Health Committee on Nov. 28th, 2017

[The Chair, Liberal, Bill Casey]

I call meeting number 81 of the Standing Committee on Health to order.

We certainly welcome our guests back. We've had Mr. Ferguson before.

I want to welcome, from the Office of the Auditor General, Michael Ferguson, Auditor General of Canada; Joe Martire, principal; and Casey Thomas, principal. They are going to testify before us today on the oral health programs for first nations and Inuit.

We will ask you to make an opening statement, Mr. Ferguson, of 10 minutes, and then we'll go to questions.

I'm sorry for the delay, but I'm sure you know the reason. Thank you very much.

[Michael Ferguson, Auditor General of Canada, Office of the Auditor General]

Thank you.

Mr. Chair, thank you for this opportunity to present the results of our audit on oral health programs for first nations and Inuit.

I would like to remind the committee that we have done other reports in the health area—one of them on the access to health services for remote first nations communities which we presented to Parliament in the spring of 2015.

In our audit on oral health programs, we focused on whether Health Canada knew if the programs had a positive effect on the oral health of Inuit and first nations people. These programs are important because they provide access to a range of medically necessary dental services.

We concluded that while Health Canada provided access to these important services, it could not demonstrate how much they helped to maintain and improve the overall oral health of Inuit and first nations people.

Even though the department knew that the oral health of these populations was significantly worse than other Canadians, it did not focus on closing the gap. Also, the department had not finalized a strategic approach to help improve the poor oral health outcomes.

We found that Health Canada did know that its $5-million children's oral health initiative, which is focused on prevention, improved the oral health of some first nations and Inuit children. However, the department's data shows that fewer children are now enrolled and fewer services are provided under the initiative than in previous years. Health Canada does not know why this is the case, which makes it difficult to address the situation.

We also found that there were administrative weaknesses in the department's management of its non-insured health benefits program. The department's service standards for making decisions on pre-approvals and complex appeals were not clear. Also, Health Canada did not always inform its clients and service providers promptly about some of the changes it made to the services it paid for. This matters because delayed or unclear communication about what services are available can affect clients' access to the oral health services they need.

We also found that, in the two regions we examined, Health Canada was slow to take action to address human resource challenges. Without action, these challenges could eventually affect service delivery.

We made six recommendations, including that Health Canada should finalize and implement a strategic approach to improve the oral health of Inuit and first nations people, and that it should develop a concrete plan to determine how much of a difference its programs are making to the oral health of Inuit and first nations people.

Health Canada agreed with our recommendations and committed to take corrective action.

Mr. Chair, this concludes my opening remarks.

We would be pleased to answer any questions the committee may have.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much. I believe those are the shortest opening remarks we've ever had.

Now we'll go to our question period with seven-minute questions.

Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

Thank you very much.

Thank you for coming today to review the report.

I was going through it, and I just wasn't quite sure of the time period that the audit covered. There was mention of 2014 and up to 2016, I think. Was it the 2015-16 year or the 2014-15 year? What was the time period of the study?

[Michael Ferguson]

The audit covered the period between September 2013 and December 2016.

[John Oliver, Liberal, Oakville, ON]

Thank you.

In terms of confirming whether there is now sufficient action on this, you referenced the comments from the department. I read through them. In your mind, in terms of the department's response to your review, are those comments satisfactory? Do you feel there is something more that could be done, or are those sufficient to address the main points in your review?

[Michael Ferguson]

The department has agreed with all of our recommendations. I guess we always reserve judgment on how successful what they say they're going to do will be until we come back and do another audit or look at exactly what they've done.

The starting point for us is always that they've agreed with our recommendations. They will be preparing an action plan as part of their normal process for the public accounts committee, which will provide more detail about what they're going to do. These are the first steps toward implementing our recommendations.

[John Oliver, Liberal, Oakville, ON]

The minister, in terms of her oversight of the department, has highlighted four key ways the government is working with first nations.

“Finalizing a strategy by March 2018 with First Nations and Inuit partners to improve oral health and service delivery”. That was number one. Number two is “Improving data collection...by working with First Nations and Inuit partners to track the needs of community members”. That's on the data collection point that you raised in your audit.

“Utilize programs with First Nations and Inuit partners to attract, educate and retain Indigenous oral health workers in communities”. Again, this is addressing service provision. Finally, “Improving how decisions are documented under NIHB by including more details on approvals and policy changes.” I assume with this is more timely communication to the communities on what the changes are.

Also, in budget 2017 there is an additional investment of $45.4 million for the children's oral health initiative over five years to expand the oral health program in up to 214 additional communities. There is $813 million in the budget, as well—$83.2 million for the children's oral health initiative and also the community-based fetal alcohol spectrum disorder programming, and the maternal and child health programs.

With the ministerial response and the department response, it reads to me as though the ship is turning. I agree with you that it has to be implemented and the plans need to be put in place, but there appears to be a very strong focused agenda now to improve the oral health needs of indigenous people, and there is a fair amount of financial resources being brought to bear to make that happen. Do you agree with that? Do you have a sense that more should be done?

[Michael Ferguson]

I would certainly agree that the items you listed were all in the areas where we found there were things that needed to be improved. Those are the topics the department needs to focus on. Again, we'll see what actually happens.

Our overall message in terms of this report was that.... The rate of dental disease, for example, in Inuit and first nations people is about twice that in other populations. With all of these different activities, we need to see that gap starting to close. Yes, there are a number of good activities, perhaps, being announced, but there needs to be a way of making sure those are all going to lead to improving the health outcomes for these populations.

[John Oliver, Liberal, Oakville, ON]

With the data collection comments I made about the investment that is input there and the department's comments about data collection, it seems as if there will now be tracking mechanisms. Were there reasonably robust indicators that you saw in use that would actually track that improvement? Are those ones that you had to develop to conduct your review, or are those in place within the department so that they can track progress themselves as this goes forward?

[Michael Ferguson]

The department has a lot of data. A lot of what it pays for is on, essentially, a fee-for-service basis, so they have a lot of data about the services that are provided under the non-insured health benefits program. They were, in fact, doing quite a bit of analysis of that data, but it was mostly analysis that was helping them manage the payments rather than helping them understand the impacts of their program on the population.

This is a program for which, first of all, we found that they do have quite a bit of data. They just need to use it in other ways, not just to administer payments but also to understand the impact.

On the other hand, there was the other program, the children's oral health initiative, which is not paid for on a fee-for-service basis, so they didn't have the same level of information on that program, although, when they had gone in and reviewed the program, they found it was making a difference in oral health.

We indicated that there were signs of a decrease in enrolment and a decrease in service, which may have, in fact, been just the fact that they weren't tracking that information the way they should have been. I think, on that program, they need to do a better job on the data collection.

[John Oliver, Liberal, Oakville, ON]

Thank you very much. Those are all my questions.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Ms. Gladu.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Thank you, Chair.

Thank you to the Auditor General and his team for attending. I did attend your briefing, so I had an opportunity to get some of the information.

I wanted to ask a little bit about dental outcome KPIs. I come from an industry focus, where you improve what you measure. I was surprised to not see a very prescriptive comparison. Does this program go across all first nations and Inuit communities, first of all?

[Michael Ferguson]

I'll ask Ms. Thomas to reply to that.

[Casey Thomas, Principal, Office of the Auditor General]

Thank you very much.

In terms of what we found in the audit, we looked at whether or not they had KPIs and whether or not they were determining what those outcomes would be. We found that the department indicated that because it pays for the services, it is therefore contributing to the overall health outcomes of the populations. It didn't have, with respect to the NIHB or the non-insured health benefits program, those sorts of measures that would allow it to determine whether or not it was actually improving the outcomes.

In COHI, the children's oral heath initiative, for example, it was measuring the DEF, or the decayed, extracted, or filled teeth, and it was using those as measures, as proxies to determine whether or not there were positive or negative outcomes for children. On the children's side, it was measuring and able to demonstrate that when COHI had been in place in communities for eight years, for example, those measures were seeing positive outcomes.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

One thing I'd like to see then, for sure, are measurements across the country that are the same, so that you could compare different first nations communities to see which ones are in more need or less need, and maybe look at things like not just the number of cavities or the number of procedures, which I think should be tracked, but also the number of prevention interventions with children in the community.

Do you think that's the kind of detail? Did you get any detail from Health Canada about what KPIs they were going to put in place?

[Michael Ferguson]

I think that's the type of thing that certainly we felt they should do. Again, the children's oral health initiative is a program that is very much geared towards prevention. If they could start to link the information they have—first of all they need to make sure they're collecting the right data—on that program to the rest of the information they have in their other program, then that would help them link some of those preventative measures to the longer-term outcomes.

Now, the children's oral health initiative—and I think earlier you asked about the coverage—was available in only about half of the first nations, even though that was an initiative that seemed to be leading to better oral health outcomes.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

When it comes to the programs, then, which ones do you think you should continue and expand? Which ones do you think you need to do more investigation on to find out why the participation rate is dropping, and which ones do you think should be eliminated?

[Michael Ferguson]

Our role is to audit the implementation of government policy. Government has to decide, through its policy, what types of things it's going to cover. I think the department will tell you, of course, that all of these are important dental care services.

In terms, though, of the children's oral health initiative, I think fundamentally it's time for them to look at the fact that only half of the first nations were covered, and decide which way they are going to go with that program. They also need to get the information to better understand what's going on with that program, because, again, the data indicated that enrolment had declined and services had declined. But the department told us they thought that was just because they weren't doing a very good job of actually collecting the data about which services were being provided.

For them to really understand whether the program is having an impact, they need to understand what services are provided under it.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

I noticed in the Health Canada response to your audit that there are actions but there are not specific timelines associated with those actions. Did you get any sense of when these things will be completed?

[Michael Ferguson]

When we do an audit and we report our findings and recommendations and we're in the process of preparing the report, we will discuss our recommendations with the department and we will get a response from them. That's what you see in the report.

Then, as part of the regular process with the public accounts committee, the department is asked to put together an action plan that includes those types of timelines. I haven't yet seen the action plan for this report, but of course they haven't been called in front of the public accounts committee yet to discuss the report.

We will, in the not-too-distant future, see an action plan prepared by the department that will include those dates.

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

Okay.

Do you think the split is right in terms of how much is being spent on preventive versus diagnostic? Did you see any evidence of...?

[Michael Ferguson]

That's not what the focus of the audit was. Again, in terms of the preventative, we looked at the children's oral health initiative, and then of course we looked at all of the other services, but we didn't look specifically at that split.

Again, I think that's the type of information we'd like to see the department analyze. Which types of services are preventative services, and for the people who get those services, what happens to their longer-term oral health outcomes?

[Marilyn Gladu, Conservative, Sarnia—Lambton, ON]

This is the engineer in me, so I'll say sorry in advance, but were you able to correlate any of the contributing factors—for example, drinking water? We know that there are more boil water advisories now than there were two years ago. That should have an effect on oral health. Are you able to see anything like that from your audits, or is that not part of the scope?