Public Accounts Committee on March 10th, 2009

[Dr. David Butler-Jones]

Yes, it's a challenge for the system, but we have planned some measures to improve the situation. I'm going to continue in English.

We have the field epidemiology programs. We have people we train, who we put out, who the provinces call on. They can come in and work with them on investigations and also do training. We also have web-based training on basic surveillance and data gathering and other things that public health workers and others can access. We also have a mentor program.

We're developing a public health service. We're actually hiring people who are agency people. They're being placed, in particular, in areas that have less capacity, like the north and the east, but they are working with all provinces and territories alongside their colleagues. That will augment their capacity, and we can call on them if there's a national emergency.

[The Chair, Liberal, Shawn Murphy]

Merci, Madame Faille.

Thank you very much, Dr. Butler-Jones.

Mr. Christopherson, seven minutes.

[David Christopherson, NDP, Hamilton Centre, ON]

Thank you very much, Chair.

Thank you for your presentation and for being here today.

I have some experience working with the medical officer of health back in a previous life as a regional councillor, as chair of the combined health and social services committee. Of course, the MOH reported back to me, so I've worked with this.

I've also seen you publicly commenting on some issues and I was very impressed. Knowing of your role, I thought the message you were conveying and what you were saying to the Canadian people was very good. I was very impressed. I wanted to start with that compliment, because it's the last one we're going to hear.

[Some hon. members]

Oh, oh!

[David Christopherson, NDP, Hamilton Centre, ON]

Yes. Enjoy it.

This is about the surveillance of infectious diseases. Given that we're a country that's gone through SARS, this is a pretty big issue for us. I have to say to you that given the nature of the report, this is pretty scathing. There's nothing here to be too damn proud about in terms of the surveillance and what's been done.

This is one of those cases, to members who are new, that I spoke about earlier. One of the things that incenses me, at least, and incensed many of the previous members, is an audit report that shows a problem, then another audit report that shows that problem wasn't dealt with, and yet a third report that says the first report wasn't dealt with and neither was the second one. That's what we have right here.

This has been dealt with before. Some of these issues are ongoing. It just doesn't seem to be getting dealt with.

I look at things like this from the auditor's report, which states, “Comprehensive surveillance standards still need to be finalized”. As well, it says, “They are essential for detecting outbreaks quickly and accurately...”. So we're not talking about some little piece of a remote department. This is essential to the ability of this department to protect the health of Canadians.

What does it go on to say? It says, “Without approved standards, cases may be reported by using differing sets of symptoms or diagnostic tests”. As well, it states, “Since 2002, the Agency has worked with the provinces to prepare the updated list...”. “The list appeared in 2006”, says the audit, but it still has not been finalized.

In 2002 the auditor recommended “that Health Canada work with the provinces and territories to establish common standards, and it agreed to do so”. Further, stated the auditor, “Work is under way on these standards, but in our view, the progress on this recommendation has been unsatisfactory”.

The report states, “In 2002, Health Canada undertook to implement a data quality framework for its public health data in response to one of our recommendations”. Further, it states, “We conclude that progress on our 2002 recommendation has been unsatisfactory”.

Says the report, “In 1999, we noted that Health Canada had completed few evaluations and had no formal plan to evaluate its surveillance systems”.

As well, states the report, “In 2002 we found that Health Canada was still developing its performance measures and that reports to Parliament remained inadequate”. The report says that “in our opinion, progress has been unsatisfactory on these recommendations”.

Then, on the next page, when you get to the four infectious diseases, it concludes, “In our view, progress on this recommendation has not been satisfactory”.

And yet here's what we get from the department--and I've mentioned this to colleagues before--and the departmental performance report. This is the kind of problem we get. That's what's coming from the Auditor General in three different audit reports, and her issues don't get raised in a 31-page report until page 24, in one little paragraph. And today, Doctor, you say to us, “I...recognize that more work needs to be done, and that protecting the health and well-being of Canadians requires effective and timely surveillance”.

I want to know, given the lack of urgency that I sense in your statement, what makes your promises of today any more credible and reliable than the promises we've already had, Doctor. We need some answers. We need some action. Start telling me things that would alleviate my concerns over this report, because what we're hearing is that this has been identified for ten years now.

You're just not taking this seriously enough, Doctor, and I need to hear more. I need to hear better.

[Dr. David Butler-Jones]

Thank you for the question and for the kind words to start.

I cannot speak for prior to my tenure and the previous two audit reports, other than to say that we have, from the founding of the agency, taken it very seriously, restructured ourselves, and restructured the system with our partners in the provinces and territories, ticking off the boxes as we move.

We take it very seriously. The fact that we developed a strategic plan to outline how we're going to get there over the next few years is pretty key, I think.

In terms of definitions, case definitions, etc., again, because we are working with our partners, it is something that we need to do jointly. The federal agency cannot say, “This is your definition”. We have to negotiate that with the provinces and territories. That's ongoing, and by--

[David Christopherson, NDP, Hamilton Centre, ON]

That's an acceptable answer for the first go-round, Doctor, but not for the third.

[Dr. David Butler-Jones]

We are now focusing on what we need to do in order to get there. We expect that the next round will be done this year for case definitions.

As well, by 2011 we will have funded through Canada Health Infoway the development of Panorama, which will allow all jurisdictions that participate to electronically input, so that we can have effectively immediate data on cases anywhere in the country.

I've outlined before a number of things that we've done, and we continue to go through the long list of things that need to be done, as we've been doing over the last four years, to continue to tick those off. As I said at the outset, each month we're better off than we were the month before. We're not there yet, but we anticipate that in the next couple of years.... So if you come back to me in two years and don't see continued major progress, then I'd be more than open to your criticism.

Surveillance is fundamental to public health. Good information is fundamental to what we do. We're starting with what we had. Part of the issue with SARS was a recognition that public health capacity in Canada had been for two decades neglected, as we focused on a very important thing, which is funding of the health care system. But public health as a priority for governments was not there, and SARS brought that out in spades, as did Walkerton, as did North Battleford. Now we have entities in place: we have the agency federally, we have agencies in provinces, we have “healthy living” ministers. Five years ago, when federal-provincial ministers met, public health was almost never on the agenda. When deputy ministers met, it was almost never on the agenda. Now it's on every agenda and is often half the agenda. There is a sea change, but as Neil was saying earlier, it's not something that happens overnight, but every year, every month, we are making progress.

[The Chair, Liberal, Shawn Murphy]

Thank you, Mr. Christopherson.

[David Christopherson, NDP, Hamilton Centre, ON]

Well, you can give that line bureaucratically, but that's not going to help families if we have another SARS, and that department hasn't been where it should have been for years.

[Dr. David Butler-Jones]

I gave the example of the train.

[David Christopherson, NDP, Hamilton Centre, ON]

And I don't appreciate your being entirely defensive on everything. Listening to your remarks, you'd swear that you're arguing this is not true.

[The Chair, Liberal, Shawn Murphy]

Order. We'll move on.

[David Christopherson, NDP, Hamilton Centre, ON]

We'll have another chance to chat.

[The Chair, Liberal, Shawn Murphy]

Mr. Saxton, you have the floor.

[Andrew Saxton, Conservative, North Vancouver, BC]

I'd like to thank Mr. Maxwell for his presentation earlier.

And I'd like to thank you, Dr. Butler-Jones, for providing the committee with so much information on your action plan and the progress you've made to date. I haven't been on this committee that long, but I have to say that this is the first time I've seen information in this detail, and I commend you for taking the quick action to implement the recommendations from this report. Specifically, I want to thank you for the summary action plan that you sent to us.

It's my understanding that this new agency was created in 2004. As I was doing some research for the committee today, I was pleased to see that your agency released an action plan immediately after this report. I think this is a good example for other agencies to follow.

My first question is for Mr. Maxwell. To me as a parliamentarian, this action plan and the information provided is very helpful. Is the Office of the Auditor General pleased overall with the information provided to date?

[Neil Maxwell]

Thank you.

The information they've provided—the update on what they've done—is certainly quite comprehensive.

Perhaps I could use this opportunity to comment a bit on some of the earlier questions as well. These are really important issues for Canadians, absolutely. We all understand that; we all get it. I think, too, it is a complex business. When we noted in our report the extent of progress, we came to the judgment that it wasn't satisfactory. We never come to that judgment lightly, and it is reflective of the seriousness of these kinds of issues.

I wouldn't discount the action plan, as somehow showing that they're not being serious about acting. I believe that what we see in the action plan represents a very serious effort to try to improve surveillance. Much of what I hear both in your question and in previous questions has focused around whether that rate of progress is enough, given the seriousness of these issues.

Thank you.

[Andrew Saxton, Conservative, North Vancouver, BC]

Thank you, Mr. Maxwell.

I have a couple of questions now for Dr. Butler-Jones. Overall, I can see that a lot of hard work has gone into this action plan, and I commend you and your agency for the work.

I see that this surveillance strategic plan was developed last year. Can you describe overall what the goals are for this framework?

[Dr. David Butler-Jones]

To be a little more specific I'll turn to Greg, but fundamentally it's a question of what we need to do. We inherited a number of surveillance systems, which may or may not have been connected, in a range of areas, as well as different approaches. What we've been doing is reconciling them and focusing on where the gaps are that we need to fill, what the areas are that we need to build upon, and how we need to move the whole thing forward so that we have a more comprehensive approach to surveillance, one that's more effective and better connected.

Greg.

[Dr. Gregory Taylor, Director General, Office of Public Health Practice, Public Health Agency of Canada]

Thank you.

As Dr. Butler-Jones indicated, the agency inherited a number of individually managed surveillance systems, systems that were managed at a programmatic level.

What the surveillance strategy is doing is putting them together so that the agency manages all of our surveillance approaches in the organization as an agency. Currently, we're monitoring well over 50 diseases, which for the most part have been individually based. Putting it together and giving it a strategic direction, with goals to be the best data source and the best surveillance system in the world, allows us to think of it from an organizational perspective.

The role of the senior surveillance adviser is unique in the agency, in that all the surveillance has direct access to the CPHO on a daily basis to ensure that it's moving in the right direction. It allows us to apply evaluation to all the systems simultaneously. It allows us to look at standards, simultaneously for all our systems rather than as a series of one-offs. It allows us to interact with all the provincial and territorial partners as an organization, rather than in one-offs. It allows us to do our information sharing agreements jointly for all of the surveillance systems at the same time. It really is giving a common organizational perspective to what in the past, when we had individual programs, were functioning relatively independently, and which the agency inherited.

[Andrew Saxton, Conservative, North Vancouver, BC]

Thank you.

Can you tell me how the appointment of the senior surveillance adviser changed the focus of the agency and how it has affected the implementation of this action plan?

[Dr. Gregory Taylor]

Sure. I speak for myself. I have the role of overseeing this and ensuring that the action plan we've made is moving forward.

We have a small group of individuals, a surveillance coordination unit, who are dedicated to ensuring that things are working and moving forward and to monitoring the progress of all the individual program levels. Along with that unit, I report to Dr. Butler-Jones on an ongoing basis, letting him know whether things are moving or not moving. If the agency is slow in one area, that's how he finds out about it, rather than its coming from the programs and through the typical bureaucratic channels.

It's an oversight mechanism to ensure that the agency is moving forward.

[Andrew Saxton, Conservative, North Vancouver, BC]

Thank you.

I have no further questions.

[The Chair, Liberal, Shawn Murphy]

Thank you very much.

That concludes round one.

I have a couple of issues I want to pursue, Dr. Butler-Jones.

The first issue I want to talk about is your departmental performance reports. You operate a challenging agency, and as you indicated, it's a new agency. Probably, if we were to go back to six years ago, it wasn't a priority with either the federal government or the ten provincial governments. It is now, and you have a broad mandate.

As Mr. Christopherson said, the audit is fairly damaging; it's not a positive audit. Canadians should be concerned. Members of Parliament should be concerned.

I took the opportunity to read your departmental performance report. It was issued a long time after the audit was out. It was signed by the new minister. To be quite honest, it is what disturbed me more than the audit. I read this departmental performance report, and in everything here there's no indication that you have any challenges, risks. Everything is very positive. Every priority goal is being met and it's checked off—whether you have the right communications; “strengthen public health within Canada and internationally” is successfully met; “strengthen public health capacity in Canada through enhancements to public health work force“; “public health information knowledge systems” is satisfactorily met. It was so positive I would think that you and your whole staff could take nine months off. You have no challenges, no risk, and no problems.

Yours is not the only agency in the department that does this. It really grates on me that departments and agencies in Ottawa write this stuff for members of Parliament, because this, sir, is fiction. You have a lot of challenges. You run a tough department. I sympathize with you; it's not an easy job you have.

But I question why, when you prepare these reports and file them in Parliament through your minister, the Minister of Health, you do not identify the challenges, risks, and problems your department faces and the things you're doing to correct them. That, to me, is an honest dialogue that I would like to have with all 88 agencies and 22 departments. But we don't see it. If I took your departmental performance report and took the document prepared by the Office of the Auditor General, the first question I would ask is whether there are two Canadian public health agencies. And I know there's only one.

My question to you is, what dialogue goes into preparing this report? And please don't say it's accurate. What dialogue goes into preparing this report? Is it prepared under your supervision, and is there any reason you don't try to identify the risks, the problems, and the challenges you face, which are real risks?

I'm not being overly critical. When you start an agency as big as yours and with the challenges you face, the problems you have are real. It's not a criticism. But why don't you mention them here, instead of saying that everything is perfect?

[Dr. David Butler-Jones]

It may be a relative measure, in terms of where we started from, the efforts and the work that have been put into place, and the processes that have been put into place to address them.

In terms of the function of public health—and as Neil was saying, there are very complex, multi-sectoral kinds of things—for us, and for me, having done this a long time, the proof is in the pudding. While we work to get formal agreements and we work to get some of these things in place, which we continue to do, they don't come easily. The secret and the challenge is can you respond effectively at the time?

Back to your question, Mr. Christopherson, I look over the life of the agency now and the events we've dealt with, and how different they are today from what they were during SARS or before SARS: the identification in the case of polio; the identification of bird flu on farms and the engagement of CFI and others; the finding of the H2N2, which could have been the next pandemic, which we figured out and found and were able to work on with the Americans and others because they had sent it all around the world to track it down. And there was the listeria outbreak. There were many challenges around that, but fundamentally, from a surveillance standpoint, during the outbreak there were five extra cases of that in Canada a week—five cases a week—against a background of 20,000-plus of us with those symptoms every single day, and we were able to figure out not only that there was an outbreak but where it came from. That's very different. Five years ago that would never have happened.

And back to the DPR—