Public Accounts Committee on June 1st, 2015

[The Chair, NDP, David Christopherson]

I now call this 62nd meeting of the Standing Committee on Public Accounts to order.

Colleagues, our business is fairly straightforward today. We have a public hearing on another one of the chapters from the Auditor General's spring reports.

Today it's chapter 4, Access to Health Services for Remote First Nations Communities, of the spring 2015 reports of the Auditor General of Canada. Unless there's some particular reason not to, we will move straight to our opening remarks. I see none, and therefore, I will turn to our Auditor General, Mr. Ferguson.

Sir, I offer you an opportunity to introduce your delegation and give us your opening remarks.

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

Mr. Chair, thank you for this opportunity to discuss our Spring 2015 Report on Access to Health Services for Remote first nations Communities. Joining me at the table is Joe Martire, the principal responsible for the audit.

In this audit, we looked at what Health Canada has done to support first nations access to health services in remote communities. first nations individuals living in remote communities have significant health needs and face unique obstacles in obtaining health services. We found that Health Canada had not adequately managed its support of access to health services and medical transportation benefits for remote first nations.

According to the department, its support to these communities extends to 85 health facilities where health services are delivered through collaborative health care teams led by approximately 400 nurses. These health facilities serve approximately 95,000 first nations individuals. For these individuals, initial access to health services is usually provided by nurses at nursing stations.

We found deficiencies in the way nursing staff and stations are managed. For example, while all 45 nurses included in our sample were registered, only one of the 45 had completed all five of Health Canada's mandatory training courses we examined.

Health Canada acknowledges that its nurses sometimes work outside their legislated scope of practice to provide essential health services to remote first nations communities. Examples of such activities include prescribing and dispensing certain drugs and performing X-ray imaging of chests and limbs. Nevertheless, we found that Health Canada had not put in place supporting mechanisms that would authorize the nurses to perform activities outside their legislated scope of practice, for example, medical directives to allow nurses to perform specific tasks under particular circumstances.

We also found that Health Canada could not demonstrate whether nursing stations built since 2009 had been constructed according to applicable building codes. Moreover, the department had not addressed 26 of 30 health and safety or building code deficiencies that we examined in seven nursing stations built before 2009.

These deficiencies included malfunctioning cooling and ventilation systems and unsafe stairs, ramps, and doors. In one community, health specialists cancelled their visits to the residence intended for their use because issues with the septic system caused the residence to be closed. These issues dated back more than two years.

In addition, we found that Health Canada did not take into account the health needs of remote first nations communities when allocating support. For example, we noted that the number of nurses assigned to nursing stations was based on past practice, and not on each community's current health needs.

We also found that Health Canada had recently defined essential health services that should be provided in nursing stations. However, the department had not assessed whether nursing stations had the capacity to provide the services, nor had it informed first nations individuals of the essential services that each nursing station provided.

With respect to access to health services outside the community, we found that medical transportation benefits were available to first nations individuals who were registered in the Indian registration system, but those individuals who were not registered may have been denied access to benefits.

We also found that Health Canada's documentation concerning the administration of medical transportation benefits was insufficient. For example, there was a lack of documentation to demonstrate that the requested transportation was medically necessary and to confirm that individuals attended the appointments for which they had requested transportation.

Furthermore, Health Canada committed to providing first nations individuals living in remote communities with access to health services comparable to that provided to other residents of Manitoba and Ontario living in similar locations. Even so, we found that the department had not gathered the information it needed to know whether it was achieving its objective.

We also noted weaknesses in the coordination of health services among jurisdictions. For example, we found that committees comprising representatives of Health Canada and other stakeholders in Manitoba have not proven effective in developing workable solutions to interjurisdictional challenges that negatively affect first nations individuals' access to health services.

This finding is important because the lack of coordination among jurisdictions can lead to the inefficient delivery of health care services to first nations individuals and to poor health outcomes for these individuals.

Workable solutions are needed to improve accountability and ensure that individuals in first nations communities have access to health services comparable to those offered to other residents.

Our report contains 11 recommendations aimed at improving access to health services for remote first nations communities and the health outcomes of individuals, and Health Canada has agreed with all of them.

Mr. Chair, this concludes my opening remarks. We would be pleased to answer any questions the committee members may have.

Thank you.

[The Chair, NDP, David Christopherson]

Very good. Merci, Mr. Ferguson.

Now, from the Department of Health, we have Mr. Perron, who is the senior assistant deputy minister of the first nations and Inuit health branch.

I'll give you an opportunity now, sir, to read your opening remarks and, if you would, to also introduce your delegation.

[Sony Perron, Senior Assistant Deputy Minister, First Nations and Inuit Health Branch, Department of Health]

I would like to thank the committee chair and the rest of the committee members for the invitation to appear here today.

I, and other officials at Health Canada, have reviewed the Auditor General's 2015 Report, and we have paid a great deal of attention to his recommendations. We take the findings seriously and are addressing each of them through an action plan. This plan will continue to be refined and defined in collaboration with first nations. Indeed, as you know, we work in cooperation with first nations. This plan can therefore only be completed with an additional commitment by our first nations partners.

The health care system serving first nations is highly complex. Provincial health systems do not directly extend to first nations reserves. To support first nations, Health Canada provides the delivery of a range of effective, sustainable and culturally appropriate programs and services. We work with first nations to increase their control of health services and collaborate with provinces to increase access and promote system integration.

We also support programs that address first nations health priorities in the areas of mental health, chronic disease, maternal and child health, and health benefits providing coverage for prescription drugs, dental care, vision care, mental crisis intervention, and medical supplies and equipment.

Most of the community-based programs have been transferred in varying degrees to over 400 first nation communities. This number does not include British Columbia, where in 2013 Health Canada transferred its role in the design, management, and delivery of first nations health programming in British Columbia to the new First Nations Health Authority.

Health Canada provides funding to first nations to deliver clinical care in 27 remote and isolated communities, again, outside British Columbia. In an additional 53 remote and isolated first nation communities, Health Canada continues to deliver clinical care. The delivery model varies based on the specifics of each province and geographic conditions. The clinical care teams are located in nursing stations, along with community health workers delivering other programs.

Because of the importance of these services, it is imperative that Health Canada ensure that remote communities have access to clinical and client care, that nursing stations are staffed with registered nurses, and that nurses work in a safe environment, have access to physicians to support them, and have access to tools.

Registered nurses and nurse practitioners are predominantly the first point of contact in isolated communities and are highly educated and qualified individuals. To ensure that our nurses are prepared for the unique demands of working in remote stations, a mandatory training requirement has been defined and is now part of the national education policy.

I can report that we currently have an 88% compliance rate on Health Canada's nursing education model for controlled substances in first nations health facilities, while advanced cardiac life support is at 63%, trauma support is at 59%, pediatric advanced life support is at 64%, and immunization is at 61%. The overall compliance rate is at 46% as of the end of April 2015. We still have work to do, and we are doing it while ensuring that we have resources in place to backfill these important positions while incumbents are in training.

Health Canada is committed to ensuring that nurses working in remote first nations communities meet established public service requirements on top of these workers' already robust credentials.

Remote and isolated practice environments sometimes require nurses to respond immediately to life-threatening or emergency situations. Nurses therefore need appropriate mechanisms to perform these important duties.

Clinical practice guidelines assist nurses to address clinical care situations and provide instruction on whether and when consultation with a physician or a nurse practitioner is required. There are arrangements in place for all nursing stations to access physicians when physicians are not located in the community. We also continue to collaborate on region-specific solutions with provinces to advance access to health services and with regulatory bodies to support nurses practising within their scope of practice.

A key challenge is the need for more nurses. Health Canada has implemented a nurse recruitment and retention strategy, which involves a number of initiatives: a nursing recruitment marketing plan, a nursing development program, a student outreach program, and an onboarding program.

Since its February launch, we have received over 500 nursing applications, with 200 of these moving to the next level of screening. As well, the strategy aims to increase the number of nurse practitioners, which will provide greater stability in the clinical teams, assist in meeting training objectives, and enhance the level of services available at the community level.

Nurses and other community health professionals require facilities to conduct their work. Currently, we invest approximately $30 million annually for repairs, renovation, and construction of health facilities, plus an additional $44 million for maintenance and operations. The nursing stations are owned by first nations communities, and we collaborate with them to support their operation.

We work with first nations communities to ensure buildings are inspected and deficiencies are addressed. In response to the audit, we are implementing a more robust tracking system to capture this work. We will also enhance our process in order to use facility condition reports as a tool to better plan maintenance and renovation work with the owners.

In addition, to ensure new nursing stations are built to code, we have updated our requirements for attestations and have communicated the change to facility management staff. The audit rightly noted that the requirements, such as the station as defined currently, did not provide the necessary level of assurance.

Another area reported on was the management of medical transportation; medical transportation that provides coverage to support access to insured health services. Health Canada spends over $300 million on medical transportation per year, and approximately 60% of that is in remote and isolated communities. The main reasons for transportation are emergencies, at 24%, hospital services, at 10%, appointments with general practitioners, at 7%, and dental services, at 5%.

The program provides coverage for transportation to the nearest appropriate professional or facility that takes place when the needed service is not locally available. Our goal is to provide timely coverage for medical transportation to avoid an undue burden for clients and health care professionals. Decisions are based on a national program framework and are made with a solid understanding of the health services available and the transportation options at the regional level.

In response to the audit observations, the program has already modified and disseminated guidelines to resolve discrepancies observed between our practices and the medical transportation framework in terms of the level of documentation required.

Regarding the transportation of children who are not registered, Health Canada has a long practice of allowing coverage for a child up to one year of age to be covered for medical transportation under the registration number of their parents. Health Canada will continue its efforts with partners to inform parents and make available registration material in nursing stations and health centres.

Health Canada and the Assembly of First Nations are undertaking a joint review of the non-insured health benefits program, of which medical transportation is a component, and I am pleased to report that the work is well under way. It will identify strengths, weaknesses, including inefficiencies in administration, and recommendations for action.

Given that the geographic location, the size of the community, and the need to ensure cultural safety influence the range of programs and services funded or provided by Health Canada, comparing one community to the other is not always possible or the best approach. Community health planning, investing in the integration of services with provincial systems, and the development of community programs and capacity have proven to be more effective and more responsive to community needs over time.

As indicated earlier, Health Canada funds a number of community programs aimed at addressing specific needs and working as a complement to the clinical and client care program. These programs are funded to support community health needs and mostly managed by the communities themselves. In response to the audit, we will improve our support to community health planning to enhance integration of the community-based programs and clinical services where these services are delivered by Health Canada. We will also engage with the communities to review the current service delivery model and clinical care resource allocations.

The last area I would like to discuss is coordination among health system jurisdictions.

We work closely with partners to build health service delivery models that take into account community needs.

We have made significant progress with health service integration over the last 10 years. We see examples in various regions where there are more physicians' visits, provincial services are being extended on reserve, and there are more collaborative arrangements between community health services and regional health authorities. Co-management and trilateral tables exist in most regions to formally engage with provincial and first nations partners to advance common practices and resolve systemic issues. We will formally engage these tables in order to make progress on the important issues raised in the report.

Health Canada will continue to collaborate with our partners to develop and implement other models of first nations-led health systems across the country, as we have celebrated in B.C. We have presented an overview of our action plan, which requires further engagement and collaboration with first nation partners. We believe the next update will be more comprehensive as it will benefit from our partners' input.

In closing, we are working on a number of actions in response to the audit, and we will continue to do so.

I would note that I am accompanied today by three senior officials from Health Canada's first nations and Inuit health branch: Valerie Gideon, assistant deputy minister, regional operations; Robin Buckland, executive director, office of primary health care; and Scott Doidge, acting director general, non-insured health benefits.

We would be pleased to answer your questions. Thank you.

[The Chair, NDP, David Christopherson]

Thank you.

Colleagues, we'll begin questions and comments in the usual rotation, beginning with Mr. Albas.

You now have the floor, sir.

[Dan Albas, Conservative, Okanagan—Coquihalla, BC]

To our witnesses, thank you for bringing forward your expertise and for the work you do for our country.

Auditor General, I always appreciate the opportunity to discuss your reports directly with you. In this report, there seems to be very much a focus on Ontario and Manitoba, but I don't see a lot of other examples such as we heard about British Columbia. Of course, I'm a proud citizen of British Columbia.

Could you share with us why that is?

[Michael Ferguson]

Certainly. I think every time we have to do an audit, we have those types of scoping decisions to make about what we can look at, what we can include in a particular audit. In this case, we wanted to look at the services Health Canada is providing to those remote first nations. The model in British Columbia that has been put in recently is significantly different. We're doing a little bit of work right now to try to understand that model so that maybe it will be the subject of something that we could do in the future.

It was really a matter of trying to identify the types of remote first nations that we could include and the amount of work that we could do over the course of one audit. We decided to scope this audit to the services provided in Manitoba and Ontario.

[Dan Albas, Conservative, Okanagan—Coquihalla, BC]

I can certainly appreciate that. It's just that it is helpful, when we have a national auditor general do a report, to give comparables right across the country. As we know, Health Canada works with first nations. I think there are over 660, if my recollection is correct. As our guest said earlier, there are many different areas of jurisdiction in managing these services. I'm quite hopeful that at some point we'll be able to see some results of some of your investigations into British Columbia. I have many first nations in my riding, and the new health authority has received some initial good reviews, but again, those are initial, so I would appreciate that.

Mr. Perron, with regard to the ownership of these nursing stations themselves, are they owned by Health Canada, or by the individual first nation, or are they leased through a different provider? Could you give us a little analysis on that?

[Sony Perron]

Yes. These health facilities built on reserve are owned by the first nation. This is according to the Indian Act. Ownership is really with the first nation community. The way we are working with the first nation community on these buildings is that basically we are funding them through contribution agreements to do the maintenance, the operations, the renovations, the repairs, and the construction.

[Dan Albas, Conservative, Okanagan—Coquihalla, BC]

When we talk about first nation communities, Westbank First Nation, for example, is in my riding. They actually do a lot of lease arrangements. When someone goes into a store on reserve...they actually are leased out to private individuals.

Do all the first nations own the facilities that Health Canada operates in, or do they sometimes lease out to private operators? How does that work?

[Sony Perron]

As far as I can tell, the nursing stations are owned by first nations in all regions. I would perhaps ask my colleague Valerie if she knows of any exception to this rule.

Usually the nursing station is owned by the first nation community and will be operated by a health director who is hired by the community as well. All Health Canada nurses, where we deliver clinical care directly, will be located in that facility, along with community health workers.

[Dan Albas, Conservative, Okanagan—Coquihalla, BC]

The reason I raise this is that, as a member of Parliament, I've been in both the Confederation Building and the Valour Building. One is owned and operated by Public Works and the other one is leased. The rules and the processes in each building are completely unique one from the other. I just wanted to see if there was that issue there.

When it comes to the governance, you mentioned in your opening statement that you're working with first nations communities. I imagine every community is different. They have different populations, different budgets, and different priorities. For example, some big issues for the Penticton Indian Band are dental care and diabetes.

How do you work with that? Is it a challenge to make sure that these facilities are working with the standards that Health Canada has put forward but also with individual first nations and their priorities?

[Sony Perron]

You have a number of questions in there. I will try to answer some of them.

First, a construction project like a nursing station is a pretty big project, ranging from $12 million to $15 million. Some communities won't see projects like that come along very often. We need to work with them on the planning, the capacity building, and the governance to handle these projects. The fact that we're doing one or two projects a year gives us lead time to work with them to set the contribution agreement and to do the phases of the project.

We also provide, in some areas, some lead time to do the design and to consult with our team. We have some resources located in each and every region—except in British Columbia, where now this function is delivered by the first nations health authority—to provide the expertise needed to advance these projects. We work side by side. The model is really with contribution agreements. At the end, the general contractor or the plumber or the electrician will be hired by the community to do the building. That includes the architect and the engineer, if needed.

One of the challenges is in bringing the material up north to really isolated communities, which is what we are talking about here today. For these nursing stations we need to plan two or three years ahead to start these projects. When it's time to construct, the material has to have been delivered.

[The Chair, NDP, David Christopherson]

Very good. Thank you. The time has expired.

Mr. Allen, you have the floor, sir.

[Malcolm Allen, NDP, Welland, ON]

Thank you to our guests.

Mr. Perron, let me start with you. On page 3 of your written testimony, you give some statistical numbers. I have a pretty simple question: does that include B.C., or is that just Manitoba and Ontario?

[Sony Perron]

It does not include B.C., because we do not monitor what is happening on the operational side in British Columbia anymore. We can ask, though, because we have a relationship with them.

[Malcolm Allen, NDP, Welland, ON]

No, it's just that apples and oranges can get confusing. I want to make sure, when I look at your numbers and I look at the Auditor General's report, I'm looking at the same two places.

[Sony Perron]

Just to clarify, it will include statistics for Quebec and Alberta as well, where we do deliver clinical care. So it will be Ontario, Quebec, Manitoba, and Alberta.

[Malcolm Allen, NDP, Welland, ON]

So I really am looking at an apple and a pear. I'm not actually looking at two apples.

When I compare your numbers and the Auditor General's, they're not the same. Statistically they're not the same but they're not the same comparators. You're looking at four jurisdictions. He's looking at two. He says quite clearly on page 5 under “What we examined”, that they selected a sample of 45 Health Canada nurses, 24 in Manitoba and 21 in Ontario.

Mr. Ferguson, I'll put the question to you. Did you study Quebec or Alberta or anywhere else when it came to that particular chart, exhibit 4.2, on page 6 in the English version?

[Michael Ferguson]

No, we didn't. I do just want to clarify that in the section “About the Audit”, we indicate that we had looked at 64% of the 85 remote first nations. So by looking at just Ontario and Manitoba, we were able to cover off 64% of these first nations.

[Malcolm Allen, NDP, Welland, ON]

Okay.

The dilemma I have, Mr. Perron, is that I'm looking at a number that says your compliance rate overall is 46%. The Auditor General has a compliance rate in Manitoba and Ontario that is significantly less than that. The problem is that I can't actually break out what you've given us and what the Auditor General's report says, unless you want to supply that to the committee for Manitoba and Ontario. I really don't know if you have it in front of you or not.

Are you any better, as of April of this year, than what this report indicates, and if so, what are the numbers?

[Sony Perron]

I'm sorry. We could have provided the breakdown by provinces. I don't have that with me.

Robin, do we have it? Okay. I will let Robin give you the details for Manitoba and Ontario.

One thing I will add is that when the audit team did their work, one thing we had a deficiency in was the supply of evidence as well. For some of the numbers in terms of the deficiency, it's due to our own lack of organization for that. Our numbers are—

[Malcolm Allen, NDP, Welland, ON]

I hate to interrupt you, but that doesn't speak well to your department if you can't supply your own evidence to support the systems you're actually working with. The whole idea of being able to tell the Auditor General and then Parliament whether your system works is that by having the evidence you can actually prove it. That's actually a deficiency of your department, sir. I don't think it's anyone else's deficiency.

Mr. Perron, on page 5 of the Auditor General's report, in paragraph 4.26, he talks about how the issue of nurses not having completed mandatory training goes back to a previous report in 2010. Also, later in his report, a similar comment is made on page 23 in the English version, in paragraph 4.115. It's a similar idea: “The need to measure whether Health Canada provides comparable access was also raised in...2010.”

The Auditor General said in both of those paragraphs that you were told in 2010 that you needed to do this. I'm not suggesting, Mr. Perron, that you might have been the person there—I don't know—but clearly your department was there. Here we are five years later and at the time you did supply an action plan to this committee for the 2010 report that said “thou shalt do”. Some of the timelines are June 2011, April 2010, December 2010, and March 2011. This is May 2015. If I were your teacher, I'd say that you've all flunked.

Do you have any response as to why this didn't get completed and the Auditor General is now back and asking you how come? You're before us and we're asking you, how come?

[Sony Perron]

Thank you for the question.

The main reason for being behind on the training is the recruitment and retention. We have a high turnover of nurses.

Our first order of priority is to make sure we have nurses in the position to deliver the service on an ongoing basis. This is not a justification for not meeting our own mandatory training standards. I would agree; this is a problem we are trying to fix.

At the same time that we are investing a lot of energy on training to improve our numbers there, we are also running a really aggressive recruitment strategy. We are hopeful that we will be able to stabilize the workforce, because to be able to deliver the mandatory training that has to be repeated every year, or every two years for some of the courses, we need to have a stable workforce. Each time we lose a nurse, we need to start back, and a new nurse may come into an employment position without that nursing background or the mandatory training met.

This is a fundamental issue we have with the training. It's the ability to stabilize the workforce. We still have a high turnover of nurses, but our recruitment strategy is starting to produce results right now, so this should help to stabilize the workforce and help improve our numbers in terms of training.

[The Chair, NDP, David Christopherson]

Very good. Thank you. The time has expired.

We'll go to you, Vice-Chair Carmichael. You have the floor, sir.