National Home Care Conference

Speaking Notes
for
Allan Rock
Minister of Health

Halifax, March 9, 1998

Check against delivery

Canada's health care system is a major concern among Canadians, and the pictures we have seen on the nightly news have not been comforting. Canadians have always assumed that medical services would be there for them when they are needed, but based on what they are seeing, many Canadians are questioning that assumption.

There is no more vital social policy challenge facing us today than to restore the confidence of Canadians in health care. We cannot simply dismiss or try to argue away the fear that is felt because that fear threatens what I believe to be a fundamental bargain between Canadians and their government.

The terms of that bargain are not very complicated. In fact, they are very simple.

Canadians, in very high numbers, are prepared to continue to support Canada's one-tier publicly financed health care system as long as they are assured that health care of the highest possible quality will be there, for them and for their families, when it is needed. And, if they do not feel that way, then their support will slip away. We cannot let that happen.

Medicare is not only a social asset of unique value, it is also an economic asset and an enormous competitive advantage for this country. Simply stated, no other approach to public health insurance comes close in terms of cost-effectiveness and social equity.

So how do governments keep their end of the bargain? How does the federal government meet its responsibilities in relation to health care?

We know that it will take a lot more than just rhetoric to do the job. One of our duties is to see to it that medicare is brought up to date, that coverage is reviewed to take into account changes in social circumstances, medical practices and current needs. That is why during the past few months we convened three national conferences, on pharmacare, information technology in the health sector and today on home and community care.

This is the last of three national conferences being convened through the Health Transition Fund. Momentum has been building since the Saskatoon conference on pharmacare and the Edmonton conference on health information, and I expect that this one will contribute in the same way.

These national conferences are about exploring new ground, canvassing new options and developing new strategies. They are about bringing public health policy in line with the modern practice of health care. And they are about free-ranging exchanges, without the constraints of traditional thinking.

I believe that we are discussing today the most urgent element of modernizing and enhancing medicare.

Home and community care has become the focus of concern and attention for a number of reasons. The need is growing, but the capacity to handle that need has not yet developed.

Why has the need grown? First because of changes in health care itself. Hospital stays are shorter. New drug treatments have replaced surgery or made recovery times for surgery much faster. When medicare was developed, our focus was on doctors and on hospitals. Even today, when most people think about health care, that is the context in which they see treatment being given. But the fact is, today's health care is not confined within the walls of hospitals or doctors' offices, so surely our focus should be on meeting patient needs for high quality care, not on the building in which those needs are met.

It makes little sense for example to guarantee public coverage for medically necessary services that are provided in hospitals but to provide only partial coverage or no coverage at all when those same services are provided in the community or in the home.

The second factor that makes this subject urgent is that restructuring in the health sector has seen hospitals closed at a pace that has been faster than the organization and putting in place of the infrastructure for home and community care. The result has been an unmet demand.

A third factor is demographics. If it is difficult to manage today's need for care of those who are elderly and unwell, it is only going to become more urgent as the population ages. With baby boomers now in their early 50s, demands will only increase.

What do we see as we look across the country to survey the state of home and community care today? At best it is a patchwork -- and I say that not to be critical or to pass judgement, but simply to describe the state of facts as we find them. Provinces are at different stages of development in home and community care. They approach the task in different ways. They emphasize varied priorities.

I do want to say that here in Nova Scotia, under the leadership of Dr. Jim Smith and the present government, real strides have been made in providing home and community care in communities where it is needed. I salute Jim and his team for the work that they have done.

But as we look across the country, we see a mixture of long term, acute and preventive care services. We see some not-for-profit providers, some public sector involvement and also some commercial and private interests at work. We see that some places administer province-wide projects while others turn authority over to regions to make decisions about delivering home care services. Those regions also sometimes offer a choice of services to be provided.

We sometimes see different criteria being applied to decide what services a client needs, different health providers for different services and various approaches in determining how much the client should pay. We also see significant private delivery of services.

While public spending -- principally through provinces and territories -- on home and community care has doubled in the last 7 years, the total of public spending on home care is still only 4 per cent of all public expenditures in the health care sector.

Now when I describe what is going on in the provinces, I am in no position to preach. As Minister of Health, I am responsible for the Medical Services Branch in my department and while we provide excellent services, we have a long way to go before we meet our responsibility of furnishing home and community care on reserves in First Nations and Inuit communities.

We are at work devising ways to better meet our responsibilities in that regard. But simply stated, if you look across the country, you are tempted to think that the state of home and community care today is in much the same position as medical care was before the Canada Health Act, or medicare.

I believe the time has come to bring a national perspective to home care.

To do that, Canadians rightly expect us to work together: governments, providers, professionals, business, labour -- and the public. And while Canadians are aware of the reality of jurisdiction, of separate needs and responsibilities, they see that as a reason for us to work together, not an excuse to stand apart. And if we need to motivate ourselves, we need only think about the burden that the present system places on individuals and on families.

I have had my own personal experience in the last few years. Both of my parents died at home, my mother in 1994 and my father in 1995. I saw for myself -- as my sisters and I tried to find out what services were available to help us -- which services were covered by public insurance, which by private and some not at all. I saw how difficult it is for people to find out what help they can get, how it can be arranged and how very much effort is required simply to understand the current system.

Our research shows that 80 per cent of home care is delivered by an informal caregiver in the home in Canada, and much of this burden falls upon women. Today, 1 in 5 Canadian women between the ages of 30 and 55 is engaged in looking after someone in the home who is either chronically ill or disabled. They spend an average of about 28 hours a week in that work. About half of those women also work outside the home, and many of them have children. The combined burden of those responsibilities is increasingly taking a toll on the health of those women. I am not suggesting for a moment that the state can or should move in and take over family responsibilities or replace community kindness. Canadians are always going to be willing to care for friends and for family. But without a reliable foundation of professional support, those responsibilities are increasingly going to take a toll on health. Stress is often at unbearable levels and despite exhaustion, career sacrifices and financial hardships, studies tell us that many caregivers experience guilt about not doing more. This situation is unfair to everyone and it is only going to get worse.

So while we cannot and should not aspire to substitute public programs for all the personal and community caring and support that exists today, let us strive for a balanced system in which personal contributions are made willingly, where generosity flourishes, together with a strong base of coordinated services.

There are some who would say to me, with the urgent needs in so many other parts of the medical system, with the demand in the acute care sector, with waiting lists and line ups, why are you bothering to talk about add-ons, or extras, or frills like home care, when you should be focusing on core medicare services. Well, I disagree.

Home care is not an add-on. It is an integral part of the health care system and unless we fix it, it will have effects in other parts of the health care system that will be very difficult to manage.

There is a direct connection between the need for home and community care and the pressures now being felt in the acute care sector. Indeed, I go so far as to say that home care is fundamental to saving medicare.

We are all aware that pressures on the current system are enormous, with many hospitals bursting at the seams and some emergency wards overwhelmed.

Take the example of the emergency room crises that have arisen across the country in recent weeks. In many cases patients languish on gurneys in corridors when it is impossible to admit them to short-term care beds. But the reason is often that those beds are occupied by patients who could be better looked after in community care or at home.

I am referring to an incident last week in Winnipeg. The newspapers carried a story about the emergency room, a very familiar story of patients lined up, beds not being available, of gurneys in corridors. A hospital official was quoted as saying the reason for the backup in the emergency ward was that acute care beds upstairs on another floor were not available.

About 200 beds were taken up by people who could be moved into community care or home care, but capacity could not allow that to happen. If those patients could be moved to community or home care, those beds would be available for the people in the emergency room, taking the pressure off the hospital. So there is a direct connection between our initiatives in home and community care and resolving many of the urgent pressures in the acute care sector. That is not the only answer. There are other challenges as well but it is part of addressing that problem.

So a strategy to establish a sound foundation of home and community care services together with primary care reform as a better approach to integrating medical services can both save money and deliver improved services across the country.

I am also asked sometimes about whether the federal government will succeed in achieving its agenda on home care, whether the provinces will permit Ottawa to do what it wants and whether the federal government will ever get its home care agenda past the provinces.

Well, hold on one minute. The need for progress in the development of home and community care in Canada is not a narrow federal government demand, it is an urgent Canadian need -- a public need. The Government of Canada's decision to make home and community care one of its priorities is not at odds with provincial priorities. Indeed, I believe that progress in home care is vital if provincial priorities are to be met because those priorities are better quality service -- better integrated, less costly and more effective service. Home care, I believe, is very much part of achieving those priorities.

So where do we go from here?

This conference marks a very important step in creating collaboration among the many interests represented here at this conference. All of us, governments, health providers, administrators and consumers must take on this challenge together as the next great step in the development of Canadian public health.

I would like to see this conference used as the starting point for the development of a coherent national approach to home and community care. And I want to emphasize that I am not here talking about a cookie cutter approach that has identical services in each community across the country, in accordance with the mandate and plan.

Different approaches should be encouraged to permit innovation and improvement. However, we need some common principles and basic definitions, and we should proceed on a shared premise as to what Canadians are entitled to under public health insurance coverage when it comes to care outside the hospital.

Perhaps the first great challenge is to come to grips with the very definition of what we mean by home and community care. It surely must mean something more than just post-acute care, although that is the example that most readily springs to mind.

We must also consider the acute shortage of long term care facilities. We must think in terms of interventions that maintain the independence of seniors, putting off the day when they give up the dignity of their own home to go into a less satisfactory and much more expensive long-term care facility.

We must think in terms of respite for caregivers who are responsible for a child with a serious disability or a partner who is suffering from Alzheimer's disease. We must not forget the need for a consistent and humane approach to palliative care that goes beyond the heroic work of community volunteers, who cannot always be available in the numbers that are required.

So coming to grips with the definition of home and community care is the first great challenge because it will affect so much else of what we have to do. Once we develop a clear idea of what home and community care services should be included in public health insurance, we can then proceed to examine the issues of cost, quality and delivery.

Canadians will support us in these efforts but with one important caveat: the National Forum on Health recommended that these steps be taken but it said this, and I quote: "The public supports care in the home and other forms of community based care but does not react well to being conscripted into care giving". This reservation is understandable.

Many people feel that they are not equipped either financially or emotionally to take on the responsibility of caring for family members. Canadians want reassurance that the appropriate professional support and respite support will also be there for them and their loved ones when it is needed.

And so our challenge at this conference is to ask the key questions, to find the real answers and then to do the right thing. I have high expectations of this conference. I want to use these days to see if we can develop a consensus among the many interests represented here that home and community care is the next most urgent challenge in the modernization of medicare.

For our part, the Government of Canada will fulfil its responsibilities. We will continue working at many of the key issues we are starting to deal with here. I know there are colleagues in caucus here today who are dedicated to that effort. I see Dr. Caroline Bennett from Toronto, Eileen Carroll from Barrie, Lynn Meyers is here as well. We will continue working on these issues in the months ahead.

What are the questions we will turn to? I've mentioned definition, focusing on crucial issues such as the scope and the content of coverage. We should also look at how a home and community care initiative can be used to accelerate other needed changes in health care in Canada such as primary care reforms and better integration of services.

• What should the scope of public coverage be?
• Should it be first dollar coverage for all the services included?
• Should there be some co-payment or deductible?
• Is there any role for private insurance?
• What is the role of the tax system in helping?
• What about the public sector in furnishing home care services as opposed to not for profit or commercial providers?
• What is the best way to recognize the support given by family caregivers?
• How can employers provide a more supportive environment for family caregivers?
• What about training for those who are doing this important work?
• What about timing? Can we phase in some of the initiatives that we decide are worthwhile?
• Can we make an initial down payment by putting in place some infrastructure or hardware?

Last night, Michael Dector provided some thought provoking ideas on many of these questions and the federal government's role at this time. How can we best coordinate and lead this national effort?

Let me close by leaving you with a clear statement of our position on home care. We believe this is indeed the next important stage in the development of health care in Canada.

Canadian values make it desirable, technology makes it possible, skill and dedication of health care workers will enable us to achieve it, demographics and health reform make it necessary. We must make home and community care an integral element of a seamless comprehensive health care system.

In that effort, we will need both wisdom and vision. We will need to pursue what our heart says is right in a way that our head says will work. We will need to see our various jurisdictions and responsibilities not as excuses to stand apart but as reasons to work together. I have every confidence that this conference will provide an important start in that vital work and I thank all of you for taking part today.