Charting the Future Direction of National Microbiological Reference Services in Canada

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Appendix B-Keynote Speaker Presentation Abstracts

Dr. Joseph Losos
Director General, Laboratory Centre for Disease Control

The Laboratory Centre for Disease Control has as its overall mission to be the national centre for identification, investigation, control and prevention of human disease. Generally, Canada has a good track record in public health, however, there are problems of efficiency in technology and communications, as well as jurisdictional issues. As such, there is a need to strengthen the National Public Health Network for optimum vigilance, expert risk assessment, and coordination of prevention and response mechanisms.

The role, position and capacity of LCDC has changed for the better over the past few years. We are now seen as a core business of the Health Protection Branch and fundamental to the evolving role of Health Canada. With that, however, comes the demand for increased responsibility, accountability, and leadership from clients and stakeholders alike.

In the February budget document, the federal government announced the Health Intelligence Network Initiative. Intelligence refers to validated scientific information about diseases and other risks to health and well being that is used for public health intervention, individual and community action, evidence-based decision making, policy formulation and to influence regulatory action. A three year initiative, it is intended to address the "blind spots" or gaps in the existing system, specifically in areas such as infectious diseases, chronic diseases, and respiratory risk of an aging population.

The processes encompassed by the initiative include:

• Active and passive surveillance
• Population based investigations
• National/international research
• National networks of expertise and consensus,

through a multidisciplinary and multijurisdictional approach.

This meeting is one of a series of coordinated sequential, expert, consensus-consultations designed to influence the direction of the change of programs.

Dr. Robert George
Director, Respiratory & Systemic Infection Laboratory, Central Public Health Laboratory, UK

In the United Kingdom, the Public Health Laboratory Service (PHLS) is a network of laboratories spread out across the UK. The Board of the PHLS is funded by the Department of Health and receives £50 million per annum. Access to reference services is essentially on demand and is free, as we are mandated and funded to provide these services. Where we have run into problems is in areas where reference labs are doing diagnostic work-services for which others believe they should be able to charge.

The UK, like Canada, is having to carefully consider how to prepare for the future of reference services-anticipating less and less central funding and seeking alternate funding mechanisms. Until three years ago, PHLS had no established method of priority setting for funding. Now however, needs are assessed based on several criteria including burden of ill health, morbidity, social impact, potential for change, and PHLS added-value.

Prioritization of services is dictated by two main groups which have impact on the Board: the Research and Scientific Strategy Committee (not employed by the PHLS) and the Overview of Infectious and Communicable Diseases Working Group (employed by the PHLS).

The main difference between reference services in England and Canada is that the PHLS is centrally coordinated and controlled, with input into strategy at and from varying levels. This allows the board to dispose of the income received from the government in accordance with perceived priorities.

Dr. Brian Mahy
Director, Division of Viral and Rickettsial Diseases, CDC, USA

The vision for the Centre for Disease Control and Prevention (CDC) is to have healthy people in a healthy world-through prevention.

The CDC is a very large organization with a budget of $2.3 billion (US). The majority of this money is apportioned to individual states in the form of grants, immunization programs, etc., leaving an actual running budget of approximately $400 million.

CDC operates in partnership with the different components of the public health system including the state laboratories and other federal agencies. One of our principle visions for the future, and one that is guiding funding, is the Emerging Infections Report that was issued in 1992, addressing the issues of emerging and re-emerging diseases, and the alarming level of antibiotic resistance.

CDC has a five-year strategic plan with four main goals:

• Surveillance and response.
• Applied research.
• Prevention and control.
• Strengthening the national infrastructure for the public health
• system.

Integral to achieving these goals are the availability of reagents for testing, a knowledgeable and incentivised staff, the ability to develop new testing procedures and techniques through research activities, and, a direct and close line between epidemiology and microbiology activities.

Dr. Fraser Ashton
Director, Bureau of Microbiology, Laboratory Centre for Disease Control

The mission of the Bureau of Microbiology is to be the National Laboratory Centre for the identification, investigation, control and prevention of human disease.

The Bureau structure consists of a network of laboratories including six National Laboratories located in Ottawa and totally supported by federal funds, and the nine National Centres located across the country and supported in partnership with the provinces. The Bureau of Microbiology provides advanced diagnostic reference and investigative laboratory services related to infectious disease to provincial public health laboratories and tertiary care hospitals across Canada. Some proficiency testing programs are delivered to laboratories across Canada, as well as practical, procedure-focused bench training.

Advice with respect to the needs of our clients comes from two advisory committees: the Technical Advisory Committee (TAC) and the TAC Subcommittee. TAC also fulfills a national quality control role through conducting peer reviews of the National Centres.

The 1995/96 operating budget for the Bureau is approximately $1.7 million (CDN), down 15% from 1992/93.

With many international programs organized through the World Health Organization and the Pan American Health Organization, the Bureau provides laboratory health care and service to the international community. It is an international centre of excellence in such areas as enteric pathogens and tuberculosis.

Provincial Perspectives

Dr. Greg Hammond, Chair Reference Centre Subcommittee
Dr. John Smith, Director, B.C. Centre for Disease Control
Dr. Jim Talbot, Director, Provincial Laboratory of Public Health for Northern Alberta
Dr. Helen Demshar, Director, Laboratory Services Branch, Ontario Ministry of Health
Dr. Gilles Delage, Director, Public Health Laboratory, Quebec
Dr. Kevin Forward, Director, Department of Public Health, Nova Scotia
Dr. Robert Martin, President, Association of State & Territorial Public Health Laboratory Directors, USA

Presentations were made by representatives of six provinces, as well as the Association of State & Territorial Public Health Laboratory Directors. (ASTPHLD). Each addressed, at some level, the areas of structure, service and funding for laboratory services in their jurisdiction. Some described only the reference portion of their laboratory system, while others included both the reference and diagnostic testing components. A summary of these presentations follows.

Structure-There was a consistent trend referenced by the group of speakers around the issue of rationalization of laboratory services occurring through consolidation of reference laboratory sites and amalgamation with hospital laboratories. The rationalization message was heard from provinces with a combination of public and private service providers, such as Manitoba and Ontario, and from those with a purely public system.

And, while not all provinces currently have private service providers, many speakers alluded to a definite move towards private and outsourced laboratory services, or at a minimum, a move towards designing service delivery in a more "private-lab" like manner. In Ontario, public/private joint venture initiatives are on the horizon.

From a governance perspective, B.C., Quebec, and Nova Scotia all have in place some form of advisory committee that reports to the Ministry. Manitoba will likely be moving towards this model in the future.

Services-Many of the comments about services shared the common thread of reduction of duplication of services, both within individual provincial systems and the national system as a whole. Across the board, reference services are being eroded by funding cuts, and in some provinces, this has lead to an increase in the quantity of tests being shifted to LCDC. There is also an awareness of a need to plan who will deliver new specialized services-development of proficiency at the provincial level, in multiple jurisdictions, versus development of centralized, national services.

A caution was offered around outsourcing of public health laboratory services, or the creation of a "virtual laboratory," and the potentially negative impact on effective prevention and surveillance this could represent.

Many speakers broached the issue of quality assurance, and while all provinces do not conduct proficiency or quality assurance testing, it is a common area of concern. Some provinces, like Nova Scotia, may pursue accreditation through the U.S. system. There has been a clear need for strategic planning of laboratory services to clearly define the role of public health laboratories, particularly in light of financially driven changes to the health system.

Funding-Funding of public health laboratories has and will continue to be a key issue. Funding levels are decreasing, with Alberta presenting perhaps the most striking picture, with a 50-60% reduction in budget from the previous year. There is limited access to funding outside of public moneys, although research grants are a potential source.

Funding is largely being delivered directly through the Ministries of Health, or from the Ministry through associated hospitals or universities, and may be contractual, block or population-based.

A specific area of concern with respect to financial resources was that the practice of joint funding for acute care and public health services leaves public health in a vulnerable position.

Dr. John Wade
(via video tape)
Deputy Minister, Manitoba Ministry of Health

Manitoba Health has as its mission "To preserve, promote, and protect the health of all Manitobans." This is in tune with the evolution of the Canadian health system, from what was classically a medical care system to a health system with a common purpose of not just preserving but promoting and protecting the health of the public.

Financially, it is clear that the federal government is moving away from its original 50/50 sharing arrangement with the provinces in terms of health. It is anticipated that there will be a substantial reduction of federal cash transfers next year. In the province of Manitoba, 34% of funding comes from the federal government. As that is compromised, the revenue of the province of Manitoba will be compromised.

The health plan that is currently being formulated in Manitoba has several components. For example, we have brought together the traditional teaching hospitals and medical schools into an academic health consortium supporting both the health needs of metro Winnipeg and the health needs of rural and northern regions in our province.

Negotiations have been initiated with the physicians of the academic health consortium to move from a fee-for-service system to an alternate funding system.

As well, a study is underway to look at integrating the hospital system with the community care and primary health delivery system.

In terms of rural and northern regions, Manitoba has worked with the rural communities to create 10 regional health associations.

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