Public Accounts Committee on June 1st, 2006

[Hélène Gosselin]

Well, I apologize. I did have one prepared, but I was under the same impression as Monsieur LeBlanc. When we asked whether we needed to make one, we were told that it wasn't required, that we were here to answer questions.

I apologize, but I could certainly answer questions about what we're doing on prescription drug monitoring. In fact, we've done quite a lot of work to implement the recommendations of the Auditor General. I would point out that out of the 14 recommendations that were followed up on in this report, we had a satisfactory assessment in 11 of those, unsatisfactory in three. One of those was dealing with prescription drug retrospective analysis, which we have implemented and are doing, but the Auditor General noted in her report that--

[John Williams, Conservative, Edmonton—St. Albert, AB]

I don't need your opening statement now. You should have delivered it at the beginning of the meeting.

[Hélène Gosselin]

Well, I was just trying to respond.

[John Williams, Conservative, Edmonton—St. Albert, AB]

No, no.

Now, the Auditor General pointed out the protocol that you put in place to try to minimize the misuse of prescription drugs. You stopped the protocol because you felt you didn't have the legislative mandate--which was pointed out to you in 1993 and has been dealt with by this committee several times. Why don't you have a legislative mandate already?

[Hélène Gosselin]

Well, in fact the department stopped at that time.

Mr. Potter is with me, and because I wasn't with the department before, if I don't have all the information he'll intervene.

It stopped at the time because of the issue of consent. The department wasn't seeking consent from the beneficiaries to share health information with doctors or pharmacists. So they stopped and looked at how we could get consent. They tried to implement a program to get consent from all the beneficiaries of the program, and that took several years.

Finally, the department started to implement the analysis again. When we identify problems, we seek consent on a case-by-case basis, as Madam Fraser has indicated, in order for us to share sensitive health information with doctors and pharmacists.

[John Williams, Conservative, Edmonton—St. Albert, AB]

Madam Gosselin, we've pointed out in this committee several times that if I or you or anybody else goes to the doctor for a central nervous system prescription drug, it is reported to a central spot to ensure that there is no abuse. We've had Mrs. Stonechild from Saskatoon here at this committee telling us how her brother and her son both died through prescription drug overdoses paid for by the Government of Canada and the taxpayers of Canada, and you haven't done much of anything to stop that.

Now, why are there rules for everybody else and no rules for first nations, where taxpayers are paying for people to kill themselves?

[Hélène Gosselin]

Well, we have done a lot of work to respond to that, Mr. Williams. We've done the warning messages that go to pharmacists if there are duplicate treatments, duplicate drugs. Those have been in place since the 1990s. We do the retrospective analysis now, as I said, case by case to identify where there are patterns of possible abuse.

[John Williams, Conservative, Edmonton—St. Albert, AB]

And if the person's dead, what are you going to do?

[Hélène Gosselin]

Well, we try to intervene before there's a problem of that magnitude. I know the department didn't do it for a number of years, but we resumed it late in 2004, and that's what's in this particular report.

[John Williams, Conservative, Edmonton—St. Albert, AB]

So how well are you controlling central nervous system prescription drugs that people can (a) sell on the street, or (b) use to kill themselves--as Mrs. Stonechild's family did--to ensure that taxpayers' money isn't being used this way?

Tell me specifically how you have stopped it.

[Hélène Gosselin]

I will ask Mr. Potter to give you the details of the reviews we do on that specific issue.

[Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Department of Health]

Thank you very much, Mr. Chairman.

As Madam Gosselin said, we have followed up on the recommendations of the Auditor General and of this committee. We have put in place a drug utilization review regime that had three components. There is a prospective component that controls the formula in the drugs that we pay for, and we've done a number of things. We've identified those drugs that are at risk and we've taken them off our formulary or put them onto an area where you cannot get them except with special permission from your physician. We've put limits on the number of drugs, on the drugs like benzodiazepine and opiates, so that when people use over a certain limit, they are cut off and they can't get any more until their physician approaches us or their pharmacist explains why.

We've also put in place a new code, an NE code. At the time that the pharmacist is filling out a prescription, it will identify whether or not that patient has had a multiple benzodiazepine or opiate-type pharmacy. The pharmacist will get a notice right then and there that there may be a problem.

We've also implemented a retrospective review. We do it six times a year. We take the records that we have and we have a system that identifies whether people have been to a number of doctors, whether they are receiving a number of medications. We identify those individuals and we follow up with those individuals. We have identified individual physicians where we have problems. We have gone through the Federation of Medical Regulatory Authorities and taken our evidence there. We've gone to the individual--

[John Williams, Conservative, Edmonton—St. Albert, AB]

I'm going to interrupt there, because the Auditor General said in paragraph 15.71: “Although Health Canada committed to liaise with provinces and territories on prescription drug-related deaths, we found no evidence that it had done so.” So is this all fluff and more reporting that's not got any substance behind it, or are you actually doing something to prevent deaths paid for by the Canadian taxpayer?

[Hélène Gosselin]

We are doing everything that Mr. Potter mentioned. All of these actions are taken to prevent possible abuse of the prescription drugs.

[John Williams, Conservative, Edmonton—St. Albert, AB]

Now, is that for every first nation member or is that only for those who have signed the waiver?

[Ian Potter]

No, that's for everyone. We look at all of the people who receive drugs that we pay for.

The issue you referred to, Mr. Williams, is a reference to collecting information on people who die due to the overdose or misuse of prescription drugs.

[John Williams, Conservative, Edmonton—St. Albert, AB]

Paid for by the taxpayer of Canada, by the way.

[Ian Potter]

We have tried to get that information. We approached the provinces and we have renewed our efforts. We have recently written to each one of the provinces' regulatory authorities because all of the information with respect to deaths is not in our hands. They all reside with the authorities that deal with vital statistics and death records.

[John Williams, Conservative, Edmonton—St. Albert, AB]

Okay. Thank you, Mr. Chair.

It's unfortunate that Mr. LeBlanc gets off the hook because I ran out of time, because he was next. Maybe somebody else will put him in the hot seat.

[The Chair, Liberal, Shawn Murphy]

Hopefully somebody else will come to that, because we'll be back.

Mr. Campbell.

[Ronnie Campbell, Assistant Auditor General, Office of the Auditor General of Canada]

Yes, Mr. Chairman, thank you.

I think there's a couple of things that are important to clarify in relation to the follow-up we had wanted the department to do. And Madam Gosselin is correct. The department has done an awful lot and there has been satisfactory progress on a number of issues, and we recognize that.

There are a couple of pieces of analysis that I think have been touched on that might be worthwhile for the committee to reflect on. Some of you will remember that we produced an audit report in 1997 and again in 2000, and in those audit reports, we produced analysis using criteria that we had taken from various provincial regimes in terms of the number of different prescriptions that people had, the number of different doctors people had gone to, the number of different pharmacists that people had gone to. I would submit that this would be a good measure, because the department does have the information. It could be tracked, and that would show there would be anomalies.

And in all of the analysis we did, it was clear that in certain parts of the country there were particular problems. I think it would be fair to say that the department should really pay attention to that because some of these are particularly problematic.

In 1997 we reported that the department had done analyses in at least one of those problematic areas, where there had been a significant number of deaths. The department had done work in Alberta with the provincial coroners to get information, and granted, the methodology might not have been perfect, but they were able to draw links. At that time, the department reported that there had been 42 prescription drug-related deaths between 1986 and 1988, and further, there was one community of 500 people where there had been 15 deaths in four years.

I think it's really important that the department keep tracking that kind of information, because you might fix all the systemic things, you might fix all of the information system things, but the department has a broad responsibility for the health of first nations, and I know Madam Gosselin would agree. I think you need to track that kind of thing, because if you don't, it could still exist even though you fix some of the systemic things.

[The Chair, Liberal, Shawn Murphy]

Thank you very much, Mr. Campbell.

We're now going to go to Mr. Christopherson for eight minutes.

[David Christopherson, NDP, Hamilton Centre, ON]

Thank you very much, Mr. Chair, and thank you all for your attendance, those of you who are here today.

I want to say right at the outset that I, and I'm sure my colleagues, all have a great deal of sympathy for the complexity of the ministry. It's arguably one of the toughest in government, no question, and we all acknowledge that. What's frustrating, though, is that the ministry makes commitments and then they're not followed up on. That's what we find unacceptable.

It's not that this is an easy job and you shouldn't have problems. It's the fact that once we find out where there are some weaknesses and work that needs to be done, particularly when it affects citizens' health, you make commitments in that regard and you should be taking into account the complexities you have. You know the challenges you have, and if you can't do what needs to be done, then tell us why and we'll work that through. What's absolutely frustrating and unacceptable is to have you make commitment after commitment because it maybe gets you out of this meeting, only to find out that it doesn't get resolved.

And that's what we're going to hold you to account on: why these things weren't done. There are policy issues and committees that can deal with moving forward, and we can talk about some of those things, but our primary responsibility here is to hold the ministry to account for what you committed to do and what you're expected to do.

From that point of view, in terms of commitments you've made, I look at what the Auditor General said in her report. I'm quoting from paragraphs 5.12 and 5.13. It states:

We expected that federal organizations would have made significant progress in implementing the 37 recommendations in seven chapters published between 2000 and 2003.

Overall we were not satisfied with the progress made by the five federal organizations.

The Auditor General went on to say:

We found that they made unsatisfactory progress in implementing 15 recommendations---generally those most likely to improve the lives of First Nations people.

So here we have these 37 recommendations. It's my understanding that 22 of them have been implemented satisfactorily, but only three of them have been completed in terms of their implementation, and the balance have not had satisfactory progress. The difficulty for me is that the ones you acted on are the administrative matters. You made yourself more efficient in terms of moving paper around, but on the recommendations that affect the quality of life of first nations citizens, that's the area where we didn't have satisfactory progress.

Had it been the other way around, you'd probably have a little more sympathy here. This is very problematic, and again, that's why I'm hitting this so hard. It's not because I think it's an easy job and you should be able to do it. It's because the ministry makes commitments and they aren't done. That is what is enraging.

I want to move quickly to the issue of mould. Again, these are the Auditor General's words from her report: “Mould is a fungus that, under certain conditions, produces poisonous substances that can cause headaches, dizziness, and nausea.” We're not just talking about it not looking nice. We're talking about serious poisonous substances.

A previous audit found that you were not doing enough to address this issue. Specifically, it turns out that the three of you had meetings but that basically nothing came out of those meetings because nobody would take overall responsibility for ensuring that there was an overall management plan. And I have to tell you, in the absence of anybody else rolling in here offering, I hope at the very least you're going to take that on today, and if not, give us a reason why not you and somebody else. But please do not leave this meeting with us still wondering which one of the entities in government is going to take responsibility, because the Auditor General has pointed out that this is the key to getting this resolved--somebody takes responsibility for pulling together those strategies. It didn't happen, and it sounds to me like there were some meetings, but that nobody came out of those meetings saying, “I'll take final responsibility to make sure this thing moves”. And so it doesn't get done. I don't know how many times they met, but it certainly didn't produce the changes we want.

My first question would be: why isn't your ministry the one taking a lead on this? Why haven't you in the past? In the absence of anybody else doing it, why haven't you stepped forward rather than just letting it go on and on? We don't see the strategies and we don't see this health issue being resolved. Why? Please.

[Paul LeBlanc]

Thank you.

Mr. Chairman, as is noted, the departments have worked together. A committee was struck to coordinate efforts. The coordinating work did result in greater cooperative efforts between the departments. An example was the development of in-community training sessions to deal with the identification of mould problems, early remediation of mould problems, and even later-on remediation of mould problems. These programs have been delivered through cooperative efforts between CMHC and INAC in, I believe, approximately 100 communities. A plan is in place to reach on-site delivery of these training methods.

[David Christopherson, NDP, Hamilton Centre, ON]

Excuse me, Mr. LeBlanc. I don't mean to be rude., but time is limited and that's why I'm interjecting. But it sounds to me like you're disagreeing with the Auditor General. Are you saying that no indeed, these meetings did produce leadership, that the strategy plan is actually under way and somehow the Auditor General's office missed it? I'm hearing you contradicting what the Auditor General was saying. That's what it sounds like to me.

What I wanted to know is why didn't you take responsibility to come out of those meetings and provide the strategy that the Auditor General said needed to be done in order to make everything effective? Please don't tell me all the little things you did do and how you improved the efficiency on the non-personal issues. Tell me why on this specific issue you didn't take leadership on it or ensure that somebody else did.