Public Accounts Committee on June 1st, 2015

[Malcolm Allen, NDP, Welland, ON]

Mr. Ferguson, I noticed that your spring report chapter 4 has 11 recommendations. I've been here for a number of years and I don't remember the last report that had 11 recommendations. Maybe it was the F-35 and even that one I don't think had 11 recommendations. Is that on the high side for recommendations from your department? It's not an average in my experience, but I was wondering if it was an average in the department's experience.

[Michael Ferguson]

I think certainly in recent practice having 11 recommendations is on the high side. I think in the course of this audit the type of things that we were noticing were at specific levels so it lent itself to being able to make recommendations at each of the things that we looked at.

[Malcolm Allen, NDP, Welland, ON]

Mr. Perron, I don't think you said this; I think Ms. Buckland gave me the number. You talked about retention. I think you said on average you recruit ten and lose five. Was that right?

[Robin Buckland]

That's correct.

[Malcolm Allen, NDP, Welland, ON]

I can imagine you do. I have no idea what you pay them and I don't want to know. But when I look at the Auditor General's report he talks about supporting mechanisms that support the scope, working outside the scope.

Personally, my wife's a nurse. She's licensed in the province of Ontario. If she works outside her scope, she will lose her licence if she gets caught. I can imagine nurses get nervous when they're asked to work outside their scope, not necessarily by the department but by a patient in a remote region who can't get service. Looking at someone who's critically ill or injured and doing what they need to do to serve the patient at the time is outside their scope. What a dilemma they're placed in, Ms. Buckland. You're a registered nurse with a licence. You know exactly what that means to them. I can imagine the stress they go through with that.

Then we hear about a residence that doesn't have a septic system for two years. I live in the country. I had three kids who used to live in my house. I can imagine that septic system being down for two days, never mind two years, and there being a riot. Can you imagine living in those conditions, Mr. Perron? Do you wonder why you have retention issues?

By working outside the scope as a professional you can lose your licence. You're asking them to do that. You're placing them in a position to have to do that. Having them reside in a place that isn't fit for human health.

Then the Auditor General goes through a litany of other things like ventilation and cooling systems that don't work. Working in an environment where the X-ray door may not seal properly and you're asking them to give X-rays to people. And you wonder why you have retention issues? It's lucky you have any.

It's amazing you don't have nine out of ten leave, never mind five out of ten. Who would work in those kinds of conditions? You would have strikes across southern Ontario and every major manufacturer if this is how they treated their employees and these sorts of things weren't addressed.

That's why you have retention issues. It isn't about how much you pay. It's about asking them to work outside the scope of their professional ability to do so and that their licence could be revoked. You place them in a place where it's unfit to live. You don't train them properly before they go. And then you say you have retention issues.

Yes, you have retention issues. You have major problems. You have 11 recommendations of which two go back to 2010, five years ago, that you promised to complete, that you didn't get completed. You said then that you had a retention issue. You still have a retention issue.

Quite frankly, your department, sir, has failed. You've failed this Parliament, because your obligation is to us, but more importantly you've failed first nations people. That's who you've really failed.

This wouldn't happen in Welland, let me tell you. Never would we put up with this service in Welland. It wouldn't happen. There would be a riot in the street if we thought this was the kind of service we were going to get. Nurses would not go to work in the places that you're asking them to go to work in if it were in southern Ontario. It wouldn't happen. That's why you have retention issues.

You have a lot of work to do, sir, and you need to start soon. In fact you needed to start five years ago and you didn't get started then. Quite frankly, I have no idea how you're going to make this up and how quickly you're going to make it up, but you need to make it up in a hurry. I don't know what resources you need, whether it be people or money, but if you intend to have a service that's equivalent or reasonably equivalent to what our expectations are, including your department's expectations.... Could you put them in writing?

I don't know when you intend to get started, but my goodness, you needed to get started a long time ago. The people of this country, our first nations people, deserve better, and we've failed. Hopefully, sir, when the next report from the Auditor General comes we won't be seeing the same thing, because quite frankly, to be truthful, in any other major industry or other place, heads would roll. My friend across the way and I worked in the auto sector. If this were an indictment of our sector, heads would roll for that kind of performance.

[The Chair, NDP, David Christopherson]

Thank you, Mr. Allen.

Mr. Falk, you have the floor, sir.

[Ted Falk, Conservative, Provencher, MB]

Just to go a little bit further on Mr. Allen's comments, your department has talked a lot about, and the Auditor General has talked a lot about, the whole issue of employee retention. Is that something that your department has addressed?

Maybe just to help you with the direction I want to go in, when people leave the employment of the department, do you conduct exit interviews? If you do that, what is the primary reason for people leaving the employment of the department?

[Sony Perron]

As part of the recruitment and retention strategy, one thing we are trying to do more and more is inform the nurses about the working conditions and the type of work they will be asked to do in the communities. We want to make that when we invest in training and integrating these people into the health team, they will stay in the business, and there won't be surprises for them up there.

We're spending a fair bit of energy up front to describe the situation. These are locations with really small teams. They're not part of large teams where they will have connections. There are infrastructure challenges in the communities in terms of access. These conditions need to be well known. This is an important component of the strategy.

There has been an important reaction from our marketing campaign. A lot of people have come to us to ask for information about this program, these services, and how this will work up there. We are really confident that we will be able to attract a new group of workers.

Within this, to address one of the issues around scope of practice, we are also trying to integrate nurse practitioners as part of the team. One of the issues with scope of practice was that our model was relying a lot on registered nurses. Nurse practitioners have the ability to perform a larger span of duties and support registered nurses to do more work as well, addressing a portion of the issue with scope of practice. I'm happy to say that in Ontario, for example, we're trying to recruit 10 more nurse practitioners to place them in remote northern communities in Ontario that will address that.

This is also about reinforcing the team, creating a cement for people to want to stay in the community in these health teams, because they will be better supported. In all nursing stations, whether in Ontario, Manitoba, or the other provinces, there are arrangements in place with physician services. While nurses there are isolated physically and in really small teams, they always have access to a physician or a nurse practitioner for consultation, helping with the scope of practice. We are trying to clarify these roles so that people are less afraid to come and work at Health Canada and will understand that they are not left alone in the field with such challenging and demanding work.

Robin, would you like to add a little bit on where we are with the recruitment strategy at this time?

[Robin Buckland]

Yes.

I want to start by underlining that scope of practice is a big issue in terms of recruitment and retention. It is really important that we have a safe practice environment for our nurses to work in. As you indicated, nurses will not want to come and work for us if they think they're going to lose their licence, but as Sony indicated, in the vast majority of situations that nurses find themselves in, they are working within their scope of practice. We do have these other supports where they're able to call a doctor and get that order so that what they've done is not outside their scope. Having that safe practice environment is really important in terms of recruitment and retention.

We're increasing the visibility of this as a place to work. Despite what the report says, there are nurses who are excited about the idea of coming and working in first nations communities. It provides an opportunity to do stuff that they wouldn't necessarily see in downtown Toronto. It provides them with an opportunity to work in another environment, learn another culture. There are some really exciting things about working in first nations communities.

In addition to our mandatory training, we're also working, in terms of recruitment, on a development program that's helping in a couple of areas. Number one is training the nurses in charge. You need to have that leadership if you're going to have a good practice environment for nurses in which the processes are followed and everything runs smoothly.

That's one part of the development program. The other part of the development program is bringing in those new grads and making sure, as Sony indicated, it's the right kind of person we're recruiting and then training them up, making sure they have what it takes to work in this kind of environment. It does take a special person.

As well, there's student outreach, connecting with new grads, going to universities and encouraging them to apply. Working at optimizing our staffing mix is another part of our recruitment strategy, making sure we have doctors, nurses, nurse practitioners, and paramedics so that we don't run into the scope of practice issues.

[The Chair, NDP, David Christopherson]

Do you have a really short follow-up? I'll allow it if it's really short.

[Ted Falk, Conservative, Provencher, MB]

Yes.

I have some good news for you. Last week in Manitoba, 60 new oral health professionals graduated from the university: 35 dentists and 25 dental hygienists. The majority of them come from the province of Manitoba. They were born and raised there. There's an opportunity for you there.

Can you speak about your new oral health initiative that's happening among the first nations people?

[Sony Perron]

We have an oral health initiative that focuses on zero to seven-year-olds, mainly focusing on prevention to avoid decay, dealing with early problems, putting sealant on teeth to prevent further problems in the future, and changing behaviour.

We rely heavily on dental hygienists to practise in the community. We are bringing them for visits in the communities. I was in northern Ontario last week, or two weeks ago, and there was a dental hygienist there with kids in the clinic doing treatments.

This is a very aggressive strategy that has been in place for a number of years. We are bringing the health and dental professionals into the communities. I'm really pleased to hear that there are more graduates that can practise in the community.

[The Chair, NDP, David Christopherson]

Mr. Casey.

[Sean Casey, Liberal, Charlottetown, PE]

Mr. Perron, Mr. Allen took quite a rip at you and your department, and didn't give you a chance to respond. He told you in no uncertain terms what he thinks is the reason that you have a problem with turnover and retention. This is your chance to respond.

Do you agree with his critique, or is there some other reason that you can put your finger on that retention is such a challenge for you?

[Sony Perron]

I agree with some of his points, obviously, that work in the communities is challenging. It's not an easy task. The isolation factor, as I mentioned before, with its small teams and lack of connection, is a challenge.

The infrastructure is a challenge as well, because it is really far to go there and to have problems fixed. I think the Auditor General's audit pointed out the fact that some of the repairs were needed but not done on time.

As for the example of the Deer Lake residence that you mentioned, this was fortunately not the nurses' residence. It was one of the residences, but it's not the one used by the nurses. There were other residences for them. Having good residences for the nurses is an important factor for retention, and we have invested in the last few years in the maintenance and construction of residences.

Those factors are all in there, but the problems and the issues appeared to be a bit different in the different locations. I would say that what has made a huge difference over time is the ability to create a team that is well integrated in the community.

One of the recommendations is about the integration of clinical care into the health planning of the community. We have in many communities where Health Canada delivers the clinical care services a situation where we deliver services and the community runs everything else in terms of health programs. There is a need to have really good integration, because the nurses are essential to the delivery of some of the community health programs, and the community health worker can also be a great support to the nurses to deliver what they are doing and deal with what they see in their day-to-day consultations with clients.

This element of integration and making sure that the nurses' work fits well with the community health plan is an important element going forward that we have tried to invest in, and we have to do it again. There is a divide there in terms of what we are doing and what the community is doing, but there is attention being put on that.

I think improving the infrastructure is also on the electronic side, electronic medical records and telehealth. We have made a lot of progress in various provinces and regions to deploy telehealth in the communities so that a patient can consult with a nurse or a physician over telehealth, or they can access mental health workers through telehealth. This is an important element of our strategy to improve the quality of the service and the connection between the nursing team, the community, and health professionals elsewhere.

Implementing electronic medical records is essential. I was talking to a physician who practises in one of the nursing stations. What they want is, when they visit for a week or so in the nursing station working with nurses, the ability to continue their practice on electronic medical records that is part of the provincial system. They will be able to advance their work and make sure that the client's next step in terms of treatment will be in the system that they know when they practise in the south.

We have to invest more and we are into the enabling infrastructure, not only the physical infrastructure but also the IT infrastructure. This is one place where the nurses have complained about connectivity for years. In northern Ontario we have five communities where the high-speed large bandwidth is not yet available. We are getting there working with partners so that these communities will be well connected going forward.

It's building this infrastructure that allows a small team into an isolated community to be connected with the rest of the health system, to transfer files, do referrals, and receive results of exams and tests electronically. This has been more and more visible in the community in the last five to ten years. We still have some issues to deal with to build that in some of the remote northern communities in Ontario and Manitoba, but we are getting there. By building the enabling infrastructure I think we'll also have a better chance to retain nurses. That can't compare because sometimes they work part-time for us and part-time elsewhere, and they say they're missing some things there that, if they had them, would work way better.

They do not dream about having road access. There won't be road access there in the near future, but they dream about having access to information that allows them to practise with their full capacity there.

Adding nurse practitioners on the team is also a way to reinforce the nursing team so that they don't feel that they are isolated, because they can get guidance from nurse practitioners in terms of doing some of these actions that otherwise they wouldn't be able to do or they wouldn't be able to do without breaching their scope of practice.

[The Chair, NDP, David Christopherson]

Sorry, but there are two seconds left, enough time for me to say thank you.

Mr. Woodworth, you have the floor, sir.

[Stephen Woodworth, Conservative, Kitchener Centre, ON]

Thank you to the witnesses.

There are two areas I'd like to ask about. I'll at least start by directing my questions to you, Mr. Perron. You can pass them on if it's appropriate to do so. You've already touched on both of the things I'd like to ask you about, so I'm essentially just going to try to get a few more details.

One of them has to do with recruitment. I noticed in your opening remarks that there are at least four new tools, or initiatives, that have been mentioned. One is the nurse recruitment marketing plan. Another is the nursing development program. Third is the student outreach program. Fourth is the onboarding program.

I also know you have to look after about 91,000 people. I seem to recall seeing somewhere in the material that there may be something in the order of 400 locations, or at least many locations, many of them in remote areas. It's that remoteness I'd like to ask about, because I think that in itself creates a challenge for recruitment, apart from everything else we've heard here today. I can think of a number of different ways whereby one can try to attract people to remote areas, but I'd like to hear what, if anything, you're doing to try to make it easier to attract people to more remote, isolated areas.

[Sony Perron]

Thank you.

One of the things we have done for almost 15 years now is we have invested in health human resources not only to attract people from the south to working in first nation communities, but also to increase the number of aboriginal health workers. This has been an important investment for the branch. While most of them may not come to work in the first nations and Inuit health branch, in the end they may decide to go to work for the provinces or for the first nation communities themselves, which is great. Having more health workers who have an aboriginal background is one element of the strategy, because we do have employees who come from first nation communities working in first nation communities. We are really proud of that, because the cultural dimension of the health services is very important.

Something all of you are probably aware of is that we have a lot of people who, when they go to the south to visit a hospital or see a physician, are a bit nervous about that contact, because they are not used to it. We are trying to bring the cultural appropriateness of the service into the community, thinking that this will also create a more resilient and stable workforce there. It's very important to invest there.

In terms of better informing the nurses, if you have not done so, I invite all of you to go to the Health Canada website to see the video and information we have displayed there since February of this year in terms of what it is like to be a nurse in a first nation community. We do this to try to attract more workers to Health Canada, but we also use that to bring those people who prefer to work for first nation communities there. It's an aggressive marketing campaign to show what it is like to work there. There are also advantages for people who like to live closer to nature, work in small teams, and face challenges. There is value. We are also trying to amplify the positive side of this. There is not only the negative.

I think working in this environment might also bring a lot of satisfaction for the health worker. In fact, we see that when we meet with our staff who are in these locations, they are very dedicated, highly professional, and highly conscientious people, and they like their work. Some will go there for a while because.... The bad side of that—and we're trying to be very transparent with that—is that there is a lot of overtime. For people working in these communities, if there is someone who is sick at night and the nursing station is not open, they will go there and be on overtime. Sometimes there are really long shifts and it's really intense at times in the community. Some people are attracted to that. We are trying to profile this, as well.

Robin, I don't know if you want to add something about the onboarding or the training action we do to prepare nurses to go to work in the communities.

[Robin Buckland]

Yes, I think the onboarding is going to be quite important in making sure we are recruiting the right kind of person and preparing them for the type of nursing they're going to be facing. I think that's really quite important.

[Stephen Woodworth, Conservative, Kitchener Centre, ON]

May I just ask about a few other issues?

I don't know what the pay and benefits structure allows. If you hire someone from the south, do you assist them at all by giving them some form of occasional leave to go back, and if so, transportation assistance? Do you provide a residence for all your nurses or give some kind of housing allowance? Can you tell me a little bit about those incentives, if you have them?

[Sony Perron]

There are housing arrangements in most communities. Health Canada has built with the first nations a nursing residence near the nursing station, and those are considered to be facilities we support. They are owned by first nations, but we invest in there and nurses have access to these residences. They will receive an isolated post allowance in addition to their pay. They will receive a retention bonus in addition to their pay to attract people and retain them in the north. They will be eligible for overtime and callback measures that are all planned in the collective agreement and are highly used in these kinds of settings. Robin was talking about a nursing station with two or three nurses. It means that team might be on very long shifts. We are trying to profile that.

Nurses going into a nursing station expect to do a certain level of overtime, because they will be posted there for a number of weeks and then will go out. We also have a lot of nurses that work part time and will want to do two months with us during the year. They go back to work elsewhere and they come back the year after for another two months or two weeks. We have a lot of flexible arrangements to allow every nurse that wants to practise in these communities to work with us.

[Stephen Woodworth, Conservative, Kitchener Centre, ON]

I want to switch gears, if I have time.

[The Chair, NDP, David Christopherson]

No, sorry. We are going to switch gears, but—

[Stephen Woodworth, Conservative, Kitchener Centre, ON]

My second point will wait. Thank you.

[The Chair, NDP, David Christopherson]

—it doesn't involve you, I'm afraid.

Thank you very much.

Monsieur Giguère.