On Friday I had the distinct honour of addressing the Canadian Association of Physician Assistants at their 2018 CAPA Annual Conference held at the Victoria Conference Centre (October 18-21).

Physician assistants are highly skilled medical professionals that work as part of health care teams to offer primary care to patients. As noted by the Conference Board of Canada, physician assistants are “a largely untapped resource that can help governments continue to provide high levels of service while reducing overall system costs”. Unfortunately, in British Columbia physician assistants are not a regulated profession.

Doctors of BC (formerly known as the BC Medical Association) is the organization that represents British Columbia’s physicians. In 2013, they issued a policy statement supporting the “establishment and deployment of physician assistants (PAs) in British Columbia.”

In particular, their policy statement recommended:

• physician assistants be recognized by the provincial government as a regulated profession, with regulatory oversight by the College of Physicians and Surgeons of British Columbia.
• Accessible, affordable, and adequate liability coverage be made available to and required of all physician assistants.
• The provincial government explore stable funding options for physician assistants.

The BC Green Party is committed to working towards the development of a community- and team-based approach to health care delivery in British Columbia. Physician assistants have an important role to play and we look forward to working with them in the weeks, months and years ahead.

Below I reproduce the text of my speech.

Text of Speech

Thank you for providing me with the opportunity to speak at the 19th Annual CAPA Conference.

Conversations about our healthcare system are more important than they have ever been. Our healthcare system was designed over 50 years ago and since that time we have seen significant changes in the demographic makeup of our country.

Since 1966, when the federal government passed the Medical Care Act, we’ve seen our population swell by over 10 million people. Canadians are living longer, and there are more of us entering the second half of our lives.

I don’t want to understate the challenge that these demographic changes will present to our healthcare system – or how other challenges further complicate this, especially in BC.

Just a few weeks ago our country’s new Parliamentary Budget Officer Yves Giroux put a spotlight on the demographic and budgetary challenges facing our healthcare system.

Mr. Giroux raised concerns that across numerous provinces the rising health care costs associated with Canada’s swelling population of seniors was putting significant strain on debt levels in a number of provinces.

He cited the increase in the senior dependency ratio – the rate of individuals 65 years or older relative to the population between 15-64 years of age. Nationally we will see it go from 25.2% in 2017 to 45.6% in 2092.

During my first term in office, I wrote about the challenges with the Canada Health Transfer – noting that BC has a higher proportion of seniors than the rest of Canada. Because it is an age demographic that requires more health services, I suggested the funding we receive should reflect the actual cost of services delivered.

As you well know, the federal Canada Health Act sets the standards for all provinces and requires coverage for all necessary care provided in hospitals and by physicians. But health care is ultimately the responsibility of the province.

So far, British Columbia has done a good job of managing the increase in health care spending compared to most other provinces.

While BC will see among the highest population growth in the country, we are second only to Quebec in terms of sustainable fiscal policy. This is despite the fact that BC is a retirement destination for many Canadians. It is common practice for individuals who have lived and worked – and therefore paid taxes – elsewhere, to move to BC later in life.

While this is certainly the largest healthcare challenge facing the provincial government from a financial point of view, the number one challenge currently facing British Columbians is the lack of family doctors.

I started my work on this file a few years ago with a policy review of how Canada has maintained and manipulated its doctor supply.

While there are no doubt countless contributing factors that influence doctor shortages, a few major policy changes shifted our course towards one critically deficient in family physicians.

In 1961, the average medical ratio in BC was 758 patients for each doctor. Much like today, however, the rural-urban distribution of doctors was uneven. In rural areas the ratio was much higher, at 1,229 patients per doctor, and 73.6% of the province’s physicians were concentrated in Vancouver and Victoria.

Sensing problems ahead, the federal Royal Commission on Health Services (who outlined the foundation for Canada’s universal medicare system) analyzed the medical workforce statistics and predicted an overall shortage of doctors by the 1970’s. Along with increasing med-student intake at universities across the country, the report recommended the establishment of at least four additional medical schools to meet the needs of a growing population. Their shortage projections extended until 1991.

When 1991 arrived, however, the perceived supply of doctors did a rapid reversal. A report presented to the Federal/Provincial/Territorial Conference of Deputy Ministers of Health by Barer and Stoddart cautioned that we were, in fact, heading towards a doctor surplus. Public policy shifted accordingly and drastic changes were made to the way physicians were trained and licensed in Canada.

In BC, the government introduced a combination of incentives and penalties in the hopes of shifting more doctors away from city centers and into remote areas. By 1993, travel assistance, isolation allowance, and subsidized, salaried positions were offered to doctors willing to move to more rural locations. At the same time, the government tried to manage doctors as they prepared to enter or exit the workforce. Young doctors looking to set up practices in areas deemed “oversupplied” were met with a 50 per cent reduction in their fee-for-service rate. This penalty only lasted a few years though, as it was challenged by physicians and the Professional Association of Residents of British Columbia and in 1997 ruled unconstitutional by the BC Supreme Court. The Court deemed the fee penalty imposed on urban doctors as a violation of the Canadian Charter of Rights and Freedoms guaranteed mobility and equity clause, as well as a breach of Canada Health Act’s requirement for reasonable compensation for insured services. Mandatory retirement caps set at 75 year were removed as well, following a legal challenge by the Senior Physician Society of BC.

A few years later, however, opinions had shifted yet again and the public and policy makers were back to being worried about a serious national doctor shortage. Incredibly, within a span of a decade the believed supply of doctors had done another complete reversal.

Five years after the BC government was taken to court for reducing urban doctors billing rates they were back to offering generous financial incentives. At the start of 2016, we found ourselves once again repeating history offering doctors a patchwork of financial incentives in an attempt to meet the province’s growing medical needs.

During their term, the previous government repeatedly vowed to end the doctor shortage. In February of 2013 they put $132.4 million into their ‘A GP for Me’ program and said it would ensure everyone would have a family physician by 2015.

Since then, the proportion of British Columbians without access a regular doctor has increased from 26% of the population in 2013 to 30% in 2017.

Given this province’s complicated history with doctor shortages, what I found most concerning about Liberal’s promise was not that they failed – One only has to look back at the struggles Canada has had maintaining an appropriate number of GPs to know this was never something that could be fixed in two years.

What is most concerning is that we failed to learn from the past and didn’t work to put the province on a path to systematically addressing the crisis over time.

We all know it can be incredibly challenging to address the structural limitations in our healthcare system, and that band aid solutions are not going to get us anywhere.

Healthcare is around 40% of our provincial budget every year. Throwing a little bit more money at it won’t be the solution either.

What I like to think makes the BC Green Party unique is that we are not afraid of change, and that even in opposition we try to take the challenges we face as a province, and find solutions and opportunities for new ideas to take hold.

So the truth is, I relish the opportunity to be here to speak with you. I think we need to be having a lot more conversations about health care in our country – how its funded, how our citizens access it, and how it is delivered.

This is why the BC Greens have been taking a hard look at two linked policy changes that could strike at the root at both the problem of long term affordability and the challenge of finding a family doctor: creating a larger emphasis on prevention, and using community based health care teams to help deliver the services British Columbians count on.

In our 2017 election platform, we put forward the idea of establishing a Ministry that is responsible for health promotion and disease prevention. I believe this is one of the most critical things we can do to mitigate long term health care costs.

Similarly, the Confidence and Supply Agreement established as a joint principle between us and the government the expansion of team-based health care, including the services of a variety of healthcare professionals. Such an approach, if done thoughtfully, can help lessen the crunch to find a GP, and actually increase the services that British Columbians receive.

I think the Canadian Medical Association captured it well in their 2017 report on the federal/provincial/territorial health accord where they argued:

“Canadians deserve a health system that starts with the patient at the centre. Such a system provides quality services in a timely, safe, effective, evidence-informed way that respects individual choice and that is actively supported by all involved in the healthcare system. To improve the patient experience, systems of services must be integrated so that professionals providing health promotion and protection, disease prevention, assessment, diagnosis and treatment, palliation… work in concert across home, community and hospital settings.”

It is within this framework that physician assistants play a critical role. Last year’s report from the Conference Board of Canada stated, physician assistants are “a largely untapped resource that can help governments continue to provide high levels of service while reducing overall system costs”.

The BC Green Party is committed to working towards the development of a community- and team-based approach to health care delivery in British Columbia. Physician assistants have an important role to play and we look forward to working with you in the weeks, months and years ahead.