PACP Committee Report
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Honourable Kevin Sorenson
Chair, House of Commons Standing Committee on Public Accounts
House of Commons
Ottawa ON K1A 0A4
Dear Mr. Sorenson,
Pursuant to Standing Order 109, I am pleased to respond on behalf of the Government of Canada, to the Seventh Report of the House of Commons Standing Committee on Public Accounts, entitled Chapter 4, Access to Health Services for Remote First Nations Communities, of the Spring 2015 Report of the Auditor General of Canada.
Let me begin by stating that the health care system for First Nations and Inuit is complex. Provinces and territories deliver health services to Canadians, but do not operate health systems on reserve. In order to improve First Nations and Inuit health outcomes, as a matter of policy, Health Canada funds or provides health programming in First Nations and Inuit communities.
Within this context, Health Canada invests more than $2.7 billion annually in First Nations and Inuit health to supplement programs and services provided by provinces and territories. This includes specific efforts to address the needs of First Nations living in remote or isolated communities where access to provincial services is limited.
In 2015-16, Health Canada invested approximately $200M to support access to primary care services in 80 remote and isolated First Nations communities, including access to emergency services 24 hours a day, 7 days a week, serving a client base of approximately 91,000 persons. Health Canada also invested $357 million in 2014-15 on Medical Transportation benefits to enable eligible individuals to access medically required health services that are not available on reserve or in their community of residence.
In its Spring 2015 Reports, the OAG released an audit that examined whether Health Canada had reasonable assurance that eligible First Nations individuals living in remote communities in Manitoba and Ontario had access to clinical and client care services and medical transportation benefits. The audit identified 11 recommendations to support improvements in nursing, health infrastructure, documentation of Medical Transportation benefits access, comparable access to clinical and client care services and inter-jurisdictional coordination.
The Government would like to report on the actions taken to date to help strengthen access to quality care for First Nations living in remote and isolated communities, including the annual turnover rate for nurses.
The OAG recommended (27): Health Canada should ensure that its nurses working in remote First Nations communities successfully complete the Department’s mandatory training courses.
Health Canada agreed with this recommendation, and committed to developing a national policy and regional action plans on mandatory training monitoring and compliance, reporting on progress and implementing the National Nursing Recruitment and Retention Strategy.
Health Canada has developed a National Education Policy outlining mandatory courses, responsibilities, and compliance monitoring for Health Canada nurses. Regional plans have also been established which consider the training of new hires, recertification, training, compliance and forecasting. As of March 2016, 55% of Health Canada nurses were compliant with the mandatory training requirements, representing an increase of 32% from April 2015.
There are challenges relative to the distribution of the nursing workforce in rural and remote locations both nationally and internationally, and similarly Health Canada faces significant recruitment challenges in attracting nurses willing and able to work in remote and isolated First Nations communities. In recognition that the rates of mandatory training compliance have been influenced by high vacancy and turnover rates in nursing stations, Health Canada launched the Nurse Recruitment and Retention Strategy (NRRS) in the fall of 2014. This included a marketing campaign to support nursing recruitment, the creation of a Nurse Resource pool, and a streamlined application process.
In 2015/16, the national turnover rate was 12.8%, representing the percentage of Health Canada employed nurses departing in relation to the overall workforce. In that year, 67 new nurses were hired and 47 departed out of a workforce of 355. This represents a modest improvement from 2013/14, where the national annual turnover rate was 14.3%. Vacancy rates for Health Canada employed nurses have in recent year experienced a greater improvement. For example, in January 2016, the nurse vacancy rates were at a current low of 6.2% for Manitoba and 18.1% for Ontario, in comparison to 2013/14 where the vacancy rates were approximately 30% and 40% respectively.
The OAG recommended (37): Health Canada should ensure that its nurses are provided with appropriate supporting mechanisms that allow them to provide essential health services that are outside their legislated scope of practice.
Remote and isolated practice environments are complex. Nurses are often the first point of contact for the community members with the health care system, sometimes necessitating registered nurses to work outside of their scope of practice in order to respond immediately to life threatening or emergency situations. In recognition of these challenges, Health Canada provides a number of supporting mechanisms, including access to Primary Care Physicians and/or Nurse Practitioners, and practice support tools for nurses such as clinical practice guidelines.
Health Canada agreed with the OAG recommendation and has committed to strengthening supports to nurses, by developing engagement strategies with provincial ministries of health and health professions regulatory bodies to explore solutions, undertaking joint working sessions, updating clinical guidelines, documenting physician access arrangements, and developing an accreditation plan to increase the number of nursing stations entering the accreditation process.
Health Canada is making progress in providing further supports to nurses. For example, physician access arrangements have been documented for each nursing station. Additionally, Health Canada has developed engagement strategies in all regions where clinical care is available, which include key scope of practice issues, engagement and regional working sessions with nursing regulatory bodies, nursing associations and other key stakeholders. Efforts are also underway to update the clinical practice guidelines and develop an accreditation plan to support nursing stations in the accreditation process.
The OAG Recommended (53): Health Canada should work with First Nations communities to ensure that nursing stations are inspected on a regular basis and that deficiencies related to health and safety requirements or building codes are addressed in a timely manner.
Health Canada works with First Nations communities to ensure buildings are inspected and that deficiencies are addressed, as part of Health Canada’s efforts to support enhanced First Nations capacity and safe health facilities. Health Canada agreed with the OAG recommendation and has committed to changing its processes to ensure that inspection reports are shared with First Nations communities, tracking inspections and major repairs, and updating the First Nations and Inuit Health Branch Framework for Planning and Managing Capital Contributions.
In September 2015, the First Nations and Inuit Branch Framework for Planning and Managing Capital Contributions was updated to ensure that processes are in place to share Facility Condition Reports (FCRs) with First Nations and track responses to key issues detailed in the inspection reports.
Budget 2016 invested an additional $82.3M in 2016-17 and $81.9M in 2017-18 to support major capital repairs, expansions and new builds to community health facility infrastructure, including nursing stations, health centres, acute care facility complexes referred to locally as “hospitals” and drug and alcohol treatment centres used in the delivery of health services and programs to First Nations on reserve. Health Canada is engaging with First Nations on project planning and providing technical guidance to support the completion of these infrastructure projects.
The OAG Recommended (56): Health Canada should work with First Nations communities to ensure that new nursing stations are built according to applicable building codes.
First Nations own facilities located on reserves, as per the Indian Act. As a result, all work on these localities is done via contribution agreements between Health Canada and the First Nations community of Health Authority.
The Department has a longstanding process that requires attestation by an architect or engineer affirming construction is compliant with applicable building codes. Health Canada agreed with the OAG recommendation and committed to updating the Capital Protocol document to clarify the requirements of attestations. In May 2015, Health Canada updated the Health Infrastructure and Capital Protocol to ensure the scope of this attestation is clear for all parties involved. This has been broadly circulated to Health Canada staff and is part of the project documentation used with funding recipients.
Medical Transportation Benefits
The OAG Recommended (81): Health Canada should work with First Nations communities, and Aboriginal Affairs and Northern Development Canada, to facilitate the registration of First Nations individuals.
Registration under the Indian Act is an individual choice, and the process is administered by Indigenous and Northern Affairs Canada (INAC). However, Health Canada agreed with this recommendation and committed to ensuring that Indian Registry application forms and brochures are available in Health Canada nursing stations and encouraging communities operating their own health centres to do the same.
Additionally, Regional Health Canada officials have contacted health directors and other First Nations partners to encourage making these materials available in their facilities as well. Furthermore, a reminder of the importance of registration has also been included in the January Non-Insured Health Benefits (NIHB) Program Update posted on Health Canada’s website.
Furthermore, Health Canada’s NIHB Program continues to approve benefit claims for children under the age of one to be processed under a parent’s registration to avoid severe access issues due to registration.
The OAG Recommended (91): Health Canada should maintain sufficient documentation to comply with Treasury Board Secretariat 2009 directive on recordkeeping and demonstrates that Medical Transportation benefits are administered in accordance with 2005 Medical Transportation policy framework.
Health Canada agreed with this recommendation and has committed to updating its operational guidelines. In April 2015, Health Canada developed and began implementing new guidelines to support the administration of medical transportation in a way that provides needed assurance without imposing additional burden on clients and service providers.
Health Canada remains committed to engaging with First Nations and Inuit to improve Medical Transportation and other health benefits and services through the Assembly of First Nation’s Joint Review and the Inuit Tapariit Kanatami Bilateral processes.
Support Allocation and Comparable Access
The OAG recommended (64): Health Canada should work with First Nations communities to ensure that nursing stations are capable of providing Health Canada’s essential health services.
Health Canada agreed with this recommendation and agreed to map current models of care in nursing stations, identify potential nursing stations to move toward interprofessional models of care and conduct a feasibility of selected sites.
In September 2015, the Department first completed a mapping of current models of care through the development of Nursing Station specific profiles which included a list of essential primary care services available at each nursing station. This included an assessment of each facility’s ability to meet Primary Care service minimum requirements and key issues to be addressed. Health Canada Regional offices are identifying their plans to address any noted deficiencies in collaboration with First Nations partners in order to move towards maintaining or meeting full service requirements.
As part of the mapping of models of care, a summary list of existing or planned interprofessional teams (e.g., plans to include Nurse Practitioners, Paramedics, Pharmacy Clerks, etc) was included within the Nursing Station specific profiles.
The OAG recommended (65): Health Canada should work with First Nations communities to communicate what services each nursing station provides.
Health Canada agreed with this recommendation and committed to providing an overview of the health services offered at each nursing station as well as developing communication products to increase community members’ understanding of available services.
The Department has completed an analysis of essential primary care services available at each nursing station and is currently undertaking a range of communication activities to increase awareness and understanding of available services, and to discuss interprofessional models of care. Regional communication activities include direct communication with First Nations community leadership, enhanced web-based service information and a new jointly designed poster of services.
The OAG recommended (107): When allocating nursing staff levels and other support, Health Canada should work with First Nations communities, and take into account their health needs.
Health Canada agreed with this recommendation and committed to revising the Health Plan Guide and developing a toolkit to share models and lessons learned to support collaboration.
Health Canada is engaging with First Nations to redesign the Health Planning Guide to better support communities in their overall health planning process, and a toolkit to share models and lessons learned to support collaboration. A module within the Health Planning Guide on clinical and client care is under development, and will provide assistance to communities on planning for types and ranges of services, clinical processes, accessibility and integration. The accompanying toolkit will be finalized following the completion of the module.
Further work on the alignment of nursing resources to community needs will also be part of the engagement described under recommendation 64.
OAG Recommendation (116): Health Canada should work with First Nations communities, provinces, and health service providers to ensure that First Nations living in remote communities have comparable access to Clinical and Client Care (CCC) services as other provincial residents living in similar geographic locations.
Canada agreed with this recommendation and has committed to developing two
internal reports. The first report will analyze clinical care access in remote
and isolated First Nations communities in comparison to access of health
services by non-First Nations communities in similar geographic locations.
Additionally, the second report will identify best practices in enhancing
access to culturally appropriate clinical care.
The Department will be completing the first report on comparative community analysis by July 2016. The second report on best practices is due April 2017, and it will focus on engagement with First Nations communities and respective provincial counterparts at existing tables and forums to identify best practices for enhanced culturally appropriate care.
Coordination of health services among jurisdictions
OAG Recommendation (131): Working with First Nations organizations and communities, and the provinces, Health Canada should play a key role in establishing effective coordinating mechanisms with a mandate to respond to priority health issues and related interjurisdictional challenges.
Health Canada continues to work with First Nations organizations and communities, as well as the provinces to explore opportunities for enhanced integration and coordination of health services based on joint priorities. Multi-lateral partnerships can take time to develop, as many strong and productive relationships require a significant start-up phase to lay the foundation for future collaboration.
Health Canada agreed with the OAG recommendation and committed to document key initiatives underway on service integration and coordination, and engage trilateral tables in Ontario and Manitoba to identify challenges and opportunities in clinical care delivery.
A compendium has been completed to highlight key multilateral tables, integration and coordination initiatives and recent accomplishments. Additionally, Health Canada has undertaken trilateral engagement process to identify challenges and opportunities in clinical care delivery in Manitoba and Ontario. Key issues and opportunities identified include training, equipment and infrastructure, mental health and other programming, and nursing. This input will inform further engagement between Health Canada and key partners on integration and addressing identified challenges.
While the Department has made tangible progress in addressing the recommendations of the OAG Report, work continues to respond to the unique needs and complexities of remote and isolated First Nations communities. The Government is committed to a renewed, nation-to-nation relationship with Indigenous peoples. Moving forward, Health Canada will continue to work closely with First Nations and Inuit organizations, provinces and territories in support of a new Health Accord, and as part of our ongoing efforts to strengthen access to quality health services and increase First Nations and Inuit control over health service design and delivery.
The Government thanks the Committee for their interest and recommendations. As expressed above, the Government takes the findings of the OAG seriously and I trust that this response demonstrates Health Canada’s commitment to address the recommendations to ensure that First Nations people receive a range of health programs and services that are responsive to their needs.
Hon. Jane Philpott, M.D., P.C., M.P.