Health Committee on May 11th, 2010

[The Chair, Conservative, Joy Smith]

Good morning, everybody. Welcome to the health committee of Canada.

Today we have a very important meeting, pursuant to Standing Order 108(2), on our study on health human resources.

We have as our witness today, from Correctional Service Canada, Leslie MacLean. Welcome, Leslie. It's nice to see you again.

We also have Fraser Macaulay, the acting assistant commissioner. Welcome, Fraser.

And from the Department of Citizenship and Immigration, we have Lise Scott. Welcome to you. I understand you're the director general of that department.

I think those are all of our witnesses for the first round. The first round is going to go from 9 a.m. to 10 a.m., and the second round is going to go from 10 a.m. to 11. So we will begin with a five-minute presentation, and then we'll go to Q and As after that.

Can we begin with Leslie MacLean, please?

[Leslie MacLean, Assistant Commissioner, Health Services, Correctional Service Canada]

I'm going to begin by passing the parole to my left, please.

[C/Supt Fraser Macaulay, Acting Assistant Commissioner, Human Resource Management, Correctional Service Canada]

Good morning, Madam Chair and committee members. I would like to thank you for this opportunity to appear before you today. I am also joined by my colleague Leslie MacLean, Assistant Commissioner, Health Services.

The Correctional Service of Canada is a federal agency within the Government of Canada's Public Safety portfolio. CSC contributes to public safety by administering court-imposed sentences of two years or more. This work involves managing institutions of various security levels, preparing inmates for safe and timely release, and supervising offenders under conditional release and long-term supervision orders in the community. CSC has approximately 16,400 employees. It is responsible for some 22,000 offenders, of whom about 13,280 are incarcerated and some 8,720 are supervised in the community.

CSC has a presence across the country, from large urban centres to remote communities across the North. CSC manages 57 institutions of various security levels; 16 community correctional centres; 84 parole offices; and four healing lodges.

As you know, CSC employs a diverse workforce comprised of correctional officers and parole officers, who, for the most part, are exclusive to CSC. The remainder of CSC's workforce reflects the variety of other skills required to operate institutions and community offices, from health professionals—such as from the fields of nursing, psychiatry, pharmacy, and psychology—to electricians and food service staff.

CSC staff routinely deal with high-need and high-risk offenders, whose needs are complex and diverse. These include mental illness, drug and alcohol addiction, and anger and violence issues. While these challenges are faced by a large percentage of CSC's workforce, for health care professionals joining CSC, this institutional work environment is unique and presents challenges not commonly confronted by their profession. Coupled with this unique work environment, when it is recruiting for health care professionals, CSC must respect Government of Canada policy, legislated budget direction, and the collective agreements governing these occupational groups. Together these factors, when combined with the remote location of many work sites, can limit our success in attracting and retaining health professionals.

In keeping with the most recent annual report of the Clerk of the Privy Council, CSC is strengthening its planning, recruitment, and employee development. This will enable human resources to build on its current foundation of sustaining its existing workforce, attracting new people, developing and retaining talent, and finalizing the implementation of our transformation agenda.

As part of public service renewal, CSC's human resource management function will need to increase the efficiency and effectiveness of its services in the organization if the organization is to remain competitive in its search for talent and deliver on its correctional results. In response to this need, the human resources section is committed to improving and simplifying its processes and systems. For example, CSC will be adopting common human resource processes, upgrading our HR management system, leveraging self-serve technology, and increasing the availability and use of strategic information by rolling out a dashboard to all regions and institutions. Together, these initiatives will allow CSC to strengthen its capacity to manage its workforce and to plan more proactively.

My colleague will elaborate on initiatives specific to health care professionals.

Throughout these various initiatives, our union partners have played a key role in identifying and working collaboratively to resolve issues affecting their membership. For example, CSC is working closely with the Professional Institute of the Public Service of Canada to address barriers affecting the mobility of registered psychologists.

Meeting the challenges outlined in the Public Service Renewal and our Report on Plans and Priorities will require strong leadership and a sustained commitment. Our renewal must continue to evolve for CSC to sustain the high level of service that Canadians have come to expect.

[The Chair, Conservative, Joy Smith]

Mr. Macaulay, can you wrap up quickly, because we need to go to the next witness?

[C/Supt Fraser Macaulay]

Yes. I would now like to invite my colleague Leslie to provide more details about the challenges facing health care professionals at CSC.

[The Chair, Conservative, Joy Smith]

Thank you very much. We usually have one presenter per organization, but we have the time and I understand that you are providing two different looks at the same thing, so I'll give you the full time as well, Ms. MacLean.

Please, go ahead.

[Leslie MacLean]

Thank you, Madam Chair.

I would also like to thank the committee members. I am pleased to appear here before you to discuss issues related to the recruitment and retention of health care professionals at CSC. As my colleague said, we will brief you today on CSC's Recruitment and Retention Strategy, including key challenges and our work to address them.

The recruitment of health professionals is key to meeting our legislated mandate of providing offenders with essential health services according to professional standards. Members may wish to note that our model of service delivery is principally nurse-based, with physician services principally provided on contract.

We are the largest federal employer of psychologists and nurses. We have a complement of about 750 nurses, or approximately 39% of nurses in the federal government, and about 340 or 71% of psychologists in the federal government. Of course, in addition to nurses and psychologists, we have a wide range of other health professionals: pharmacists, social workers, psychiatrists, occupational therapists, and of course contracted physicians.

It is an ongoing priority and challenge to recruit health professionals to the service. In addition to the challenges my colleague Mr. Macaulay has mentioned, the first is the reality of a very competitive national and international market for health professionals. Provincial and territorial health systems, as well as other federal partners, have the same requirements for health professionals, and in some cases they have more attractive compensation packages.

The second issue is the one of social and demographic trends affecting the pool for all health professionals across Canada. Of course, they apply to the service, so we also face the challenges of an aging workforce and staff who are becoming eligible for retirement.

The third issue was mentioned quickly by my colleague: the challenge of providing health services in a correctional setting. Some of the factors include particular challenges responding to the complex physical and mental health needs of offenders or the occasionally stressful working conditions of a penitentiary environment.

Of course, we're working very actively to recruit and retain these critical health staff. Since 2008 we've had a dedicated recruitment and retention strategy for health professionals. It lays the groundwork for a long-term approach. We are beginning to see some impact. According to our latest vacancy figures, we are beginning to make improvements in vacancy rates for health professionals. For example, last year we would have hired 172 new health professionals, including 125 nurses.

We're also striving to become an employer of choice—everything from having many of our health services staff reporting up through a health organizational structure, new training and development, and working toward the accreditation of all our health care units. We are working, of course, to promote the unique challenges of a career in corrections, with brochures that speak to the challenges and opportunities for psychologists, social workers, and nurses. We've recently had articles promoting our special workplace in the Canadian Psychological Association newsletter and one in the Canadian Nurses Association magazine.

We've also been working with our colleagues in the federal health care partnership, both to find students and to retain them through practicums and internships, which of course produce job opportunities for our staff and provide a collaborative opportunity to recruit to the federal government as an employer of choice.

Retention of health care professionals is a key component of the Strategy. To support our efforts in this regard over eight million dollars has been provided annually to support the training and development of nurses both to improve their skills for working in a correctional environment and to keep them current with respect to modern nursing practices.

In addition, psychologists have been provided with dedicated annual funding for their professional development for the last three years.

In summary, we recognize the unique recruitment and retention challenges we have. We're working diligently to reduce our vacancies and of course to retain the excellent health professionals we have. We're committed to focusing our efforts to attract--and retain--qualified employees to careers in the challenging yet rewarding environment of the correctional service.

Thank you.

[The Chair, Conservative, Joy Smith]

Mr. Macaulay and Ms. MacLean, you've given some really very important information this morning. Thank you.

We'll now go on to our next guest from the Department of Citizenship and Immigration, Ms. Scott.

[Dr. Lise Scott, Director General, Health Management, Department of Citizenship and Immigration]

Thank you, Madam Chair.

Good morning. Thank you for inviting me to speak to you today.

I am the Director General of the Health Management Branch of Citizenship and Immigration Canada. My branch holds the responsibility for delivering the Interim Federal Health Program, also referred to as IFH. This is a health coverage plan which reimburses the costs of health services for refugees, individuals who claim asylum in Canada, individuals who are detained under the Immigration and Refugee Protection Act, and victims of human trafficking.

There are approximately 128,000 clients eligible for this program. In terms of numbers and the breakdown by client type, approximately 110,000 are asylum seekers--that's refugee claimants--and approximately 18,000 are convention refugees who were selected abroad and resettled in Canada. There are usually, at maximum, 300 individuals detained at a given time. There are approximately 10 to 15 victims of trafficking throughout the year.

The expenditures of IFH are included in the attached table. For 2008-09, the program expenditures were $65 million, and there were approximately 550,000 claims. The program has seen a significant increase in cost. The program reimburses basic health care services, similar to what's available through provincial plans for Canadian citizens and residents, and supplemental health services, such as medication and dental and vision care, similar to what's offered on provincial social assistance.

The IFH program is operated as an insurance plan. Their clients, with the exception of detainees, obtain their services from the provincial-territorial health network and practitioners, and IFH reimburses the cost of such care. This means that IFH is not the actual provider of care. It should be thought of as more of a reimburser. We recognize the importance of fee schedules to help ensure access to services, which is why the program aligns its fee schedule as much as possible with provincial fee schedules. To process a claim, we utilize a third-party claim administrator.

The role of CIC in delivering this program is to define program policy, to define the benefit structure, and to maintain oversight of the claim administrator activity. It should be noted that the detainees are held in Canada Border Services Agency detention centres. Contracts are in place with medical providers, who come to the centre for eight hours a week to deliver health care. The costs are covered by IFH.

In conclusion, because the mandate of the program is to reimburse health care services provided by the PIT health care system, we do not deal directly with issues related to access to care, compensation of physicians or other health care professionals or high turnover of health care staff. However, as for the other Federal Healthcare Partnership partners, the considerable increase in program expenditures reflects the fact that the cost to obtain health services has grown significantly

Thank you. I would be pleased to answer any questions Committee members might have.

[The Chair, Conservative, Joy Smith]

We certainly have some great witnesses today. It's been really good to hear your initial presentations. If there's anything else you want to include as the questions are being asked, feel free to do that, because we rely on your expertise.

We'll now go into seven-minute questions and answers. We will begin with Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thanks very much.

My question is for the Correctional Service.

Obviously, mental health is a huge priority I think in terms of your institutions.

You said that your latest vacancy report for health care professionals has improved in most cases. Can you tell me how you ascertain that in terms of the need for doctors, the need for nurses, and the need for social workers? What are your targets, and where are you in each of those? There may be some things that don't need to be done by licensed professionals, but probably lots do. Could you just tell me what your target is for each of those categories and where you are?

[Leslie MacLean]

I'd be pleased to respond to the member's question.

To begin, mental health has been a top priority for the Correctional Service for the last several years. We're working within, of course, the various scopes of practice, as regulated by the eight provinces in which we have our 57 institutions.

For example, the institutional mental health initiative, for which we first received funding in 2007, has a complement of about 90 health professionals, and in that we have psychologists, social workers, occupational therapists, and psychiatric or mental health nurses as well. I don't have them broken down by each initiative, Dr. Bennett, but I could, for example, speak to our current complement for psychologists, which is 340 psychologists. That's how many we're funded for across the service, and that's certainly one of our areas where we are struggling with recruitment and retention.

Our current vacancy rate in psychology is 20% of our positions. So when we have vacant positions—of course, we have to ask people to not ever work outside their scope of practice—we look at triaging the work that psychologists do to make sure we're concentrating them on the core areas where we need their valuable expertise, whether it be risk assessment, diagnosis of mental health conditions.... Then we work to provide an interdisciplinary team approach to support the inmates through the provision of mental health services.

For nurses, which is our largest employee group, as I mentioned in my opening remarks, we have a complement of 750 funded nurse positions. Our current vacancy rate is about 6% for nurses in the service.

[Carolyn Bennett, Liberal, St. Paul's, ON]

And social workers?

[Leslie MacLean]

I'm sorry, I didn't speak to social workers. They're a very important part of our mental health workforce. We have a complement of 55 social worker positions, and six of those are vacant now, for a vacancy rate of 11%.

[Carolyn Bennett, Liberal, St. Paul's, ON]

And family doctors?

[Leslie MacLean]

For our physician complement, we have six, either physicians or psychiatrists, who work with us. The vast majority of our psychiatry and physician services are provided on contract, so we have over 50 physicians on contract who might come into our institutions for two or three afternoons a week, for a clinic. Similarly, for psychiatrists, we have over 50 psychiatric contracts as well.

[Carolyn Bennett, Liberal, St. Paul's, ON]

In terms of addiction, how is that dealt with?

[Leslie MacLean]

For addiction, this is a substantive challenge for inmates. About 80% of inmates of the federal correctional system have some sort of substance abuse issue, and we have an extensive suite of substance abuse programming, which is offered in an effort to respond to those issues.

[Carolyn Bennett, Liberal, St. Paul's, ON]

What percentage of your health care team would you consider focused on mental health?

[Leslie MacLean]

I've never calculated our staff ratios that way. Certainly I could perhaps give you, Dr. Bennett, an overview of the budget. We have about $194 million, which the Correctional Service spends on health services. Of that, about 60% is actually salaries, so the people. Within that envelope we spend about $50 million of that on mental health services, either health services in one of our five psychiatric treatment centres or on our mental health programs that are offered in our other institutions.

I would be glad to give an undertaking, Madam Chair, to come back with more analysis of how that breaks out between physical and mental health services, but that's the overview of the resources.

[Carolyn Bennett, Liberal, St. Paul's, ON]

And maybe in terms of how long you've had this kind of shortage, the fact that you've said that some of the vacancy rates are going down.... But are some going up? I mean, 20% for psychologists is huge, because you can't actually see more patients per hour. You can't hurry up in mental health, compared to maybe seeing sore throats.

How do you deal with the fact that you're 20% down in psychology? Does that mean patients aren't being seen or that there are waiting lists?

[Leslie MacLean]

There are probably several ways by which each institution is working to respond. One is, of course, triage to ensure we're using our valuable resources on the most important and urgent cases; another one is through contracting for psychology support as and if required; and of course, as your question suggests, trying to get to root causes to really improve the initiative. For example, I think it was in February 2009 our psychology vacancy rate was higher; it was 23%. We brought it down to about 16%, but it's creeping back up. So we'll continue to work diligently on understanding what issues are affecting recruitment and retention for us and of course do our best as a service to respond to those.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Do you use unlicensed professionals to fill the gaps?

[Leslie MacLean]

We have been working on a regulated, licensed health professional as our model for service, so one of our challenges is making sure we're aligned appropriately with regulated scopes of practice in each of the jurisdictions where we have institutions.

[Carolyn Bennett, Liberal, St. Paul's, ON]

In order for them to have a licence, they actually have to abide by the various provincial.... So you don't have a cross-institution approach to who gets to do what?