Health — Issue No. 27 — Wednesday, July 6, 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	427
D. Cross
R. Moerman
M. Fromberg
C. Redknap
S. Lamont
M. Sandler
C. Kozakowski
R. Hood
P. Webster
C. Dickinson
D. Durksen
M. Bueckert
R. Turner
C. Hostland
F. Knox

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

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

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

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

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

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

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

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

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

D. Plecas: Hi. I’m Darryl Plecas. I’m the MLA for Abbotsford South, the Parliamentary Secretary for Seniors and the parliamentary secretary for access.

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

L. Larson (Chair): Sam, are you there? We think we have Sam Sullivan on the speaker, from Vancouver. So thank you.

Also assisting the committee today are Susan and Stephanie from the Parliamentary Committees Office, and Mike and Alexandrea from Hansard Services are here recording the proceedings, as mentioned.

With that, I’ll turn the floor over to our first presenter. Welcome, Rees. I’m really pleased that you’re here and looking forward to your presentation — and also Deanna. Thank you. Go for it.

D. Cross: Thank you. Good morning, everyone. My name is Deanna Cross. I am the director of the market research for Digniti Home-Hospital. I want to thank you for taking the time to be here today to hear more about this revolutionary project.

Digniti Home-Hospital Research Project is a privately funded, Okanagan-based research firm. We are focused on the specific quality of needs for elderly and frail patients. Our mission is to vastly improve B.C.’s long-term-care experience, whether remote or urban.

As bioengineers, we have solved the majority of expensive and painful problems related to the ADLs or activities of daily living, especially isolation, rehabilitation and therapeutic services provided by formal and informal caregivers.

Our revolutionary approach to frail care technology collapses the historical care cost by 80 percent. Esteemed institutions such as the Ivey school of health innovation evaluated our approach as one of the best new Canadian health care ideas of its time. For the past ten years, we have been faithfully supported in our groundbreaking research by the federal government’s SR-and-ED program.

B.C.’s frail senior and largely non-ambulatory geriatric population will double over the next decade. This demands a doubling of institutional care capacity and medicare budget. Without a change or innovation, this will likely bankrupt the province. Blindly continuing in the current trajectory risks systemic failure. There are too many high-needs seniors with insufficient skilled help or adequate safe, modern facilities to meet this growing need. Our singular vision is to empty institutional nursing homes of two-thirds of their residents and return them home, where they wish to be.

We see every senior as a valued client, and we are patient-
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centric in our philosophy. The Digniti system is exclusively user-pay and provided at an amenable cost.

Reframing long-term care requires a rethink in how all services and clinical interfaces are delivered. Digniti’s central objective is to conjugate intelligent assistive devices with telemedicine, which, in turn, is supported by modal nursing practices.

Rather than an outer space capsule, imagine an inner space care capsule. This inner care capsule is provisioned with every conceivable life and comfort support feature, while the patient remains wired into a clinical command centre which oversees their minute-to-minute health care needs. By stripping out all superfluous elements and remaining focused on core needs, a hyper-safe, hyper-flexible and hyper-comfortable environment can be delivered on an as-needed basis anywhere in B.C. Families are then empowered and thus willing to take on far more responsibility as informal caregivers.

The solution to managing the ever-growing frail care caseload is to provide a nursing zone in granny’s bedroom rather than a nursing home away from the family. This is accomplished by installing a modular system of components we call ABLE or assistive biomechanical living environment. ABLE is a group of harmonized devices assembled into a care pod which can be installed into a patient’s bedroom for as long as needed.

The ABLE care pod includes an articulated bed deck, dual incontinence bidet roll-in-place toilet, full bath, bedside hand washlet, air purification system, TV and hospital interface monitors as well as a multi-harness device for repositioning, gait or balance rehab. It also includes cutting-edge social software programs which assist the patient and the caregiver to link, via video conferencing, to others in the Digniti community or to additional support organizations or groups.

The ABLE care pod includes a multiple selection of harnesses, lift jackets, fall prevention rails and even a bed swing which improves lymphatic condition. ABLE care pods solve one of the greatest problems of frailty, which is the challenge of gravity. Customized harnesses can be provided for every type of patient and every disability. Bed top repositioning is made easy. Balance, retraining and assisted ambulation becomes a daily self-care practice without need of expensive outside help.

Fall prevention and strength-building exercises are a part of everyday activity. The average senior in a hospital loses 5 percent of muscle function per day. With the ABLE care pod, one day after surgery, the patient can be up and mimic walking in the assisted ambulation harness.

Toileting is provided by a roll-in-position, full-sized ceramic toilet. The toilet is self-sanitizing, with a wash, rinse, dry cycle for patients that need hygiene assistance. It hides discreetly in an adjacent cabinet and includes a built-in modesty curtain. If the patient is unable to move or position themselves easily, they can gain secure assistance with the lift harness, allowing them to maintain dignity in caring for their own toileting needs.

A range of exercise and toning devices are provided by prescription from the family physician or geriatrician, who stipulates the degree and extent of customized rehab activities.

The patient’s health status is telemetrically monitored, including hydration, diet, pharmaceuticals, weight and movement. This data stream can be continuously accessed by the attending physician. In addition, leading geriatric specialties can be teleconferenced through a global doctors-in-residence program via Skype. Physicians in Ireland, Hong Kong, Australia or even Israel can be engaged.

In Canada, bathing is considered to be a basic human right. Unfortunately, due to time, heavy lifting and labour constraints, most seniors in B.C. nursing homes only get bathed once every ten days. This lack of regular hygiene worsens many problems, such as Norwalk, E. coli and a host of other avoidable infections.

ABLE solves this problem by making daily bathing safe, easy and on demand. A portable bath rolls into position on the bed top, opens up, and the patient is harnessed into the bath. Afterwards, the collapsible bath self-sanitizes, dries and is automatically stored away in a hidden space located in the platform ceiling.

With an ABLE care pod, bathing can occur as often as wished. Modesty panels ensure patient privacy. Bath time setup becomes brief and seamless, and bathing becomes an enjoyable experience to the patient once again.

The ABLE care pod allows each patient to customize the appropriate rehab program for his or her personal needs. The recumbent bicycle assists the patient to rebuild lower body strength while remaining prone.

Compression injuries are often an indication that insufficient caregiving attention has been spent in patient repositioning. The ABLE care pod has a computer-driven actuator, which gently repositions the mattress through innumerable micropostures. In addition, an electrodermal stimulator promotes topical skin circulation. We call these companion devices FIGIT or frequent interval geospatial impulse technology. This approach resolves most compression wounds and infections caused by infrequent movement. A harness system also partially lifts specific body parts, promoting gentle, tai chi–like restorative movements.

Infections such as influenza, pneumonia, AIDS, TB or any condition where the patient needs to be isolated are easily resolved by inserting a portable biohazard membrane, which isolates the patient until the risk period passes. The ABLE care pod’s ambient air purification system is deployed to keep the bed zone fresh and purified and can be enhanced with sanitizing aerosols which eliminate viruses and odours. This system includes an airlock technology so the bugs can neither get in nor out.
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In summary, an ABLE care pod solves most of the high costs and long-standing irritations encountered in long-term care. Digniti has spent ten years researching and designing frail-care environments and developing appropriate, affordable solutions.

The Digniti program doubles the effective hospital bed capacity in any community who adopts this breakthrough care model. It does this without added cost or labour increase to the current acute care hospital system. It solves B.C.’s current bed-blocking problem. Digniti remonetizes geriatric care from that of welfare to one of taxfare.

A typical nursing home costs the B.C. government $8,000 per month per senior, whereas the Digniti program costs $1,000 to $2,000 per month per senior. Our approach reduces the B.C. government’s long-term-care subsidy by $6,000 per month per senior.

In the near future, we will be pursuing the best community to launch our pilot and show the world how compassionate technology can affordably deliver high tech with high touch. Past experience has shown that B.C.’s medical system is a slow adopter of innovation, typically delaying taking on new technologies until proven in other regions. For this reason, it is more likely that the test pilot for this project will occur outside of B.C.

Thank you, again, for taking the time to learn more about Digniti’s revolutionary approach to long-term care.

I would now like to pass the session on to Mr. Rees Moerman, who is the principal designer for the Digniti Home-Hospital Project, as he is better equipped to answer any technical or policy questions that you may have.

L. Larson (Chair): We will direct our questions towards you. Is that right, Rees? Okay.

D. Plecas: I have a zillion questions. Thank you for your presentation. It really does sound exciting.

D. Plecas: Of course, that’s not the case. Even if we look at most people in complex care, they’re spending most of their time outside of bed.

R. Moerman: That’s correct. We look at the statistics, mostly, from Ontario because they have the best database. The cost parameters are such that 5 percent of the population consumes 90 percent of your medicare dollars, and 1 percent consumes 50 percent. They’re mostly non-ambulatory.

If you can solve that 1 percent that’s drawing 50 percent of your resources and provide an environment, you solve your bed-blocking problem, your high-cost problem. That’s the population that’s sucking the budget dry, essentially. You have to create a pressure relief valve, systemically, and that’s the place to do it. You have to pull them out of institutions and engage families to make their lives easier and lower our cost structure.

This entire approach is one, really, of entrepreneurship, from the standpoint that we deliver this as a direct pay. There’s no government involvement whatsoever. We’re not asking the government for a penny. Never have. In ten years, we’ve self-funded. We have a lot of interest outside the country. The real issue is non-ambulatory, long-term care. That’s where the majority of the costs are. You can’t solve all the problems — aging, fragility. Senescence is a progressive biological phenomenon. The real problem is in the later stage of life where most of the money is spent.

D. Plecas: If I may, just to follow up, one last question. Then I’ll hopefully have a chance to meet with you later.

Somebody says: “I’m going set this up in my house.” I’m thinking that would be a pretty expensive proposition for the setup. I get that the monthly thing is different but….

R. Moerman: No. The cost structure is identical to what the copay rate would be in a B.C. hospital. It’s about $900 a month for the equipment. Then you have to rent specialized services at another $1,000 for practical nursing or specialty para-care. Not all families are going to want to engage.

You’re initially going to start with test pilots and what we term ageanaughts. An ageanaught is a senior who is very feisty and very independent and is losing physical function. But their brains are intact. We’re looking at that population. We’re not going to solve all the problems. We’re going to do a test pilot.

Typically, we try to get 50 beds in a community. With 50 beds, you can take the institutional unit, put it into a hospital at no cost to the hospital. The patient load is driven from the hospital traffic administrator who’s trying to empty his hospital. He says: “You have a choice. You can stay here and pay $900 a month to sit in this hospital bed and get poor service, or we can assess your home environment.” For about $500, we do an assessment. We figure out whether we can install a bed. Then we set up all the co-services for about $2,000.

D. Plecas: No, I meant…. Let us say that I say, in my house, I want to have this setup. I want to have the bed. I want to have everything. It seems to me there must be some kind of cost to install it and the equipment. So there’s an initial outlay.
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R. Moerman: It’s approximately about $150 to $300 to do a site assessment to make sure that the facilities are appropriate. You don’t have third-floor stairs or attics or other difficulties in terms of safety and ambulation. The second part is a $500 setup fee where, basically, the equipment comes in a little truck. It gets set up in three hours. All you need is a waterline and one egress hose and a 4-inch vent.

R. Moerman: You rent it for $50 a day. If granny needs it for five years, she gets it for five years. If she needs it for one month…. You can’t do it for less than a month. It doesn’t cost….

J. Darcy (Deputy Chair): I think, certainly, we’re all searching for ways to reduce people’s stays in hospital and ensure that people are able to be more active and recover more quickly. I wonder, though…. You referred to various people who would be part of a support team or a health care team, including, you said, licensed practical nurses. I would think, also, registered nurses, physiotherapists…. There are a number of members of the broad health care team that are identified there.

I’d like you to talk a bit more about that. The costs for that entire team would seem to me to be far in excess of the figures that you’ve talked about.

J. Darcy (Deputy Chair): Sorry. We only get one question, so I’m going to weave my supplementary into the body of my main question.

The other issue that we know is critical, especially for seniors, is the issue of isolation and socialization. That human interaction and that relationship-based care are absolutely critical. We have seen what happens, in one community after another, when continuity of care is broken and when there isn’t that relationship built between care…. So how does that work?

R. Moerman: Technology without…. High tech without high touch is a failure. You have to have high touch. It has to be 50 percent technology, 50 percent highly skilled modal nursing.

R. Moerman: We take a mid-career nurse, a practical nurse, and we’re going to treat her practice like it’s a dental practice. We’re going to hire you. We’re going to find 200 patients that you’re going to care for. They’re your clients. They will pay you a stream. That $1,000 a month is going to be a service through that practical nurse that has a patient care load, because the patient is paying that $2,000 a month regardless.

If we can do the service component for a $1,000 a month, with 200 patients…. We take a practical nurse who then has her own home care practice. She has her own care aides, and she governs the relationship with that patient. It’s through the Health Ministry, because these are not subcontracted but subrelated.

We’re trying to remonetize long-term care. We want to take every component and structure it as a tax-paying service. The way we make it a tax-paying service is we make it so hyper-efficient, in the same way that social technologies these days — Facebook, Google, etc. Technology is changing our relationship with the world. We have to take long-term care and bring it into the 21st century.

We’re going to do that through modal nursing services. It’s a whole new model. I spent some time at the University of Arizona. We looked at a program of: how do we re-engineer nursing where it becomes social work, part lawyering — because there are a lot of family issues and a lot of end-of-life legal issues — and nursing care? Two-thirds of nursing care disappears with long-term care because the nature of the need changes. But the legal component and the social component dramatically increase.

R. Moerman: Yes. You are part of a community we call Faithbook instead of Facebook. Faithbook is an analogy of how Facebook works, except there are special communities of common interest. If your family has Parkinson’s or your dad has Parkinson’s, he taps into a Parkinson’s community, and you all share that experience. You have time with that group, through teleconferencing with families that don’t feel abandoned, so that care-
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givers have a relationship with other caregivers through this network, and patients have a relationship and share their experience.

When pain is shared, it solves a lot of problems. It reduces stress. We don’t have 100 percent of the solutions, but we have a better model than anyone has come up with so far anywhere in the world. And we’ve looked at this issue for a long, long time. It’s not perfect, but it’s better than anything we’ve got.

M. Dalton: Yeah, a very innovative and exciting project you have going here. This is a model — a prototype, I would imagine. How long would it take to get into production? That’s kind of a…. And the question I have is…. Under $1,000 a month — it just seems that the caregivers and the persons themselves would have to control a lot of the controls and apparatus, I would imagine.

R. Moerman: Yeah, in the same way all of us learned how laptops work, and we don’t have secretaries anymore. In the same way, about two-thirds of the para-support workers simply disappeared because the bed does what we term the “scut work.” All the lower-ordered biological functions are beautifully and seamlessly managed using the analogy of how we do it in space.

We looked at the Soviet space program. We looked at the Chinese space program. We looked at the American space program. We looked at some of the Canadian innovations. And we simply said: “Let’s bring a spaceship into the bedroom, and let’s take everything that we know right now and reformat in a way where we can provide maximum environmental care in a confined space.”

But we have a Houston. The B.C. medical system is still responsible for that patient. When you come out of a hospital, you’re still in that hospital; you just happen to be in your bedroom. And the entire continuing care team has access to the telemetry and the health status. If grandma goes into fibrillation, there’s a call back to the call centre, and an ambulance shows up.

What you want to do is take every disorganized, expensive, slow, lethargic component, and strip all that out. Start with a fresh sheet of paper. Say: “If we’re going to do this differently….” Our cost target is because you can’t afford more than $1,000 a month. That’s our cost target; we have to deliver it for that. We may not. We may find that, you know, we’re at $3,000 or $4,000 and it doesn’t fit for the Canadian situation and we’ll have to go to another region.

We already are being dragged to other locations, desperately asking us to relocate. The sad part is that we have shut down our operation in B.C. We’re not pursuing this in B.C. at this point. Because over ten years, in my discussions with various political and medical thinkers, there is a division. It wasn’t until we could show people where we’re at that people got it. So far, no one believed us.

I’m a Canadian, but I worked in Silicon Valley for 20 years. I’ve taken companies from a few hundred thousand to 100 million. So I know the process of how to create wealth, and I know the process of very involved technologies and very involved relationships. I thought this could be done in B.C. I thought we had an integrated medical system that would be open to it. Regrettably, that has not been the case.

D. Barnett: I think you just answered my question. I was going to ask what kind of buy in has the provincial government shown you. I see you’ve had some monitoring done by the federal government, but did they approve the…?

R. Moerman: We are Health Canada–vetted. We could go into business tomorrow as far as Health Canada is concerned. We’re a class-one medical device.

D. Barnett: Have they given you any other encouragement or support — the federal government?

R. Moerman: There’s only one agency in ten years that has been our champion, and it was Revenue Canada. Revenue Canada came to our facility, which is in Oliver, by the way — surprise, surprise. We’ve been very hidden and very low key.

Revenue Canada did a full audit. It took us half a day. I had that revenue agent, at the end of the day, sit in front of me, and she had tears in her eyes, because she had a mother in long-term care, and she understood the issues. That champion in the federal government made sure that every year we got our SR-and-ED funds approved.

When we spoke about this to anyone else in B.C. and B.C. government, the lights are not on. It’s very regrettable, but you have to go where you’re welcomed. It’s very easy for us to go, next week, back to Silicon Valley, talk to some venture capitalists, raise $10 million or $15 million. It’s very easy to do that in the U.S., and I’ve done that two or three times.

Unfortunately, there just isn’t the vision here, and it’s really sad. Because I’m from British Columbia, I would like to do it here. I wanted to do it here.

L. Larson (Chair): Okay. I’ve just got — we’re getting short — Doug, and then Sue with the last question.

D. Bing: Sure. I just wanted to know how long you’ve been in business, and whether you have some successful projects anywhere in the world at the present time.

R. Moerman: We’ve been at this for ten years. I’ve raised $3 million in venture capital through my reputation of prior successful projects. Medical innovation takes ten years to fully vet. This is our only project. But in the same way Facebook and Google…. Unless you under-
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stand and can vision the future, that question doesn’t even fit. You’d have to look at our financial statements, and you’d have to look at my prior reputation in terms of being involved in companies.

This company is still in R-and-D mode. We are not ready to go public yet. We will launch next year, and there will be a full flowering of the concept. I think at that point, we’ll probably have 20 or 30 different regions in the world that say, “Please come. Please come,” because it’s a global problem. Aging is a global problem. We could move to Denmark tomorrow and be fully supported.

S. Hammell: I think your concept is very, very interesting. I do see how you are taking this particular care and modernizing it through technology. So help me with the care part. You’re saying that for $1,000 you hire people to come into the home to do the high level care. So how many hours a day are you looking at, or how many days?

R. Moerman: It depends what the nursing costs are. I mean, if the need is high in nursing, and the nursing cost, costs $60, take that thousand and divide by 60 and whatever’s missing you would have to get support through community care.

We’re not a separatist of the B.C. medical system. We’re simply providing families that want to engage in care a relief valve to be able to do more of the caregiving. Over time, the system will evolve, and through conversations and negotiations, the Health Care Ministry will come back and say: “You know, we have a pitchfork moment here in the Okanagan. We’ve got a hundred seniors and their families are raging. What can we do together to solve this problem?” That’s, I suspect, what’s going to happen.

S. Hammell: So this, the pod, is not only in the home. Is it also in long-term care facilities yet?

R. Moerman: Yeah. The problem with long-term care facilities is they are the worst constituency to do anything new. And that’s around the world. They have a vested interest in asking for more help, more money, more labour. It’s an old model. It would be like these computer companies using old technology. It doesn’t fit anymore.

Long-term institutional care is a completely obsolete and unhappy model. If you survey 80 percent of long-term-care patients, they want to go home. Twenty percent don’t, and you still are going to need one-third of care in auxiliary hospitals. They’ll be a mix between a dialed down version of a hospital and a long-term-care facility. But people don’t want to age in long….

I mean, let’s do a vote. How many people want to end up in a long-term-care facility? How many people want to age at home? It’s unanimous. We’re in agreement.

L. Larson (Chair): Thank you, Deanna, for your presentation and, Rees, for answering our questions. Very interesting new pieces of technology.

We’ll take one minute just to flip over here. We will stay on air. Just so that everyone knows, as we don’t allow any time during our presentations for the panel to actually take a break, whatever that might be, please understand that the panel will move in and out on occasion, but everything is being recorded.

Okay, I’d like to welcome Dr. Fromberg here this morning. I see that you do have a lot of slides to go through, so I’m sure you’re going to skim them quickly in 15 minutes and still give us the bulk of your presentation. Thank you very much.

Thank you for providing me an opportunity to be part of this health care conversation on primary care. It’s an area that’s a deep interest of mine. I’ve spent 30 years in primary care, and in that time I’ve seen a lot of changes that I and my colleagues have been deeply concerned about, in the sense that the job has become progressively harder to do and interest in a career in primary care has also diminished in that time. I don’t see that either of those are good signs.

We also feel that the status quo, what we’ve been doing so far, is really no longer an option. In fact, I’ve pulled off this quote from the Hon. Roy Romanow from 2002, when he said that the status quo in primary health care is no longer an option. That was 15 years ago.

A couple of things, very quickly, about me. I am a recently retired — yay — primary care physician. I spent 30 years in general practice. I did all forms of primary care — office-based work, hospital work, emergency work, delivered babies, walk-in clinics. I worked in an interdisciplinary team doing chronic pain medicine, which was a very interesting experience. I’ve had a lifetime interest in preventive health, and I’ve always wanted to get more of that into primary care.

I’ve worked in four different provinces — on the east coast, in Ontario and here in B.C. I spent 22 years in B.C. I want to declare that I have no conflicts of interest. I’m not trying to sell anything. I don’t have a horse in this race. I’m just here because of a consciousness that hasn’t let me go quite yet. I also want to say up front that I’m completely and totally biased as to the primary role that a primary care physician has in primary care. I’m going to tell you that right up front.

I’m delighted, in fact, that this committee is taking on what I think is a very difficult but very important question
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on how to build a cost-effective primary care team that has an interdisciplinary component to it. I think interdisciplinary care and a team approach have been in the works in so many ways for years. I think it was first mentioned in the 60s by the American Academy of Pediatrics. It’s also been recently embraced by the College of Family Physicians of Canada in their medical home document that you may be familiar with. That was in 2011.

As you probably also know, the General Practice Services Committee just recently published a visioning statement in the spring of this year. Both of those documents have actually embraced the idea that an interdisciplinary team is really part of the future of primary care. I make note on the slide that one of their quotes there is: “To assemble and coordinate a team of health care providers and community services.” The third point there — that’s one of their quotes.

These are four documents that I’ve actually reviewed. I’m going to go through them, relatively quickly. At the end of this long talk — which is short — I’ve actually given a few extra quotations for you, as references. I think after slide 42, it’s just pure references. Don’t be too daunted by the idea that I have 67 slides. I’ve only got about 40.

Anyway, I’m making a couple of quick assumptions — first of all, that the medical home is really very much synonymous with the concept of interdisciplinary team approaches in primary care. They are, I think, maybe perhaps a subset of the other.

The other assumption I want to make is that interdisciplinary teams can include a wide variety of health professionals. I’ve given you a list there: nurses, nurse practitioners, dietitians, midwives, physical therapists, mental health counsellors and the rest.

We have referred to interdisciplinary teams in various ways as physician helpers, physician extenders and physician assistants, although I want to use the term “physician assistant” carefully because it’s actually an official role in the U.S., where it is not here. So small letters not big letters.

I guess the real question is: if interdisciplinary teams are so well endorsed by leading authorities, why are they not significantly embraced here in B.C., at least not now? What I’d like to suggest is that there are least four barriers. I suspect there are more, but I don’t have the time to go through the rest of them. I want to go through those, as well as provide what I think are some meaningful solutions to them.

The first one is simply that primary care physicians cannot delegate. I’d like to put it out there that everybody’s doing it: nurses, pharmacists, lawyers, engineers, accountants, mechanics, bankers, professionals. God knows, I suspect even politicians are doing it. That is: they delegate.

Delegation is not a complicated idea. You hand off lesser skill-requiring duties to somebody else. Delegation saves money. It saves time. It allows more work to get done, and it allows the more difficult work to be done by the highest-skilled professional in the group.

Physicians, frankly, would love to delegate. There are lots of basic procedures, basic clinical assessments, routine follow-ups, a lot of forms, renewals, phone discussions, etc. These are all things that could be delegated, but they can’t. They can’t because the guide to fees precludes it, and that is even if the doctor was to take full medical and legal responsibility for that delegation.

Here it is, just as I circled right it out of the document. This is from page 119 of the B.C. guide to fees for this year. Essentially, that quote reduces it down to: “Visit-type services may not be delegated.” That is the first barrier to primary care.

The second one, in terms of delegation, is that other professionals — for example, if a nurse practitioner was to work for a doctor, or a nurse was to work for a doctor — the College of Registered Nurses of B.C. as well as the College of Physicians and Surgeons would take some issue with that, and there would have to be some kind of agreement set out.

As of this year…. This is a quote from the actual CRNBC scope-of-practice document. It says: “Where a formal delegation process is in place. To date, no activities for nurse practitioners have been approved for delegation. Therefore, nurse practitioners are not authorized to carry out any activity outside of the scope of practice.” Delegation would therefore require some kind of agreement between the two colleges. There’s another barrier that is a matter of working through.

To summarize this point, delegation, to me, is absolutely necessary for the development of a comprehensive team as a medical home to be created with allied health professionals, which is the way you’d want it to be. If that was the case, I think the family physician would be more than prepared to take full medical and legal responsibility for that patient in any delegation that would happen with that patient.

To do this, though, you would require a change in the B.C. guide to fees. That requires some consideration by the Doctors of B.C. tariff committee, the Medical Services Commission and, possibly, the GP Services Committee. Of course, the colleges would also have to be involved and agree to the idea that this can actually be allowed.

The second barrier has to do with the daily volume visit cap. Just to give you clarity as to how this cap works, if a family physician was to see more than 50 patients in a day, any further fees that this doctor would be trying to apply for would be discounted by 50 percent. If the doctor was to try to see 65 people in a day, then that discount becomes 100 percent, which means that the doctor gets paid nothing for the service.

Being a family physician is the only job I know where the harder you work, the less you get paid. If you were
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to work extra hours, you get nothing — not time and a half, not double time. You get nothing. That, to me, is a flawed model.

I appreciate why this volume cap is here, and perhaps I could give you some background to that. What’s interesting is this is a selective model as well. The discount is only selective to most GPs. It’s waived for physicians working in underserviced areas, such as areas where the northern isolation allowance is, and specialists are not similarly restricted. There are dermatologists up there who can see 95 people in a day, no problem, but GPs, curiously enough, are restricted. That really puts a fly in the ointment in terms of how much work the average doctor can do.

Has the cap outlived its purpose? As I recall — and I remember this vaguely — the cap, I think, was created primarily to protect at the time the onslaught of walk-in clinics into general practice. People were worried that family practices would be ruined, and doctors wouldn’t work in them anymore.

Today, actually, at least certainly in the area that I’m in, walk-in clinics support family practices. I don’t know any doctor who is open seven days a week, but most walk-in clinics are. Most walk-in clinics are open in the evening, and they actually support family practices much more so than before. The concerns that were raised 20-odd years ago by GPs at the time have completely gone. Walk-in clinics are almost a necessary part of primary care delivery.

If the volume cap was eliminated, one thing that’s really important is that the primary care practice could actually pay for the interdisciplinary team members that actually see these delegated patients. What’s also interesting is that practice could now increase its capacity so that instead of being limited to 15 a day, it could see 70 in a day, 80 in a day. A practice would have more capabilities, and it would also, obviously, be able to provide more services.

What I think is really exciting is that morale and interest in primary care might actually increase, because now a doctor has kind of some control over building a practice in a meaningful way, as opposed to having all of these things cutting off at the knees. Of course, all the concepts of a medical home, I think, would apply, which is really exciting.

Barrier No. 3: lack of sustained system support. I think the one document says it best here, and I just want to quote it if I can. It says: “If there is a lack of system support for everyone on the team, including a lack of appropriate funding, chances increase that the team will be dysfunctional and will not be able to produce the anticipated benefits for the patients being served.”

Basically, you need some solid footing here. If there was sustained system support, an interdisciplinary team could be reliably formed and sustained. You wouldn’t have people going, “Well, I don’t know if there’s going to be funding next year” and “I’m out the door” — this type of thing. Hierarchies could reliably be established within those medical homes. You could actually improve the quality and quantity for an entire population base that you’re serving.

Family physicians could reassert themselves for their important role in community and primary care delivery, and the primary care physician morale, I think, would increase, because that’s certainly been on the decline for many years. Burnout, I think, would decrease as well. What I think is also exciting is that maybe more and more people would be interested in doing primary care, which is also another very important issue.

The last barrier I want to talk about is what has been also very subtle but has been eating us all alive, and that is increasing competition and encroachment into the primary care model by other health care professionals. Specifically, despite the family physician being recognized as the most trusted, the most skilled, the most qualified primary care provider, many other professionals are wanting to either provide or even replace primary care physician services — such as pharmacists, nurse practitioners, chiropractors, naturopaths.

Most primary care physicians these days are working so hard they don’t have any time to actually defend their neck of the woods, whereas other niches are just sort of taking pieces off. That, to me, is breaking apart family practice, and that absolutely has to stop if we’re going to actually have any preservation of primary care, interdisciplinary care or a reasonable family practice model.

If, somehow, primary care physicians are re-instilled into this captain role, if you will — being the only person, for example, to direct an interdisciplinary team — then a couple of things, I think, would also be immediately advantageous.

First of all, I think it’s the family physician that would have the best broad vision about what and which kind of supporter, team member, they might need. Obviously, it would be different in a skid row practice versus a small rural practice versus an urban setting.

The training and experience of a family practitioner could also maintain a very broad community base, and in fact, most family physicians are well community connected with hospitals and community services. The science-based training of a family physician would maximize evidence-based best practices applied to a given population, so I think you’d know that you’re getting pretty good quality care. And the central role of the family physician in the patient-physician relationship would be preserved, which is a very important thing for me.

Let me finish off by just a couple of summary points. Those are the four barriers, and these are just a repeat of kind of what I’ve said. I think the patient’s medical home is, as I mentioned, synonymous with interdisciplinary care, and I think this is a widely endorsed concept whose time has come. It’s going to be a challenge to change a
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bunch of models, but I hope I’ve given you a few ideas as to how to do that.

I think it’s effective because it can reduce costs with reduced ER utilizations and hospitalizations. There might be the beginnings of something called preventive health, which is something I’ve had a long passion in. The family physician, I think, is the best qualified, the most experienced, the most trusted, the most respected health professional to coordinate and direct an interdisciplinary medical home. I don’t think there’s anybody else close, and I think that needs to be preserved.

The context of any given family practice would actually dictate the kind and the number of those physician-helper extenders that become part of the team. I think the physician himself or herself would be the best person to decide that.

I think what’s exciting here is that there’s no training program that needs to be created. Nurses, dietitians, social workers are already out there in the community. You just have to pick them out and say: “Okay, I want you. I want you. I want you. Let’s make a team. We’re good to go.” It’s not like we have to create a physician assistant program, which would take years of academic wrangling and all of the rest. They’re ready. They’re willing. They’re out there. You just have to give them a reason to work.

The family physician, as I mentioned before, would be more than happy to take full medical and legal responsibility. Certainly, I’ve worked with many nurses over time, and as I got to trust and know what they did and I showed them how I do certain things, I would let them run with progressively more and more abilities.

What’s interesting is that much of the nurse practitioner training that’s out there actually states categorically that the average nurse practitioner can do 80 percent of what a GP can do — 80 percent. Well, okay. Have at ’er. I’ll take the other 20, and we have it covered. So in principle, it’s out there.

What’s also interesting, though, is that a nurse practitioner can do four years and is fully able to practise, whereas a medical doctor in training…. Four years — they’re still not allowed to practise. It’s still two more years before they do. So there is a difference between the two, and that’s why I think a nurse practitioner should actually be under a primary care provider.

M. Fromberg: Okay, sorry. All of these points are just repeats of what I’ve said. Changing the preamble. The College of Physicians and Surgeons needs to be…. Delegatable duties, as I mentioned. The fee cap needs to be changed. All of those things can increase the capabilities.

What I liked about this model also is that the whole GP for Me concept that has slid sideways…. I think it could solve this — i.e., if you have a broad-based medical team. Without actually increasing the number of doctors, if you increase the capacity of every practice out there by 30 percent, you will take that 30 percent of the population that doesn’t have a doctor — fixed.

L. Larson (Chair): Yes. We have heard what you’re saying as we have listened to others, so thank you very much.

J. Darcy (Deputy Chair): Your passion is quite catching for primary care and family practice.

A couple of things that I think are related. On the one hand, you seem to be saying we should remove the cap or raise the cap, which would allow family doctors themselves to see more people. Yet you’re also saying delegate — that there should be more ability to delegate. That means changes to what physicians can do as well as other health care providers can do.

But the more delegation, presumably that means the physicians would see the more complex patients, which need to take more time rather than less time. So I wonder if you can explain that.

Also, in terms of it always being a physician-led team…. We’ve been talking to people in urban and rural communities, but one of our big focuses is rural health. Some of the models that have been shown to work best and where some of the best innovation has been is where there are teams — sometimes led by physicians but sometimes not — that serve remote communities. Or there can be health centres or clinics, practices that have satellites and have mobile clinics that serve remote communities. And there is no possibility of having an entire team led by a physician in all.

So how do we meet the needs in remote and rural communities, and how do you square the circle of the fee cap, removing fee cap, and more delegation and more complex patients for doctors?

M. Fromberg: Sure. Let’s see if I can get to the beginning of that question first. If I had a practice where all of a sudden I’m just seeing the more complex people, chances are I’d be maybe only seeing 20, 25 of them because they’re each a half an hour of work per patient. Elderly patients — you know, they have a list of 15 medications and 14 different problems, etc. Yet somebody who’s coming in for a routine prenatal check or a blood pressure review or maybe a diabetic checking their sugars or a lab review or a form or camp physical — any number of lesser items….

If I had a nurse, a nurse practitioner, a kinesiologist, a dietitian all doing all of those things…. A dietitian might see ten people. A nurse practitioner might see 20, 25. Depending on how big my team was and what its focus was, my office would now have the capacity of seeing 75 people, for example, or 80 people, whereas before I would
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have had to have seen them all myself, and that’s the only way it could have worked.

As much as I could have had all these people in my practice, I still have to see them to get paid, and that’s really where the delegation is quite limited.

Now, you mentioned the rural issues. I think the whole concept of the medical home and the interdisciplinary team varies with every setting. Downtown Eastside is one setting; downtown west side is a different one. Small, medium and larger communities, of course — Kelowna, Kamloops — would be…. You know, in my community, I could well imagine hiring two or three different types of people. I might have a sports medicine interest and have a kinesiologist working with me. “Hey, deal with this guy’s ankle” — this type of thing. I would have some flexibility about that.

For things that I couldn’t access in my community, then, “Okay, hey, I don’t have any physios in this neck of the woods, but there’s a guy in the next town” or down the street or something like that. It doesn’t all have to be in-house. I mean, the more of it in-house, the easier it is, but it can still be captained from afar. I can still send somebody to a different community that I have some liaison with and still make that connection.

Right now, of course, we have lots of rural communities that don’t even have physicians, and doctors are running the other way. I wonder if that would be as true if the physicians had some more — I don’t know — power, if you will, some more ability to sort of run their own ship as opposed to being dictated to. “Hey, you do this; you do that” — that kind of idea.

S. Robinson: I also want to comment on your passion and your commitment to providing really good service to patients.

I have a question around just a couple of comments that you made towards the end. I’m just looking through the notes. At one point, you talked about evidence-based — right? — that the family physician was the best-positioned for evidence-based. Then you commented in your summary that the family physician remains the best qualified, experienced and most respected health professional.

Based on what we’ve been hearing in terms of the evidence and the outcomes for patients from other sorts of models — it’s sort of team-based but slightly different modelling — what sort of evidence do you have from that perspective that sort of supports that it should come from the physician who then delegates? Is there any outcome data? Do you have anything that would support that statement that the family physician is the best qualified, experienced and most respected health professional to do…?

M. Fromberg: Well, I’m coming from a clear bias. I mean, medical school is based on the idea that everything is science-based, and certainly everything that we do we research. I’ve had other health professional…. In fact, I’ve seen patients come in and bring me stuff from their other health professional, whatever that is. It has no basis in science whatsoever, and yet it’s sort of part of their mainstream. Without sort of pointing fingers here, it’s really a question of….

I can think of one example. A certain professional said: “Look, we’ll do these manipulations for your child’s bedwetting for a year once a week.” It’s like: show me the paper that says that, and I’ll sign up for it, but until you do, that’s a stupid idea. You know, that kind of idea.

There’s a lot of stuff out there that really is borderline. I can’t speak to what they learn in chiropractic school and naturopathic school, but there’s some stuff out there that I’m concerned with — not the least of which is naturopaths selling their own concoctions, which I think is a fundamental conflict of interest. Physicians can’t and don’t do that.

The question I have…. A lot of people ask me the same question, and I have no answer. The College of Physicians and Surgeons and the college of nurses — how could you get into these institutions to change the mindset to move this forward?

M. Fromberg: It’s a great question. You know, I think one of the problems here, to me, is really a lack of a team commitment from all the players involved. I mean, government is only one part of the team. Physicians are another. The colleges are another.

To give you an idea, I was at a conference once where a college representative was speaking his mind and then promptly left after. Obviously, he’s busy, but he clearly didn’t give a damn about whatever others had to say about this kind of thing. That I found extremely frustrating. It’s like: “Our way or the highway. We’re the boss. To hell with the rest of you.” That doesn’t work.

Colleges are ivory towers, to some extent. They sort of have this dictum on high. I don’t pretend to fully understand the health professions, the board above them that they have to answer to. But somewhere along the way, there must be some kind of government influence there that, “Hey, get these people to the table to be part of the solution” as opposed to just hammering, hammering relentlessly and not even worrying about what the implications are of what they’re saying.

D. Plecas: I hope you don’t retire anytime soon. I know you said you’re officially retired.

D. Plecas: I know you’ve said that, but I mean retire from your efforts to do what you’re trying to do now.

I’m only allowed one question, so I’ll put it into one. What percentage of physicians, do you think, think like you do? Secondly, as part of the same question, related to what my friend Donna was asking: why is it so damn difficult to get these ideas to have wheels, to have traction? In your experience, what’s the stall here? I know you’ve answered that in part.

M. Fromberg: Well, I put up four barriers just for fun, and I could probably have put up four or five more. That said, the first part of your question. Among my colleagues…. To be frank with you, most of them are barely treading water. They are so busy. Family medicine is a 24-7 service. If you dare go out and have a break for yourself, it’s like: “Where the hell were you? I tried to call you.” You get crapped on.

I don’t know. The college expects us to be able to respond to our patients 24-7. I don’t know about you, but I need some sleep once in a while. The very idea…. In fact, I abandoned family medicine after ten years. It was absolutely killing me. Deliveries, as you know, come when they goddamn please. I can think of more than a few times where I was socializing and having a single beer, and then all of sudden getting called, showing up, and: “There’s alcohol on that guy’s breath.” Like, oh god.

What do I do? I can’t separate myself. It’s so part of you. It’s a part of you. That’s why I think so many of my colleagues don’t even bother with the idea of jumping into this, because they don’t have the time or the energy. I mean, I’m only here because I’ve had a whole week to actually prepare this. I couldn’t imagine doing this if I was actually still practising. I’d probably write you a quick note, scribbled, that you couldn’t read: “Hey, this is what I think. See you later.”

That’s what I think my colleagues are up against. They’re just backs to the wall, and you don’t have time to actually elicit their opinions.

D. Plecas: No. What’s the stall here? What’s the stall to getting to the barriers? Your ideas — they seem like such great ideas. Like: “Duh.”

M. Fromberg: Well, sure. Like I said, I was at a conference where I thought I could actually speak to the college representative that was there, but he didn’t stick around five minutes to actually have that conversation informally. So it’s like: gone. You know, that kind of idea.

One of my classmates is the registrar of the college. I haven’t had a chance to speak with her personally in the last 15 years. I’d love to have that opportunity, but she’s in one town and I’m in another. I mean, things get in the way. Sometimes I think the best thing is sort of the personal cocktail kind of discussion, which, frankly, doesn’t happen as much as it could.

L. Larson (Chair): Thank you. That’s all the time we have for questions this morning. However, if anyone on this committee has questions they would like to ask Dr. Fromberg, we will send them through to him. I know that he will now respond, as he has all this time on his hands.

L. Larson (Chair): I really appreciate you being here. You’re speaking to the converted, so to speak.

M. Fromberg: I’m in Kelowna. Linda has my email. Please write to me. I’m happy to meet with any of you any time.

L. Larson (Chair): Yes, we may get you together again for some more in-depth….

L. Larson (Chair): I’d like to invite Connie Redknap. Would you introduce yourself and where you’re coming from? We don’t have too much information.

C. Redknap: Okay. My name is Connie Redknap, and my background — my career, actually — started here in Kamloops as an office skills instructor with Cariboo College. I taught business skills for a number of years and then got sidetracked into senior care, which has become a passion.

I don’t have a formal presentation. I was sitting there, thinking: “Oh, I could have done this on the phone at home.” It would have been better. The good thing is you guys might get an early lunch break, and the bad thing is that you do have a three-page package of solutions to everything, which is mandatory reading.

L. Larson (Chair): Why don’t you just speak to that? That would be great.
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C. Redknap: Okay. Based on the first two presentations, I didn’t have a formal plan. I didn’t want to read what was on there. I was very interested in the first one, the dignity-at-home project, because they have a lot of really good systems. There’s a need for some automation in senior care.

I mentioned about starting my career here, because it was back in the ’70s. It was a college system, and there were a lot of awkward situations that we encountered. I had a boss I respected very much, and he commented: “You know, don’t you guys get discouraged, because the college system is in its infancy.” I reflect back on that, and I think: “Well, really, senior care is kind of in its infancy too.”

About eight years ago, I got involved with…. I just semi-retired and took on some work with a care agency. That took me into the private homes of seniors, into assisted-living facilities, into complex care facilities. I kind of became aware of a lot of the challenges and problems that are occurring.

I’m concerned about the cost as well. One topic I want to zero in on is in complex care facilities. There are a lot of referrals to emergency, and emergency care, I know, is very expensive.

Residents in complex care have a lot of challenges. Most of the staff are care aides. Care aides have basically six months of training before they start, and it can be overwhelming. Their job description includes things such as transferring heavy patients from one place to another; setting up dining rooms for meal service; helping people get dressed, toileted, groomed; and dealing with individual issues. It can get overwhelming.

Also, there are often emergency situations that occur, most commonly falls, and these result in transport to the hospital. I know there’s been some concern about how these emergency visits can be reduced — and just concerns about overall patient comfort, resident comfort.

Some things I found were that a lot of the elderly people, some of them, seemed very spaced out. You would assume dementia, but a lot of it was hearing. Sometimes it was hearing issues, and as a support worker I was often asked to look after these hearing aids — replace the filter, the battery and get them set up. It was a simple thing to do, and as soon as it was done, it made a big difference. The person was there again. They could hear what was going on. They could communicate.

A second item that was of concern is that it’s very important in complex care for people to have as much mobility as possible. Both as a support worker and as a visitor to an elderly relative that I recently lost, in my mind it was very important that the person be mobile.

On staff in care facilities…. They have physio support and various social supports. But one big issue I encountered that really concerned me was that often people had very severe problems with their feet. In one facility that I worked at, a podiatrist visited, and there was a lineup that went the full length of a long hallway.

Those are two items I’m concerned with. Number 1 is hearing. Number 2, foot care, is vitally important and should be a really strong part of the care of the resident. It should be offered for them if needed.

The fourth thing that is a huge issue — I was particularly interested in the Digniti Home-Hospital Project — is incontinence. Incontinence is a reason that people have to switch from assisted living, where they have a lot of people coming and going and things going on and they’re independent. As soon as they need assistance that way and can’t manage themselves, they often end up in residential care, and that’s kind of a tragedy. It’s time-consuming for the care staff. The residents get used to it, but it’s a huge issue.

There should be research being done into some sort of a robotic system that would streamline that process. There should also be links with doctors to see if there are causes that can be treated.

I also have a passion about the environment. Residential care homes…. Well, there are just a few people who make it to the end of their long lives without ending up needing incontinence care. It’s as simple as that. Think about the landfills — all that disposable stuff. I don’t have the answer for that one, but it’s an important issue.

Automation, adjusting the plumbing, whatever needs to be done that can facilitate people in the management of their own self-care…. These are fairly simple issues, but they are really, really important. If everybody can project forward, at the end of a long life, that’s something you don’t want to deal with.

Just a couple of other comments. Having a background as a college instructor and listening to Dr. Fromberg earlier, his frustration in linking up with the education system…. I think it’s important to work on that. It’s important that people who are training for medical careers have solid information on where the opportunities are and where the market is overrun.

Building a career on a passion is great, but you need to grip reality, and there are some places, for example, where there are far too many medical specialists. That’s a problem in itself when there are other places that are struggling to get the care for the people that need it. There has to be a collective effort between the medical community and the college training system to get the needs fulfilled.

Dr. Fromberg also talked about delegation. I’m sorry. It was over my head — most of it. But I have to comment that I feel that it’s very important to have teamwork, and I think the doctor’s responsibility should be to make care plans that make sense and give the other health workers clear guidelines on what they should be doing. There is a need for stronger links, connections and so forth.

L. Larson (Chair): Thank you. It’s wonderful to hear from someone who works with seniors. We have had other presentations prior, for another report, that were based mostly on seniors. I live with my 95-year-old mother — or she lives with me, I should say.

The things you’ve mentioned about a podiatrist and so on…. When we’re looking at teams, that’s another team member that is incredibly important for seniors. It’s just one of those things that often, we miss — and certainly the hearing one. The other one — we’ve actually heard about it too — is dental care, when it comes to seniors, as well.

Thank you very much for your presentation, and I’ll take questions. We have a minute for questions.

C. Redknap: Wait. There is one important thing I forgot — I’ll be short about it — with regard to emergency care that is needed in seniors facilities.

I’d suggest having a paramedic or a highly trained first-aid person who also could be there, not just for emergencies, but could be there on standby to oversee and monitor things such as what’s going on with this patient’s foot care or that patient’s teeth or, you know, how this person is doing with their incontinence or whatever.

J. Darcy (Deputy Chair): Thank you very much. It’s wonderful that you’ve come forward as an individual to make this presentation.

We’ve been talking a lot about primary care and community care. Seniors care is obviously an integral part of that, and I want to echo what the Chair said about…. You’ve spoken to other members of the team that we haven’t heard as much about, including care aides, people who deal with hearing loss, podiatrists. But also, it is often nurses that can do fairly sophisticated foot care programs. I think the big challenge that we face is that our seniors care team is not nearly as robust an interdisciplinary team as it needs to be in order to deal with the variety of complex conditions that people are dealing with.

We’re going to hear from ambulance paramedics who are going to talk about community paramedicine, which touches on some of what you just mentioned. But I wonder if you could speak in particular to….

You talked about seniors who were diagnosed, who people assume have dementia, when in fact they have hearing problems, often, or other undiagnosed conditions. Can you talk a little bit more about your own experience, about how we ensure that seniors get the care from the right care provider to give them the best possible quality of life, whether that’s the podiatry or whether it’s the hearing loss? I’d just like to hear more about your own experience in that regard.

C. Redknap: Most of the people I’ve worked with have had some level of dementia, although some are sharp as can be. I have a private client right now who will turn 100 in September. He just keeps the library rolling, and he walks a mile or so a day. But it is tragic when somebody does have a hearing issue that’s not diagnosed, and on entering a care facility in particular. I really do believe that should be part of the protocol to start with, to zero in on some of these things and make sure they’re dealt with.

Some of the aspects of hearing care can be fiddly, but if somebody is there and checks on that patient once a week or so, then all the routine care aide staff has to do is get that hearing aid in every morning. Usually, monitoring once a week or so by someone else works fine. It makes a huge difference, because there are just too many hearing aids in drawers.

D. Plecas: Hi, Connie. Thanks very much for your presentation. You’re very, very inspiring.

One thing that I wondered if you could elaborate more on is podiatrists. I hear this over and over again, the importance of foot care, and we seem to have a big void there.

C. Redknap: Yes. At an assisted living facility in Summerland, podiatrists visited, and it is a concern to me that…. I think there is a strong need for podiatrists, especially amongst the elderly, because foot care can mean the difference….

You know, if you’ve got something, even an open sore, on your foot, between your toes, it can mean the difference between being mobile and sitting in a bed all day.

I strongly believe in the services of people who do foot care. Sometimes they visit the hospitals, but it’s very important that they be qualified to determine when more specialized care is needed. As I understand it, podiatrists…. It’s kind of a secondary form of medicine. But I believe they have eight years of training in foot care. So for something that is a foot problem, I would prefer a podiatrist to an orthopedic surgeon, myself.

Thank you so much. I really appreciate it — like I say, especially the seniors’ end of it. I live with that every day.
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So thank you very, very much for coming this morning and for sharing your experiences.

L. Larson (Chair): We do have a few minutes, so we will take a five-minute recess.

L. Larson (Chair): I’d like to welcome our next presenter, from — I hope I’ve got this right — the B.C. Transport Nurses Network.

L. Larson (Chair): Scott Lamont and Michael Sandler, thank you very much for being here this morning. We’ll turn the microphones over to you. You have 15 minutes to put everything you possibly can on the table. Then we will ask you questions.

Michael and I are the co-leads for the B.C. Transport Nurses Network, which is a practice network that is forming with the support of the Association of Registered Nurses of B.C. as part of their specialty practice groups initiative.

We represent emergency, pre-hospital and retrieval critical care transport nurses practising within health care authorities, private air-ambulance services, the military and volunteer organizations such as search and rescue and ski patrol. These are some of the places that you’ll find nurses like us.

By way of introduction, I have over 31 years in health care, about 20 of those as a board-certified flight nurse. I have practised emergency pre-hospital flight and critical care nursing in settings ranging from the far north to the American southwest and both Alberta and B.C. I was the original care leader for the collaborative critical care transport program done by Interior Health and BCAS that was based in Trail. Then I was the original patient care coordinator for the high acuity response team that replaced that program. I currently work full-time as an emergency nurse in a rural community.

M. Sandler: My name is Michael Sandler. I’m currently the clinical practice educator for a dedicated group of critical care transport clinicians within the Interior. We service almost a third of the rural and remote areas within the province. My background is in tertiary and middle-sized, and rural and remote critical care emergency and transport, and I’ve actually managed to work as a transport nurse on almost every continent in the world.

I’m looking forward to this opportunity. I have a distinct and unique interest in rural outcomes, and this is an opportunity to speak on behalf of our patients to try and improve those outcomes. So thank you for seeing us today.

S. Lamont: We would like to thank you a lot for the opportunity to present. We would also like to emphasize that we are here representing only the specialty of transport nursing. We do not speak for any particular employer or any other agency.

We understand that the committee is interested primarily in new or updated information pertaining to our previous submission, the key premise of which was to improve rural health outcomes by leveraging existing human resources already in place — namely, critical care–trained registered nurses working in rural settings using interdisciplinary collaboration that crosses traditional practice boundaries. Very similar, in some ways, to the community paramedicine model that is now being implemented.

We suggest, in this update, three separate and specific actions to make this change possible. First, reliable provision of funding support for skills development to provide the proposed patient care enhancements.

Second, modernize legislative regulatory and administrative language to emphasize not only clear mechanisms to support matching enhanced scopes of practice to rural needs but also the cultural changes required for effective collaboration across disciplines and across settings.

Third, a review of scopes of practice reiteratively, on an ongoing basis, with an eye to adapting to changing rural health care needs and adopting best practices from national and international examples as they become evident.

We realize that other presenters have discussed funding needs, and it seems that there is no such thing as a health care conversation without a discussion of money. So we are aware of that. We do support suggestions by the ARNBC and BCNU that standing funding for education and clinical development opportunities be considered as a mechanism to promote retention of rural RNs.

A few key issues we identify in relation to this. One is that the registered nurses, themselves, must be able to select some of their own educational needs, as competency self-assessment is actually a licensure requirement — required by the College of Registered Nurses of B.C.

Spending money on only packaged or employer-driven education initiatives will, even if they are valuable, not consistently meet the needs of front-line RNs. So there has to be that opportunity for self-assessment to be expressed in a realistic way for them to address self-identified needs to maintain the competencies that they believe they require for their populations.
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Second, models exist where the enhanced education and skills can be shared outwards through in-services and on-site collaboration. This means that the money spent at individual or small-practice group levels can still actually spread outwards to a larger group of professionals. We believe that the heart model is actually a good model of that and that other health authorities could take advantage of similar initiatives that would move skilled, highly educated and respected colleagues out into rural communities to work alongside staff to help them improve their skills and enhance the capabilities and capacity of rural sites.

Third, there are excellent training programs nationally and internationally in what is referred to as pre-hospital emergency and retrieval medicine or critical care transport, depending on which continent you’re on. If we could support some B.C. nurses involved in transport in going to some of those programs, it would be possible that they could bring that back and inform the development of a made-in-B.C. transport and emergency care training program for registered nurses that could be based out of a recognized institution like BCIT, like the University of Northern British Columbia, like the Justice Institute.

Finally, training on collaboration itself and how to bridge interdisciplinary gaps is something that is really required. If there is going to be funding that looks forward at how to improve rural health care and the idea of collaborative teams, collaboration itself, communication, territoriality, overcoming barriers — those are actual skills — need to be taught. Those need to be supported in terms of funding in order to support and develop a new culture in health care.

M. Sandler: I’ll speak to the second point, which is scope of practice. It’s far more targeted, in the sense that if we can enact targeted enhancements to the current scope and the current legislation, which really meets most of our needs currently, we can have a full scope that meets the needs of our rural patients. There are just little pieces that we need to enhance that will allow us better rural outcomes.

I think one of the key considerations is that, although there are 26 health care professional designations within the province of British Columbia, there is usually only one designation in those rural and remote sites, which is the nurse. We have to make sure that we address some of that overlapping scope issue so that the nurse can initiate and care for their patients appropriately and timely.

Currently, our scope of practice is out of step with national and international best practices, and it requires some modernization. Those are easy fixes. We don’t have to make massive changes to legislation or anything like that. We just have to make some targeted changes.

Lastly, we want to ensure that the CRNBC, which was designed to enhance nursing practice in the interests of the public, maintains access to this process at all levels so that we maintain public perception that we are safe. Our ultimate client is the public, and we want to make sure that they receive the best care that they can receive. We are of the position that CRNBC is in a targeted position to be able to help implement these changes.

S. Lamont: It’s worth noting that we are in discussion with CRNBC and have been for a while and have presented them with some of the documentation similar to what we have provided to this committee. That is a process that is underway and, of course, like all these things, it takes some time to make it through.

M. Sandler: Just to finish that off, there is some new literature that will be coming out from UBC as it relates to best practices within rural health care. There is a homegrown solution that rates in the top five of rural transport and treatment systems.

So we’re close. With a little bit of extra work, I think we can probably standardize that across the province and start to be on par with some of our colleagues across the border in Alberta and north of us in the Yukon.

S. Lamont: In terms of the scope of practice, from our perspective, where it has fallen out of step, I think, is part of the challenge of health care changing: what “belongs” to any particular health discipline, the evidence supporting when and where certain skills or knowledge should be deployed for best outcomes. All of those things are a moving target, and so the review process needs to be reiterative, that being that there needs to be a constant mechanism that, as new practices and new literature comes forth, those can be implemented in appropriate scopes of practice.

Here we’re not talking just about nursing, but we’re talking about all of the different health care professions. That is how we are going to be able to drive evidence-based scopes of practice that meet real needs, rather than having a huge lag time.

I was part of the emergency cardiac care committee that set up the guidelines and rules for registered nurses to provide emergency cardiac care. The very first thing the committee, at their first meeting, recognized was that one of the key skills that should have been in the regulatory language wasn’t there.

Why? Because, somehow, in the process of developing that language, the list that was made had already fallen behind the science of what needed to be delivered. That resulted in CRNBC having to publish it with a caveat that one of these key interventions…. If nurses needed to routinely deploy it, employers had to find their own solution to making it fall within the nurse’s scope or finding a way for it to be achieved with an order. It’s a band-aid, and it puts a lot of the requirement back on the nurse and back on the employer.
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Finally, with that idea of scope, other aspects of legislation and administrative language include things like access to resources. This is a vast province. Time is everything. Weather is usually against us. Providing, for example, ambulances that are designed for street responses to provide four-, five-, six-, seven-hour critical care transports, with all of the equipment and resources that are required, including much higher power consumption, much higher oxygen consumption.

We have had cases where ambulances have had to switch main tanks two times in order to get the patient to the hospital alive. That’s because the wrong resource is being made available. There is plenty of evidence and best practices available from other jurisdictions, both on this continent and off this continent, about when air should be accessed. When should it be fixed-wing? When should it be rotor-wing? When should you consider a boat? What type of ground ambulance is appropriate?

Street ambulances are great if you’re moving a patient from one hospital to another in a metropolitan centre, it’s 15 minutes away, and they’re going to the cath lab. Try to do that from Trail in the winter. That doesn’t work. Yet that’s the resource that’s made available.

In conclusion, we believe that transport nurses and the provision of this particular specialty in B.C. can make a real difference, particularly for rural communities, which tend to be under-resourced and tend to have providers, especially of emergency services, who have less training and less support.

We think that the way to improve those outcomes is to improve access to highly trained clinicians and equipment and bring those people not only into referral centres more quickly but bring referral-level care to those patients more quickly. That is what’s going to make the difference.

L. Larson (Chair): Okay. Thank you so much. I can speak from experience to the excellent transport that does happen, as I had my husband transported from Kamloops to Vancouver, but also the fact that we had to wait extra till a plane with the proper equipment came to move him because of his brain injury.

So I can understand that that issue must have…. And that’s not rural -remote, so I can understand how valuable having the right equipment and the right aircraft available is to what you do.

D. Plecas: Yeah. I, too, can speak to personal experience about the great work that you do. I can’t say enough good things about that.

The question I have relates to your concern about scope of practice. That always sounds intriguing. You think: “Gee, what else can we have nurses do?” But there always seems to be someone who says: “Whoa. Hold up here.”

I guess my question, then, would be: Who do you think might not like the idea of you extending your scope of practice? Where would the alarm bells be going off there? And when you talk about extending scope, does it really mean that we should expect there’s added cost to go with that or just that nurses would have an opportunity to do different kinds of things?

M. Sandler: To answer your first question, I would suspect that there are several groups that would probably raise some alarm bells. Scott mentioned that we need to provide some access to training about true intercollaborative teams. I think if you have that discussion around intercollaboration and what’s best for the patient and we keep it patient-focused, we can get past those concerns related to what I’ll call sandbox issues or siloing of health care.

One group might be the physician group. Another group might be the paramedical group. A third group could be the respiratory therapy group. Each group addresses and approaches health care in a slightly different function, and there is a prevailing opinion out there that they take care of the issue just fine without it being expanded any further.

I think that goes back to the initial comment that although there are 26 health care professional designations within the province, in our rural and remote sites there is only one. So while I don’t disagree with respiratory therapists that they’re excellent at airway control, they aren’t in Blue River. They’re in Kelowna and Vancouver and Prince George.

We have to figure out a way to enhance the current scope to allow that skill set to be included within the nurses’ scope because it’s the nurses who are going to bring that care to the bedside for the patient. To have arbitrarily restricted comments in there like “application of electricity,” or “orotracheal intubation” or several other kind of small individual pieces isn’t patient-focused.

That’s an answer to your first question. Scott, did you want to answer the second question?

S. Lamont: Yeah. I think, in terms of cost, there are some aspects that will have up-front costs — for example, where greater independent-decision-making is required. The nursing scope…. One of the strengths of the way the scope is designed in B.C. is there are aspects of the scope that the nurse is completely accountable for, so they do not need an order from another practitioner in order to carry them out. Others they do all the time, but it has to be with a patient-specific order.

The crossover there, sometimes, is a skill that they already have, that they already do routinely. There’s no real extra cost. It’s that they need to be able to initiate it independently in certain circumstances.

That can be changed at the regulatory level, and then the employer still say: “Only this group of nurses who’ve
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had this additional training can do this aspect independently, and we are going to restrict the scope so that everyone else who doesn’t have that training still requires an order.” So there are multiple layers of protection and refinement to make sure that what’s being offered to the public is appropriate for that group and that setting.

S. Robinson: Thank you for your very pragmatic perspective on all this, recognizing that this is the framework that we live in currently. There will never be enough money to do all the things that we all want for everybody so let’s be very pragmatic about this.

I just want to ask a couple of things around the scope of practice. In particular, you commented around the idea that it needs to be iterative. I’m wondering if you could just sort of elaborate. When you say iterative, that’s like every four years it goes under review based on changes.

If you could just provide an example of what you mean by that and also comment about culture. You talked about — and we’ve certainly heard from many different groups around…. You mentioned territoriality in particular. This idea of collaboration — it’s not as simple as saying: “We’re a team, and now I’m going to tell you what to do.” That’s not collaboration. If you wanted to speak to those two things, that would be really helpful.

S. Lamont: I had a thought, and now it’s fled my head. I hate it when it does that.

S. Lamont: Oh, the iterative, yes. It's interesting. I had a conversation with a member of the administrative staff who works with the health care act and the regulations under that and their process. One of the things that came out of that is: “Well, how do you do a reiterative process?”

My suggestion would be that although having a routine timeline is useful, it is: how do you have the right information in front of you when you get to that timeline? I think that you need, at least, an individual who is dedicated to screening new literature as it comes out that looks at specifically skills or interventions that might cross disciplines or might move out of one setting into another setting and be beneficial.

A great example is ultrasound. Ultrasound used to belong exclusively to radiologists. It was done in a diagnostic imaging suite. That was where you found it, and look no further. Emergency physicians very quickly recognized that being able to screen patients who needed critical interventions or the intervention of a surgeon could be done at the bedside in the ER with the support of the radiologists providing additional training, and it is now the standard of practice.

It went from being sort of an “aha” thought — with a lot of the radiologists going: “Oh, you don’t have the expertise to do that; this won’t be safe” — to now a recognized part of emergency practice. That is now moving into the transport world, where handheld, very powerful ultrasound devices are available. They’ve been able to demonstrate that they can teach RNs, paramedics and RTs how to use these devices to screen for things, which can and do go wrong in transport, very quickly and effectively.

That would have all come out of the literature, and the literature would have been constantly putting forward new articles: where is this coming out, and is it making a difference to patients? If you had someone doing that constantly, then when you hit whatever the benchmark is for review, you would have a literature review ready for what, of these restricted activities, we should be re-examining.

M. Sandler: Just to add to Scott’s point, I think that is already been done. We have rapid reviews — literature reviews at the graduate level, for example, within the academic realm — that are looking at evidence-informed practice. It’s not a stretch to take a specific portion of rural medicine, for example, and spend some time looking at outcomes as it relates to evidence-informed practice. I know Jude Kornelsen at UBC, for example, is just about to publish a lengthy article on rural and remote outcomes.

It’s already embedded within the system. We would just have to find a way, practically, to carry that embedded portion forward. There are a host and variety of ways that we could do that. It would depend on who would be interested in being part of that discussion.

To your second point, which was as it relates to intercollaboration and how we break down those silos, one of the ways that we found to be very beneficial is actually going out to the small communities, bringing education to them and trying to expand their understanding of the current system — where the rubs are, how we can work within that current system to get the care that the patient needs, so almost like a workaround.

What we would like to see is that we don’t have to work around that. We have the appropriate resources and facilities, scope of practice, clinicians, etc., within the areas that they are required to be in that can bring that scope right to the patient. But we can still go out and teach.

We can still go out and spend time talking about how we work together, giving those skills, that bedside skill set to say: “Hey, listen. Just because you’re a physician doesn’t mean we have to bring that baggage between physicians
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and nurses to the bedside here.” We can have a collaborative discussion that has physician-focused interventions, nursing-focused interventions, that work collaboratively to get the patient where they need to go.

We just have to spend a little bit of time doing it. All of that stuff is already there. We just need to go out and do it.

S. Lamont: Part of it, I think, comes from understanding each other. When I was in New Mexico, I was on the SDMS board when the Red River project was first started. That was one of the early community paramedicine programs.

One of the things that we recognized from that is that their training and their focus is on emergent, episodic, essentially undifferentiated problems. Their focus is on problem-solving: deal with the most critical things and move them somewhere. As they extend their education, they tend to get more and more granular in depth but still inside that range.

When you move into community paramedicine, now you’re moving into things like pharmacy and social work and nursing and medicine. They have to then learn those pieces. By learning those pieces, they learn about those disciplines, and those disciplines learn about them.

I think that the opportunity lies in creating venues where just the discussion about: not just collaboration, but what does collaboration look like, and what do each of us bring to the table so that we all understand where the rubs will be? Because there will be rubs. At least then we’ll be able to identify them up front.

L. Larson (Chair): We have run out of time. Any other questions we will certainly have sent through to you.

L. Larson (Chair): You’re just going to have to do it by email, sorry. We do have another presenter who will be coming in on our phone system.

Thank you so much for being here. Like I say, I’ve had the experience so I know the good work that you do and applaud you for your efforts and for your suggestions on how to make things better.

L. Larson (Chair): Okay, thank you. Sorry, we ran out of question time on that one. We have somebody else who is phoning in, similar to what you’re doing. Hopefully, you’ll be able to hear it clearly.

L. Larson (Chair): Christine Kozakowski — if you would just introduce yourself and tell us what your background is, that would be great.

C. Kozakowski: First, I want to thank you for giving me the opportunity to speak to you today. My name is Christine Kozakowski. I am a member of the Parkinson Society of B.C. and also of our local support group. I was, in the past, facilitator of that group. I’ve lived with Parkinson’s for a long time. Both my father and father-in-law had Parkinson’s, and my husband has it as well.

L. Larson (Chair): Yes, just please keep going. You’ve got just under 15 minutes to present, and then we’ll be able to ask you questions.

C. Kozakowski: I’m here today in support of the Parkinson Society B.C.’s request for funding for a provincial strategy for the health care of people with Parkinson’s disease. I’m also representing members of our local support group.

I don’t know how much you know about Parkinson’s — I know somebody from the Parkinson Society will be speaking to you — but it’s a progressive neurological disease with a wide range of symptoms individual to each person. The tremors are most recognizable, but there are a lot of other things — freezing, body stiffness. It’s just a multitude of things, including dementia in some patients.

There’s a huge increase coming, according to statistics coming from the Parkinson Society, in the number of people living with Parkinson’s. It’s the second most common neurological disease, after Alzheimer’s, and the third-highest level of direct health care costs. The need is there to manage costs but also to do things that we can do to help people, serve people in a better way — those with Parkinson’s.

When my husband was diagnosed, I was scared. I was scared for my husband. I was scared for myself and for my children. I was scared for myself because I’d seen what Parkinson’s had done to my mother and my mother-in-law and seen what it had done to the condition of their health over the years. I was scared for my husband because I’d seen what had happened with my father and my father-in-law, who had two very different forms of Parkinson’s — one majorly the tremors, and my father had severe dementia with his.

I was scared for my children because, with Parkinson’s
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on both sides of the family, I didn’t know what their future would be.

I really want to thank the government for all that has happened over the past 35-plus years since our fathers were dealing with this disease. We’ve come a long ways, but I think we still have a long ways to go.

My husband, when he was diagnosed…. His Parkinson’s came on very suddenly. We went to Toronto for a conference. At the time we left, he had a very mild tremor in one hand. When we came home, he had major tremors in both arms. His entire body shook. So it was really terrifying. We went to our family doctor — a younger doctor, probably in his early 40s. He had one other patient with Parkinson’s, and he admitted to us that he didn’t know much about it. He said he’d only had a few hours of training in all his seven-plus years of medical school.

We asked for a referral to the centre at UBC. That was where my father went, and I knew that that was the best place to get help for my husband. The wait at that time was several months. We were sent to a neurologist, who, again, didn’t seem to know much about it — just put him on Sinemet, ordered some more tests and basically sent us on our way. We got very little information from either the family doctor or the neurologist.

It wasn’t until we went to UBC that we really learned about Parkinson’s, and we found that this was the place for him to be. When you go to the centre at UBC, you not only see your doctor to get your medications altered, to get them fine-tuned. But when you’re there, if you’re having problems with your gait, your walking, any of the other symptoms that go along with Parkinson’s disease, they have nurses, they have physios, they have other people there on staff, and you get the full range of treatment.

You’re given a thorough examination. You’re given the opportunity to take part in research studies, which my husband has done. Really, you get a different level of care.

In working as facilitator of the Parkinson’s group here in Campbell River, I learned that many patients…. On diagnosis, their doctor says: “Yes, it’s Parkinson’s, and I can deal with this.” Some are sent to a neurologist, but often a neurologist such as we were sent to, and they really are not given access to the full level of care. That’s a real concern for me. Being part of a support group, we really support each other and encourage our members to request that higher level of care that will really make a difference to them.

I can attest to that, because I’ve seen patients who’ve only seen their doctor or only seen a local neurologist, and their symptoms are worsening. We encourage them to go to UBC. They do. They come back, and their condition is so much improved. They’re able to do things that they have not been able to do for a long time.

When I started facilitating the group here in Campbell River, most members of our group were fairly recently diagnosed. They were very capable, able to do most of the things that they had always done, just with a few challenges. They were still able to work, to help around the house, to do the gardening, to look after the car, to go out and go on holidays, to do all the things they’d always done.

Here we are about ten years later, and what I’m seeing is a huge difference. In fact, I was away from the group for a short period of time, about a year and a half, and when I came back, it was really visible to see how people’s lives had degenerated. Many of them now are having trouble walking, some having great difficulty in talking, most with writing, some having problems even feeding themselves. Sleep is a challenge for them.

Forget working around the house or the yard, and many of them are having trouble driving. They can drive locally, but to get to appointments out of town is a challenge for them. Their partners are having to take on a much larger share of the workload within their homes.

What we’re finding now within our group, because many of us do access assistance, go to UBC, some to Victoria — a couple to Victoria…. Our members are having a real challenge even getting there, getting to centres of care where they need to be because their symptoms are really increasing and they need that bigger level of care much more than they did in the past. Some people are saying: “I just can’t do it anymore.” They’re just staying here and sticking with their local doctor.

I just bumped into a couple yesterday while I was out shopping, and they told me that they’re flying over to Vancouver. They’ve got people over in Vancouver who are able to pick them up at the airport and take them to their appointments.

Others are struggling to drive over. Often it’s the husband who has Parkinson’s within our group. He’s done all the driving in the past, and now the wife is having to learn how to drive in the traffic in Vancouver. When you come from a small community like ours, that is a real challenge for people.

I’d also like to just talk a little bit about deep brain stimulation surgery. It’s an alternate treatment for Parkinson’s. My husband was fortunate enough to have had this surgery done about five years ago.

Prior to his surgery, he could barely feed himself. He had great difficulty walking. Just the simplest of tasks were a challenge for him because his tremors were so severe. He would try to type something out on the computer, and it was just becoming too much of a challenge for him.

He had the surgery done, and his life took on a whole new meaning. The tremors are gone. Still to this day, for the most part, the tremors are gone. He was able to take on many things that he could not do in the past.

We had a young fellow in our group who’d had this surgery done prior to Bob, and he was able to go back to work. It terrifies me to think of what my husband’s life would be like today if he hadn’t had that surgery done.
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DBS gave Rob the ability to work for several years longer than he would have. He’s a young-onset with a young family at the time.

For my husband, it’s been a great help for both of us, because I’ve been able to maintain my health for a longer period of time. We’re now at the stage where his symptoms are increasing, and I’m having to take on most of the duties around the house, even with the DBS. If he hadn’t had that….

We know this, because he can turn his unit off. Within seconds of him turning it off, his whole body shakes and he’s just unable to do anything. With the unit on, at least he can still dress himself. He can feed himself. He can help a little bit around the house. He can make us a meal. He’s still able to drive and do things that he just would not be able to do without this.

At the time Bob had the surgery done, the province of B.C. was only funding 30 surgeries a year, and that was for Parkinson’s and about five other disorders. For Bob, it was like winning a lottery, being chosen for this surgery.

I think about all the people who could benefit from this. Their lives would be benefited. We would have people working who are currently not able to work. Bob didn’t apply…. It took him several years before he applied for the disability tax credit and Canada Pension disability, because he was able to function that much longer.

Also medications — some people go off medications entirely. Parkinson’s meds cost hundreds and hundreds of dollars a month in many cases. So there are so many financial advantages to DBS.

I think there are also financial advantages to patients having access to better treatment in hospitals, emergency, care facilities, from daycare, even their own doctors — having access to specialized physiotherapies, special programs for people with Parkinson’s, to speech-language pathologists and a range of other medical specialists. Without these services, what we see are patients having more falls. It’s just a wide range of things — longer stays in hospital.

My own experience and the experiences of some of the members of our group is when the person with Parkinson’s goes into hospital, they’re expected to fit into the very efficient and cost-saving regime of meds being given at particular times. With Parkinson’s, everybody’s medication schedule is different. Some people are on maybe two or three meds, and they take them at, let’s say, seven, 11, three and seven. That’s great. But others….

You see the little unit they have that gives them all their medication reminders. Their meds are taken at totally random times — not random, I guess, for them, because there are specific times throughout the day. They might have something at five o’clock in the morning, something at six and something at eight, something at nine and ten — just interspersed throughout the day. When that doesn’t happen, it really puts their body into a difficult situation. Everything changes for them.

I’ve kind of rambled a little here, but I just wanted to try and paint a picture for you of what it’s like living with Parkinson’s, what the current medical system is like. It really does not cater to the best health care practices for that person with Parkinson’s.

I truly believe the Parkinson Society B.C. proposal will help people. Having a strategy that covers all aspects of health care for people with Parkinson’s will result in a better quality of life for them, keep them out of nursing homes and care facilities, with shorter stays in hospital and less falls, which is a big part for anybody with a disease like this — just a better result overall.

L. Larson (Chair): Thank you, Christine. We did have a very passionate presentation in Victoria on Monday from the Parkinson Society and a wonderful lady that was certainly suffering from Parkinson’s. All of the points you have raised were raised at that time as well.

We certainly are aware of the shortage of neurologists and of the length of time it takes to get the appointments and of how much somebody’s life can deteriorate in that two- to five-year wait time. I’m going to just see if there are a few questions for you, so just hang on a second.

M. Dalton: Thanks, Christine, for sharing your experience. I’m sad to hear what you’re going through but happy that your husband is getting treatment.

One of the concerns that was brought up to us was, obviously, the knowledge — the physicians being really aware of Parkinson’s. One aspect was the…. There was a service, and I’m wondering if you’ve used it and if you had any comments. It was for medication — for calling, I believe, a nurse that was specialized, 24-7, if they’re having problems with care, with the medication. I’m wondering if you’ve used it, or if people that you know have used it, and the impact that this has had upon you. Possibly if it’s….

C. Kozakowski: I’m not aware of it, and I don’t know if our support group is aware of it. So it’s a 24-hour service? And what is it?

L. Larson (Chair): It’s possible, Christine, that it was something that they put on the table as being very helpful if such a thing existed. I’m not sure 100 percent….

M. Dalton: My understanding is that it was there, that there was a person that was trained already and that that person was retiring.

M. Dalton: And they don’t think they have anybody to take over this.
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M. Dalton: I know this was something from Vancouver Island, but obviously with phones, you can access this anywhere. So I’m just wondering if you were aware of it and if you had used it.

L. Larson (Chair): Okay. It was brought to our attention, though, that that type of service apparently had been available.

C. Kozakowski: For the person with Parkinson’s, it’s really that good relationship with their doctor — their specialist, typically — because they’re constantly having to have things adjusted. With my husband and his DBS, he’s going on Friday to Vancouver because things have changed for him. So he’ll go in, he’ll see a nurse there, the DBS nurse. She will adjust his settings on his DBS to get more out of that.

His Parkinson’s continues to progress. The surgery doesn’t stop the disease or halt it in any way, but it certainly makes a huge difference for him. But that may then mean an adjustment in his meds, and that’s where he has to go to…. He can just call UBC in that case, talk to the nurses there and get some instruction on things that he might be able to do to get some more out of the combination of his meds and his DBS.

L. Larson (Chair): Okay, thank you. Are there other questions for Christine while we have her on the line?

J. Darcy (Deputy Chair): Thank you so much for sharing your story, Christine. I wonder if you’re aware…. I thought it might be worthwhile to mention, because they’re very…. The Parkinson’s society…. You’ve also spoken about some very specific needs that you consider to be quite urgent.

The Finance Committee does tours, and they accept, prior to every budget being developed…. I know that we shared that information with the Parkinson’s society, but I think it’s good for you to know, and to let other people know, that there are opportunities for both individuals and organizations to present either in person or in writing or with a video submission.

J. Darcy (Deputy Chair): The Finance Committee. That’s the budget-making process, and it might be faster than our ability to effect change.

C. Kozakowski: Yes. We spoke to a person with Parkinson’s in his life. The three of us went and spoke to Claire Trevena, our local MLA, a couple of months ago, so she had given us this information. She did give us the information on this committee meeting, and I’m hoping that she will give us an update on when the Finance Committee meets.

L. Larson (Chair): I’m sure she will. Certainly, you could ask her so that you get the schedule when it comes out. It won’t come out probably till September.

S. Sourial (Clerk Assistant, Committees and Interparliamentary Relations): Christine, the committee is statutorily required to consider the budget consultation paper, which isn’t released before September 15. The committee typically sets its schedule…. Sometime in August we will post it on the website. Then the committee has about a month of public consultations before it has to table its report by November 15. So the consultations typically start around the 15th or 16th of September and will go for about a month to October 15.

C. Kozakowski: Okay. Would that be similar to this? They would come into communities, I believe.

S. Sourial (Clerk Assistant): Exactly. Even if we’re not in Kamloops — off the top of my head, I can’t remember; I don’t think we’re coming to Kamloops this year — we are on Vancouver Island. You can also participate by conference call or possibly even video conference.

L. Larson (Chair): All right. I think that’s it, Christine, for us. Thank you so much, again, for sharing your story. As I said, we did hear a very passionate plea for help on Monday as well. We have taken note of it. It will be part of our report.

I would like to invite our Wellness and Health Action Coalition to please take their places. We have 15 minutes, which starts now. If you could take your positions and just leap right in.
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R. Hood: Okay. We’ll leap right in. If we all fidget, it’s because we’re all used to walking around and talking at the same time.

Thank you for this opportunity. Good afternoon. I’m Ron Hood, from Ashcroft. This is Chellie Dickinson and Pam Webster. We have a backup crew here in case you have a question that we can’t deal with.

We’re going to demonstrate, first of all, that rural health care delivery needs are different than urban. It’s simply not the same. This is the theme that we’re going to take — that it’s a different place altogether. Pam has an interesting story that she’s going to start us off with.

P. Webster: Good afternoon. After 35 years working as an RN at the Ashcroft Hospital, I was devastated to find out that our ER was closed on a day that my family found themselves in an emergency situation. My one-year-old grandson suffered a grand mal seizure. The seizure was not caused by an illness but just happened. It was a very scary situation for all.

The child’s father and aunt were present for this event. They called me, and I gave them instructions to prevent any further injury to the child. They called 911, and I ran to the house, which was just a few doors down.

While the ambulance crew was loading my grandson into the ambulance, I learned that the Ashcroft ER was closed. As there was no physician available to work, he would be taken to Royal Inland Hospital, which was an hour away. I was shocked and dismayed. This was an emergency situation, and my grandson could have died.

The local ambulance can only provide supportive care and cannot administer any medications to control a seizure. I would like you to understand that if a seizure continues for more than five minutes, there’s a great risk for brain damage and even death. Medications are essential to control the seizure.

There have been many other life-versus-death situations in Ashcroft where the outcomes were not favourable to the patients because the ER was closed and they had to be transported an hour to Royal Inland Hospital. Unfortunately, the rural ambulance crews are minimally trained and can provide only supportive care and transportation.

Nursing recruitment is also a major concern at our hospital, leaving RN positions unfilled. Our community deserves better. We need 24-hour access to reliable and full health care services.

R. Hood: We asked Pam to share that story with you just to demonstrate that being on the fringes of an urban health care system is not the same as being in it. It’s just not the same. It doesn’t work that way. To simply stick a compass into a map and draw a circle with a diameter of 200 kilometres doesn’t mean that everybody can get to the pointy part when they need to be there.

We need a different kind of a model in rural health care, and that’s where we’re going to take it now, if we can. Referring to the little handout that I gave, we got started…. Jackie’s here. She’s responsible for all this, by the way. She pulled this all together and showed us what another community was doing and said: “Okay. If they can do it, you guys can do it too.” So here we are after two years.

That led to a community consultation process that gave us a recipe for action. It basically told us what was working and what was not and put things in black and white for us. Then, when we started doing research, we discovered…. Well, first of all, on our wish list…. We created a wish list — if we could have anything we wanted in rural health care. We started researching and found out that it’s already been said. We didn’t invent anything. It’s already there.

As we were building up our capacity, we learned more and more about the complexities of health care, how huge it is and how impossible it is to get a grip on, frankly. We learned that our local health care centre had no form of central management. What used to be a hospital now houses 16 different departments and agencies all reporting to different off-site managers. There’s nobody in charge there. That makes it very difficult for them to get things done. Things usually end up defaulting to whichever registered nurse happens to be on duty at the time, which includes the removal of snakes from the long-term-care centre.

We learned at that time that government’s expectations of the health care system were hidden. They were in a secret document that even our MLA couldn’t get access to — or if she could get access to it, she certainly wasn’t allowed to share it with us. That made us a little bit nervous to think: “Well, what’s so important that it has to be sealed up?”

Then we found this document, taxpayer accountability principles, that was published in 2014, right out of the Premier’s office. This became an addendum to the document that we were searching for, so at least now we knew it existed. This document made it clear that the next one would be public, and indeed it was.

When we found that…. You people have got all the…. I didn’t copy these because I know you’ve got it all. We’ve got the mandate letter from the Premier to the minister and then from the minister to the health authority and then everything that the health authority publishes to explain what they’re going to do. Everything we want is there — everything.

There’s really only one thing missing. We found that this involved a whole lot of downloading of information
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and downloading of responsibility, all the way down till it hits the bottom of the pile. It normally ends up in the hands of a small group of dedicated volunteers who have no status, no authority and as few resources as possible.

This document made it fairly clear that the taxpayer/shareholder was both the top and the bottom of the cycle. It’s right in the middle, and it’s all the way around the edge.

The Premier was telling us that it’s our responsibility. We were prepared to take that responsibility, but nobody gave us any authority to do anything. So here we are pleading.

This downloading thing, when it gets to the bottom…. And how does it work? Well, I think you’re already aware it doesn’t work, because the responsibility is there without any authority or resources to do anything with it.

We’re going to get in now to some notions as to how we can deal with it. We’re talking about a specific group of communities here, so this may not be a cookie-cutter solution. I don’t know. But we do know that there’s such a great flurry of activity in trying to solve the question of rural health care that, obviously, we’re not the only ones who think that there’s an issue. This is pretty well universal.

The problem, in our minds, began with the creation of the super regions. There are lots of compelling reasons for that super region, of course, but what happened as a result of them is they took the rural communities completely out of the picture. All of the decision-making and planning was centralized into a few small or a few urban centres — centralized all the planning and implementation.

Here again, we want to emphasize that what we need in our rural areas is not the same as dealing with a major urban hospital. It’s just not the same. I won’t go through all that stuff. The answer, as we see it, is to bring the rural communities back into the process by establishing some kind of a program of authority and responsibility in localized areas. Just allow us back into the implementation process.

Now, how to do that. On the bottom of page 4 of this little bundle, we’ve got a proposal specific to our region. I’ll just read through this if I can. “Consultation with medical professionals supports our contention that part of the answer lies in the creation of a mini-region of rural community health facilities” — in our case, we’re talking about Lillooet, Ashcroft, Clinton, Lytton and Logan Lake and all of the other communities in between, but those are the ones that have some kind of health care facility already established — “all of them acting as a collaborative and supportive administrative unit under a local advisory board.”

Now, to whom or what such a board as that would relate to, we don’t know yet. We haven’t gotten that far. It could simply be a division of Interior Health but only if it came with a pathway to the board table, because we want the rural communities back in. We’re tired of being left out.

This approach is supported by other studies, including one called the Rural Regional Locum Planning, and I’ve attached a copy of the executive summary to that, and there are others of that same nature.

Now, the key elements to having this kind of a mini-region are already in place. We were working towards this kind of a solution when, to our absolute delight, the medical community came to us with exactly the same solution. By medical community, now, I’m talking about the doctors and particularly the physicians in the area who are also struggling, trying to solve this issue.

They too are quite isolated and can see that a collaborative approach is going to solve many administrative issues for them. The last doctor we lost expressed that fully two-thirds of his time was spent doing things that didn’t require a physician to do. That’s not a particularly useful way to treat that type of a resource.

I’m going to ask Chellie now to jump in, because the committee came to us with three specific questions. You’ve already got a lot of answers to those, but we’re going to add to the heap if we may, and Chellie is going to do it for us.

C. Dickinson: Well, thank you for listening to all of us. The first question: “How can we improve health and health care services in rural B.C.,” and “what long-term solutions can address the challenges of recruitment and retention?” I have three suggestions for that.

One is to reintroduce some form of localized health care advisory board with money for implementation of programs. It could be patients. It can be anybody who’s not directly involved in health care but who has experienced health care from a user point of view. They could sit on the local medical advisory committee — you know, piggyback them into something that already exists.

Redirect funding for training for local health care workers who are already in place. So encourage rural generalism. If you train somebody who already lives in the community, there’s far more chance that they will stay and you won’t lose that resource when they’re finished their training.

Involve community leaders and groups to welcome and support incoming health care workers. Make them feel like they’re part of it. Ask the village or the town to collaborate with Interior Health, with the physician office, and put some resources in place for them, whether it’s housing, transport — something like that.

How can we create a cost-effective system of primary community care built around interdisciplinary teams? I’m sure you’ve heard this one, but we need a single EMR. If Australia can do it countrywide, then we can surely do it, starting at, perhaps, the health authority level and then
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expanding to the provincial level. It’s the single-greatest barrier to longitudinal care.

Create protocols that permit rural health care professionals to tend to the needs of individuals without hampering their earning capacity — that is, build the interdisciplinary teams.

Increase the capacity for specialists to come out. Have them rotate through…. We already have the northern and isolation travel assistance program. If we used that and brought a specialist out to travel and share them through the communities, then each person who needs that specialist attention could get it in a timely fashion without having to travel to Vancouver or Kelowna or those outlying areas.

If we grouped our health care assets…. And we do that to a certain extent. We have mental health workers who do two days in Lytton, two days in Ashcroft, two days in Lillooet. But if we built a slightly bigger pool so that they could be shared…. We could do it with diabetic nurses, we could do it with physio, and we could supplement that with telehealth. We could use…. Rural people are good at stretching out small amounts of resource to fill the gap.

Train, again, local people — nurses, paramedics, health care workers — so their skill levels increase. Then they will stay in the community, because they already have roots in the community, and they won’t leave once the training is over. If you further fund them while they’re training, they won’t lose money. I mean, everybody wants to increase their skills but not at the cost of their living. If you’re supporting a family, you can’t take two months off to go and do an upgrading course without getting paid for it.

I feel that the upgrading and the bringing in of specialists and the sharing of resources would address four of the five key strategies that Interior Health is trying to attack. If we improve everybody’s skill levels, then you get this domino effect, and it improves right across the board.

The addiction recovery programs. We feel that if you support the programs that are already in place, extend them a little bit…. You don’t have to bring new and improved things in, but if you fund the resource that’s already there, they’ll find new and improved ways to serve the community. Speed up the intake process and have some sort of support system when people come back to the community.

If people go away to Kamloops — which they have to do from some of our smaller areas for recovery programs, for mental health programs, for being in hospital for mental health issues — and then come back to the community and there’s nothing there…. The local physicians are stretched already. They don’t have time to sit for two hours and counsel. But those people need that support. So if we had social workers, if we had mental health workers, then I think the good that’s done in the programs in the larger centres could be continued.

L. Larson (Chair): Thank you, Chellie. We have run out of the 15 minutes of presentation time, which lessens the time that we have for questions, but we will try to do that as succinctly as possible.

J. Darcy (Deputy Chair): Wow, awesome presentation. Do you want to help us write our report? I think you just did. You covered so many bases. Thank you very much.

Certainly, you’re echoing the voices that we’ve heard in rural communities, but you’ve gone a lot further, in many cases, with some very practical solutions.

I want to zero in, in particular, on the issue of community voice — patient voice, community voice. I’d like you to explore some more what you think this could look like. I think we’re all mindful. We don’t want to spend years restructuring a health care system, but we know we need to make some big…. Well, there are lots of things we want to restructure, but whether it’s the health authority structure…. We have to find a way to give communities a voice, and you’ve spoken to that.

I wonder if you could just expand on that a little bit — how you see that community representation, how you see them interacting with a board, for instance. You’ve said there’s a need to have a voice at the table of a health authority. What do you see are the barriers to realizing this?

J. Darcy (Deputy Chair): Well, in a nutshell, and then maybe you could write a longer answer.

R. Hood: We’ve actually have talked about this sort of thing and haven’t come to any conclusion. Somewhere between an independent community health board and a division of Interior Health is the answer.

C. Dickinson: Can I make a suggestion? We already have medical advisory boards that the physicians and the health authority staff attend — on a monthly basis, I believe. There is a Patient Voices Network. If we got representatives through that culling system, those people could attend those medical advisory boards and speak to, perhaps, a broader agenda.

I mean, right now the agenda is very medically focused. But sometimes those things that they discuss — cutbacks, rerouting of services — affect people in unintended ways. If a person was there who had experienced some of those unintended consequences, they might be able to better adjust those changes. So I don’t know. Through the medical advisory boards, I’m thinking.

D. Plecas: Thank you for your very awesome presentation — very thorough. My question, I guess, is a take-
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off akin to my friend Judy’s comment. It seems to me…. I love everything you’re saying. I’m not so sure about the establishment of an advisory board.

I think to myself that you’re a great advisory group yourselves. But you have one thing that’s better than that: that word “action” in there. So I sometimes wonder: is that what we really, really need? Is it that, or is it that we just need somebody to take action here?

D. Plecas: That’s right. My worry is that you set up an advisory committee — thank you very much for the couple of years that will take — and then make suggestions again. That’s part of why we’re here. I’m just wondering if there’s another path to that with yourselves leading that and more pointed towards “Let’s get some action here”? And together with your wonderful….

R. Hood: I think part of the answer is downloading a little authority to go with the responsibility that’s already been assumed. There are boards like us all over the province already. They’re all in place. They’re all sitting…. They’re not connected in any particular way other than by common interest.

C. Dickinson: That’s why I’m thinking if you bring representatives from a board like this to medical advisory meetings that are held in all these health sites, then they would be the voice of the patients, and then they could work with the health authorities, with the physicians. Because the health authorities and the physicians are at those meetings.

D. Plecas: Although somebody would say that you shouldn’t have to do that. It should be happening.

C. Dickinson: Well yes, but I still think it has to be a cooperative process, you know? We need somebody leading the charge, but you have to have a group behind you to carry it through. You understand what I’m saying?

R. Hood: I would refer back here to David Durksen. He’s got a partial answer to this.

I think one of the things that has to happen is…. In our proposal, we talked about the sub-region and having the ability of that group to have some funding and some autonomy. So our professionals within that group and our communities within that group would then be responsible for the health care in that area, within parameters. We don’t want to get into defining what those parameters would be, so that’s why we’re being a little vague.

Until we have some authority and some of the money that’s already being spent in our area having some influence or control from that area, nothing is going to change.

That’s why we’re looking at that sub-region. With that sub-region, it allows us to more easily recruit nurses, lab techs — all of those people. In each of our communities, all of those are in crisis. Then we’re dealing with that. Interior Health…. Nurses in all of the province are in crisis. But we have to be able to focus on that, and as it sits now, we can’t.

D. Barnett: Thank you for your presentation. I do work with your colleague, your MLA Jackie Tegart, and believe you me, Jackie has brought this issue to the table. I’m the Parliamentary Secretary for Rural Development. We have many discussions about this because I, too, live in rural British Columbia.

I read your report here very quickly. You’re talking about interdisciplinary teams, which we have been talking about for quite a few years and quite a few days and have had some great submissions over the last two or three days on this topic. The next step is: how do we get there?

There are so many impediments that are very large for us to get to this — huge and entrenched in the health care system. I sincerely believe that once we can move that, we can change the way we deliver health care all across this province, and it certainly will benefit rural health.

C. Dickinson: Can I make a suggestion to that? One thing that I’ve seen over the years is that when you have students come out and do practicums in rural areas…. You could have student physiotherapists, you could have student nurses and you could have student diabetic nurses — all of them. If you could spread them out amongst the rural areas….

We get medical residents in Lillooet, and we have found that they come back because they know the area. They know what’s bad and good about it, and they decide that they like it. But if you had students from all of those disciplines coming out and experiencing it, I think you’d have a far greater chance of recruiting those kids back again. I know, because I have a son and a daughter who are a doctor and a nurse.

L. Larson (Chair): Actually, we did have a presentation from UNBC, which does take all of those young people in all of those disciplines out to the rural area —
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and actually came to Merritt and also to Princeton this past spring. What a wonderful way to introduce them to rural communities, and hopefully, they’ll come back and do their practicums and things like that there.

S. Hammell: Okay. I’m actually from Surrey, and I don’t think you’re unique in being disconnected from your health care system. In an urban area like…. What’s going on is quite beyond most of us.

My question to you is around mental health. I’m curious about what the face of mental health looks like in your rural communities. Are there street-entrenched and homeless people? What is the range at which your mental health system is trying to address mental illness, and do you have the resources needed? Or are there significant gaps that you can help me understand?

C. Dickinson: I don’t know how it is in your town, specifically, but in Lillooet, there’s no after-hours crisis response — nothing. It’s the ER and transport to Kamloops. It could be a minor incident, where a teenager is having a minor meltdown, which just needs a little bit of counselling. Instead, they get the Cadillac treatment of being shipped to the ER in Kamloops and then going through the psychiatric assessment.

My feeling is — and I’m not a physician — sometimes that’s almost more damaging than just a minor treatment of a minor issue. That’s where after-hours crisis response teams would make a huge difference.

R. Hood: One of our members, Marilyn Bueckert, has been concentrating specifically on the question of mental health in our region. The biggest observation is that if they had twice as many staff, they still couldn’t handle it.

M. Bueckert: We have two workers who come in twice a week, into Ashcroft. I believe they also work in Lillooet and so on too. But when I spoke to Therese Harrison, one of the workers, she said that they really need to be coming twice as often as they are, because the number of people with serious mental health concerns in our area seems to be quite large. Schizophrenia is one of them. Alcoholism is another, and on and on it goes. There is more focus on teens and young people now.

R. Hood: A really quick wrap-up. To summarize the whole thing: bring the rural communities back into the planning and execution process in some manner, download some authority to go with the responsibility, and give the communities and groups like us the tools to create a mini-region of collaborative health care that would be unique to our region. There are solutions if we could just get our hands on them.

L. Larson (Chair): Yes. We’ve heard similar messages from everybody who has come to speak to us, so that will be captured very strongly in our report.

Thank you so much for being here today, and for all of you coming and acting as support. I’m sorry we didn’t have more time for you, but we try to get as many people as possible in front of this committee, and we have somebody waiting on the phone line.

L. Larson (Chair): I should say we have the next speaker in the room, I believe.

Is Mr. Turner here? We’re still on air, so we’ll go right into your presentation.

R. Turner: My name is Rick Turner. I’m a co-chair with the Kamloops Health Coalition. I’m also co-chair with the B.C. Health Coalition. I am an advocate for a good, strong public health care system. I make no bones about that. My purpose this afternoon is to offer…. I’m sure you’re well aware of all the research that supports integrated health care. I have a little bit of that to offer, but also my own personal experience, as well.

I was born and raised in Trail, British Columbia. Lived there for 22 years — a rural community. I lived in the Queen Charlotte Islands, now known as Haida Gwaii, from ’73 to ’77. I lived in Barriere from ’77 to ’88, another small, rural community. I’ve lived in Kamloops since 1988, which is a mid-sized community by most people’s standards. I did have the pleasure of living in Vancouver for four years when I was attending UBC, getting my teaching degree. So I offer a mix of both.

I just would like to go back to a number of years ago and begin my presentation there. The doctor-focused model of the 1960s no longer works. It was great when the baby boomers came along 60 or 70 years ago and were coming of age in the ’60s and ’70s, but the times and demographics have changed dramatically. Where seniors were a small portion of the population then, today roughly one in six Canadians is over 65 and, in only a few years, they will outnumber the youth of this country. Eventually, they’ll make up 25 percent of the population.

The Canadian population has grown too. When public health care became national, back in Lester Pearson’s day, we numbered only about 18 million people. Today, we are twice that, at 36 million. Everyone had a family doctor back then, and home calls to sick children were common. Today, they are not. Today, the doctor shortage in B.C. has left many without a family doctor and without continuity of care.
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Some examples…. I have a friend over in Cranbrook. I was talking with him on the phone the other day as part of the health coalition working group. He said that for his wife to see the doctor that she needs — three weeks to get in to his family doctor.

A duty clinic will see him in three days. He does not know what doctor will be there. It’s a rotating kind of schedule. Indeed, if it’s an emergency, he can go to the regional hospital — but again, no idea what doctor will be there, no firsthand knowledge of his spouse’s condition.

In Kamloops, I can see my family doctor in about three or four days. If it’s something that needs immediate attention, I can go down to the walk-in clinic, and as long as I’m there before 8 a.m. — I live over on the North Shore — then I can see a doctor that day. I have no idea which doctor it’ll be, and in the times I’ve been there over the last few years, I’ve never seen the same doctor twice.

I would also add that in an emergency, I can go to the emergency at the hospital. Again, I get superb treatment, but it’s not the same doctor. There isn’t that continuity.

I would add that the old model is outdated. If we were to continue with it, in only a matter of years we will no longer have an effective public health care system. Many of us will be left behind. We just can’t continue with that old model. Only the wealthy will be able to get the care they need, in that they have the wealth to purchase services privately, be it here or abroad.

According to Dr. Charles Webb — this was at a conference; I think, Ms. Darcy, you were there too, at “Don’t Leave Seniors Out in the Cold” — the current seniors population in B.C. is about 820,000 people. This statistic he relayed to us back in September. His practice includes geriatrics, and he advocated moving to an integrated care model.

The seniors population is not expected to peak and then level off until 2036. That may not decline until somewhere in mid-century, perhaps even later. Their health needs are different now than they were in their robust youthful years, back in the ’60s and ’70s. Other needs have changed for them as well. Many now have mobility issues with simply walking. Many can no longer drive a car and are separated by many miles from assistance from children and grandchildren.

But there is hope. We can change, and many see a more integrated, patient-focused model of public health care services as the answer. Numerous learned studies, ranging from the Harvard Business School to Drs. Chappell and Hollander in B.C., cite the huge savings to be realized when we leave the old model of doctor-focused care and move to a patient-focused team approach.

The Conference Board of Canada, in a paper released in March of 2014, tells us that “team-based care significantly improves the health and wellness of patients with and at risk of chronic conditions, reduces emergency room visits and offsets costs in other parts of the health care system.” That was published under the name of Thy Dinh, a senior research associate.

It also goes on to say that interdisciplinary primary care team care could save the health care system almost $3 billion in direct and indirect costs of diabetes and depression complications alone. Imagine the savings to be realized if the IPC team approach were broadened to the treatment of other maladies.

In addition to these cost-effective benefits, patients get the treatment they need in a more timely manner — that’s the biggest complaint in my travels: it takes too long; wait times are too long — and require fewer follow-up visits and have better outcomes. Doctors and surgeons are freed up to see more patients who require the skills and expertise that only doctors can provide.

An integrated community health care centre where patients can go regularly for their health care needs is probably the best solution in many instances. Such a centre would get to know each patient’s history and personal needs — important factors in a patient’s confidence in their team.

When one first enters the centre, perhaps a nurse practitioner might examine the patient’s symptoms or conduct an examination and assessment of the patient. A health care team who knows, or eventually gets to know, the patient’s history might then be involved in deciding what course of action is best for that individual patient. Perhaps a visit with a doctor is in order; perhaps not. Perhaps a visit or course of action with another professional — for example, a physiotherapist — is the next best step after the assessment; perhaps even a social worker to determine if the client might be considered for some form of social intervention — poverty assistance, home care support, assisted living.

According to Dr. Chris Simpson from Queen’s University, also a speaker at that seniors conference last fall with Dr. Webb and also an advocate for the integrated care model, social factors count for about 50 percent of a senior’s health.

You are probably much more aware than I am of the different benefits an integrated team approach can make, so I’d like to spend a little more time talking about the importance of a centre, especially in the context of an area like Kamloops.

In recent years, we’ve seen a lot of seniors from outlying rural areas moving into Kamloops because the services they need simply aren’t available in 100 Mile House, Clearwater, Ashcroft or one of the many other rural communities in this part of the province.

Imagine the senior who lives in Clearwater, for example, an hour and a half up the North Thompson, and must travel to Kamloops to get an MRI done. He or she must purchase a bus ticket to Kamloops, rent a motel room just below the hospital, buy meals in a restaurant, get to the hospital, get their MRI done, take a city bus up
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to the bus depot and then another Greyhound back up the valley to Clearwater.

Test results may show another trip to Kamloops is necessary for more testing or treatment. In some cases, once the treatment has been decided, then more arrangements may have to be made to bus again to Kamloops, rent a hotel room and so on.

It costs that person a lot more money and time than a resident in Kamloops. For example, I can drive from my place out in Westside over town in half an hour, get my MRI, then drive home again. Total time: two hours. Cost: three bucks for gas, $2 for parking.

As many seniors in outlying areas age, and Oncore…. That is a service for seniors in this area that deals a lot with housing and accommodation. They are overwhelmed with requests from seniors in outlying areas for accommodation here in Kamloops. They’re forced to sell what they have, those seniors, leave old friends and perhaps family and move here in order to access the services and treatment they need and start rebuilding their lives again with what little they may have left socially, emotionally, financially and physically.

What if there were a centre in Clearwater where a nurse managed cases, more regularly scheduled visits from professionals could be arranged and those centres were staffed by those who could provide primary care when needed and leave other care up to others, reducing the demand on the already short supply of doctors in many of these communities, or if a senior could make one visit to Kamloops for tests and treatment rather than several?

Please also consider the many seniors who now find themselves in Kamloops for the very reasons I’ve given and for a variety of other reasons as well. Many find travel around the city very difficult.

I think immediately of the urban aboriginal population of Kamloops. It’s something like 8,000 people, and a number of those folks come here from small reserves way out in the bush, out behind Lillooet, where you can only get by water, sometimes, or with a four-wheel drive. They come to a place like this and they’re overwhelmed, absolutely overwhelmed.

Many find travel around the city very difficult, especially with no car and meagre finances. Many are unfamiliar with the city and have come here from small communities. To travel to one building for a diagnosis — for example, the walk-in clinic on Tranquille — and then have to find a lab in another part of the North Shore or at the hospital in South Kamloops can also be a daunting task. We know that many simply won’t do it, as the travel and complexity of the whole of Kamloops is too much for them to manage.

Then back to the walk-in clinic doctor on Tranquille once he or she has seen the lab results, then a referral up to Sahali for another form of treatment, then back to the doctor on Tranquille, then another part of town and so on. What if there was a community centre on the North Shore, and the client…? There was an announcement two days ago, after I’d written much of this, that there is one. I don’t know the details to it. I’ve asked the minister’s office for some more detail, and they haven’t given it to me yet. But if there was a community centre on the North Shore, the client could access the services they need at that one location without having to see a doctor before each and every step.

This could greatly reduce costs by decreasing the number of visits with the doctor; free up more doctor time so that doctors could devote their skills and expertise to the tasks that only they can do; and significantly reduce wait times for patients — again, one of the biggest concerns of patients today and for the past number of years.

In Kamloops alone, it appears that at least 15 more family doctors are needed, according to a report from local doctor rep Dr. Shirley Sze on CBC’s Daybreak on June 15. Six new doctors are coming, but they will be replacing two who are retiring and also providing relief to those doctors who are on vacation or going to workshops, etc. Other senior doctors in Kamloops are now either cutting back on the hours they work as they age or simply retiring. Wait times under the doctor-central model will only increase, at a time when a significant number of patients need a health care professional other than another visit and wait to see a family doctor.

The old system will crash — longer wait times, not enough doctors and increasingly difficult health problems that could have been remedied with timely treatment. We must change.

We don’t have to look that far for examples of how well integrated and team-based approaches work both for patients and our public health care system. The Home VIVE program in Vancouver — which dealt with frail, elderly seniors in their 80s and older who remained in their homes — reported in 2011 that ER visits had been reduced 56 percent, and readmissions to hospitals had dropped by 80 percent. This is extremely cost-effective for MSP and the Vancouver health authority and frees up more beds in acute care for those requiring acute care, thereby, again, shortening the wait times for many.

Also reported at that conference was that in the Northern Health Authority, integrated care was employed with seniors ranging from 56 to over 100 years of age in an effort to have them remain at home longer, where they wanted to be, and not in a hospital, where they didn’t want to be. The savings to the system were considerable, especially when estimated costs for hospital beds range from $800 to $1,200 a day and home care can be less than $50 a day.

In my own experience in rural B.C., I’ve seen considerable benefits from a less doctor-based approach. In Masset, Haida Gwaii, in the 1970s, we had access only to a nurse. If we were sick or injured, she was able to take
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care of us in most instances. “You’ve got that flu that’s going around,” she might remark. “Go home, go to bed and get some rest.” Or she might clean a bad cut and perhaps even stitch it up.

If your symptoms were indicative of something more serious, you might be referred to the Armed Forces doctor up the street a half-mile or even air-evacked to Prince Rupert, about 80 miles across the ocean, in an extreme emergency.

I also recall my elderly aunt dying from cancer in Rossland in the West Kootenays about 20 years ago. For months, she was in the hospital — terminal. Her condition was monitored at great cost through expensive equipment in the hospital and by expensive health care professionals.

Last November, however — now, that’s only a few months ago — my mother-in-law in Castlegar, also in the West Kootenays, became extremely ill. The root cause was initially undiagnosable. In December, even though her family was no longer capable nor skilled enough to take care of her, she was able to stay in her home of the past 70 years as a team looked after her needs.

A registered nurse was her case manager. She received daily assistance with tasks, such as bathing, from a home care aide. An occupational therapist and a physiotherapist came by only on an as-needed basis. Blood samples were also collected in her home as needed. Though a doctor was still involved, she was not required to go to his place of work in all instances. Phone calls — and on one occasion, a home visit — sufficed.

One morning, her pain and discomfort required a visit to the hospital, where tests revealed the cause of her illness: a rare form of cancer. Her condition was terminal, and she was administered a potent painkiller. She returned home after only a matter of hours in the hospital and died less than a day later.

When we contrast the two situations — my auntie and my mother-in-law — we see that the team approach allowed someone to stay in her home at the end of her life, surrounded by her loved ones and cared for by a team of professionals, who were able to improve considerably the quality of the last months of her life through the integrated use of their skills and expertise.

Please don’t underestimate the value to an elderly person of being able to die at home, rather than the hospital. Also, please don’t underestimate the cost-effectiveness for the system when a team’s approach is used in a situation as this, rather than a hospitalization approach.

L. Larson (Chair): Okay. We don’t have a lot of time for questions. We wanted to hear you go through this, because it’s very good. Thank you.

Judy, I’m going to turn it over to you to take down questions. I have to go and do a phone call.

We’ve heard over and over and over again about the interdisciplinary teams. The question is…. There are many impediments to get there. Different colleges of nurses and doctors. It is a very large undertaking, and believe you me, we have the message loud and clear.

I do come from rural British Columbia. I do live in 100 Mile. I can tell you, we’ve got some of the best health care there is. We have teams available there to keep you at home when you’re in palliative care. It is so valuable. It is a wonderful, wonderful approach.

Yes, we need to have some improvements. But from some of the other rural communities that I listen to and hear from, they’re not so fortunate. We are looking at re-evaluating the whole health care system. But to get there is going to be very complicated and very complex.

R. Turner: I think there’s a whole culture out there, in terms of: “This is the way we’ve done it for so long.” It’s going to be really hard to get people to move from those habits, from that way of thinking and so on.

D. Barnett: We do have some great health care workers who are participating, believe you me.

S. Robinson: The personal stories are always, I find, so much richer in that it helps us hang the ideas on sort of the real picture, in terms of how it plays out in people’s lived lives. I thank you for sharing that.

In the beginning of your presentation, it mentions that you’re the co-chair of the Kamloops Health Coalition. I’m wondering if you could just tell me a little bit about the health coalition and if this was a presentation on their behalf or on your behalf. I just want to make sure that….

R. Turner: Good point. This is largely on my behalf, with some encouragement from the B.C. Health Coalition and some members of the Kamloops Health Coalition, but this was not organized by either group. They encouraged me to do it. This was an opportunity to do it, and so I grabbed that opportunity. I can tell you that both coalitions, though, are in favour of the integrated approach. But I have not vetted this with several members of either group.

S. Robinson: Great. Well, thank you very much, once again, for the personal stories. It really helps to put dress-
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ing on the framework that we’re looking at, and I appreciate you coming out and taking the time.

S. Hammell: Thanks, Rick. I think you might enjoy the expression that we got. Yesterday, I think it was the doctor that said it’s like trying to change the shape of the airplane while it’s in the air. I do think that is a pretty apt, kind of, metaphor. We have something going, and yet it has need to change. Yet it’s entrenched in the shape it’s in.

We have heard about this, and so I have made myself…. I have asked continually about mental health. Do you see how that plays out in this? Or is it something that the coalition talks about?

R. Turner: We don’t talk that much about mental health, to be honest with you, so I’m really not much help in that regard. I do appreciate the metaphor, though, of trying to change the airplane while it’s flying.

I hear anecdotes from people in health care, health care professionals. I’m acquainted with several who’ve indicated that it’s tough to change that culture — very tough to change that culture.

I think on the third page, you refer to: “The old system will crash. Longer wait times. Not enough doctors. Increasingly difficult health problems.”

I think we know that when people are in acute distress, the health care system is generally there for them.

J. Darcy (Deputy Chair): But I think it’s fair to say that we are in the midst of that crisis right now, as far as primary health care in many parts of the province, including Kamloops. I hear from people from Kamloops all the time, because the problems in Kamloops itself with primary care are aggravated by communities that don’t have access to family doctors or primary care, who then come and line up at the same walk-in clinics and so on.

I guess I’m asking you because I know that you’re speaking on your own behalf, but you’re also someone who’s very concerned with sort of the bigger picture about what we need to do. What does Kamloops need as far as interdisciplinary team-based care?

R. Turner: I think the first that needs to be recognized is that there’s a huge hinterland — and it is huge. I meant no criticism of 100 Mile House and the services they offer, but I’ll give you an example. The Hamlets out in Westsyde, an old folks home, if you like, where I think 85 percent of the people there are no longer capable of taking care of themselves — a lot of them with dementia and things of that nature.

It’s often thought that we only deal with Chase, Barriere and Logan Lake, and it’s a much bigger hinterland. Not that that isn’t enough, but it’s a huge, huge hinterland. The first thing that has to be recognized is that Kamloops is the central place for that huge area, and it is vast.

Kelowna seems to be…. It has a lot of services, there’s no two ways about it. Certainly, in a lot of instances, people from Kamloops have to go down there for particular needs. The folks from Ashcroft are no exception. You can go up the river a long ways — up the North Thompson, Clearwater, perhaps even Blue River — and you’ll find that where do people go when they need special services or equipment? There’s a number of stores here in Kamloops where, if you are having mobility issues, you drive in from Blue River or wherever and you go to one of these stores in Kamloops to get the piece of equipment you need to get around your house or to get around your community. I think that’s the very first thing that needs to be recognized — that it’s a huge, huge area and that people do travel great distances.

The anecdote I gave about Clearwater. That is an anecdote shared with me by a gentleman from Clearwater. This all comes to me. I’m just the messenger. These are things people have told me. I know that the doctors are now…. Many of them are cutting back. Some are retiring. That comes to me directly from doctors, many of whom I’m acquainted with here, and other health care professionals.

I think that’s the starting point, Judy, for that. It’s to recognize that, in the Interior, you have centres like Kamloops that serve huge populations. My understanding — not to speak for the West Kootenays or to pretend to speak for them — is there used to be a hospital in Castlegar and Nelson and so on. Now Trail is considered the main centre. I can think of places like Kaslo, Argenta, Edgewood, Nakusp. Nakusp — probably Vernon is the closest one now with the roads that have happened.

The other thing I think, and I may be behind one step, but the availability of technology…. One of the interesting things to me is if we could get more in the way of high-speed Internet up the valley, up in places like Clearwater, Blue River…. Imagine someone who is hurt or sick in Blue River, which is 2½ hours from here and one heck of a highway in the wintertime. If they could contact a specialist here in Kamloops and at least get that need….

But you can’t count on the Internet, the further up the valley you go, sometimes. It’s getting better. I know from firsthand experience that if I tried to check my cell phone in Clearwater a few years ago, I couldn’t get anything. No service. Now I’m getting some service, so it’s getting better. Once that technology is expanded and the avail-
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ability of experts and specialists and so on through that technology is more readily available, I think the quality of service to someone who’s just been hurt or is very sick in Blue River can be improved tremendously too.

D. Bing: Thank you for your presentation. As I was listening to you, I was thinking of what you were mentioning. They were short 15 doctors in Kamloops. It’s partly because the community is growing. I’m from the Lower Mainland, and they’re predicting that there’s going to be another million people there in another 30 years.

I’m just thinking of…. We’re a province that attracts people. People think we’ve got a great economy. We’ve got a great climate. They all want to come here. Our problems seem big now. They’re going to be even bigger as time moves on. How are we going to house all these people? How are we going to provide jobs, medical care?

Your little story. I was just thinking this will be magnified many times in the future.

R. Turner: Yeah, I think so too. I would add that the wants and needs oftentimes of some professionals are changing over time too.

We know that up in Clearwater, it’s hard to attract doctors. In the old days, the doctor would go there and his partner, his spouse, would go along. Nowadays, today’s doctor’s partner is probably well-educated and has a career of her or his own and wants to pursue that career. Perhaps in a smaller, rural community, they can’t do that. That’s why, oftentimes, doctors aren’t going to the smaller, rural communities, because their partners don’t have the opportunity in those smaller, rural communities to pursue their careers.

There’s a marvellous doctor at UBC. I wish I could think of his name. He used to be a doctor up in Clearwater. Now he’s a professor at UBC. Oh jeez. You get older, your memory is not so hot.

L. Larson (Chair): Thank you so much, Rick. We really appreciate you coming today. Everything you’re saying is…. We are hearing very similar messages from everyone. Your thoughts are much appreciated. We will be capturing everything in our report.

R. Turner: Thank you. I wish I had more to offer on how to overcome the obstacles. I am aware that there are obstacles and impediments.

L. Larson (Chair): Yes. That’s all right. Eventually it will all work its way out.

R. Turner: I think so, yeah. I just don’t think we can delay on those much longer. It’s been a long time that people have been waiting for the services they need.

L. Larson (Chair): Our next presenter is on the phone line, I believe. Is it Craig?

L. Larson (Chair): Oh good. Okay. We will ask you to, if you can…. I think we have a PowerPoint from you, so if you can just give us a minute, we’re just going to put the PowerPoint up and then we’ll give you 15 minutes to present.

All right. I think we have your presentation up on the screen. If you’d like to go ahead, we’ll move it along as you speak.

C. Hostland: Wonderful. To my colleagues and members of the select committee, I propose health care sustainability utilizing the SIRAPP program with interdisciplinary teams.

The crash theme that you see has a number of common elements with my proposal, including the criticality of the subject matter, the opportunity to apply an engineering approach to quantify what might be otherwise seen as random events and effects, and viewing a real-life drama from a new perspective.

The Select Standing Committee on Health is undertaking further consultations to identify strategies for improving the sustainability and quality of B.C.’s health care system. One aspect of the call for submissions pertains to determining how to create a cost-effective system of primary and community care built around interdisciplinary teams.

This paper is in response to the call by presenting a cost-reducing, sustainable, IAQ, residential asthma prevention program, or SIRAPP, to be undertaken by the public health care system, utilizing a prevention policy–based public health care system program structure outline, founded on financially viable, proactive decision-making based on engineering risk assessment.

Mould- and dampness-induced high-use asthma is used as the researched disease, but other reversible respiratory conditions can be researched and implemented with the same sustainable prevention policy.

Respiratory health consequences within the health care system have a $62 billion impact in North America. The total yearly public health care system and societal cost impact to British Columbians due to indoor mould and dampness is $153 million, for slightly over 4,400 high-use asthmatics.

Societal savings accrued through program implementation are $97 million, or a 63.5 percent reduction in that cost after the first year. The reduction in public health
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care system costs for mould- and dampness-induced high-use asthma alone is $31.7 million in B.C., which projects to $380 million in Canada and $3.8 billion in costs to the United States.

As background to my proposal today, my 2015 thesis quantifies and addresses indoor environments with respect to health effects using engineering techniques. I use this as a basis for accepting the challenge of the B.C. Ministry of Health to address sustainability in the B.C. health care system. The subject matter has evolved and grown significantly since I formally started indoor environmental assessments at the millennium.

Research is trending towards accepting that indoor mould and dampness have a strong association with respiratory ill health, specifically asthma. My thesis confirms this association at a 98 percent confidence level and that health effects cannot only be reversed to a 70 percent reduction level, but also at a significant cost savings to the B.C. public health care system.

In the 15 minutes I have, I will introduce my motivation and proposal objectives, introduce the concepts I researched and the solutions I developed towards my goal of developing a sustainable prevention health care program for respiratory disease. Further background information is provided in the appendices of this presentation document.

By 2008, through my work, I had developed a belief that certain indoor moulds likely caused debilitating occupant health problems. That belief required substantiation, and I had an opportunity to pursue solutions through a PhD program, starting in 2009.

My thesis progressed certain hypotheses into these two theories. I developed a solution with a sustainability framework that could facilitate long-term change in pre-existing societal and health care norms through the application of good science to design and economically justify a sustainable remedial health care prevention program for high-use asthmatics. Along the way, I developed and validated a quantitative model and tool to evaluate indoor environments and predict respiratory health effects.

The social cost-benefit analysis I conducted verified the public health care system cost benefit towards identifying respiratory candidates and the residential indoor environments, undertaking cleanup under a social contract agreement, measuring the reduction in health care requirements for the candidates and reallocating those public health care system savings towards further prevention methods.

My presentation is founded on an indoor environment mould and dampness prevention methodology with a financial payback structure that identifies crash sites that would provide an acceptable financial rate of return on investment by implementing prevention measures that also demonstrably make lives better.

Consider vehicle A as hazard-level indoor mould and dampness and vehicle B as environmentally affected occupants. The crash site is the intersection of vehicles A and B. Prevention is finding those types of homes and those types of occupants and preventing a predictable critical occurrence that would result in a consequential impact to both occupant and society.

The use of a prevention model that benefits the patient, the health care system and government, based on socioeconomic modelling valuation for health care initiative decision-making, has gained success in other sectors, as exemplified by the Insurance Corporation of British Columbia road improvement program. It improves hazardous traffic corridors based on an economic payback valuation of reduced crashes and injuries.

The ICBC model prioritizes projects based on a benefit cost greater than two and a three-year capital period payback. Its sustainability is based on a 20-year track record to date.

Not unlike this accident scene, I submit to you that prevention may well reduce the risk of the debilitating effects of uncontrolled asthma. Prevention is in the form of hazard identification and hazard removal before the occupant or patient reaches that crossroad that could culminate in a physical crash. This is a comparable discussion to the identification of asthma triggers, which is now common in asthma care. In either case, one cannot remove themselves from the crash after it has occurred, particularly if they don’t have another house to return to.

I observed that ICBC, an insurance company, was actually participating in and underwriting road improvements. That began to make sense to me in the context of my PhD concept, if I took a broader view of what it means to provide insurance or address health impact and looked at it from a risk perspective. I thought of a damp and mouldy indoor environment as a crash zone that, with societal support, could be prevented — or at least the risk of it happening, to some extent.

I am not a health researcher. I have not and did not conduct epidemiological research on the subject matter. But as an applied scientist and being a user of the health care system, I felt I could consider this approach by pondering a social remedy. I began to see the public health care system as I now saw ICBC in its broader role — as a facilitator and instigator in identifying the hazard, determining if the hazard can be significantly reduced or eliminated through risk assessment and cost-benefit analysis, all within a financially viable business plan, and then remedying the hazard.

The beneficiary, like ICBC, is the public health care system — to the benefit of its stakeholders, which are the public health care system, the affected patient and society itself. The bonus is happier and healthier people and a host of medical care provider teams with a renewed focus on prevention medicine. The concept is well known — prevention — but is rarely enacted. The literature iden-
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tifies only 5 percent of health care expenditures accruing to medical prevention methods or procedures.

My motivation fits with this particular message and remains a key motivator to keep me actively working towards effective social-level solutions to day-to-day problems. This is an American author’s treatise, based on American culture, but this circumstance happens in Canada as well, all too often.

The economic justification, using social cost-benefit analysis for a high-use asthmatic prevention program, is provided in my 2015 thesis. With this, the use of an economic basis to undergird a health prevention program is plausible.

The cost to the public health care system is $10,000 per person-year for environmentally affected severe uncontrolled asthmatics, with a 71 percent cost reduction upon removal of mould and dampness from their indoor environment. The overall cost to society was determined to be $34,000 per person-year, with a reduction estimated at $22,000 upon hazard removal. The benefit cost was well greater than one and the capital expenditure replacement in less than a year.

Literature provides that certain moulds can trigger asthmatic episodes. Mould exposure can cause a manifold increase in emergency department visits, onset and asthma exacerbation, in part attributable to certain mould and dampness exposures with an odds ratio average value of 1.1 to 16, with sufficient evidence. There is a strong association between mouldy and damp indoor environments and onset or exacerbation of asthma. There is a high correlation between high-use asthmatics and environmental impact.

Slide 9. The overall results from my thesis, as noted in table 2.3 in my thesis, indicates 47 study outcomes with sufficient evidence — and five study outcomes without sufficient evidence — of an association. The results also demonstrate that environmental effects can be subtle and may vary by study. From this research, I concluded that a strong association existed between mould and dampness, visible mould, dampness, mould odour and increased asthma effects.

By replacing the public health care system direct process-specific costs with the reduction values developed in chapter 2 of my thesis, from remediation of residential indoor environments, as summarized in table 4.4, the cost savings have been calculated to be $7,100 per person-year. This only addresses the specific impact reduction values known through literature and provided by professional opinion.

In addition, I propose, with the reduction of symptoms, the reduction of severity may also occur, which would logically reduce standard and critical care bed-stay durations, daily hospital drug costs and drug use duration, thereby increasing the overall cost savings to the public health care system.

Table 4.6 lays out the cost savings per person-year on direct, indirect and external costs. I won’t go into any more detail because of time.

Framework for the SIRAPP health care prevention program. It’s proposed that a sustainable mould and dampness prevention framework could enhance the existing methods undertaken by the public health care system to reduce asthma impact risk levels and enhance the functional life of an environmentally affected asthma patient while developing interdisciplinary health care professional teams based on a financially based prevention model.

The sustainability principles and assumptions behind this program are noted in more detail in my presentation that I’m providing by the end of the month.

This proposed flow chart is how the SIRAPP program would function with the hospital emergency department to provide real-time benefit results that can be measured to confirm success through administrative metrics that are, again, identified in the more detailed presentation.

Conclusions. This proposal provides a social cost-benefit-based economic justification method that supports a health care sustainable prevention program, utilizing a system-based implementation strategy. This program will open the door to many other sustainable prevention and health care programs, as well as assist in integrating interdisciplinary health care teams towards disease prevention. It is argued that a prevention focus in a health care environment will enhance interdisciplinary team-building and team-based health care efficiencies.

A sustainable indoor residential asthma prevention program, or SIRAPP, integrates the patient-home environment into the public health care system diagnosis protocols. The SIRAPP proposal includes detailed implementation strategy considerations, as well as a process flow chart to promote an economically sustainable health care program, which is all provided in more detail.

I would like to take this opportunity to thank the Select Standing Committee on Health for their outreach towards sustainable health care. I would also like to offer that the means to introduce an all-new process into the health care system will require incentives that are reward-based. This is outlined in my thesis.

Towards that, I also wish to offer that a means to recruit and retain remote community medical professions is to, one, significantly increase the number of entrance enrolment opportunities. There were only 256 enrolled each year until 2010. From 2011 to 2014, that increased to only 288 per year, although official applicants increased to well over 2,000. There are willing applicants, but there are insufficient spaces.

Secondly, there are a number of successful recruitment and retention methods provided in other provinces and other countries, such as in Australia, where the outback is even more remote and challenging than northern
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B.C. I know because we lost our daughter to an available medical school in Australia that also provided reduced schooling costs for remote community indenture after graduation, with excellent programs in place for her professional development.

Thirdly, ongoing incentives, such as allowing financial benefits to accrue to the doctor for developing his or her medical practice, not unlike a lawyer or an engineer or a realtor who all have financial incentives to build their businesses and sell them to new entrants for a tangible retirement fund. I am aware that medical practices in B.C. are literally having to give away their asset and customer basis to new entrants.

Doctors may get paid well while seeing patients, but they must work 70-hour weeks and ostensibly limit their free time with family. Their reward is to walk away from their public practices with nothing or become fee-paid specialists outside the public practice.

Provide more entrance opportunity, enhance the benefits of remaining in public practice, provide logical financial and team-based incentives for remote community service, and we’ll be seeing more of our children becoming doctors and nurses and more of an interested group of health care workers available for remote community service.

L. Larson (Chair): Thank you, Craig. We’ve gone past your time a bit, but your talk was very interesting. I have a few questions here, starting with Darryl.

D. Plecas: Hi, Craig. Thanks very much for your presentation. I’m sensing, unless I’m missing something, that at the end of the day, what we’re talking about here is a need to remediate residences where there’s some evidence of mould or dampness. I know there are lots of people who would agree with that. The question is: who pays for it? It sounds like you’re proposing, of sorts, that it be the government, with the view that we could perhaps ultimately reduce health care costs.

C. Hostland: Actually, the thesis outlines different methods of undertaking that program. But I argue strenuously that the public health care system benefits so much from being involved in the implementation and the immediate financial payback in instituting the protocol that giving it away or allowing outside interests to run the program for a profit would not be beneficial. I show a capital payback in less than one year and in the order of $30 million a year.

This is just for a small demographic of the asthma population. They are 1½ percent high-use, uncontrolled asthmatics who are affected by internal environmental consequences. They only constitute 1.5 percent of the entire asthma population, yet we can save over $30 million a year in implementing a program which includes cleaning the environment of that individual who is entering the public health care system at a cost to the public health care system of over $10,000 per year per person.

D. Plecas: But I guess what I was getting at is: why can’t the responsibility for that fall on a landlord or a homeowner?

C. Hostland: Well, why isn’t it happening now, Darryl? It’s the same thing as dealing with asthma triggers. There’s an asthma care centre here in Kelowna, and the manager was able to prove a 95 percent reduction in asthma impact to the health care system, yet her job and her business were cut a few years ago. It’s considered an expense. When government decides what stays — either outreach programs or hospital beds — the hospital beds are going to win, and the doctors are going to win.

What I came up with is more towards a methodology of implementing a program that actually returns money back to the health care system. It’s a cost-reduction program. It just so happens that I used high-use asthmatics. And it just so happens that I was able to find that there was a 71 percent reduction in health impact to high-use asthmatics when their indoor environment was cleaned.

I proposed that we do a social outreach. I know that’s the hardest part of this program, but when I can show economics within a comprehensive, sustainable system, then I would suggest that using certain methods that are outlined in my thesis, we can accommodate this.

D. Plecas: I guess, again, all I’m saying is that I agree with you, absolutely, that there’s a cost saving. I know your research regarding the relationship between asthma and mould and dampness is unassailable. It just seems to me — and I guess it’s a debatable issue — the savings will still be there if landlords, or homeowners themselves, are made to pay. Or say to those people…. It’s like anyone else who has a problem with their residence. Like: “Fix it up.”

C. Hostland: Darryl, I’m in complete agreement with you. From a theoretical perspective, I had to look at the most austere condition for the financial analysis. If society did not have to pay the $5,000, on average, to clean a home of a high-use asthmatic, environmentally affected occupant, that’s $5,000 more that goes into the coffers of the health care system.

So absolutely. Part of the program would be to find those circumstances where there’s a least-cost impact to the health care system and return even more value back into the health care system.

But again, I had to look at worst-case scenarios, and that would be a worst-case scenario. It was actually going in and having to clean a person’s indoor environment. It’s unfathomable in most societies, but I would argue Canada — and maybe Denmark and Sweden — would
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be one of the very few that actually would embrace that as a means of reducing the impact.

It’s the same argument as paying somebody to not smoke. Well, if that person continues to smoke and it costs the health care system, let’s say, $100,000 a year, and you can get them to stop smoking for $5,000 a year, wouldn’t you do it?

L. Larson (Chair): Excuse me, Craig, we have more questions for you, and we’re running out of time. So if you could keep your answers as brief as possible, or we’ll be finished before we get through it.

D. Barnett: Thank you very much. You did your thesis, which is great, and you’ve come up with some great work. If you don’t mind me asking, what is your profession at this point, Craig?

C. Hostland: I am a professional engineer with a PhD in environmental engineering.

D. Barnett: Thank you. So you would actually go in and validate homes that have got some kind of an environmentally unfriendly substance in it. You would go in and certify those homes, would you?

C. Hostland: Well, Donna, that’s what I do as a professional, but I’m not looking for a job here. What I’ve done is I’ve laid down a process that anybody could undertake. It’s free. That’s what the PhD program is all about. I’m handing this over to somebody.

That’s what I do, and that’s where I got my data from. That’s where I was able to satisfy my own curiosity of why the medical system did not accept mould and dampness as a cause for disease.

Thank you. It’s obvious you’ve done a lot of work on this. We are very well aware that preventive methods and preventive procedures save the health care system a lot of money, so thank you very much. It’s similar to what we’ve heard in other presentations, and we appreciate you taking the time to be with us today.

L. Larson (Chair): We are back on air. I would like to welcome Fawn Knox from the Kamloops Health Coalition.

We have 15 minutes to hear what you have to say and then 15 minutes for us to ask you questions. Go right ahead, Fawn.

F. Knox: Thank you. All right. If I could take the liberty, could I start with the middle question? Okay, good. It’s the longest, but it’s the one that closest to the kinds of things that I want to do: how can we create a cost-effective system…?

Sorry, I’ve got to start and tell you who I am. I’m Fawn Knox. I’m a retired teacher. I’d been in School District 73 for over 30 years, and when I retired I got interested in universal public health care, which, all of you know, is enshrined in the Canada Health Act. I felt that maybe my serving duty from there on was to defend the health care act. Not that I’m making much progress, but I’m quite happy at doing what I’m doing.

The question, the second one. I did want to change it to “create an effective system” rather than “cost-effective.” You’ll find out why I’m doing that.

I want to start by saying that I attended a conference in 2008. It was called Re-imagining Health Services: Innovations in Community Health. It was because I was part of the Kamloops Health Coalition that I got invited to it. It was part of the economic security project at that time. The Canadian Centre for Policy Alternatives and Simon Fraser University were putting this on. They only accepted groups of people that had nothing but positive solutions for our health care crisis at that time. So that was a good way to start.

They did do these presentations. They were making a difference to the health care outcomes within the community health sector. Many of these projects…. Now, first of all, I have to say these projects came from right across Canada and some from the United States, and there was one that I do remember from northern B.C. They began as pilot projects. They continued to operate, but they were not part of the core funding at that time. They only continued out of fundraising or, probably, lobbying to get money, which you probably know.

Prior to us all going to our different workshops that we chose to go to, the umbrella group, the keynote speakers…. One of the things I gleaned from it, anyway, was that…. What was like a by-product was that it was cost-saving. I mean, the most important thing…. And that’s why I say effective system, effective for the people that are going to obtain the health. But the by-product was that it was cost-saving when they did have these primary health care places in the community.

They said the primary health care, the home support and the community health centres overall were the least expensive component within the heath care system. Telling us that was good and all the more reason for it to
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happen. These innovative initiatives created cost savings in the entire health care system.

You’ll find out that I’m good at quoting other people. They seem to be able to say it better than me. From my point of view about having primary health care, what was quoted from Roy Romanow’s commission in 2002…. It was exactly like “the bottom line was what you need.”

He talks about the platform for primary health care built on four essential building blocks. That was: continuity and coordination of care — I know for myself, having a doctor, continuity is so important; early detection in action; better information on needs and outcomes; and new and stronger incentives. That was back in 2002 in terms of what to do.

Then I just look at Kamloops, ourselves. I know — and I’m probably understating it — there are 20,000 people in Kamloops who do not have a doctor. I don’t know what that’s like, but I’m sure it contributes to my good health because I do have one. As you can tell, I’m very much in favour of primary and community care–built facilities with the interdisciplinary teams.

I have a quote here. It says: “From the humanitarian standpoint, there is, we believe, an obligation on society to be concerned with the health of its individuals. But on the economic side, investments in health are investments in human capital. They pay great dividends to a nation that looks after the health of its people.” That was stated in November 1964 by Emmett Hall. Of course, that was in answer to a question: why is universal health so important?

I also read from Roy Romanow that we can have the best primary care facilities, which I hope we do, but we have to look at the social determinants of health. In what I’ve given you, and it’s very brief, I just listed 14, which I didn’t come up with but got off the Internet, of the social determinants of health. If we don’t address them, then we’re not going to be able to address the health of people. You’ve got to look at food insecurity and housing and all those other things that are equally important.

As a citizen, I’m trying to understand where you’re coming from in terms of politicians and what you can and cannot do. I think, as the public, we don’t understand. We know you’re elected to serve, and I think that’s a very noble thing.

I do listen to CBC. When I heard yesterday that the lobbyists in B.C. alone are 30 to 1, I thought: “How do you get your work done when there are so many lobbyists?” I don’t know. It said 30 to 1 to all the MLAs, and I don’t know if all of them are lobbying the Liberals. Or do they go to the NDP too? I think that’s quite a….

F. Knox: Well, good for you. But I do have to say that my MLA would not meet with me, but I don’t know. It was because he had 30 in line. But I think it’s important that you have to hear the public too. When I heard that, I thought: “Well, that makes it difficult too.”

The other thing that I wrestle with is…. As you can see, I am a bit of an ideologue myself. I’m all in favour of public health care. So how do we blend the two ideologies?

I look at the Liberals, and I say to myself that much of it has to do with privatization. I know you’re lobbied. I have yet to find the benefits, but of course, I’m reading the literature that tells me there aren’t the benefits of the private.

I know before…. I grew up here in Kamloops. We’ve always had some private facilities for seniors. I think there is room for it, but I’m just afraid that it might dominate.

That’s all I have to say, really, about effective systems. I hope you go ahead. I think I did hear an announcement from Dr. Lake yesterday that there is going to be a primary health care facility — I don’t know how soon in the near future — in Kamloops. I’m not sure if it’s a 24-7 one, but I hope it is. I think it’ll take the pressures off of the hospital. I do hear through the Kamloops Health Coalition how difficult it is at our local hospital.

D. Barnett: Thank you very much for coming here this afternoon and giving us some insight into your philosophies and your beliefs. I sincerely appreciate them.

Public versus private has always been a topic of conversation. There’s room for both, and we need both. Most people don’t realize that your doctor has a private business. His clinic is a private business, yet he is taken care of by the public system. So they integrate, and they work quite well together.

A lot of people say: “Well, the private clinics are going to come along. They’re going to dominate, and only the rich are going to get healthy.” It hasn’t worked so far, and it won’t ever get to that, believe you me, because people won’t accept it.

D. Barnett: We do need both, and we have to make sure that we keep our philosophies and our eyes open and do what’s right for all the people of British Columbia. Whether you’re a Liberal or whatever you are, it’s about what is right for the people of British Columbia.

A lot of times your policies and your philosophies do work quite well together, as this committee is. We have our disagreements. At the end of the day, we’re all here
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for one reason: what is the right way to deliver interdisciplinary health care to the citizens of British Columbia? It’s a big question, and hopefully, we can get to the end and find an answer.

L. Larson (Chair): I just want to ask you, Fawn. That was one of the three things. Did you have something to tell us on the other things?

L. Larson (Chair): Okay. Then what we’ll do…. Instead of asking…. Normally, we wait until the end. So go ahead.

L. Larson (Chair): Yes, that’s fine. Go ahead. Then when we ask, we’ll be able to encompass everything that you’ve brought.

Improving health and health care services in rural B.C. I basically just looked at the Internet, but I also took from my own experience as a teacher. Now, I’m talking 30 years ago.

One of the things that was lucky for me…. I was homegrown. The school board said: “Let’s focus on the people that lived here and went away.” At that time, you had to go away to go to university. And they came back. My mom was phoning me, as a secretary of a school, at the age of 19. “Are you ready to teach?” “No, I’m not.”

They were bringing in Australians. There was a shortage of teachers like there is a shortage of doctors. But that was one of the things, definitely — looking at homegrown. I’m sure that hasn’t been anything new.

One thing that intrigued me much was telehealth. From the little bit I have read, it certainly is working. There were concerns that the doctors didn’t want to be replaced. But, boy, to have at your fingertips another doctor or someone to guide you…. I think that would be important as well.

Something that I can speak to, to some extent, is mentorship. I don’t think I got it as well as I could have, but I had a great career. But I did see it with my daughter. She had a fabulous kindergarten mentor when she started in Vancouver, and she’s up here in Kamloops, and it’s paid off in spades. It’s been wonderful. I think mentorship is very important.

Another term I’m new to but I thought was good was job embeddedness. I don’t know if you’ve heard of that. I hadn’t heard of it either, but it’s all about really keeping people on and what it would be if they had to leave. You know, what sacrifices would it be? For me, as a teacher, to leave teaching, one of the sacrifices would be giving up a pension. That, I tell you, is…. I don’t know. It’s pretty nice. That would be something that would be for job embeddedness. A pension was certainly something.

Now, I did not say that at 27. I didn’t think the pension was anything. I wanted that 7 percent of that money to go towards my kids. But I thought that was an interesting concept, about looking at what keeps people in their jobs and what links they have and how they fit into the organization, and the social links as well.

The other thing, which I don’t know if…. I can’t think that it’s done in teaching so much. Input from those who you’re looking at to be retained — you know, talking to the people that are going to be our future doctors. “What do you need to go into these rural areas? What are your wages like?” I know for teachers, the farther north we went, the more money we got, so that was an incentive.

Working conditions, equipment and infrastructure, and supervision. Supervision is so important — to know that you’re on the right path and correct it.

Effectiveness of addiction recovery program. Well, it’s all over CBC, talking about this new drug that is now being released — you probably are aware — for a new drug therapy. For all the 474 cases that have overdosed over…. It is really quite scary. I guess these are our most vulnerable members of society and, of course — another quote — “the true measure of any society can be found in how it treats its most vulnerable members.”

My feeling is they need the basic ingredients of shelter, food, and then you have to create and support an environment that’s conducive to healthy living. I don’t really know how you do that, but I know everyone wants to do something about it. I also know people have to decide themselves too. But you want to create an environment.

Yes. I’ve been listening to this generic version of this Suboxone, which is a new opioid drug treatment therapy that is being scaled up, I guess, and going to be available. I did hear one gentleman who talked about it and said there should be a wider availability of addiction treatment and greater support outside the Lower Mainland. This probably isn’t anything new to you.

What I also did…. I just put three references that are probably already spoken to. I did write a report, and I just made one copy, but you’re welcome to have me send it to email. Because I was so taken by this conference that I went to, I wrote a report on it, and I can’t remember who I sent it to, if I sent it to anyone. It was just some examples of the workshops that I went to that I was so taken with because they were making such good headway.

The commission, 2002 — Building on Values: The Future of Health. That was Roy Romanow. Then the Social Determinants of Health. Actually, I downloaded that — 63 pages — and I’m going to read it. It’s the most recent. It’s 2010. It’s Canada-wide. It’s The Canadian Facts, it says, about social determinants. I think those are important —
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to have those in our minds. Once we establish these primary health centres, then we need to delve a little further.

L. Larson (Chair): Thank you so much. You have obviously put a lot of time and effort into researching what you do, and you’re right on with everything that we’ve heard so far, and so and so.

D. Plecas: Fawn, you mentioned primary care and your interest in primary care. What does it mean to you?

F. Knox: Well, what it means to me is looking at the people that have chronic conditions, people that don’t belong at the ER when they have a time of crisis. They know there is a place that they can go 24-7.

We talked to Andrew Noonan, I think it was, when he was head of the Royal Inland Hospital. Rick Turner and I talked to him quite some time ago about the same kind of thing.

Can you set something up maybe right next door to the emergency centre, just to take the pressures off? If you have the same people in those areas that people just come to and know they could come to so they know they have access — easy access — rather than sitting…. Well, I don’t know. Maybe the primary care will get backed up too. But it’s basically, I think, the chronic and maybe the education of….

F. Knox: Yeah, exactly, so that we can start working on some of the preventative as well.

But I think of people. My feeling is that people are aware that we’re in a crisis. I think they believe if you don’t have a doctor, and so you’re relying on these walk-in clinics and emergency, those are just one-time shots. If they can feel that there is a connection there, I think they might feel a little bit better about their health, knowing that you’ve got someone that cares. I think that makes a difference.

J. Darcy (Deputy Chair): Thank you so much, Fawn. You’ve touched on so many issues.

I want to zero in on the social determinants of health. I’ll maybe ask you because you’ve spent 30 years as a teacher. An awful lot of the folks who don’t have access to primary care are people whose health is related to social and economic determinants.

I wonder if you could just talk from your experience as a teacher, because you would have seen students of various social and economic backgrounds — the social determinants of health, what you saw, and the impact on their ability to learn and succeed in school.

F. Knox: Now, it’s very interesting, because what I can really talk to you about is my daughter’s experience. I wouldn’t mention any names. The reason is, first of all, I was a teacher-librarian. I remember when I went into that field, I lost my class. They were like my own kids. I had them for five hours. I went through a little withdrawal. I was quite upset.

Anyway, what I was going to say is those kids that I noted…. I wasn’t in a low socioeconomic group for 14 of my years, but I did see children that were neglected, were deprived. But, boy, those children were resilient, because they wouldn’t share that with you. They kept it quiet.

My discussions with my daughter, private as they are…. She would vent with me. She was working in — she’s not anymore — a very low socioeconomic grouping. Those kids that went…. She would tell me how difficult a child would be in the classroom. I’d say, “Yes” — she needed to vent, and I knew that — “but you’ve got to think of where he’s coming from.” She knew that it was drug addicts and it was….

She told me one story, and I’ll share it with you. A little boy found out…. He had wonderful foster parents — absolutely wonderful. She said: “I could phone them any time, and they were good.” But he was to see his mother every Monday. She didn’t want to see him anymore, not because she didn’t love him — maybe she didn’t — but her focus was drugs.

Well, he came to school that Tuesday, and there was nothing she could do. She saw that. I said: “You know, you just have to take the rest of the kids and say, ‘He’s had a difficult time.’” We don’t expect the rest of them to behave like that. She says: “You can’t have someone behave like that. They all think they can behave like that in primary.”

The principal took him out, and he could get to do what he wanted. But he also had to realize there was a consequence. The consequence was to apologize to the class and the teacher. But that came. That was after he was listened to. “I know that you have a very difficult time”.

What I saw in that area…. I thought, as a retired person, and I don’t have all…. I think it’s a place that we need volunteers. We need people to help with those kids — maybe for someone to listen to. I think that’s a start. When they go without food or when they go without…. How can you expect them to learn? It’s very, very difficult. You go into a hostile situation. This is what some of these children are….

They have put a lot of resources in some of these schools, but I don’t agree with it. I know how closely connected young children are to the teacher, and my answer would be to give those teachers 15 kids and spread that around — not 30 kids or 25 kids. Because there is such a close connection. I saw how those kids love my daughter, and she could not provide for all of them, and it upset her — not upset her because she wanted control; you want to teach. That’s what you’re good at.
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I have to say…. I saw it through her eyes more than mine, and I don’t know whether it’s because there is a rise in that, or I never really was long enough at a low socioeconomic school to really see that — see some of those social determinants that enhance the social injustice that we need to work on.

M. Dalton: Darryl touched on the question. That really was the primary health centre — what you meant by that, because it can be different things. You’re thinking more like a health clinic, where you have, with different…?

F. Knox: Yeah. I think what really stuck in my mind, or what I heard through my health coalition, was that a lot of chronic cases ended up in the emergency. So you’re seeing those same people all the time, and they saw a different doctor all time.

If you were able to get…. That was one of the…. I thought that might be quite a number of people, so I thought if we could take that pressure off the emergency and have those people at a primary health care clinic, knowing that their chronic conditions would be attended to. Maybe, once they know they’ve got a rapport with that same person, it might be alleviated. They might learn how to handle their condition, too, because they’ve got the same person. I know exactly…. I see what my doctor says to me when she knows where I’m at when I come in with….

M. Dalton: I guess in my mind, I’m wondering. If you have physicians there, you’d still need appointments and it would still be, kind of, a doctor’s office in some ways, except for different other options — one location, I suppose.

F. Knox: Options. That’s right. And I guess, too, if you had your interdisciplinary groups, then you might know right at the onset, when someone comes in: “Well, you’re not going to see a doctor right now. You’re going to see a nurse practitioner or a physio.” I’m not sure how costly that is, but I would…. Well, I don’t know. Some of those pilot projects seem to be working.

M. Dalton: It deals with the proximity issue. I mean, you’re dealing with an issue. There are relationships among the different professionals, and you’ll be able to collaborate that way.

I know a friend of mine whose husband has been in the hospital, and he just was sitting there with a team of people. Then they zeroed in and we know what…. The doctor was off and doing his thing. We knew, exactly, that he needed some physiotherapy, etc. That seemed to be…. Everyone was on the same page. I mean, that doesn’t happen overnight.

S. Robinson: Thank you, Fawn, for your presentation. I, too, am interested in…. Your conversation about your daughter, actually, was the part that captured my attention. The parallels between teaching…. That profession and the challenges had with not having enough teachers, and here we have doctors and we’re in a sort of similar role.

You talked about your daughter going away to school and coming back, and it reminds me of some of the things that we’ve heard about rural. If you could just, maybe, say a little bit about…. I mean, she was raised here in Kamloops and went away to school and came back. If you could just speak to the desire to come back, because that’s been one of the things that we’re struggling with.

We have young people who come from rural British Columbia who may or may not go away to school, and how do we get them to come back? So if you could maybe just give us a little bit more of a story about that.

F. Knox: Well, that’s interesting, because I was thinking about that. I hate to sound sexist, but I have to say…. My husband came back. He came to Kamloops and he’s from Burnaby, and I met him here. I was thinking, as a…. I grew up with a family of four — two girls and two boys. The two boys moved away. You know, they did not…. Their jobs are what it was that took them farther afield.

For my sister and me, teaching was anywhere. I was quite happy to return. I say to my high-school friends: “You know, I got 18 miles out of Kamloops” — because I went to Black Pines — “and that was as far as I got.”

So I don’t know. I have three children. One daughter has left for Calgary, but that was to do with a job. For teaching, and as a doctor, she was quite happy to return to Kamloops.

S. Robinson: Do you think that was about having grown up here? I mean, sometimes it’s family relationships. Sometimes it’s: “I like this size town. I don’t want to live in a big city.”

F. Knox: I think that was, definitely, for her. Yeah, and she was very much involved in the soccer community and that kind of thing. She certainly felt that Kamloops offered just as much and at a smaller level, and she was quite happy with that. It’s interesting, yeah.

Thank you so much, Fawn, for coming today. We do have a copy now of what you brought with you, and we appreciate that very much.

I’ll leave these here. I don’t know whether you want them. These are some examples of the reimagining health services. I’ll just leave the one copy. You can share it.

F. Knox: I did do an overdo of job embeddedness theory. I thought it was great. I did some primary health care and prevention. These were some cases that changed, and that one came out of the Romanow thing.

F. Knox: The other thing is, which really hits on ideology or whatever…. It talks about the private…. There was an article in the paper July 1 by Dr. Karpiak. Now, I don’t know if you’ve heard about it.

F. Knox: He just lambastes about the administrative increases from the time he was…. Not in defence of the…. It’s the same in teaching; it’s the same everywhere.

I don’t know what governments can do. I know they can do something, but it’s rampant. You know, we don’t need all these administrators. When I started teaching, there were three people up at the board office. Now we have so many assistant superintendents, and they’re tripping over one another. I mean, that just seems to be the pattern. I think we need to get out of it, but anyway.

L. Larson (Chair): Thank you for bringing the extra paperwork. We’ll get copies of that. Thank you very much.

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

1) Digniti Home Hospital Research Project	Deanna Cross
	Rees Moerman
2) Dr. Mark Fromberg
3) Connie Redknap

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

4) BC Transport Nurses Network	Scott Lamont
	Michael Sandler
5) Christine Kozakowski

6) Ashcroft and Area Community Resources Society; Wellness and Health Action Coalition	Ron Hood
	Pam Webster
	Chellie Dickinson
	David Durksen
	Marilyn Bueckert
7) Rick Turner
8) Healthy Homes IAQ	Craig Hostland

REPORT OF PROCEEDINGS(Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH