Introduction

The Nova Scotia Citizens Health Care Network appreciates this long-awaited opportunity to meet with both of you this morning.  It has been at least a year and a half since our last meeting with Deputy Doiron on July 22, 2004 prior to the First Ministers’ Meeting on HealthCare in September 2004 and at least two years since our last meeting with Minister MacIsaac on December 5, 2003.

A great deal has happened since those meetings such as the so-called Ten Year Plan, the establishment of the Health Council of Canada, the Chaoulli Supreme Court decision, the recent announcements on wait times and health human resources, and the current federal election campaign in which healthcare is once again the predominant issue.

We remind you that our Health Network is a broad provincial organization of concerned individuals and organizations representing youth, seniors, women, anti-poverty, persons with disabilities, community groups and labour.  We have been in existence since 1996 and we are affiliated with the Canadian Health Coalition in Ottawa and other provincial health coalitions.

We are dedicated to protecting, strengthening and expanding Medicare.    We are not calling for everything to stay the same as some people have suggested.  As was stated in the final report of the Royal Commission on Health Services in 1964, we are committed to seeing the following overall goal realized:  “…that as a nation, we now take the necessary legislative, organizational and financial decisions to make all the fruits of the health sciences available to all our residents without hindrance of any kind”.

Over the last 30 years or so, there have been many clear and well-established benefits to Medicare in Nova Scotia and across the country.  There have also been many challenges facing Medicare in that time.  However, it is our current assessment that Medicare is at greater risk than it ever has been mainly because there are increasing pressures to open the door to privatization and for-profit healthcare in all its forms while there are only a limited number of measures being taken to protect or expand publicly funded and delivered healthcare.

In this submission and in this meeting, we want to focus on the current situation with wait times, privatization, uninsured physician services, health human resources and home care. At the same time, we want to indicate there are many other issues that deeply concern our members such as accountability including a detailed public accounting of the additional funding from the federal government that have been and will be provided as part of the Ten-Year Plan, long-term care including the sending of nursing home patients up to 100 kilometres away and out of contact for spouses or family and the costs that residents and their families must still cover, pharmacare including the plans of the Department to provide for catastrophic drug costs by 2006 and the need to cover proven non-traditional therapies in a universal pharmacare plan, mental health including the rights of mental health patients, and the determinants of health including the increasing rate of child poverty which means one in five Nova Scotian children live in poverty. 

Wait Times

As you may recall, the issue of waiting times for diagnostic and treatment services was a major issue for our last two meetings.   Regrettably, it still is a major issue for many Nova Scotians including us. 

At the same time, we are pleased firstly with the wait times website that was officially set up on October 7.  This clearly provides invaluable information that was not previously available.  We were also pleased that with the announcement on December 12 about an agreement between all provinces and territories on common benchmarks for many chronic health problems.  Both of these measures are very useful steps towards resolving this long-standing and complex problem for our healthcare system.

For us, the next key step is what we have been urging since at least 2002 is as stated in the provincial-territorial media release of December 12.  This is the development of a strategy (which we think should be a comprehensive wait list management strategy) that will establish multi-year targets to achieve the benchmarks and most importantly, improved access to timely care.

There are clearly some key elements of such a comprehensive strategy outlined in the “Plan to Improve Wait Times” portion of the new wait times website.   However, they do not by themselves yet constitute a comprehensive strategy.  As the Minister was quoted on December 13, there must be a more effective use of existing physical and health human resources.

As we recommended in December 2003, there must be a full investigation of all possible ways in which waiting times can be reduced such as extended hours of operation, use of alternative rooms or facilities, other diagnostic or treatment modalities and better information management systems.

At the same time, as one of our members concisely stated the situation, the new benchmarks are quite meaningless unless we have appropriate human resources and the beds to accommodate the patients receiving care.   He pointed to the acute shortage of anaesthetists and the warnings we have since heard about reductions in surgeries even in the next few months.

We strongly urge the use of measures to strengthen publicly funded and delivered healthcare as a central part of the needed comprehensive strategy.  For example, we are impressed with significant progress achieved by Saskatchewan in reducing its surgical wait list in the province’s seven largest regions by more than 3,200 people between January 2004 and June 2005.  This was apparently done by additional investments to give their health regions the resources they needed to increase surgical capacity and better manage access to surgery.  We have included a copy of the article about this achievement at the end of the text of this submission.

In addition, the interim report of the first eight months of the Alberta Hip and Knee Replacement Project showed that patients could receive needed surgery within four months of the initial consultation.  Central assessment clinics were set up so that a patient could be seen within 17 days of a family physician referral and provincial funding was provided to support an additional 1,200 hip and knee surgeries.  There is apparently some speculation that this team model could be extended to the treatment of other areas such as breast cancer, prostrate cancer and mental health. A copy of the media release and an editorial about this project are also found at the end of the text.

Furthermore, we think a December 2005 report entitled “Public Solutions to Health Care Wait Lists” prepared by Dr. Michael Rachlis for the Canadian Centre for Policy Alternatives offers a strong case for public sector solutions to problems with wait times.   In particular, this publication sets out two specific solutions:  the use of more specialized short-stay surgical clinics within the public sector and adopting lessons from queue-management theory such as having single waiting list within a given jurisdiction rather than each surgeon having their own wait list.  A copy of this report is also found at the end of the text.

A better use of resources within the public system must include a better use of health human resources.  We urge again the development of a comprehensive health human resources plan or strategy that we will cover later in this submission.

We do not support a so-called Wait Time or Health Care Guarantee that was first proposed by the Kirby Report in 2002, and subsequently by the Nova Scotia Liberal Roundtable on Wait times last April and more recently, by both the federal Liberal and Conservative Parties in the current election campaign.  We think it is a false solution that does nothing to ensure patients receive timely access to care and worse still, opens the door to privatization.  We have enclosed a copy of a brief statement from the Canadian Health Coalition on this issue.

We are also concerned that the benchmarks announced do not yet include diagnostic services such as MRIs or CT scans.  Nor do they include emergency room visits where there have been significant problems across the province especially at the QEII in Halifax even with the so-called 10-Point Plan.

We were pleased to see some reference to the role that primary healthcare

can play.  However, we see no direct reference to the specific role that community health centres could play to help reduce the need for high demand treatment services as well as to assist with many diagnostic and treatment services.  We urge again discussions with the Nova Scotia Federation of Community Health Centres and DHAs about the development and expanded use of a broad network of community health centres.   We have enclosed a copy of a media announcement from November from Ontario about the setting up of 22 new CHCs and 17 satellites.

Privatization

As we suggested earlier, the most serious threat to the future of Medicare and its further development is the rise of for-profit healthcare.    In the wake of the Chaoulli Supreme Court decision of last June which ruled narrowly against the Quebec government’s ban on private health insurance for publicly insured medical services where there are unreasonable wait times in the public system, we have seen a major increase in pressures for more private, for-profit healthcare facilities including the development of a so-called parallel system of private healthcare.

This ruling will not by itself mean the end of Medicare as we have known it.  In our view, the real problem is what happening in reaction to this ruling.  For example, delegates at the Canadian Medical Association’s Annual Meeting last August decided to support the development of a parallel, private healthcare system.  A Canadian Independent Medical Clinics Association has been established to build broad support for a private healthcare agenda.  More recently, the Alberta government has floated the idea of allowing private health insurance compete the public health system for all insured services and Premier Klein toured the country calling for consideration of what he calls the “Third Way”.

Another impact of allowing private clinics to open is that once they allowed to compete with the public sector, the protection for Medicare under NAFTA and WTO rules disappears.  Governments would then be forced to treat private providers on the same basis they treated public ones.   In addition, this would make it almost impossible to remove them from the system in the future since in order to do so under these agreements we would have to pay them for lost profits.

In Nova Scotia, we have seen the rise of several private, for-profit healthcare clinics such as the private MRI clinic in Halifax, the private East Coast Medicenter established by Scotia Surgical Centre in Dartmouth and possibly a private plastic surgery clinic in Halifax.   Of particular concern is the loss of skilled health providers from the public system to the private facilities.  This has happened with the private MRI clinic in 2002 and in December 2005 with East Coast Medicentre in Dartmouth.

The impact of the rise of for-profit on healthcare workers is very eloquently expressed by Karen MacKenzie (Vice-President of CUPE Nova Scotia):

“Nova Scotia’s healthcare workers are highly skilled, highly educated and soundly trained workers. They are compassionate and caring employees who deal with many facets of the public. If they were not committed to their employment, it would be impossible for them to be successful. That fact has always been outwardly recognizable within the healthcare system.

One of the major root problems of the system in Nova Scotia is the continuance of supply and demand. Many of the current healthcare workers are aging with few people emerging to take their places in the workforce. Many new folks come out of our schools are quickly recruited out of province with contracts to larger facilities both nationally and internationally. Nova Scotia must do all it can to cement our students here in Nova Scotia and keep our skilled workers already in the workforce here as well.

Privatization of the system at this level complements the drain on the human resources within the public sector. It has been well documented that the public sector is now struggling with a lack of skilled workers. Any form of intrusion, such as a private hospital or clinic, will lure the public sector workers away from the public system thus compounding this problem even more. The number of Nova Scotian citizens accessing our healthcare facilities is not declining but our workforce is and will continue to. This is a fundamental problem within our system today.

Many of our current healthcare workers are aging and their expectations of daily living are changing. Our outlook and life priorities at the age of twenty are drastically different then our outlook and life priorities at the age of forty-five. If there are no twenty-year olds in the system to do the extras which help to establish their own footings within their careers, this is left continually to the older workforce. The older workforce however may not be interested in working “double shifts”, “overtime”, “extra shifts” and through their annual leaves as their priorities direct them elsewhere.

That being said as we continue to force the older workforce beyond their expectations, they tend to look elsewhere for different circumstances to fit their life styles. This is what will happen in Nova Scotia and did indeed happen last month at Colchester Hospital in Truro. Four highly trained operating room nurses left the public system to join the private sector at the new East Coast Medicentre in Dartmouth. There is no way that District Health Authority #4 can replace those skilled workers affectively. It is said that to be proficient as an operating room nurse, the intense training alone would be six months to a year. Colchester Hospital still will have the same amount of sick people to help, surgeries may be postponed thus driving up wait times when the public still anticipates and demands effective services from the District Health Authority.

If the government of Nova Scotia continues to look the other way, starve the public system of the resources needed to deliver the service expected and allow outside private influences to lure away the public workers, the public system will collapse. Private hospitals/clinics can set their own hours of work and this is an ever increasing attractive benefit to the aging public sector worker force. In private hospitals and clinics patients are all mobile, walking, talking and functionally coherent.   The private sector will also cherry picking the easiest and most profitable patients thus putting increasing strain on the public sector to look after the most difficult and expensive cases.

Another big draw to the aging public sector workers.  The public system can not compete with the private sector for human resources as its own system is so ailing now. If you think there is room for both, we can assure you that from a worker’s perspective there is not. There are not enough workers to go around and the pool to choose from has not been addressed over the last six years. Privatization of the healthcare system will break the public system on human resources alone regardless of many other factors affecting the system.”

There is other compelling evidence against the use of private, for-profit healthcare facilities.  A Harvard study published in the December issue of American Journal of Medicine found that the quality of care delivered to Medicare beneficiaries in the U.S. was significantly lower than in non-profit health plans.   British doctors who are part of the NHS Consultants’ Association sent an open letter to the President of the Canadian Medical Association last year urging their Canadian colleagues to learn from their mistakes and reject private care and other market-style policies.  An Australian professor of health policy wrote an article in the Canadian Medical Association Journal last September calling on Canadians to be wary of developing a significant private sector, especially if that sector seeks the level of government subsidies that they receive in Australia.  A copy of these articles is also found at the end of the text.

In September of last year, the Minister was reported to have said that legislation dealing with private health clinics would not come forward until the spring.  Prior to the legislation, there was to be a consultation process.  To the best of our knowledge, we have heard nothing since that article about either the legislation or the consultation process.  We want to know the current status of these plans and to stress the urgency of legislation which should have been developed long before now.

We are also concerned about the accuracy of the reporting by the Department about “Private, For-Profit Facilities” in the Canada Health Act Annual Report.  We wrote to the Minister on March 30, 2005 to question what specific private, for-profit surgical facility was included for the years 1999-00 to 2003-04 and why there was no apparent reference to the private MRI clinic in Halifax under diagnostic imaging facilities which opened in August 2002.  To the best of our knowledge, we received no reply to that letter.  A copy of this letter is found at the end of the text.

If legislation is to be developed, we urge that it include the following provisions: 

·                     a tracking and annual reporting on the for-profit facilities that exist

·                     a requirement that all public funding is only to be used in publicly delivered facilities

·                     a prohibition against health care providers (especially physicians) from working in both public and private facilities at the same time

·                     A prohibition against new facilities from opening unless they become part of the public system as has happened in Manitoba.

Uninsured Physician Services

We continue to be very concerned about the extent of uninsured physician services and the direct charges that patients are facing for them either at the time of service or on a monthly or yearly basis.  This issue gained new urgency for us with the article on December 28 about Dr. Mark Kazimirski’s plan to charge a monthly fee for a package of uninsured services.  This issue started for us with the news in May 2004 about Dr. Cathy Felderhof setting up a so-called health co-operative to handle the payments for these services.

In the first place, one of the major reasons Medicare was established in Nova Scotia and across the country almost 40 years ago was to eliminate financial barriers for any needed health service.  The practice of doctors charging for so-called uninsured services whether at the time of service or on a monthly or yearly basis goes against this basic principle.

We think it is important to remember that Nova Scotia was the first province to ban extra-billing or balance billing by doctors in 1984 after the Canada Health Act was passed that same year.  And the clear intent of this ban was to stop direct charges to patients for insured or uninsured services.  In fact, when some doctors in Halifax charged for prescription refills right after the ban took effect, the then President of the Medical Society wrote to all doctors in the province advising them against such charges.  

Regrettably, both the Department and the Medical Society/Doctors Nova Scotia have allowed these charges for uninsured services to continue and even be expanded.  The intent of the legislative changes in Bill 106 in 1984 was to make sure doctors would negotiate with the government for what they feel they need in terms of payment and coverage of their costs.  In addition, the legislative provided for a final offer arbitration process to help resolve all outstanding issues in these negotiations.

We therefore question why patients should have to pay for such services as paper file management, ear syringing, prescription refills or telephone access. For many patients, these services may be as important as seeing their doctor in their office.  Why would they continue to be treated as "uninsured services"?

Despite the assurances by Doctors Nova Scotia that no one should be denied a service if they can't pay, the research on user fees clearly shows this happens especially for persons of low and fixed incomes.  This is especially the case if an individual or her/his family has been going to the same doctor for years. In fact, we heard from patients of Dr. Kazimirski when he first introduced this payment plan in his practice and we forwarded their concerns to the Deputy Minister from whom there has been no response.

It is long overdue that both the Department and Doctors Nova Scotia acted to stop patients from being billed for these uninsured services in the following ways:

·         The results of the Department’s investigation of this issue be publicly released.

·         The extent of billing for uninsured services should be investigated and publicly reported as extra-billing for insured services was prior to 1984.

·         Most if not all of the current uninsured services should be recognized as insured services.  

·         Any doctors charging for uninsured services should not also be able to receive payment from M.S.I.

Literally thousands of Nova Scotians supported the end of extra-billing by doctors in the mid-1980's.  We didn't do so just to see one form of direct charges by doctors replaced by another.

We have written to both the Minister and the Deputy Minister on this issue on several occasions and we met with two Department staff persons on April 11, 2005.  However, we remain unconvinced that our concerns are being taken seriously and that any decisive actions will be taken against this problem of uninsured services and the billing of patients for them.  We do not agree that the focus of the Department should be strictly on whether a specific service is an insured or uninsured service.  In our view, this focus misses the point about how doctors are being compensated and the extent to which patients are expected to pay for medical services.

Health Human Resources

As we indicated two years ago, the overall quality and success of public health care is largely affected by the health human resources available to it.   However, despite its obvious importance, very little consideration has been given until recently to the understanding of and planning for health human resources.    It has frankly seemed to us as though it is generally assumed that if funding was available, facilities open, equipment and supplies provided, they would pretty much operate on their own. 

For example, there are serious issues with respect to physician recruitment and retention such as the shortage of anesthetists, the shortage of ICU physicians at Dartmouth General, the shortage of oncologists and the subsequent increasing wait times for cancer treatment, the increasing average age of our physicians with the greatest proportion of our physicians are between 45 and 55  who are looking forward to retiring before the age of 65, and the increasing levels of burnout among the physicians practicing today?  In addition, do we really have the staff needed to operate the 6 new MRI machines?

We were therefore pleased to learn about the Department’s Health Human Resources Action Plan released on December 21 which contains four overall goals and a commitment to help develop detailed plans and comprehensive strategies for the future.   We understand that Nova Scotia is one of four provinces to come forward with such a plan.

However, in our view, this Action Plan is only a starting-point for what steps we think are needed for health human resources:

·                     A comprehensive health human resources plan or strategy as recommended by the Nova Scotia Royal Commission on Health Care in 1989 and by the Blueprint Report in 1994.   As recommended by the Royal Commission and still to be fulfilled, that plan or strategy should be based “…on the health needs of the population and a review of the present and future roles of all health professionals to determine [at a minimum](our addition) appropriate entry points to the health system, numbers, mix, training, scope of practice and distribution of health professionals in Nova Scotia” (p. 65).

·                     Ensure this plan or strategy covers all health occupations including assisting, support, clerical, administrative staff as well as volunteers and family caregivers.

·                     Investigate fully the compensation and benefits for frontline healthcare workers and how they will affect future supply and working environments.

·                     Develop specific plans to encourage all healthcare workers to stay in the public healthcare system.

·                     Adopt long-standing occupational health and safety regulations related to violence in the workplace, indoor air quality and joint occupational health and safety as well as a more recent proposed needlestick regulation for safety-designed needles.

·                     Involve frontline workers and their unions fully (and not just on a token basis) in all stages of health human resource research and planning processes.

Home Care

As we were two years ago, we are very concerned about the current situation of our provincial home care. It is certainly not what we were hoping would happen when the present home care program was launched in June 2005.  On June 13, 1995, then Premier John Savage described Home Care Nova Scotia as being a program that will provide “….true community-based home care to Nova Scotians.  It will support individuals and families across the province and help communities meet local health needs more effectively.”  He went to say: “The strength of this new program will be its absolute attention to people’s needs.” 

Unfortunately, what our members are seeing and in some cases, experiencing is a worsening state of home care with wait times, cutbacks in service, the lack of continuity of care. In fact, one of our members had  to go through an appeal process last week just to retain the level of home support service that she used to get, namely, just two hours once a week.  Another person could not access provincial home care upon leaving the hospital and so was sent to the VON until other arrangements could be made.

The key problems we see for home care seem to be well-summarized on page 38 of the Final Report of the Capital Health District Level Committee for the Continuing Care Strategic Framework Project released last October included:

·      Poor wages and benefits for workers

·      Inconsistency in workers resulting in poor continuity of care 

·      Scheduling is often inflexible and does not allow for full complement of staff

·      Not enough workers to meet the demand 

·      Health care sector does not always use employees efficiently and effectively in the workplace and community

·      Not enough recruitment and retention initiatives to keep young adults from migrating elsewhere after education is complete

·      Not enough human resource strategies to entice new workers from other parts of Canada and internationally.

As we did two years ago, we therefore urge again that the following steps be taken:

·                     Home care needs to be improved, not cut back or “de-proved”, especially to help keep people out of hospitals and nursing homes.

·          More services by homemakers and home support workers are needed, not less.

·          More money should be put into home care to provide the services we need in order to allow everyone receiving these services to live comfortably.

In addition, we recommend the following:

·                     A comprehensive health human resources strategy that includes fair wages and decent working conditions such as guaranteed hours of work. 

·                     There must be a new legislative framework at least for Home Support Services.

·                     All home care services must be brought under one provincial program.

·                     Home care must become an insured service that is part of a comprehensive, accessible and publicly financed and operated national continuing care program.  

Conclusion

In this submission, we have presented our major concerns and recommendations on wait

times, privatization, uninsured services, health human resources and home care.  We

believe the public healthcare system must be strengthened and expanded to effectively

deal with these serious issues.   We think the evidence is clear that allowing more

private, for-profit healthcare is a major step backwards that will add greatly to the costs of

our system but also adversely affect the health of Nova Scotians.  We need strong

government leadership to stop privatization and to strengthen public health care.

As Tommy Douglas said in 1982, “We can’t stand still.   We can either go back or we can

go forward.  The choice we make today will decide the future of medicare in Canada.”

List of Enclosures

“Surgery wait times dropping”. The Leader-Post, October 5, 2005.

Alberta Bone and Joint Health Institute. “Alberta Hip and Knee Replacement Project reduces wait times” (media release). December 19, 2005.

Dr. Michael Rachlis. “Public Solutions to Health Care Wait Lists.”  Canadian Centre for Policy Alternatives. December 2005.

Canadian Health Coalition. “Reality Check  Wait Time ‘Guarantee” a Trojan Horse”.  Canadian Health Coalition website, accessed January 9, 2006.

Association of Ontario Health Centres.  “Cheers and applause as government launches new era in community-based health care using CHC model” (media release). November 10, 2005.

“Quality of care in for-profit and not-for-profit health plans enrolling Medicare beneficiaries” (Abstract). The American Journal of Medicine, 118 (112), pp. 1392-1400.

 “Open Letter to the Canadian Medical Association from UK doctors”.  CCPA Monitor, October 2005. pp. 8-9.

“Living in the parallel universe in Australia: public Medicare and private hospitals”.  Canadian Medical Association Journal, 173 (7), pp. 745-747.

Letter of March 30, 2005 from Debbie L. Kelly to Hon. Angus MacIsaac.

“Private  clinics bill not ready for fall session”. The Chronicle-Herald. September 15, 2005, p. B2.

“MD offers monthly fee service”.  The Chronicle-Herald.  December 28, 2005, p. B4.

Letter of June 24, 2004 from Ian Johnson to Hon. Angus MacIsaac.

Letter of July 22, 2004 from Hon. Angus MacIsaac to Ian Johnson.

Letter of November 22, 2004 from Debbie L. Kelly to Hon. Angus MacIsaac.

Email message of December 9, 2004 to Hon. Angus MacIsaac to Debbie L. Kelly.