Health Minister Terry Lake comments on St. Paul's Hospital redevelopment
FULL TRANSCRIPT FOLLOW: SHAW Voice of BC 13-Mar-2014 19:00
Dr. Ian Courtice: “Roy Romanow was asked, after the Romanow commission — which is ten or 15 years old now — what was the biggest challenge to health care. That answer, for him, was leadership — there needs to be better leadership in health care.”
Vaughn Palmer: Good evening, and welcome to Voice of BC. I'm Vaughn Palmer, and tonight's guest on the show is British Columbia's new Health Minister — well, new to me, anyway; he's probably feeling a little worn out at the job already.
Welcome to the show, Terry Lake. Gotten on top of that giant ministry by now?
Terry Lake: Well, nine months in…. It's been a challenge, for sure — just the learning curve — but it's an area I've had a great interest in for many, many years, so I'm really enjoying the role. And I have a great team, which makes it a lot easier to do the job.
Vaughn Palmer: You're a veterinarian. People have said to me that the only people in British Columbia who really know what the health-care system costs are the people who pay the bills on their pets.
Terry Lake: It's probably true. When you see the cost of health care for animals — as I certainly did — you understand the cost of all the different procedures, the equipment. And then of course you step it up to human health care, where the scope is greater, the standards higher. You can imagine the leap in cost as well.
People don't see that, for sure, but I think a lot of people recognize that we have a very good health-care system — that is expensive, at the same time.
Topic: Cuts at Community Health Centre
Vaughn Palmer: I wanted to ask you about something you got asked about in the Legislature today. The Opposition led off Question Period this morning about cuts at a community health-care centre in the province. They pointed out that the government talks about promoting community health — these centres where it's to look after multiple afflictions — and yet this one's looking at layoffs and budget cuts. What's the answer there? Why is that happening?
Terry Lake: Well, it actually isn't budget cuts. There's no cut to the budget at all. This is Vancouver Coastal doing what I think is the responsible thing to do, and looking at their primary and community health care — particularly in the downtown area — and matching it with the patients, the clients, they're trying to serve.
When they looked at it over the last 12 months, they realized there was a mismatch there. Their primary health centre is designed to help people that are most vulnerable — people with mental-health issues, substance-abuse issues, elderly frail — people that need to have longitudinal care, a continuity of care. A lot of these people were ending up at the emergency ward, at St. Paul's or wherever, and not getting that continuity of care.
They have redesigned their primary health-care facility to match that population, which needs that high level of support, and then the other clients that don't have such high needs will then be directed to fee-for-service providers in the area — which is your regular physicians that work in teams or by themselves — versus the primary integrated health-care system, which is really geared to that vulnerable population.
Topic: Health-Care Budget
Vaughn Palmer: I wanted to ask you something that really jumped out at me in the budget lockup this year, and I've been covering…. This is probably my 32nd or 33rd BC budget that I've covered. Something that I would not have believed I was ever going to see, which is…. They call it “bending the curve” on health care, but essentially health-care spending and health-care budgets in my time have been growing at 5% or 6% a year. Even in a good year of controlling costs, it goes up 6%.
What we've seen with your government is it's dropped below 3%. I would guess that there must be some interest from other provinces as to how this has been accomplished. What's the executive summary for how you got the cost below 3%?
Terry Lake: Well, first of all, I think necessity is the mother of invention. If you allow health-care costs to rise past the growth of the population and the growth of the economy, a few things can happen. You can either steal from other ministries, or you can raise taxes. Neither of those is really palatable to politicians, either here in BC or elsewhere.
You really have to come together as a team and reduce those cost pressures. We've done a lot to do that. We've done consolidation in the lower mainland so that things that health authorities can do together — the Provincial Health Services Authority, Vancouver Coastal, Fraser Health, Providence — doing things together and taking advantage of volume buying, and the procurement process.
That has reaped us quite a bit of savings. We are redesigning the laboratory system and hope to reap savings there. We have negotiated better deals for pharmaceuticals — in fact, saved about $110 million over two years there — so we're able to actually decrease our Pharmacare budget by about 8.5% this year. We've done that while we've maintained frontline health care.
It doesn't mean there aren't changes; there have to be changes, and you always have to look at the system and optimize the system, as we were talking about with Vancouver Coastal.
If you look at Alberta, they are doing exactly the same thing. I think last year they had a 3% increase in their health-care budget; this year it's under 3%. Ontario is doing the same. Province after province after province knows that you can't balance your budget unless you get health-care increases under control.
Now, we're — luckily — in an era of low inflation, so that helps us too. And I must say that our workforce has been a big part of that. Whether it's physicians, nurses, other health-care professionals, they've been partners with us to reduce the increases in costs.
Topic: Health Sector Bargaining
Vaughn Palmer: Now you've had unions sign for zero increase; you've seen them sign for tradeoffs. Across the health-care sector, where do the talks stand at the moment? I guess you've still got doctors and nurses that haven't come to terms.
Terry Lake: Right. We have had a deal ratified with the HSA.
Vaughn Palmer: Which is technicians and health-care [inaudible].
Terry Lake: Correct. Then the community-service component, so the health-care workers in the community. We are now with our Facilities Bargaining Association, which includes the ambulance service, for instance. From there, we've just started with the doctors of BC as well — and of course they're a big partner with us in terms of the provision of services through physicians. The nurses we'll probably get to in May. They are going through their executive elections over the next little while, so bargaining will start after that.
Vaughn Palmer: Well, speaking of nurses, we've had a lot of questions for the Health Minister on tape. Let's start with the head of the Nurses' Union, Deb McPherson.
Topic: Care Aides Replacing Nurses
Debra McPherson: “Minister Lake, in Nanaimo the employer has replaced large numbers of registered nurses and licensed practical nurses with care aides, increasing their workload to the point where nurses now care for eight to 12 patients or more, at times. This is leading to unsafe working conditions for the nurses and jeopardizing patient safety. Nurses are getting tired, frustrated, and burnt out by this. Illness and injury are now common. What is the minister going to do about this?”
Terry Lake: Well, what Deb's talking about is a new nursing model that was implemented first in some community hospitals on Vancouver Island, then rolled out to Nanaimo and later, in April, will be rolled out in Victoria as well.
When you look at the changing patient population — you think 30 years ago the patient population had relatively simple problems, was a younger population — the nursing model was different than it should be now, with a population that is more elderly, has complex needs. And we have to look at the workforce as well. There's a big gap in the number of nurses for the available position.
So what Vancouver Island Health Authority did was what has happened in other jurisdictions, including places like Ontario and the Mayo Clinic and Alberta. They've all looked at a new nursing model, where they nurse in teams. So licensed practical nurses and registered nurses are looking after the patient-care plan, making sure there are proper discharge orders, and looking after the things that they are trained to do — at a very high level.
And yet the day-to-day, minute-to-minute, more personal-care activities can be maintained by health-care aides, which I think is the optimum use of resources and provides the right treatment for the right person in the right place.
That's the goal. I would say that Vancouver Island Health Authority has realized that the implementation of that model in Nanaimo could have been smoother. But I can say, in terms of patient safety, that surveys done — and there's a range of different things that the health authority looked at, in terms of adverse events, in terms of patient-care plans being completed — that with very few exceptions, the results of those surveys have been very good, compared to before the model was implemented.
We are working to make sure that before it's rolled out in Victoria, that there's more communication involved; that we maybe bring health-care aides on sooner, before the model is fully implemented, to make sure that they understand how the teams will work.
But ultimately, if you look across jurisdictions, the nursing model is changing to meet the needs of the patient and, of course, the demands of the workforce.
Vaughn Palmer: Health critic for the Opposition, former head of the Hospital Employees Union, now MLA for New Westminster, Judy Darcy.
Topic: Access to Family Doctors in BC
Judy Darcy: “Four years ago, your government promised British Columbians that every single person would have a family doctor by 2015. It's now 2014, minister. What do you say to the 175,000 British Columbians who still can't find a family doctor?”
Vaughn Palmer: Many of them, I gather, live in Kamloops.
Terry Lake: Well, it is a challenge. We're still catching up from the '90s, where here in British Columbia we limited the number of doctors that were being trained. It happened in other jurisdictions too, to be fair, but the NDP government here restricted the number of doctors that were being trained. The whole theory was if you restrict the supply, you will manage your costs.
We're still catching up. It takes 15 years, really, by the time you're finished your training as a physician. But in that time we've more than doubled the number of doctors that we are training. We're training them not just in Vancouver but Victoria, Prince George, and Kelowna — and they do their family residency programs in cities like Kamloops, where we do have a shortage of family practitioners, and we hope that they will in fact stay in those communities.
But to encourage that to happen, we've formed divisions of family practice, and we've supplied money through the committee of the BCMA to support these divisions. What they do is they bring family physicians together and they provide an infrastructure for them to work together with the health authorities on recruitment, in making sure they're managing lists for patients that are unattached.
Up in Prince George, for instance, I went to the Blue Pine Clinic in Prince George, downtown Prince George. They've attached 4,000 patients since this program started — the GP for Me program. I think that's a remarkable success, of taking patients that didn't have a family doctor and attaching them to a family doctor.
Now, we have some work to do, and we're obviously working hard, through the GP for Me program. It's rolling out in other cities. We've heard about it in Vancouver last week, for instance. We're also looking at nurse-practitioners and increasing the number of nurse-practitioners around the province.
I think it's going to be a challenge, to make sure that there are enough physicians — because this is a worldwide challenge; it's not just here in British Columbia. But I think we've made good progress, and I think we are going to see even greater progress over the next 18 months.
Vaughn Palmer: My father-in-law was a family doctor — and a baby doctor, actually. He died recently at age 92, so he lived a long life. But he always said that the other thing you had to keep in mind was that, in his day, doctors worked a lot longer hours. You graduate 50 doctors today; they don't work the kind of hours that 50 doctors did 50 years ago. The other thing he said was that they didn't all want stand-alone practices. They like working in clinics, some of them. They like fixed hours. So you're not getting as much work out of them as you used to.
Terry Lake: Your dad was very wise. [Laughter.] He's hit on a real change in the profession. First of all, the profession has become more feminized — which is happening to a lot of professions — and that means that many female doctors, of course, will take time out to have a family and to care for their family — which is absolutely expected and something that we want to support.
But even male physicians these days don't work the number of hours they once did. They want quality of life; they want balance. That makes for a healthy lifestyle, so we again support that — but we have to realize that that does mean that the number of hours available per doctor is going to be less than it was, which is why….
Vaughn Palmer: You also push more patients and doctors into the clinic model, where they share the work and….
Terry Lake: Well, I think there's a tendency with young physicians to want to work in clinics — again, I think this is a good thing — rather than what they call “doc in a box,” where everyone just sets up their own practice. If you get a number of family practitioners together — so physicians and nurse-practitioners — and combine them with other health-care professionals, whether they be chiropractors, physiotherapists, pharmacists, you can have a fully integrated primary-care facility that, I think, meets the needs of a complex population that we have.
Vaughn Palmer: Well, David Schreck — he's always got something provocative to say, and I like this question.
Topic: Private Clinics — a Medical Money Grab?
David Schreck: “Dr. Lake, when I look for a family doctor on the [North Shore?] — and I use a walk-in clinic now, because I can't find a regular family doctor — I'm told they are not taking patients. Unless, of course, I'm willing to pay $500 or more per year in order to cover so-called 'uninsured services.' It looks to me like that's a way of grabbing more money from the patients. It's contrary to the rules of the College of Physicians and Surgeons, yet they work their way around it. Are you concerned about it? What are you going to do?”
Vaughn Palmer: Does this go on?
Terry Lake: Well, there are clinics that do offer an annual fee — and we have looked at those clinics to see if they are, in fact, in contravention of the Medicare Protection Act, which does not allow you to charge for services that are covered by MSP. We're satisfied that that is not happening.
But there are practices — interdisciplinary practices — where you can pay an annual fee, but any time you see the physician, that physician will bill MSP. So they're not charging you for the insured services; the fee is for the other services that are uninsured.
Vaughn Palmer: Such as?
Terry Lake: Well, it may be counselling services. It could be chiropractic services. It could be nutritional counselling. A lot of people don't understand that of our health-care system, 30% of it is actually privately funded and privately supplied. When you think about chiropractors, physiotherapists, massage therapists, a lot of it is covered by third-party insurance, but not by the public insurance.
So what they're doing is combining those services together, and they're paying an annual fee for those non-insured services — which is not against the Medicare Protection Act.
Vaughn Palmer: I see in the budget as well that the government has put some money up — added to the capital plan two more hospitals, both here on Vancouver Island: Comox and Campbell River. A little over half a billion dollars for the two of them. What's your count on building hospitals now, since the Liberals came to power?
Terry Lake: Well, today we've spent $8.4 billion in that time. By the time we get to the end of this three-year capital plan, I believe that will be up to about $11 billion — so a significant investment in the hospitals.
We were at the opening of Surrey Memorial Emergency last fall, and the surgical tower will be opening soon. You look at the new hospital in Abbotsford. We are building additions to hospitals in Kamloops at the moment. We're replacing the hospital in Penticton. And of course a significant investment in the Okanagan, both in Kelowna and in Vernon. So we've built a lot of hospitals, and there's more to come.
Vaughn Palmer: St. Paul's is still not on the list, I don't think.
Terry Lake: Well, St. Paul's is there on the long-term plan. We've looked at the concept plan. We are going to rebuild St. Paul's. We're still waiting for the final business plan, which brings it down to a more specific kind of a project so we know how to price it and put it into the capital plan. The same with Royal Columbian; that is coming soon — which also needs to be replaced.
Vaughn Palmer: St. Paul's, though, will be on site. The idea of moving it to the east side of Vancouver, over by [inaudible] — that's been given up?
Terry Lake: Well, there's still some discussion around that, but I haven't seen any convincing arguments that would put it there. But we're always open, in this government, to making sure that we look at all of the options. If you're building a brand-new hospital, I think you want to make sure that you build the very best one you can.
Vaughn Palmer: With that, we'll take a brief break with Health Minister Terry Lake. Stay with us.
Jordan Bateman: “The MSP does bring in a couple billion dollars a year, but I'm not talking about actually rolling it back or eliminating it. I'm saying just freeze it for a year or two. You've had five straight years of an increase. It's just too much. People are really struggling just to find a way to pay this bill.”
Alan Cassels: “If you don't have an independent source of quality evidence around prescription drugs, you're going to make bad decisions — not just bad decisions on funding treatments, but bad decisions around prescribing them and using them.”
Vaughn Palmer: Welcome back to Voice of BC with Health Minister Terry Lake. We are going to go straight into a question about pharmaceuticals. Former Health Minister, former Finance Minister as well — so he knows this problem well — Paul Ramsey.
Topic: Lobbying by Big Pharma
Paul Ramsey: “You look at the huge marketing budgets of pharmaceutical companies. At times they're drug pushers that make your local meth dealer seem kind and gentle. They organize patients to advocate for drugs; they organize doctors. There are I don't remember how many GPs in the province — 8,000, or something like that?”
George Abbott: “There's more than that.”
Paul Ramsey: “There's about a thousand detail-men and -women — a lot of good-looking young women, too — that go from office to office to office, pushing drugs. They've spent huge amounts of money making sure doctors are, quote, 'informed' — whether it's in their office, or at a special conference in Whistler — about the benefits of new drugs. They market intensely; they market, I would say, unethically.”
Vaughn Palmer: I'm glad that Paul Ramsey doesn't keep it all bottled up inside, how he feels about Big Pharma. Has he got a point?
Terry Lake: Well, I think he's exaggerated the point, but it's a very powerful lobby; it's a powerful industry.
But look at where we are today. We live longer; we manage diseases far better than we ever did. We're able to diagnose earlier — and that doesn't happen unless you have people that are supporting research, turning that into a product that can be utilized.
I think it's fashionable to bash the pharmaceutical industry — and you have to be tough when you're dealing with them — but I don't think we should overlook the huge benefits to our health care that have been provided by the pharmaceutical industry.
Vaughn Palmer: This one came up in the Legislature recently, as well. A good question — a good framing of it — from Andrew MacLeod of The Tyee.
Topic: The $1 Million Payout to Maximus
Andrew MacLeod: “In the wake of a data breach in the last couple of years, the Ministry of Health hired Maximus for over a million dollars to contact the people who were affected. There were a grand total of 1,132 phone calls to their centre, working out to about a thousand dollars per phone call. How do you justify that?”
Terry Lake: Well, I believe there were…. I can't remember the exact number of people that were potentially affected — hundreds of thousands. So when you are making sure that you are providing them with an 800 number, you want to make sure that if they all phone, that someone's going to answer the phone.
As it turned out, much fewer people used the toll-free line than anticipated. But if we had not hired Maximus to do that at that level, and people weren't able to get through to that 1-800 number because they're concerned about their privacy, we would have been criticized for not providing the level of service that was required.
In hindsight — which is always 20-20 — yes, we probably could have done less, but at the time it was important to make sure we did as much as we possibly could.
Vaughn Palmer: Every time I hear that name, I think of an Italian gladiator film; I'm sorry. [Laughter.] Bill Tieleman — dismissals in health.
Topic: Dismissals of Researchers in Health Ministry
Bill Tieleman: “Minister, 18 months ago seven researchers in the Health Ministry were fired from their jobs or suspended. There's been never a real explanation of exactly what happened, and we now learn that one of them has been reinstated with full back pay. Surely British Columbians deserve some explanation from you as to what happened.”
Terry Lake: Well, first of all, I'm not going to talk about personnel issues; I don't think that's fair to the people involved, and there are still some legal proceedings that are underway — so I really won't comment on those kinds of matters.
Vaughn Palmer: Can't you even tell people what it was all about, still? Will people ever get a story of what happened?
Terry Lake: There was obviously some concern about data that was not used according to the way it was supposed to be used. We did an investigation. We hired Deloitte to come in and take a look and give recommendations. We worked with the privacy commissioner and followed all of the recommendations — so they're all being implemented, to make sure that people's data, their privacy, is protected.
But in terms of personnel involved, it would be, I don't think, very ethical for me to talk about that.
Vaughn Palmer: The privacy commissioner and information-access commissioner, Elizabeth Denham, will be on the show later this spring, and we'll obviously ask her for an update on where that stands.
We covered this a little bit earlier, but I'd like to go back on it, because it's a good question. Canadian Centre for Policy Alternatives, Seth Klein.
Topic: Options for Doctors' Pay Structures
Seth Klein: “A recent survey of medical students in British Columbia found that a significant majority of them would prefer to practice under something other than fee-for-service. What plans does the province have to move away from fee-for-service and towards an alternate payment system?”
Vaughn Palmer: The alternate would presumably be salary, or something like that?
Terry Lake: Well, there's salary; there's a sessional capitation system, where you set a maximum on the number of people and provide incentives to look after certain kinds of populations.
We've actually done a lot of that over the last number of years. There's quite a few doctors…. You look at a hospital — let's say in hospitals. They've not paid on fee-for-service; they're paid on a salary. A lot of people in emergency departments are paid on salary.
I think Seth is getting to the primary-care system that we're talking about. Again, this is where health care is moving. We want to move things out of the hospital, or prevent them from getting in the hospital, by providing really good primary and community care. That's the interdisciplinary primary health-care system.
I think in that system there is huge room for alternate payment programs. In fact, we have those in the Interior Health Authority, where I'm from. There's quite a number of doctors that work on that basis. So I do think we are moving towards that. The health-care system is not very nimble, so these kinds of movements happen over time.
I was just rereading a book from the '90s — and by the way, the health-care system was in crisis in the '90s, according to the book.
Vaughn Palmer: Yeah, I know. I was doing shows on it then, too — and in the '80s.
Terry Lake: Exactly. But a lot of the things that that book recommended we do — moving away from acute-care and more emphasis on primary and community care — have actually started to happen, over the last four or five years, and I think you'll see much more of that over the next four or five years as well.
Vaughn Palmer: Wait times — Jarrah Hodge.
Topic: Programs to Reduce Wait Times
Jarrah Hodge: “BC's public health system has several innovative pilot programs that have drastically reduced wait times. Examples include the specialized hip and knee replacement programs at Richmond and UBC Hospitals, and the breast health centre at Mount St. Joseph Hospital. What is the government doing to work to expand these programs to reduce wait times around the province?”
Vaughn Palmer: Other experiments?
Terry Lake: Well, we had some really good results with those. What we are going to do — and started, really, last year, but are moving that into the normal way that we fund health authorities — is to instead of giving them a big pot of money, say that this amount of money is going to be withheld, and you have to almost apply for it for activity-based funding, or you have to meet certain performance targets to access that money. So that's an incentive for health authorities to manage those wait lists.
But there are other things. We have surgical wait-list times. People can go on the Internet and find out what their surgeon's wait-list time is, compared to other surgeons — and essentially can go to a different surgeon if their wait list is much lower than someone else's.
But we're still not there. I'm going to go to Saskatchewan later this year to visit with them. They've had some really good success with surgical wait lists. I want to see what they're doing there and see if we can implement some of that here in BC. As I said, we've done some things that are successful, but we still have wait lists that I think are still too long.
Vaughn Palmer: Jane Sterk, former leader of the Green Party.
Topic: The Use of Private Clinics
Jane Sterk: “Terry, Island Health has just announced elective-surgery cuts because there aren't anesthesiologists for the surgeries — but they have indicated that people can go to private clinics. Does that not undermine the public health system? And does it not indicate a lack of planning on the part of the health authority, to anticipate long-term ability to provide these services to the people of BC?”
Terry Lake: Well, I don't think I've ever heard a health authority say, “You should go to a private clinic.” As I said, we support a publicly funded health-care system. Lots of the providers in health care are private. I think that's important. Most doctors are private businesses, so most of our health care is actually provided by the private sector, but paid for by the public system.
Anesthesiologists are a challenge. It's been a challenge on the Island; I know it's been a challenge in some other parts of the province. Part of that is the amount of anesthesiologists that are being trained, but part of it is the fact that we're competing with a province next door that, in my view, has been slightly irresponsible in the way are reimbursing people working in health care and in other public-sector organizations. So it can be difficult….
Vaughn Palmer: They've got to persuade them to live in Alberta. [Laughter.] It's going to take money, isn't it?
Terry Lake: Perhaps.
Vaughn Palmer: Alberta, I'm sorry.
Terry Lake: I spent a lot of time in Alberta, so I'm not going to argue too much with you on that one. But the fact is it's hard to compete with a province that was very prolific in their spending on health care.
We're seeing that change now, and in fact doctors in Alberta are taking very little, if any, increases. So I think we'll see that field level. I think we'll see anesthesiologists and other specialists come back to BC.
Vaughn Palmer: Okay. Your government is involved in some kind of a court case with private clinics, right? Where does that stand?
Terry Lake: Well, there are a number of clinics which we audited, to make sure that there wasn't any double billing that occurred. We felt there was double billing occurring, and the clinics…. That's the Medicare Protection Act that I was talking about, to make sure that the public system remains intact.
The clinics decided to sue us and I believe are making a constitutional argument that access to health care is not being provided, so people should have a right to spend their own money to get access more quickly.
That's still in the courts, and we've seen this occur in the province of Quebec in the past. We'll have to wait for the court decision. As you know, the court often informs the way policy is developed, so it'll be interesting to see how that plays out.
Vaughn Palmer: As the teachers of the province have discovered. The other thing they've discovered is these cases can take a long, long time — so I wouldn't hold my breath on that one.
Jim Sinclair, BC Federation of Labour — a question about health-care workers.
Topic: Policies for Long-Term Care Workers
Jim Sinclair: “Terry, the relationship between workers and seniors in long-term care facilities is critical to providing quality care. Yet your government passed legislation that allowed long-term care owners to simply fire all their staff, and then bring in lower, cheaper-paid workers to take their place, who have no relationships with seniors at all. This is a destructive practice for both the employee and for the seniors themselves. Are you willing to take steps to review this practice and to stop it, so that the care that seniors get is the best quality that we could possibly provide?”
Vaughn Palmer: How often does that happen?
Terry Lake: Well, occasionally you'll see a long-term residential care facility change owners, and they may decide to put the service contract out for a bid. This happened recently on the Island here. But interestingly enough, when that contract was awarded by Vancouver Island Health Authority to the provider, that was a non-union provider — a private company with non-union workforce. Shortly afterwards, the HEU came in and organized the workers.
Vaughn Palmer: The Hospital Employees Union.
Terry Lake: Costs went up. There was a deal signed by the HEU and the owner that there would be no contracting out until the end of March 2014. Well, guess what? That's what's happening: that they are contracting out. Most of those workers will likely be rehired.
But this isn't…. Jim makes it sound like the shoe is on the other foot. What happened here was you had a non-union organization being unionized, which changed the economics for the provider that won the bid originally. So they're trying to make their budget work for them, which is what happens.
We have a tremendous delivery of health care to people in seniors' facilities around the province, by non-profits, by health authorities, and by the private sector. So I would stand up and say that we have a tremendous level of service in our private sector for seniors.
Vaughn Palmer: Former head of the BCMA, a doctor here in Victoria, Ian Courtice.
Topic: The Ability to Say No in Health Care
Ian Courtice: “There isn't a good system to say no, with good data and good reasons to say no. Doctors and nurses are always making judgements, day to day, as to what a patient should have. In many cases the patient and family may expect more than the system is actually capable of delivering, and in many cases they do go and scramble and provide the care in a futile situation that really we can't afford to do into the future. The old data about the biggest chunk of health-care dollars is spent in the last six months of a person's life — how much are you buying for that funding?”
Terry Lake: That is a very good…. Well, a very heavy topic, for sure.
People often don't want everything thrown at them in their last days on the planet. That's why we are really trying to work with health authorities and the public to educate families and individuals about advance directives, so that you can ensure that people in the health-care system know how you would like to be treated when you are in a situation from which you're not likely to recover.
If you talk to the current Doctors of BC president, Dr. William Cunningham, he works in emerg and he'll say that sometimes people come in and they don't know what their wishes are. It is hard on health-care professionals, hard on families, to see a patient go through that in a futile attempt to give them a few extra days or weeks.
Vaughn Palmer: I was…. This is an issue that I think about, now that I'm in my sixties. I've seen it with other people that I know. I was really disturbed when a court recently interfered with what a family thought was a clear direction to not intervene — no extraordinary measures. A judge came along and said it wasn't clear enough.
It got me wondering whether one of things that a government may need to do in this country is dictate clearer legislation: what needs to be in those wishes, and what needs to not be in there — because I know it would infuriate me to think that I'd given direction, told my family I don't want extraordinary measures, to find that I was being kept alive in a vegetative state because some judge or lawyer decided that I wasn't clear enough in my instructions.
Terry Lake: Well, I think there's a little more to that case, Vaughn, than that. The judge listening to the arguments, I believe, determined that the patient in this case was making a choice, when offered food, to consume that food. That was based — again, in my understanding — on the fact that the patient would eat more at certain times, would show preferences for different foods.
While that's extremely hard on the family — and boy, I really feel for this family too. My mom was able to die at home when I was with her. I wouldn't want anyone not to die in the way they wish to.
However, the judge in that situation, I think, made a decision that this patient was in fact capable of deciding whether to eat or not — so to not provide that, the health authority felt that that was not the right thing to do.
It's complicated, but I don't think that should make us shy away from the discussion. I think it's a healthy discussion to have, and I think we should encourage that.
Vaughn Palmer: Well, tough cases make for bad law, as the lawyers always say — and I wasn't specifically picking that one out. I was thinking more of just whether or not there needs to be more clarity in legislation.
But on that note, we will take a brief break with Health Minister Terry Lake, and return soon.
Jarrah Hodge: “Communities across BC are facing big gaps when it comes to mental-health services. One of the greatest needs is in Surrey, where police report that up to 30% of calls are mental-health related. The government needs to work with the community to develop a mental-health action plan, to ensure that people with mental-health issues get access to health care instead of being criminalized.”
Debra McPherson: “To really start to get control of health-care spending, we need to be investing in primary health care; health prevention; health promotion; keeping our seniors healthy at home, with more home-support services, for example; making sure that when people are discharged from acute care after only one or two days that they have people they can go home to immediately, who will help them stay healthy at home.”
Vaughn Palmer: Welcome back to Voice of BC. Next week on the show, Jim Iker, the head of the BC Teachers' Federation — and gee, I wonder what we'll talk about. [Laughter.] It's hard to think of anything you might want to talk to him about these days. I'm looking forward to that one — and I appreciate, in the middle of negotiations, him making himself available, coming over to the Island to spend an hour on this show answering questions. That'll be good.
Tonight we've still got the Health Minister on, Terry Lake, and lots to talk about. I want to go back to a question from — you just saw her there — the head of the Nurses' Union.
Topic: Nurses' Input into an ER Review
Debra McPherson: “Mr. Minister, as you know, the emergency rooms across the Fraser Health Authority are jam-packed with patients. The wards are over-capacity on an ongoing basis. Now they have 'over over-capacity' protocols, to deal with the glut of patients waiting for care. This is stressing the nursing staff greatly and putting patients at risk.
“The government has established a review, but has no mechanism for the frontline workers like nurses to have input into how the situation could be improved. What will the minister do about this?”
Terry Lake: Well, I've been to many hospitals throughout the province, including Fraser Health — and I've got to tell you, the men and women who work in our hospitals are amazing. They really care about their patients; they work hard — and there are times when it is very, very busy, very congested. There are times when I've gone through emergency rooms and it's very quiet — so they invite me back, because they like it when it's a little quieter than normal.
But when you think about the winter and the flu season, it's not unusual to have congestion. As one head of ER told me, he's been in it for 30 years, and he says it's always been that way: congestion.
You can't predict when you're going to be busy, but you can, I think, plan flows. We've tried to do that a lot by, as Deb said earlier, providing those community-care settings so that people aren't coming to the hospital and emergency; trying to move them as soon as possible out of the hospital, back home or to a community-care facility — which frees up a bed, which then decongests the emergency room.
So a strong primary and community health-care system will help the emergency departments, for sure — but again, this is something that every health system struggles with. I think we're making some strides. The huge expansion of Surrey Memorial Emergency is beginning to really help it. Especially with the flu season ending now, I think we'll see a lot of improvements there.
Vaughn Palmer: Are you saying it's inevitable that at some times of the year there will be patients in the hallways in hospitals?
Terry Lake: Yes. To be perfectly frank, it is inevitable — because you can't build a hospital to maximum capacity and expect to run it efficiently. You have to build it for times when you know you're going to be at 110% capacity; other times you're going to be at 90% capacity. But there will be times when it's congested, for sure. To build them to that level, I think, wouldn't be a very efficient way of delivering care.
Vaughn Palmer: Back to the subject of pharmaceuticals, and back to Alan Cassels.
Topic: How Well Tested are Prescription Drugs?
Alan Cassels: “People go into their pharmacy, getting prescription drugs, thinking that the province is somehow doing some evaluation and monitoring to ensure those drugs are safe. That's an illusion; that's not happening. We believe that Health Canada is working on our behalf, to the extent that they approve and give licences to companies to market new drugs. But when it comes to the important aspect of what we call 'post-market surveillance,' which is looking at the safety and effectiveness of drugs in the real world, very little of that happens.”
Vaughn Palmer: Has he got a point?
Terry Lake: Well, I think Alan is one of the people who does that, on behalf of the ministry, with the Therapeutics Initiative — so it is happening.
And the drug-approval process is pretty rigorous. I mean, it has to go through the Common Drug Review in Ottawa before it comes to consideration by British Columbia. It goes through the Drug Benefit Council. Once it is out there, we hire people like Alan and the Therapeutics Initiative to go and look at the efficacy and safety of those drugs in the real world — and the Therapeutics Initiative has done some very good work, and will continue to do good work on behalf of the people of British Columbia.
So it does happen, and I think by and large our system works extremely well.
Vaughn Palmer: Andrew Weaver, Green Party MLA from Oak Bay, with a good question.
Topic: Adolescent Mental-Health Services
Andrew Weaver: “There's presently insufficient access to adolescent mental-health services across the province. What does the minister plan to do to improve the situation and, in particular, ensure that in the transition from adolescent to adulthood, children don't get lost in the mix?”
Terry Lake: Well, Andrew makes a good point. There are challenges. We recognize those challenges.
Interior Health is just doing a very big collaborative piece of work with Ministry of Children and Family Development and Ministry of Health, to address just that issue that Andrew is talking about — because as people do mature into the adult system, there are gaps that are there. We're trying to close those gaps. We are working with family physicians more and more, providing information through the Doctors of BC and the joint services practice committee that we have with them, to educate family physicians about child and youth mental health.
I think we are making progress in many areas. We've got facilities in Kelowna that are regional facilities in the interior, and here on the Island as well.
Mental health is an extremely challenging part of health care; there's no question. I don't think anyone would tell you any differently. To deal with mental-health issues is going to require great effort. We have a ten-year Healthy Minds, Healthy People plan. We will have a three-year update on that, and the ministry is working very hard with health authorities to make sure that we are reaching those targets.
Vaughn Palmer: Is this like the problem with children in care — when they become adults with care, they go to a different ministry, a different set of programs, and there is a gap there?
Terry Lake: That's often the case in government. Government tends to be siloed. We're trying to break down those silos as much as possible.
I work closely with the Minister of Children and Family Development and the Minister of Social Development as well, trying to manage those transitions. I think there's a greater understanding of the need to do that than there ever was before. I head up the Strong Tomorrow committee, which brings all of the social ministries together so that we can try to make sure that we're not having those siloed approaches to health care or other needs of young people.
Vaughn Palmer: Jordan Bateman, Canadian Taxpayers Federation, with a question on a topic other than the government's relentless increases in MSP premiums.
Topic: Overuse of Emergency Rooms
Jordan Bateman: “One of the biggest costs in the ever-growing Health budget are unnecessary emergency-room visits: people who go to the emergency room because they have nowhere else to go to get health care. What can we do? Has the time finally come for British Columbia to find a different way of serving these people? What can be done to fix this part of the health-care system?”
Terry Lake: Well, I talked about it earlier: the multidisciplinary primary health-care facility. If you look Oceanside urgent-care centre in Qualicum, that's an example of providing about 90% of what people need — but they know if they have a real emergency, a life-threatening emergency, they're going to have to go to Nanaimo. We can provide a great deal of people's needs in that urgent-care setting so that they don't have to end up in an acute facility like a regional hospital. That's happening already.
When you think about the mental-health issue — because we get a lot of people suffering from mental-health issues that come to emergency — we're doing more to support people in communities. We have Car 87 here in the lower mainland, Car 40 in Kamloops, where you can put a health-care worker with a policeman to respond to those situations on the street that in other situations that person would have ended up in emerg. You can deal with their problem right there and then, and direct them to the right social agency or other need that they might have.
Jordan's right: there are better ways to deal with a lot of people that end up in emergency, and we're working very hard on those types of changes.
Vaughn Palmer: Back to Ian Courtice with another question.
Topic: Technology Challenges within the Health-Care System
Ian Courtice: “One of the problems we have in BC is that we've got five geographical health authorities, and three of them are on one major platform, and two are on another major platform. So those two can talk, and these three sort of maybe will be able to talk — but there's no ability yet for them to all talk to each other. That's something we have to work on, so that wherever you are in the province you should be able to have your health information transferable to another health authority.”
Vaughn Palmer: I think the last time I checked, the government was spending hundreds of millions of dollars on something called e-health. Is that part of it?
Terry Lake: It is part of it. I can tell you it's probably the single most frustrating part for me to understand, because it seems so simple: that you should be able to have your health information — and you should be the owner of your health information, and you should be able to make sure that it follows you around, and that everyone that needs and is appropriate for them to have access would be able to have access.
But as much as I try to dig into this, it is so…. It's a difficult one. The biggest difficulty is around privacy issues — because as soon as something goes wrong with privacy, of course, everyone takes a step back. I think there's so much risk-aversion when it comes to health data that we have allowed that to prevent us from getting to the point where we can access health-care information at the right time, by the right person.
I totally agree with Dr. Courtice. It's something I'm committed to trying to bust through.
Vaughn Palmer: Well, you see, you say people may not believe that this is frustrating — but as someone who three or four times a day would like to throw my computer through the window, I perfectly understand that they're incredibly frustrating. Talking to the IT department, there's no solution most days, either — so I can believe it's expensive and frustrating.
We've got time for a couple more questions. Let's go to David Schreck.
Topic: Medeo Video-Chat Service
David Schreck: “Dr. Lake, the new service Medeo claims that anyone with MSP coverage can consult with one of their doctors over their smartphone or computer. That has to result in increased billings to MSP, and I don't know what it says about quality of medical care. What's the position of your government, and how is that being paid?”
Vaughn Palmer: Is it allowed?
Terry Lake: Yeah, the Medeo service — which is essentially a virtual doctor visit — certainly can bill for that. I've asked our ministry to take a close look at this, because there are some huge opportunities for access and for convenience. I mean, let's face it: we do a lot of things at our desk or our home that before we had to get in our car and travel somewhere to do. I think a follow-up visit with your doctor by a virtual visit is totally appropriate.
There's a concern, of course, I think that you will develop virtual walk-in clinics so that there isn't that continuity of care. We also need to make sure that…. There's privacy issues around the information that is transferred.
This, again, is sort of the leading edge of technology, interfacing with the health-care system. We need to fully understand this and I think work together to take advantage of that opportunity, but make sure we build in the proper safeguards too.
Vaughn Palmer: Now, you've heard the other side, I'm sure, from doctors and nurses, which is the number of patients who research their own medical condition online and arrive at the doctor's office announcing what they have, based on what they've discovered on some website.
Terry Lake: Well, I do that when I go to see my doctor. I basically have a little chat and say, “I think I've got this kind of a thing. What do you think?” Of course, as a veterinarian in my practice, people did that to me all the time.
But I think informed patients are the best patients. I don't think physicians these days — nurse-practitioners and physicians — really are concerned about that. It opens up the dialogue, and no one is threatened by that anymore like they used to be. But there's a lot of misinformation on the Internet, as well.
Vaughn Palmer: I'll say. Let's go — we've got time for one more question, and we have a former Health Minister to ask it, George Abbott.
Topic: Did the Government Move too Quickly on Seniors' Care?
George Abbott: “Overall, in terms of the record of the provincial government from 2001 through to the present, the one area where I think we moved rather more quickly than we should have was in terms of seniors' care. I think there were some pretty dramatic changes made in the early 2000s which, in retrospect, it might have been far better in lots of ways to pace that out more.”
Vaughn Palmer: Fair criticism?
Terry Lake: Well, first of all, I want to give George credit. He's the one who started bending the health-care curve downwards, and we're seeing a lot of his work pay off now.
Vaughn Palmer: And Margaret MacDiarmid, who followed him, too.
Terry Lake: Well, Mike de Jong and Colin Hansen, Margaret MacDiarmid — all of them did a lot to help us today.
In seniors' care, what we have now is…. If you look at long-term residential-care homes, they are like five-star hotels. I think what George is referring to is that we probably need more of a continuum of options for looking after people that need some level of assistance. Right now it's either independent living, assisted living, or complex care. I think there probably needs to be a little more of a continuum, because not everyone will fit nicely into those two slots.
Vaughn Palmer: Okay, so are you moving on that?
Terry Lake: Well, it's something that…. We will be announcing our seniors' advocate soon, and that's something that I hope that the seniors' advocate will be working on. We're working with the seniors' community — the home-care providers — on this type of issue.
Topic: New Nurse-Practitioner Legislation
Vaughn Palmer: We had legislation introduced in the House this week which had been talked about before, which is really to give…. Maybe one way of putting it is to give nurse-practitioners something to do, but the other is to integrate them more into the system. I notice you've got a whole bunch of places now where what only doctors could do before, now nurse-practitioners can do as well.
First of all, are the nurse-practitioners being integrated into the system in sufficient numbers, in your mind? And are the doctors accepting their presence in the system?
Terry Lake: Well, I think there was some initial resistance on the part of physicians. I think that's changing. We have about 270 nurse-practitioners around the province, compared to about 10,000 doctors — so they're still a relatively small portion of primary-care practitioners.
But through our Nurse-Practitioners for BC program we have provided funds for health authorities to incorporate nurse-practitioners into primary care, and that's met with great success. We have another round of that coming up. So I do believe they are part of the solution.
Vaughn Palmer: Thank you very much to Health Minister Terry Lake; I appreciate you being on the show.
Next week on the show, Jim Iker, BCTF; lots to talk about there. Thank you for watching Voice of BC, bringing the Legislature and BC politics into your living room. Good night.
Dr. Scott MacDonald, Providence Crosstown Clinic