Public Accounts Committee on June 1st, 2015

[John Carmichael, Conservative, Don Valley West, ON]

Thank you, Chair.

Welcome to our witnesses today and to Auditor General Ferguson.

Mr. Perron, I'd like to begin with you with a question following up on the line of questioning by my colleague opposite. I want to talk about qualifications that nurses must have through their provincial certifications before they are employed in nursing stations. We can start there. Could you expand on that and talk to what it takes in terms of the qualifications that are going to produce somebody who is clearly capable of doing the job?

[Sony Perron]

Mr. Carmichael, I'll do the introduction and let Robin Buckland add to this.

To be employed by Health Canada, you need to be a registered nurse in one of the provinces where we are operating and in the province where the service will be delivered. Sometimes we have nurses who are registered in more than one province, and then we can have them practising in more than one province.

Robin is probably better placed than I am to tell you a bit more about the credentials these nurses need to have to be able to work at Health Canada.

[Robin Buckland, Executive Director, Office of Primary Health Care, First Nations and Inuit Health Branch, Department of Health]

Thanks, Sony.

I am a registered nurse, and I have been for the last 27 years. To become a registered nurse, you have to complete a nursing program. In the vast majority of the country, it's at the baccalaureate level; you have to have a degree in nursing. In Quebec, the entry to practise is actually a diploma, so you can obtain a nursing diploma from the CEGEP in Quebec. Basically, through nursing school, you obtain the core competencies that are required to function as a registered nurse.

Generally speaking, nurses come out of nursing school and they are generalists. They're able to practise in a wide variety of areas.

In remote and isolated locations, there are additional competencies that are required. As the report indicated, they are often the only provider in the community and they are the first point of contact for the patient. They need to be able to respond to what comes in the door. If it's an emergency, a trauma, they need to have the competencies to deal with it. That is why Health Canada has identified advanced cardiac life support, pediatric life support, trauma, and the other courses you'd see listed as our five courses. Those are the key competencies that RNs will require to meet the needs of the community, in addition to so much more.

[John Carmichael, Conservative, Don Valley West, ON]

Robin, you explained—and, again, I'm from a long way outside of the medical profession—about the core competencies. When they move into first nations and isolated communities as the sole provider of health care in that area, are the types of qualifications they're required to have fairly common across the country, or is this the entry level and then we have to increase the standard from there?

[Robin Buckland]

Our expectation is that they have those competencies. That's where it begins; it's not where it ends. In addition to those, I would say more highly technical skills, there are also a lot of additional skills that are required, including cultural competencies, to be able to offer safe health care services.

They are often the only provider and the first point of contact, but we do work toward having a team within the nursing station. Nurses have access to nurse practitioners, to physicians, either in person or via telephone or e-health. We do like to make sure that they have access to an interprofessional team.

I'm going to stop. I'm not sure that I've fully answered your question.

[John Carmichael, Conservative, Don Valley West, ON]

It's clear as you explain it and from the report that each of these individuals is very integral and very important to the care in that community.

You talked about turnover. You lose one nurse, one key individual, and you have a major gap.

Could you talk a bit about the recruitment process and how you deal with the loss? You talked about a team. How many teams are out there, and how many locations are there with a single practitioner?

[Robin Buckland]

We have very few nursing stations with less than two nurses within them. Generally speaking, we like to make sure there's at least a team of two. We have 53 nursing stations that we deliver nursing services in, which as Sony indicated are in Alberta, Manitoba, Ontario, and Quebec.

I forgot the second part of your question. I apologize.

[John Carmichael, Conservative, Don Valley West, ON]

Could you talk about recruitment briefly? Obviously, that's integral.

[The Chair, NDP, David Christopherson]

Very briefly.

Go ahead, please.

[Robin Buckland]

Okay.

We're working hard—and I think this responds in part to your colleague's question about how have we come this far and not had our training done—but our turnover rates are very high. We recruit ten nurses and we lose five. It's very difficult. When you have a nurse going out of the community to obtain their training, we work hard to get a replacement so that the community is not missing access to services. We do that in a number of different ways, to make sure that service is continued.

[The Chair, NDP, David Christopherson]

Very good. Thank you. The time has expired.

Over now to Monsieur Giguère.

[Alain Giguère, NDP, Marc-Aurèle-Fortin, QC]

Thank you, Mr. Chair.

My question is for Mr. Ferguson. It is a little more general.

This is not the first report you submit to us on matters pertaining to first nations. Very unfortunately, these reports tell us time and again that first nations don't have all of the services they might expect. Promises made are hardly, if ever, kept.

In Canada, in terms of services, would it be that there is one set of criteria for Canadians and another for first nations? In fact, given the number of reports tabled in recent years indicating that first nations still have poor quality services, the question arises. Are there two standards for the public service? If not, how do you explain that once again a report is indicating that first nations are not receiving what they should?

[Michael Ferguson]

I think that, generally speaking, what we see here is similar to other problems we have observed in other audits concerning first nations.

I think of things like departments having said there are certain standards that they have to meet, that they have to live up to, but not doing that. Again, in this case, it was a situation of nurses who were supposed to have the training and not getting the training.

Again, it was mentioned earlier that some of these problems have been known for a while but have not been fixed. Over the last few years, we've done audits on policing services on first nations and also on emergency response on first nations, and I would say that the types of problems we are identifying here are similar to the problems we've identified in those other audits.

We haven't done anything to look at it from the global perspective to try to understand why those problems are persistent. Certainly, we're dealing with first nations that are remote, but nevertheless, I don't think that excuses the fact that departments are not living up to their own set of standards, the expectations they've set for themselves for the services to provide on the first nations.

[Alain Giguère, NDP, Marc-Aurèle-Fortin, QC]

Mr. Ferguson, in point 4.4, you talk about social determinants as one of the essential aspects that harm the health of first nations' members the most. You talk specifically about overcrowded housing, high rates of unemployment and problems with access to drinking water. The problems mean that first nations currently have a considerably lower life expectancy than the general Canadian population. Statistics Canada data indicate that these problems are very serious and that, unfortunately, with the very significant population growth of first nations, they are worsening rather than resolving themselves.

You told us about coordination among the different stakeholders. Since prevention and public health are important aspects of access to health care, I would like to know if, in terms of coordination, the department is making an effort to resolve problems that aggravate the health of first nations individuals, for example the lack of access to drinking water, overcrowded housing and poor follow-up for psychological care, which results in very high suicide rates.

Are efforts really being made to address these problems? I won't even get into problems with food, which are significant all over Canada.

[Michael Ferguson]

I don't want to downplay the issues, certainly, that were found here. I think when you look at our conclusion, you see that we have said that the department does not have reasonable assurance that these first nations had access to the services and the medical transportation benefits that we examined. But I don't want to downplay the complexity of the environment that the nurses are operating in and the challenges they face, including these types of social determinant challenges.

Fundamentally, in the course of this audit, we found that there were a number of things that the department could have been doing better that were within their power to do better. Despite the complexity of the situation and those problems they face, there's more that they could do.

Now, the department has agreed with our recommendations. They've said that they're going to implement our recommendations. In this audit, we made 11 recommendations, which is more than we make in a lot of audits. If they can put measures in place to deal with those issues we found, to deal with the recommendations we made, we certainly feel that it's possible for them to significantly improve the services to these remote first nations.

[The Chair, NDP, David Christopherson]

Mr. Giguère, your time is up. Thank you.

We'll move over to Mr. Hayes. You have the floor, sir.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

Mr. Perron, I'm looking at page 18 of the Auditor General's report, exhibit 4.3. That's a chart, and there's something I don't understand on the chart.

In terms of pre-authorization of non-medical escorts, in all circumstances that occurred, in Manitoba 18 of 18, in Ontario 14 of 14, I'm confused as to how there could be a pre-authorization of non-medical escorts without even knowing that medical transportation was required. I want to understand that pre-authorization.

[Sony Perron]

The non-insured health benefits program is a quasi-insurance program. It confirms that coverage and payment will be provided to the provider, whether it is the airline, the bus, the hotel, or the restaurant for the meals for the client.

Every time someone needs to leave a remote community, they will go to their nursing station. The nursing station will contact the Health Canada regional office to say that the patient needs to travel to a place for an appointment with a physician, let's say, or go for an X-ray. Our officer will verify that the client is registered, that this is eligible under the framework, and will confirm to all the providers who will need to assist the client to get to the appointment that we will pay and cover the fee for the services.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

In that particular case, all 50 requests, can we assume that all of the individuals were registered in Aboriginal Affairs and Northern Development Canada's Indian registration system, as well as Health Canada's status verification system?

[Sony Perron]

Yes. It's the same database. They are connected. We are using the Indian registration system from AANDC as our source of information.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

With respect to registration, does anybody get turned down if they're in a dire medical situation and they need transportation and they're not registered? Do they get that transportation?

[Sony Perron]

Especially in these remote and isolated communities when someone needs to be evacuated in an emergency situation, we do not get in the way of health services with administrative considerations.

The person is medevaced or will get an ambulance service and get to the point of services. It's only after the fact that we will confirm that the person is registered. If it happens that it is someone who is not registered, then we'll have to send the bill for the ambulance service to someone else, but it doesn't get in the way of accessing emergency transportation.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

Then why isn't registration mandatory?

[Sony Perron]

This is an individual choice. If people want to register and become an Indian under the Indian Act, they need to make the decision. Usually it's the parents when the newborn comes who will make the decision to fill out the paperwork, provide all the pieces of evidence, and get registered with Indian Affairs, but once you're registered as a first nations person, you cannot deregister.

It's an important decision, and we understand that various factors influence the decision to register or not.

[Bryan Hayes, Conservative, Sault Ste. Marie, ON]

You talked in your opening statements about I think it was $300 million that was appointed for transportation services. What portion of that is for medevac access? Can you talk a little about the medevac access program that's in place for remote reserves?