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.
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.
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.
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?
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.
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.
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.
That concludes our usual rotation and therefore concludes our hearing.
Let me pose one quick non-partisan question, in light of the fact that this is our last public hearing before the election of a new Parliament.
Tomorrow we will have the Truth and Reconciliation Commission report. Mr. Auditor General, I've been on this committee 11 years now consecutively, and this one file, involving services for remote communities, first nations people and Inuit has been a colossal failure across the board.
This is not partisan. I've been here under different governments, minority and majority. Your predecessor, the wonderful Sheila Fraser, as one of her last comments as she left office, raised this issue and talked about it as a remaining challenge for Canada, in her view.
I'm rather putting you on the spot, but I wonder whether you have any thoughts at all to give to the incoming Parliament, the 42nd Parliament. From that Parliament will be chosen the next government, and they're going to have to deal with these files.
Given the fact that we as a country—because I believe most of the people on these files are people of good will—have tried to overcome these challenges and give our sisters and brothers in the remote north the quality of life they deserve and that being a Canadian is supposed to guarantee, can you give any advice or thoughts to the next Parliament, as we adjourn here in this, the main accountability committee of Parliament, for both candidates and the next MPs to consider as they form government and move on this agenda?
What we don't want is another decade of failure. Do you have any thoughts or words of wisdom to give to that incoming Parliament on how we can have different outcomes from those we've been having?