians do.
[ Page 422 ]

It really is about acknowledging that everybody matters and everybody has a say and they should be heard. That’s how, I think, you grow a team that really makes a difference.

You just mentioned that you had elders involved. Now, you had just one that was kind of like full-time or somebody that was there a lot?

M. Krause: We have a part-time elder. I know that within probably any health authority, there’s not a funding line for elders. Northern Health has been very good in trying to find…. It’s probably slippage at the end of the year, which they give us in March and which is for the next year.

We have a part-time elder right now. We’ve had varying programs, where we had more funds from elsewhere, where we had an elder coordinator, where we had four or five elders engaged in the clinic part-time. So we know the merits of that, and we’d like to get back to that at some point. Of course, we need the resources to do that.

L. Larson (Chair): The other thing we heard is that you need to put a dietitian on your team.

M. Krause: Yes. Luckily we have…. One of the things is that we now have a dietitian visiting. We’re getting more and more of that happening as well. Dr. Hamour, the HIV specialist, the dietitian and other…. We have a pediatrician that consults and comes into the clinic to see people — again so that we have the success that we need, because if we refer out, it might not happen.

It really is about time we do have a dietitian coming. Again, it’s difficult working with some of our patients, because if they get their food from the food bank, when you talk about dietitian and what really needs to happen, we know some of the things. The dietitian knows it too. So it really is about trying to encourage people to make some different choices, but sometimes it’s limited.

L. Larson (Chair): And the friendship centre here does an amazing job with introducing people to cooking their own food and doing all of that kind of thing too. So I’m glad to see you have that connection.

J. Darcy (Deputy Chair): Thank you so much. What’s the funding model for the society? You referred to it as a health centre, a society. How does the funding work? You mentioned you have part-time doctors.

J. Darcy (Deputy Chair): Oh, on sessional, so they’re paid on the alternate payment plan from the province.

J. Darcy (Deputy Chair): Okay. What about the other health care providers? Are they employees of Northern Health? How does the funding work?

M. Krause: The nurse practitioners are employees of Northern Health, and all of the rest of the employees are paid by the society. We are pretty much 100 percent funded by Northern Health, and we have a really solid working relationship with Northern Health, the people who are our direct contacts — and with Cathy Ulrich.

We work very closely with Northern Health in making sure…. We’ve always seen, as a society…. Maybe this is just who I am. When it was regionalized, I suggested to the health authority that maybe we should have a non-hierarchical approach to that as well, that we see it as a partnership and that we will do a good job for Northern Health and they will support us well.

Again, they wouldn’t be seen as the funder and us as the fundee, and we’d try and make it work. It really is about constant conversations and really asking them to give us advice or feedback when they think that things should be done differently.

D. Barnett: A couple of questions. Do you travel out to any of the remote communities, First Nations remote communities?

M. Krause: No, we don’t. We’re really seen as urban-centred — the people who identify as living in Prince George. We know that lots of our patients…. They can become a patient if they identify as living in Prince George, but we know that very often it’s seasonal, because people return to their home communities to harvest and do all kinds of things, or to be with their families. So we constantly try to make sure that there’s a connection in their home community with a nurse or somebody in their community. We try and make sure there’s some continuity.

We have been asked by some communities about: could they rely on us to provide some services in Prince George when people are in the hospital? We continue to have those conversations as the First Nations Health Authority evolves.

D. Barnett: And the elders, the seniors that go into long-term care. Do you have any relationship with them?

M. Krause: Yeah, we have the full spectrum of patients. We have people who are really street entrenched, and we have people who are in long-term care. I mean, that
[ Page 423 ]
makes it healthy for everybody. It really is about providing that longitudinal care as well so that they don’t drop off the end. Lots of times, of course, the elders have had long-standing relationships with the nurse practitioners or with the organization, so we maintain that relationship.

S. Robinson: Thank you, Murry. It’s nice to see you wearing a different hat. It’s a treat for me.

Murry’s also a city councillor, so that’s the relationship that Murry and I have when I wear my other hat in local government.

I have a couple of questions. I’ve learned from my colleague Darryl over there. I’m just going to throw them all into one. I’m just curious about how many people you serve — just in general, so I get a sense of the numbers. And I’m interested if you’ve done any research in terms of the outcomes. When you have this kind of model in place, what are the real outcomes? Finally, your governance structure. As a society, what’s the involvement of the community in terms of how the services are delivered?

M. Krause: We serve anywhere between 1,100 and 1,500 patients. We try and only take on patients when we have the ability to do the job and do it well. We’ve always said to Northern Health, and they’ve agreed, that it’s about quality, not quantity. It really is about staying true to that.

It’s very enviable, in some ways, that our physicians can spend as much time as they think is necessary with each and every patient. It really is about building that level of trust, because if we don’t have the trust, we won’t get anywhere. We’ll just be a walk-in clinic. It really is about doing that.

M. Krause: One major research project we’ve been involved in — but it might not be so focused on outcomes — was the School of Nursing at UBC, Dr. Annette Browne. They looked at: why did Vancouver Native Health and Prince George Native Health become so successful? What contributed to that success? So that could be documented and, hopefully, shared with other communities in British Columbia.

We’ve had a number of enquiries. Our board is committed to allowing me and others to assist other communities in establishing a community health centre if it works.

S. Robinson: Since you mentioned your board, maybe you could just explain to us about how the community is involved in the governance structure.

M. Krause: We have six board members, all of them aboriginal people, all from the community. One of those board members is a Métis elder, and the other five are very, very involved in community service delivery here in Prince George. So the tentacles, if you want to call it, are into everything. It really is.

We have an annual general meeting, just like anybody else does. We encourage people to put their names forward if they would like to serve on the board.

We’ve also always been very, very committed in our strategic planning process to making sure that the community’s involved. The community, our patients, our allied service providers to the community — everybody should be engaged in that. That’s what we see as our structure.

Several times we’ve talked to our patients. We asked them once why they continue to come to the Native Health Centre. Why do you keep coming through the door? Because we’ve decided the best measure is if people’s feet…. People vote with their feet. It really is about what gets you in the door.

They said: “Well, it’s got Native in the name.” And they said: “Because you ask us what we need, and you ask us how you could make the service better.” The bottom line is they said: “You really care about us.” We carry that, because we think that’s important. We figured out a long time ago that you can have it all right, you think, but it’s got to go from here to here or you won’t have the success that you need to have.

D. Plecas: Murry, it’s very encouraging listening to you. You’ve been around since 1991. How long have you had the doors open?

M. Krause: The clinic actually opened in 1993. The society formed in 1991, right after the conversation with the royal commission. It took about two years because the government of the day also created the aboriginal health division at the Ministry of Health. It was pretty much a policy division, but then they started having conversations about getting funding out into the province.

Four health centres were created at that time — Prince George, Vancouver, Kamloops and Nanaimo. Kamloops and Nanaimo were associated with the friendship centres. They never did evolve into medical clinics. They did a lot of great psychosocial work around sexual abuse intervention, mental health and addictions, and some of those things.

D. Plecas: My question. Because you’ve been around so long, you’ve really proven the value of what you do. Why don’t we have these everywhere?
[ Page 424 ]

M. Krause: I think we should. I mean, I’ve presented to the Northern Health board….

D. Plecas: A little bit of what troubles me is the funding. For as much as you do, for as well as you do it, for as long as you’ve done it, why are we still having these funding questions? It’s almost like you’re going to get funded for this, this year — you know, the half-time elder — but maybe not next year. How does that happen?

M. Krause: The elder is the only sort of iffy one, because it’s hard to find a line in the budget, for Northern Health to find that line. I think they’re so committed to it that we pretty much have a three-year agreement: “Tell us well in advance if this isn’t working for you, and then we’ll see what we can do about it. Or you can let us know that you’re not going to fund us anymore.” But it really is that we had the longer-term commitment from Northern Health. The only issue is around the elder.

D. Plecas: I just want to echo again my friend Selina’s comment about outcomes, because it would seem to me that you’re probably saving the system a whack of money.

M. Krause: We try and do all the regular things that people do, in terms of people’s blood sugar and everything else. We do all the good chronic disease management, and it’s great with an EMR to be able to do that. It really is that we see the outcomes, of course, as bigger. It really is about watching, and incredible things happen, especially around street-entrenched women who are pregnant.

One of our stories. If you seize the moment and really work hard, we have seen really street-entrenched women come in, get clean and sober, produce a beautiful, healthy baby which they might keep — and that might be the first baby they’ve been able to keep — and then we work hard to keep that family together and then also provide really good pediatric service for those children.

But again, it can’t happen in the regular system. If you encourage somebody to get clean and sober — if they’re really addicted, entrenched — you can’t say: “Come and see me in two weeks.” So it might mean that that woman is in the clinic every day, and you’ve got to be there for her. It doesn’t matter who’s there for her, but somebody’s got to be there for her. So it really is about not letting that person down. Those are the things that we use as measures in terms of success.

S. Hammell: Can you just talk to us a little bit more, Murry, in particular about your mental health and addictions section of your work? It’s an area I am particularly interested in.

M. Krause: We are very concerned about it too. We’ve had psychiatrists do some work in the clinic. We’ve had nurses with mental health and addictions training.

Right now, Northern Health, like many health authorities, is going through a bit of reorganization around primary health care. We had a clinician in our clinic for our clinical meetings once a week, and then one day a week having a clinician in, seeing patients. I was concerned when we didn’t have anybody for a little bit. But they’re reorganizing right now, and I’ve been assured by Cathy Ulrich that that reorg should be finished by the middle of July. They’re very committed to at least sustaining what we had before and, hopefully, some more.

S. Hammell: You said you have a methadone program. What is the bundle of services that are there for people…?

M. Krause: Okay. We offer, hopefully, full primary health care as a family practice for all of our patients. Then it’s augmented by those programs that, we’ve known, needed to evolve. One of the things, why we’ve got the methadone program, is that at one time there was a methadone clinic in town that just closed its doors. So we had the medical health officer sitting in our office wringing her hands — “What am I going to do?” — as she might.

And we said: “Well, maybe that’s something we could do.” I mean, if you look at, probably, who the methadone clinic is serving, why wouldn’t we give them comprehensive care rather than them going into a clinic and just getting a script?

The medical health officer agreed. So we scrambled. We got a physician who could prescribe, and we built a team around them. Of course, now — not of course, but now — we have a team of people who are trained in methadone maintenance.

That’s the kind of thing…. It’s about being able to respond. That’s the beauty of non-profit. It is that you can change on a dime. It really is that you can respond very, very quickly, especially if it makes sense for your mandate and what you’re trying to do.

S. Hammell: Murry, we talked yesterday in particular to one person who says we talk much too much about addictions and not enough about recovery. Is that also a part of your program, where you’re…?

S. Hammell: And is it part of the everyday, or is there a particular program you’ve got that you’ve decided is effective around recovery?

M. Krause: We have an addictions counsellor. She is a First Nations woman. She’s from the McLeod Lake Band,
[ Page 425 ]
and her son is the Chief — really well connected, really well known in this community as a wonderful human being. She does excellent work. Actually, last week, with our support, she accompanied the mother of a woman who was graduating from a treatment program down south — got on the bus and accompanied this mom down — and then they brought the daughter back.

So it really is, again, about that hands-on stuff. But we have a harm-reduction model. It really is about meeting people where they are in the moment. We would hope…. It would be wonderful if people got clean and sober, but that’s not our ultimate goal. It really is about meeting people where they are in the moment, because we know from the people we serve that if we insisted they be clean and sober every time they come in the clinic, we might never see them again.

It’s all about behaviour for us. If somebody comes in and everything’s okay — it seems to be okay — we might seize that moment, especially if we know they’re a diabetic. The nurses can look at feet for foot care and all those kinds of things. Seize that moment, because we may not see that person again for a month.

It really is a potpourri of all of those things, but it’s trying to react in the moment and trying to just be there for that person.

L. Larson (Chair): Last comment, Sam, if you have any comments before we go off air. No? Have we lost Sam again?

All right. Thank you so much, Murry, for your presentation. It was wonderful to hear what you do. It’s absolutely amazing, and we really appreciate you coming and sharing that with us today. We will take what you have said and put it into our report.

Access to on-line versions of the report of proceedings (Hansard)
and webcasts of committee proceedings is available on the Internet.

1) Northern B.C. First Nations HIV/AIDS Coalition	Emma Palmantier
2) Dr. Denise McLeod
3) University of Northern British Columbia/University of British Columbia, Northern Medical Program	Dr. Sean Maurice
4) Dietitians of Canada – BC Region	Sonya Kupka
	Courtenay Hopson
	Marianne Bloudoff

5) Physiotherapy Association of British Columbia	Hilary Crowley
	Jenny Hogan
	Kevin Evans
6) University of Northern British Columbia, School of Health Sciences	Dr. Martha MacLeod
7) University of Northern British Columbia, School of Nursing	Dr. Martha MacLeod
	Dr. Lela Zimmer
8) Central Interior Native Health Society	Murry Krause

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)
	Marc Dalton (Maple Ridge–Mission BC Liberal)
	Sue Hammell (Surrey–Green Timbers NDP)
	Dr. Darryl Plecas (Abbotsford South BC Liberal)
	Selina Robinson (Coquitlam-Maillardville NDP)
	Dr. Jane Jae Kyung Shin (Burnaby-Lougheed NDP)
	Sam Sullivan (Vancouver–False Creek BC Liberal)
Clerk:	Susan Sourial

REPORT OF PROCEEDINGS(Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH