At the Biennial Convention and Annual General Meeting of the Canadian Nurses Association

Speaking Notes
for
Allan Rock
Minister of Health

Ottawa, June 15, 1998

Check against delivery

Thank you, Rachel. Thank you for your kind words of introduction and thank you, ladies and gentlemen, for your warm welcome.

On behalf of the Prime Minister and the Government of Canada, I want to convey our congratulations to this great association, the Canadian Nurses Association, on the occasion of your 90^th anniversary and also to express warmest best wishes for success during this, your annual meeting and biennial convention.

Before beginning my formal remarks this morning, I thought I would make reference to three items that I jotted down while reading some material in preparation for coming. I believe they provide some perspective and perhaps a good starting point.

The first is a 1995 survey in which Canadians were asked who they trust on health issues. Well, the results were very compelling. Seventy-five per cent, by far the most, said they would believe a nurse. Fifty-five per cent, 20 per cent fewer, said they would believe a physician. Nine per cent said they would believe a Minister of Health. I guess that says a lot about our respective reputations. But one of the questions that has to leap to your minds is, who on earth are those nine per cent?

The second item is a quote that appears in a short history of nursing, published by your Association. The quote is from the London Times of 1857 and it describes the then-status of nurses. I quote: "They are sworn at by surgeons, grumbled at by the patients, insulted if old and talked flippantly to if middle-aged and good-humoured."

To that, you must say: "Plus ça change, plus c'est la même chose."

Finally, as I consider the past weeks and months which have not been the most joyous of my public career, I was struck by the slogan that the Association has developed as part of its effort to attract people to your profession. According to the slogan: "No one ever said it was going to be easy, just worth it."

Well, I will take that to heart and hope the second part comes true.

The recent past has indeed been difficult for me and for others as we have grappled with the issue of who should receive cash in addition to care as a result of contracting hepatitis C through the blood system. The issue has been complex and it has been wrenching.

From the day I assumed this portfolio just over a year ago, I was convinced of the need, indeed the obligation to resolve the claims of those who were infected during a time when those responsible could have acted and did not. And, as a result, I initiated a federal-provincial process which arrived at an early agreement.

Today, although no one can be happy with the delay and the difficulties, a new process is underway, working toward a fresh national consensus.

I strongly believe that it is in the interest of everyone to have governments act together rather than unilaterally. That was my view at the beginning and it's my view today.

I am confident that we can find a solution acceptable to all governments that will deal fairly and compassionately with the interests of all of those infected with hepatitis C through the blood system.

With that said, let me turn to the business of this meeting.

For 90 years, you have come together in common cause, "to advance the quality of nursing in the interest of all Canadians." Through good times and bad, you have done so in an exemplary fashion. As the largest group, by far, of health care providers in this country, you deserve recognition, gratitude and support for the fine work you do -- together as an association, collectively as a profession, and individually as registered nurses. Today, I salute you.

You know, I realized in preparing for this morning that it has not historically been a firm tradition for the federal Minister of Health to appear at your meetings. Yet, it is a tradition, for example, that he or she be present at the annual meeting of the Canadian Medical Association.

And speaking personally, I believe it is high time for a parallel tradition to be established with the Canadian Nurses Association. So if you will have me, let me undertake today to do everything within my power to make myself available at your gatherings in the future. It will be an honour to participate in the creation of such a new tradition, to allow me an opportunity every year to report to you on the state of affairs in my Department and to make Health Canada and the Minister of Health accountable to your annual meeting in session.

One of the obvious reasons that this association has flourished for almost a century now is the quality of its leadership and I want to take this opportunity to publicly express my appreciation for the work done by your outgoing President, Rachel Bard. With a voice as clear as her vision, she has shown vigorous leadership in expressing the policies and perspectives of your Association on important issues of health care reform and the need to show proper respect to your profession within the health care system in Canada.

I want to thank you, Rachel, for all the work you have done and congratulate you on your success. Thank you.

In the same spirit, let me extend every good wish to Linda Kushnir Pekrul who, at this Biennium, will begin her important work as your new President. Supported by the strong team she will have behind her, I am confident of her success in meeting the challenges that lie ahead -- and I look forward to working closely with her in the coming months.

Today, I would like to address three connected issues, if I may. First, the current state of health care in Canada; second, the road forward towards renewing health care; and, third, the pivotal role of Canada's registered nurses in ensuring the success of that effort.

Let me begin by acknowledging some hard truths. I think it is best to be blunt.

No professional group has borne the brunt of health care restructuring more than have Canada's nurses.

That burden has been the more difficult to bear because of the degree to which nurses have been excluded from the process of restructuring and reform. While others have been at the table, you have too often been left outside the room.

You have seen widespread lay-offs. Those who remain face increased workloads. Too many have had to cobble together a series of part-time assignments just to forge a career, to support themselves and their families. And just as sad as the loss of job security, has been the diminished job satisfaction as it becomes harder and harder to feel like a valued member of the team when your work does not seem valued and when your teams have been disbanded.

If nurses are unhappy about the present and anxious about the future of medical care, those same feelings are found among your patients and the public.

Canadians cherish medicare because to us, it is about more than just hospitals and healing. It is about values. It is about being Canadian. And Canadians worry about our treasured health care system slipping away.

We worry about waiting lists.

We worry about the morale of the health care professionals that we see when we visit a hospital or an office.

We worry about shortages in the supply of physicians and nurses.

We worry about getting access to the highest possible quality of care when it is needed for ourselves, or our families.

Now I know that registered nurses do not need to be told about the reality of that concern. You see it in the patients you care for, in the families you counsel, in the communities you serve. You see it in wards that are too often overcrowded, under-staffed, among families being conscripted to give home care when sometimes they cannot. You see it in the gap that too often exists between the rhetoric of integrated services and the reality that falls far short.

So how do we alleviate that anxiety? How do we restore confidence and rebuild faith?

Well, I think we can look upon medicare as the result of a bargain between the Canadian people and their governments and the terms of the bargain are not very complicated. In fact, they are rather simple. Canadians are prepared to continue supporting a publicly-funded single-payer system of health care in Canada so long as they can be assured that it will provide the highest possible quality of care as and when it is needed.

But if they feel that it won't, then they will, to that extent, withdraw their support for medicare, and the pressure for a parallel private system will grow until it becomes irresistible.

So we must preserve the bargain. And what is it governments can do to achieve that? More specifically, how can the Government of Canada make sure that it keeps its end of the bargain?

Well, first and most fundamentally, we must assure an adequate level of financing from the federal government to the provinces for health care and health services.

That's why, following on the recommendations of the National Forum on Health, we have established a cash floor for transfers to the provinces and territories of $12.5 billion.

That's why the Prime Minister has committed that 50 per cent of all future surpluses will go to reinvesting in social programs, including health care.

And it's why we have been very forthright in saying that if and when a common will develops -- and when the homework is done -- whether on national approaches to pharmacare or home care, we, the federal government, will respect our promise in concrete terms.

The second thing that the Government of Canada can do to keep its end of the bargain is to demonstrate leadership in the renewal and strengthening of medicare. And that is why, after consulting with knowledgeable persons and organizations, including the Canadian Nurses Association, we asked our provincial partners to agree on a short list of key priorities for the reform of health care. We then set aside $150 million to create the Health Transition Fund. The fund is to be spent this year and next in developing ideas for reform and changes in practices through pilot projects.

Now some of those pilot projects are actually widespread test runs of new ways of providing care, with exciting implications for both the scope and the pace of health care reform.

The four key areas where this money is being spent -- and these lessons are being learned on the ground -- are the following: first, primary care reform; second, a better integration of health services; third, home care and, last, pharmacare.

The first two, of course, are closely related. One of the essential ways to improve primary care is to deliver it with integrated services.

And so, we are testing throughout the country, strategies for bringing health care providers together in one place, working toward one purpose -- better patient care. We are looking at new ways of paying for services. We are having patients and problems dealt with by the person, regardless of title, whose training is most appropriate to the task.

As I have travelled throughout Canada during this past year, I have been encouraged to see successful models of reformed primary care with integrated services offered in clinics, co-ops, and community health centres where teams of providers worked together in a coordinated way, doctors and nurse practitioners, nurses, nutritionists, therapists, counsellors, pharmacists, each a valued partner, each with a vital role to play in a holistic and seamless response to the public's needs.

Integration is needed across the spectrum -- linking hospital care to home care; physical care to mental care; prevention to the treatment of illness; primary care to acute care to continuing care. We need integration across service providers and we need integration that brings planning together with implementation, management and evaluation.

The third priority in health reform is home and community care.

I was delighted to see such a strong representation from this association at the national conference we convened in Halifax in March of this year. The home and the community have become our focus of attention in health care reform because more and more care is delivered in those settings.

When the Canada Health Act was written, the focus of care was the hospital and care provided by doctors. But since 1991, there has been a 23 per cent reduction in the number of hospital beds in this country.

New treatments, new techniques and practices and the pressure of cost means that even when admission is necessary, patients are spending fewer days in hospital. The aging population means that the frail elderly require care in a less expensive and more desirable way in the community. When you add the needs of those who are chronically ill or disabled, there is a very significant demand for home and community care.

But in much of Canada, there is no community care infrastructure to deal with this demand, and even where it exists, there are real issues in terms of cost and coverage, training for workers and standards of care.

The result has been that the burden, too often, falls on the family and disproportionately, upon women. Statistics show that one in five Canadian women between the ages of 30 and 55 is engaged at present in the care of someone in the home who is either chronically ill, or disabled. Those women spend an average of 28 hours per week engaged in that informal, but exacting care. About half of them also work outside the home. Many of them have children of their own and the combined effect of these responsibilities is taking an immeasurable toll on their own health. We all know someone who is living and working in those difficult circumstances.

Well, it is time we decided that the coverage for health insurance should follow care, not be limited to place. That is why in the home and community care initiative, we are looking at the prospect of extending public insurance coverage to essential services that must now be provided in the home and the community.

Based upon the good start we made in Halifax with our national conference, we are examining issues like definition and coverage, the proper role of registered nurses and the delivery and adminstration of home and community care, the training of workers, the standards of care, and ways to ensure that cost is not a barrier to these necessary services.

The fourth area is pharmacare. That is to say, ensuring that medicines that are necessary are available without cost standing in the way.

Again, we had a national conference in Saskatoon in January with this association well represented. And our cross-Canada survey of pharmacare coverage, revealed a patchwork.

We emphasized that while drugs are freely available so long as the patients are staying in hospital, as soon as they are discharged, the question of cost and coverage becomes very clouded.

And the fact that one has to pay for drugs when receiving care at home but not in the hospital is clearly not in keeping with the trend toward greater community care.

And even where coverage is available, we learned that in some areas, deductibles and co-payments mean patients sometimes cannot afford the drugs they need, or must choose between food, or rent and their pharmaceutical products.

And among the many interests represented at the national conference on pharmacare in January, there was, I believe, a consensus that pharmacare is a worthy national goal, that we must work now on a critical path in order to get there and take the time and do the homework and collaborate to the extent necessary to succeed.

Now there are many other areas where we must work quickly to manage change in health care so that governments can keep their end of the bargain and restore the confidence of the public in health care in Canada.

One area which forces us to think about the future is health human resources. What will our needs be in terms of health human resources and how will they be met? Are we doing enough now in terms of research, and training and preparation of the health care providers and professionals we will need to maintain the standards of quality and care we want?

Another is information technology. The question we asked at our national conference in Edmonton, is how can we manage what we do not measure and why can we not integrate the various information systems that are already in place in this country to provide a coherent national database on which to predicate our research, our administration, and the making of policy and evidence-based decision-making in every aspect of the health care system?

A third is the need to establish standards of quality.

When the Canada Health Act was written, it contained those five principles of which we are so proud. None of those principles included quality because, I assume, that at the time, quality was taken for granted.

The experience over the last 15 years has shown that that is not always a safe assumption, and more and more often we must turn our attention to the issue of how do we maintain standards of quality in health care in Canada -- through encouraging the development of clinical practice guidelines and their adoption on a standard basis throughout the country, by introducing elements of accountability for institutions, by looking at the practice in other countries and seeing what we can learn from them, by creating a national council, directly involving consumers, to look at the performance of our health care sector, to give it a grade and to identify areas where there are weaknesses and where further work is required.

Finally, but by no means least important, we must make health promotion and the prevention of illness true national priorities.

Strengthening quality care addresses the supply side of the equation. But strengthening our focus on health will address the demand side.

This requires a focus on the determinants of health that we all know exist, whether they are social, economic, or environmental.

Which leads directly to our concern about Canada's children. Focusing on children is, of course, the best health investment we can make. You call it "let's get back to basics" and, of course, we must.

On Thursday of this week, I am joining my colleague Pierre Pettigrew, the Minister of Human Resources Development and together, we are convening a meeting of the Ministerial Council with provincial ministers from across the country to look at the next steps in developing Canada's National Children's Agenda. The adoption of the Canada Child Tax Credit was a good first step on the income side. We must now look at the services and program side to see what else governments can do together to address the urgent agenda of intervention in the early years -- zero to six -- for Canada's children.

We will need your help and advice in that process, and coming out of Thursday, I believe there will be a process that will involve consultations directly with those who could help us develop that agenda and among the first of them, I assure you will be the Canadian Nurses' Association.

Madam President, let me turn now, if I might, to more specific issues -- that is the role of registered nurses in my Department, and the relationship between this Association and Health Canada and the possibility of even closer cooperation in the future.

I have been deeply impressed by the degree to which registered nurses are involved in the ongoing work of Health Canada. They are there as nursing consultants, advising on issues directly related to your expertise and your profession.

They are in every branch, trained as nurses, but now working as planners, researchers and managers across the full spectrum of services provided by our department.

And they are there, as well, in the field. Some 600 nurses providing services in remote locations to First Nations communities, taking on a range of responsibilities, almost always in very difficult circumstances.

Day by day, these nurses perform their duties in an exemplary manner, sometimes in a heroic manner.

You may recall hearing of the actions of the nurses of the Little Grand Rapids and Pauingassi Nursing Stations in Manitoba, following the tragic plane crash there last December.

Working alone, without physicians at the site, they provided the kind of emergency care that was, well, extraordinary testimony to the commitment and professionalism of our Medical Services Branch nurses, a dedication to client and community that is shown daily across this country.

I understand profoundly the critical importance of the nurses' role on questions of policy, not only the invaluable work you do, but the contribution you make to developing policy as to changes in health care. I want to strengthen that policy focus still further.

Let me stress that my purpose here is not to supplant or replace existing lines of communication and cooperation, but rather to supplement and reinforce them.

I am happy to tell you that I am going to be creating within my Department the position of Executive Director of Nursing Policy and what I would like to do is to have the functions and responsibilities of that position reflect the advice of this Association and others in the nursing profession.

I have already communicated in writing with your Executive and with other interested parties, and I have received very helpful advice on the shape and format of this new position. I now propose that we form a working group to arrive together over the next few weeks at a mutual agreement as to the terms of reference of this new office.

I want to emphasize that I do not regard the Executive Director of Nursing Policy as a figure-head position. I regard it as an opportunity to place nursing and nurses' perspectives at the forefront of deliberations on health care renewal in all areas of policy, including, but not limited to, home and community care.

After all, as the title of this conference advertises, nursing is the key. Speaking for myself, I recognize it is simply not possible to contemplate effective models of primary health care that do not include an enhanced role for nurses. It is simply not possible to move forward on innovations like home and community care without nurses being an integral part of the planning.

We will not develop practical and useful ways to use health information systems without your involvement. And whether it is issues of rural and remote service delivery, or prevention and health promotion, you must be essential partners if we are going to progress.

Through the Executive Director of Nursing Policy, I want to develop in partnership with you, practical strategies for dealing with human resource issues in nursing, the looming shortage of nurses in this country and the lack of opportunities for full-time and fulfilling employment because, the fact is, the country needs nurses now more than ever. You are, you always have been, at the core of care.

When I was reading about the superb work done by registered nurses in Manitoba last year after the plane crash, I was struck by the words of one of those brave individuals, nurse Susan Smith.

When she was asked why things worked out so well, notwithstanding the very difficult circumstances in which the injuries had to be dealt with, she said: "It only worked because we all worked together."

In future years, I believe that we will be able to look back with satisfaction upon this difficult period of transition in health care in Canada, at the way we met the challenges that face us now, and I believe that we will succeed because we are going to work together.

For over 350 years, since the moment that Jeanne Mance set foot in this land, nurses have been caring for this country and now more than ever, it is time for the country to show how much it cares for nurses.

And so I thank you for having involved me in your itinerary for this busy and important conference.

I look forward to working with you in partnership, toward common goals and I congratulate you on the fine work that you do every day in Canada.

Thank you very much.