Public Accounts Committee on March 22nd, 2018

[The Chair, Conservative, Kevin Sorenson]

Good afternoon, colleagues.

This is meeting 90 of the Standing Committee on Public Accounts for Thursday, March 22, 2018.

Today we are here to consider “Report 4: Oral Health Programs for First Nations and Inuit—Health Canada” of the fall 2017 reports of the Auditor General of Canada.

I would remind all of our guests as well as members of our committee and those in the audience today that we are televised.

I welcome our witnesses today. We have the Auditor General of Canada, Mr. Michael Ferguson. Welcome back. As well, from the Office of the Auditor General, we have Jo Ann Schwartz, Principal. Welcome to you.

From the Department of Indian Affairs and Northern Development, we have Jean-François Tremblay, Deputy Minister; Sony Perron, Associate Deputy Minister; David Peckham, Chief Audit and Evaluation Executive, Audit and Evaluation Sector; as well as Marc Plante, Manager, Dental Policy, First Nations and Inuit health Branch.

Colleagues, I would like to point out that when this audit was undertaken by the Office of the Auditor General, the authority and responsibility for first nation and Inuit oral health programs fell under the purview of the first nations and Inuit health branch within Health Canada. Due to an order in council dated November 30, 2017, it is now under the purview of the Department of Indigenous Services Canada, and thus the reason we have officials from the Department of Indian and Northern Development here as opposed to from Health Canada.

We welcome our guests today. I open the floor and turn it to Mr. Ferguson, our Auditor General.

Welcome.

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

Mr. Chair, thank you for this opportunity to present the results of our audit on oral health programs for First Nations and Inuit.

In our audit of Health Canada's oral health programs, we focused on whether the department knew if its programs, the non-insured health benefits program and the children's oral health initiative, had a positive effect on the oral health of Inuit and First Nations people. These programs are important because they provide access to a range of medically necessary dental services.

We concluded that, while Health Canada provided access to these important services, it could not demonstrate how much the services contributed to their objective to maintain and improve the overall oral health of Inuit and First Nations people.

Even though the department knew that the oral health of these populations was significantly worse than that of other Canadians, it did not focus on closing the gap. Also, the department had not finalized a strategic approach to help improve the poor oral health outcomes in the populations it served.

We found that Health Canada knew that its $5-million children's oral health initiative, which is focused on prevention, improved the oral health of some first nations and Inuit children. However, the department's data showed that fewer children were enrolled and fewer services were provided under the initiative than in previous years. Health Canada didn't know why this was the case, making it difficult to address the situation.

We also found there were administrative weaknesses in the department's management of its non-insured health benefits program. The department's service standards for making decisions on pre-approvals and complex appeals weren't clear. Also, Health Canada didn't always inform its clients and service providers promptly about some of the changes it made to the services it paid for. This matters because delayed or unclear communication about what services are available can affect clients' access to the oral health services they need.

We also found that in the two regions we examined, Health Canada was slow to take action to address human resource challenges. If unaddressed, these challenges could eventually affect service delivery. We made six recommendations, including that Health Canada should finalize and implement a strategic approach to improve the oral health of Inuit and first nations people, an effort it began in 2010. We also recommended that it should develop a concrete plan to determine how much difference its programs are making to the oral health of Inuit and first nations people.

Health Canada agreed with our recommendations and committed to take corrective action.

Now that these oral health programs are the responsibility of Indigenous Services Canada, we understand that it intends to fulfill the commitment made by Health Canada.

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

[The Chair, Conservative, Kevin Sorenson]

Thank you very much, Mr. Ferguson.

We'll now turn to you, Mr. Tremblay. We look forward to your comments.

[Jean-François Tremblay, Deputy Minister, Department of Indian Affairs and Northern Development]

I would like to thank the committee chair and the rest of the members of the public accounts committee for the invitation to speak here today. I would also like to acknowledge at the outset that we are meeting on the traditional territory of the Algonquin Nation.

I am accompanied today by Sony Perron, Associate Deputy Minister, Dr. Plante, Dental Policy Manager, and David Peckham, Chief Audit and Evaluation Executive.

I want to assure committee members that officials from Indigenous Services Canada welcome the recommendations of the Auditor General of Canada's oral health report and are fully committed to their implementation with First Nations and Inuit partners.

Oral health services for First Nations and Inuit funded by Indigenous Services Canada reach a significant number of people. Last year, more than 300,000 First Nations people and Inuit received dental benefit services through the non-insured health benefits program, while the children's oral health initiative provided oral health services to 237 First Nations and Inuit communities.

It is important to note, however, that these numbers do not include First Nations service by the First Nations Health Authority in British Columbia, which began to administer all federally funded First Nations health programs in 2013.

In all other provinces and territories, Indigenous Services Canada relies on an interdisciplinary team or oral health professionals to both advise and manage the suite of oral health programs and services to ensure that they reflect the current evidence base.

The children's oral health initiative provides direct clinical preventive oral health services for children, including screening, application of fluoride varnish to prevent decay, placement of sealants on teeth to help prevent tooth decay, sterilization therapy to stop the progression of cavities, and the provisions of oral health information sessions at the community level.

In 2016, through the children's oral health initiatives, 16,000 children received dental screening and 10,677 children received at least two fluoride treatment applications. According to the recent published national report, the “First Nations Regional Health Survey”, access to oral health care for first nations children aged zero to 11 living on reserve and in northern communities has increased from 69.1% in phase one of the RHS to 71.4% in 2015-16.

Based on the strength of existing programs, new funding was received in budget 2017 to support the increased utilization of non-insured health benefits and to invest $45.5 million over five years to expand the children's oral health initiatives. Following regional engagements with first nation and Inuit partners, the department has developed detailed implementation plans for these investments, which will result in greater first nations and Inuit access to oral health and at the community level.

As recommended by the Auditor General, the department is also completing a comprehensive plan to improve measurement of the impacts of First Nations and Inuit oral health programs, including data collection, analysis and reporting.

The plan will help to ensure that data collected in the course of the delivery of services under the children's oral health initiative and dental therapy programs are accurate and rich enough to contribute to the department's overall management and quality assurance of these services.

To ensure that population-level oral health data are also available, the department is working with the Public Health Agency of Canada's Office of the Chief Dental Officer, Statistics Canada, and first nation and Inuit partners to explore the feasibility of conducting new first nations and Inuit oral health surveys. This could dovetail with an oral health component of the Canadian Health Measures Survey cycle in 2022 and 2023.

The department has also sought the advice of the non-insured health benefit program oral health advisory committees on ways to improve its oral health data collection and analysis. The committee is composed of highly qualified, independent oral health professionals and academic specialists. It provides the department with impartial expert advice on a variety of topics, including current and evolving best practices, evidence-based oral health prevention and treatment, non-insured health benefits oral health policy, and clinical technologies and procedures. We have recently received feedback from the committee, which we are incorporating into our oral health data plan.

In addition, there is research funded by the Canadian Institutes of Health Research that aims to evaluate the impact of the children's oral health initiative in first nations and Inuit communities across the country. The department intends to review the findings of this research to identify further service improvements.

Regarding the integrated oral health approach,

The Auditor General recommends that the department finalize and implement a more strategic approach to First Nations and Inuit oral health and actively monitor its implementation. The approach would be accompanied by a detailed action plan to be delivered by June 2018.

In an effort to reduce the oral health disparities experienced by First Nations and Inuit, the department is leveraging the opportunity under this new integrated oral health approach to set evidence-based targets in discussions with First Nations and Inuit partners that will measure progress in reducing these disparities.

Getting these targets will require the department to better mine the data captured across its programs to create a more robust and holistic profile of First Nations and Inuit oral health needs and outcomes.

The strategic approach takes culture, context, and the social determinants of health into consideration.

The integrated oral health approach is in its final stages of development and will be presented for approval in June 2018 to the first nations and Inuit health branch's senior management committee. Members of the committee include the Assembly of First Nations and Inuit Tapiriit Kanatami.

On service standards, decision-making and communications, the Auditor General also calls on the department to better document when and how decisions are made by the non-insured health benefits program to change the coverage of health benefits. In particular, the Auditor General specifies that both service providers and clients need to be advised quickly of these changes.

We accept this recommendation.

An evergreen decision-making process map and governance documents were revised in 2017 that solidify management processes with respect to policy coverage.

To improve program management, the Auditor General recommends that the department clarify its service standard for pre-approvals, clarify the service standard for complex appeals, and improve data entry, so that it has accurate and reliable information in its appeals database.

Mr. Chair, we also accept this recommendation.

Evergreen client and provider communication process maps are under development and will be finalized in April 2018. Information for clients and providers will be provided in a clearer and more timely manner.

The department further revised the appeals section on its website, including clearly stated service standards for appeals. Quality assurance processes are currently being developed and implemented to ensure improved data entry in the appeals database. The department is also in the process of revising its service standard for dental predeterminations.

Now, I'll turn to responding to human resources challenges.

Lastly, the Auditor General recommends that the department implement strategies to ensure there is adequate human resources capacity to deliver first nations and Inuit oral health programs over the long term.

We, of course, accept this recommendation. To respond to it, regional service delivery plans are under way. These include regional-specific strategies to identify and address human resource needs. In addition, the department is supporting the Canadian Dental Hygienists Association to advance their work on curriculum development for an expanded scope of practice for oral health practitioners.

The department encourages all non-insured health benefits providers to enrol with its automated claim processing system, allowing claims to be processed in real time and payments to be directly deposited. This greatly simplifies administration and timeliness of payment to providers.

In closing, the department is committed to continuing to expand access to oral health services that contribute to the overall well-being of First Nations and Inuit.

As the Auditor General's review makes clear, we recognize that there is room for further improvement and are taking concrete steps to improve service delivery.

We will continue to work closely with our indigenous partners to support better access to effective, sustainable, culturally appropriate health services, and to expand their roles in the design, management, and delivery of oral health services.

We would be pleased to answer questions. Thank you.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Mr. Tremblay.

Mr. Massé, you have the floor for seven minutes.

[Rémi Massé, Liberal, Avignon—La Mitis—Matane—Matapédia, QC]

Thank you, Mr. Chair.

I would like to thank the witnesses for being with us to answer our questions, and I thank the Auditor General for his excellent report.

My first question is for Mr. Tremblay.

Mr. Tremblay, in your opening remarks, you mentioned that by bringing health services together with education, child and family services, and infrastructure under the responsibility of one federal department, Indigenous Services Canada, you will be able to better support the needs and priorities of Indigenous communities.

Could you explain how bringing these services together will enable you to concretely help with the delivery of services to Canada's indigenous communities?

[Jean-François Tremblay]

What we think it important is the ability to work on the social determinants of health. When working in health, such as on TB, issues related to home construction and housing can't be ignored. If you are working on the issue of oral hygiene, you also have to look at other things, such as those affecting food security, for instance.

There are many things to consider when trying to treat health properly and effectively.

In some ways, the creation of this department is offering us capacity. One example that is quite easy to understand is mental health. Mental health touches many areas in health, not only one place, so you have different ways of approaching it. Working with child and family services, for example, what you do with income assistance, what you do with health, what you do in other areas gives you a chance to have a more holistic approach and develop an approach that, over time, will better respond to the needs of the community and also to the way they want to shape their programs and respond to the challenges they are facing. For us, it's actually a very good opportunity.

In many respects, this reiterate the points made by the Auditor General about the need for better data. If you want to do that, you will need to have better information about what exactly impacts what, how you can have an impact on that information, how you can have more success, and how you can improve the situations over time. We will look forward to developing that. That's a challenge for us, of course, that we will be addressing with our partners over the next few years.

[Rémi Massé, Liberal, Avignon—La Mitis—Matane—Matapédia, QC]

Thank you.

At point 4.28 of his report, on page 8 of the English version, the Auditor General raised something important. The paragraph reads as follows:

We found that the Department drafted strategic approaches to oral health in 2010 and 2015, but did not finalize them. The Department committed to the implementation of an oral health strategy and action plan in 2015 in its Report on Plans and Priorities. Department officials developed regional plans for oral health service delivery. They also continued to discuss a strategic approach to oral health, and in 2016, the Department hired a contractor to develop one.

Obviously, it's the last sentence that is important. I'd like your comments on this. The sentence is:

At the time of our audit, the Department had not finalized a strategic approach.

I would like you to explain to us why, at the time of the report, this strategy hadn't yet been developed and implemented. I know that officials from Indigenous and Northern Affairs Canada are very qualified and engaged, and I know you are, too. In fact, I want to recognize the officials from your department because I know a lot of work has been done to prepare you for this testimony.

Please explain why there was no concrete strategy at the time to address these pressing needs and issues.

[Jean-François Tremblay]

An approach had been developed, but it was more a regional approach. We work a lot at the regional level because, as you know, the health systems come under the provincial government and the rules differ from region to region. Some work had been done.

I think Parliament had neither the means nor the ambition at the time. With the funding we received in budget 2017, we decided that it was an opportunity to step up. With the report of the Auditor General helping, we are now moving towards what is now more of a national strategy, where we would exchange information from region to region in looking at the trends, at where we're going, and at what we think are the needs, and we would also exchange information about best practices from one place to another. For example, on human resources, the services are not necessarily shaped the same way from one province to another or from one region to another, especially on the COHI side, the oral health initiative side.

I think it was Parliament's intention to develop that. I will let my colleagues to say more about that.

I think the first thing was to address the regional aspects, but there was not necessarily the second level, if you like, which is more about a real national strategy. With this report and the engagement they're undertaking now, I think we're basically putting the system at the maturity level that we would like to have and that I think we need to have for the country.

[Rémi Massé, Liberal, Avignon—La Mitis—Matane—Matapédia, QC]

A national strategy is an important aspect of this approach, and it should be implemented quickly.

I would like to point out that two Indigenous communities in my riding expect the government to support them in a practical way.

When do you think this national strategy will be developed? What is your plan of action, and what schedule will you adopt to develop that strategy?

[Jean-François Tremblay]

I will ask Dr. Plante to speak to the next steps and the schedule we will follow.

[The Chair, Conservative, Kevin Sorenson]

Very quickly, please. You have under a minute.

[Dr. Marc C. Plante, Manager Dental Policy, First Nations and Inuit Health Branch, Department of Indian Affairs and Northern Development]

In terms of strategy, we are now at the senior management stage. It should be understood that these are separate programs, which concern both the Office of the Auditor General of Canada and the First Nations and Inuit Health Branch.

In terms of oral health, everyone will try to go in the same direction. Our branch is in the process of identifying priorities. Goals will be established. Some targets will be more specific: we will have an action plan for the next 10 years.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much, Mr. Massé.

Monsieur Deltell.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Thank you very much, Mr. Chair.

Ms. Schwartz, gentlemen, welcome to your Parliament.

Mr. Ferguson, it is very nice to see you again. Congratulations on the quality of your French and your bilingualism.

I am always very proud to say that I represent an indigenous community, the Huron-Wendat Nation, which is located near Quebec City, on the Wendake Reserve. It is at the heart of my riding. The people on that reserve have been my neighbours since I was born. I know them very well, and they are very close friends.

We all know that there are communities in Canada that live in urban or semi-urban areas, and others that live in less densely populated areas. We also know that it is sometimes urgent to be seen by a dentist—everyone has suffered a toothache—that it is always difficult to find one on Saturdays or Sundays, although it's possible. This happened to me seven years ago. That said, in your report, you mention 300,000 First Nations and Inuit, and 237 communities.

For the moment, my question is for the officials from Indigenous and Northern Affairs Canada.

Is there a noticeable difference between access to dental care for First Nations and Inuit in urban areas and that for First Nations and Inuit in non-urban areas?

[Jean-François Tremblay]

I think my colleagues, particularly Dr. Plante, are better positioned to answer your question.

[Sony Perron, Associate Deputy Minister, Department of Indian Affairs and Northern Development]

Thank you for the question.

You've put your finger on the problem: the geographic distribution of clients and service providers. The programs make it possible to reach these clients differently, which is why a strategy is needed. The non-insured health benefits program is actually a benefits program where the expenses incurred by the client are reimbursed directly to the dentist. It works extremely well in urban or suburban settings, where people have access to dentists.

We usually use more programs like the children's oral health initiative to provide services in communities where we would not otherwise find them.

However, even in peri-urban areas, these programs can be useful for prevention in schools and to ensure that parents bring their children to specialists first, and to dentists, second. It's a combination of services, so it's important to have the strategy that we talked about earlier. Efforts should be combined when it comes to these programs. In remote areas, we have to face more difficulties.

The non-insured health benefits program, for example, will sometimes make it possible to contract work to dentists rather than having them present themselves as independent service providers. In fact, we are awarding contracts in certain regions to get dentists to practise in communities, which is more efficient and less expensive. This also provides support and a clientele to service providers who come to work in a remote community. The approaches to services are therefore very different depending on the regions and geographic distribution of customers and service providers.

Mr. Tremblay spoke earlier about our strategy and regional access plans that take into account this dynamic and the type of tool we need to bring clients closer to service providers or, conversely, to bring clients closer to service providers in communities.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

In fact, when we say “bring service providers”, we understand that they are dentists, their assistants and the necessary equipment. We also understand that dentists don't walk around with their equipment in a small suitcase, as Dr. Welby did—it would be a bit heavy.

Does the majority of the fees apply directly to care or to being able to provide care, that is, bringing the physician or dentist with the necessary equipment to the communities living in the North? In other words, is the budget spent primarily on logistics rather than patient care?

[Sony Perron]

That’s a very good question. Let me reassure you in this regard.

Part of our program spending goes to the transportation of medical personnel and equipment, and it is calculated differently. The figures presented in the auditor’s report relate to services and medical procedures.

According to our infrastructure program, when renovating or building facilities for nursing stations in remote communities, for example, a room is often set up for oral care, and there is a dentist's chair.

Some funding will be provided to have local workers, for example, who will be responsible for scheduling appointments, ensuring that clients keep their appointments, and providing local support. There is a little bit of that in the programs, and it's extremely useful.

In fact, one of the truly positive things about the children's oral health initiative is local support. Irregular visits to a professional service outlet have an impact on oral health. We think it is extremely important to have a person from the community there at all times. The person ensures that clients are registered, calls them to confirm their appointments and ensures follow-up at the school, to obtain parental consent for services, for example. In this sense, we do not have many requests for service. We should really ensure a local dynamic, especially in remote communities.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Mr. Auditor General, in the report, you mentioned that indigenous people experience twice as much difficulty as non-indigenous people in terms of services and dental care.

Is this true from coast to coast to coast? Is there a difference between urban and non-urban indigenous people?

Are the statistics for urban indigenous peoples similar to those for non-indigenous people? Is there a major difference between those who live in the north and those who live in urban areas?

[Michael Ferguson]

We have not specifically analyzed this issue, but we mentioned in paragraph 4.2 that more precarious oral health is related to factors such as geographical barriers.

Clearly, it is more difficult to provide those services to more remote communities. So this is a challenge. However, I think it is one more reason why it is important to have a national strategy to determine how to serve those populations.

[Gérard Deltell, Conservative, Louis-Saint-Laurent, QC]

Perhaps I could ask the people experiencing this reality on a daily basis.

Mr. Tremblay, what do you think?

[Jean-François Tremblay]

There is information, but it would probably be difficult to obtain very recent information. We can provide the committee with a survey on oral health from 2007, I believe. It probably shows regional disparities between what happens in northern and southern Canada or in small and large urban centres.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Mr. Deltell.

Mr. Christopherson, please. You have seven minutes.

[David Christopherson, NDP, Hamilton Centre, ON]

Very good. Thank you, Chair.

Thank you all for your attendance today.

Again, it won't come as a surprise to anyone that when it comes to services for indigenous peoples, Canada does an abysmal job, especially when compared with our reputation in so many other areas. This report is not the worst I've seen—I've seen some nightmares come through here—but it's still not good. My colleagues have already addressed some of the most obvious questions. I'd like to drill down just a little, if I might.

Auditor General, at the beginning of the year, or certainly near the beginning of the term, you presented us with the fact that you consider data collection, data analysis, and accuracy of data to be key components. You were concerned, and you addressed our committee about the fact that it needed to change, that after all these years, we're great at getting bunches of data—my word—but in using them effectively, analyzing them effectively, and getting the best benefit, it hasn't been so good; again, my word.

I want to focus on that. In your report, on page 10, paragraph 4.45, you say, “However, Department officials informed us that the apparent decline in enrolment might reflect poor quality in data collection and recording...”. On the very next page, your recommendation is that Health Canada “should improve” its analysis of data.

Deputy, in your remarks, I found at least three occasions where you mentioned it. On page 4 you talked about data collection, analysis, and reporting. On page 5 you mentioned that your plan will ensure that data collected in the course of the delivery of services will be accurate and rich enough to contribute to overall improved management. On page 6 you talked again talked about the importance. In fact, we find that it's a focus of the action plan, which is a critical component of the work we do. In there, referring to the recommendations coming from paragraph 4.47, the key interim milestones, you make a reference to the data improvement strategy working group.

I would like you to talk to me about that group. Is that new? Is it a result of the initiatives of the AG? Is it something you've always had? Can you talk to me about that, please, before I go any further? Again, it's the data improvement strategy working group.