Thank you, Mr. Chairman. To my left is deputy minister of Health and Social Services, Paddy Meade; and, to my right is director of finance, Mr. Derek Elkin. Thank you.
Thank you, Minister. We are now open for comments. We are on page 8-17, activity summary, program delivery support, operations expenditure summary, $31.936 million. Mr. Yakeleya.
Thank you, Mr. Chair. Mr. Chair, the area I want to focus on is on the recruitment and retention programs. As we know, it’s been noted that the issue of doctors in the Northwest Territories into our regions is very tough right now in terms of having good doctors coming to our regions and there are vacancies in the health care system. I want to ask in terms of have we seen a slight increase in terms of securing some doctors in our communities and some of the nurses in our health boards. I’m not just speaking for my own region but for the North in general. Thank you, Mr. Chair.
Thank you, Mr. Yakeleya. Minister Lee.
Thank you, Mr. Chairman. If I may, I would like to ask the deputy minister to give some information on where we are with physician recruitment in our authorities, especially in light of the new Collective Agreement and as well as the work that the deputy minister has been doing with the medical forum on this issue. Thank you.
Thank you, Minister Lee. Deputy Minister Meade.
Thank you. The issue of physician recruitment, whether it’s full-time physicians or on locum, continues to be a challenge, but this is a challenge internationally. I think, in general, that while we do not have a full quota of physicians in full-time positions, we have been extremely successful, and I believe part of the last agreements were part of the success in ensuring that we have locums and coverage. But this does put a different challenge in how you plan your delivery and how you manage case management. It creates greater continuum of case management issues and another reason why we have to rely more and more on our Health Net or eHealth system.
There have been in some areas physician recruitment and stability, but in the smaller communities and the ability to have physicians come in either for longer term locums to be willing to move on mobile provider teams or to have any interest in moving continues to be a struggle. So the conversation with the Medical Directors Forum is how we actually look at our physician resources as a territorial resource and look at innovative ways to be able to recruit and maintain a more permanent base, but it will require moving to different delivery systems. So, yes, the agreements have had impact, given the international shortage and continued shortage, and in particular where we need specialists. So hard to recruit areas continues to be internal medicine, psychiatry, areas that support good community delivery. Work in progress, I think one that we have to continue to work with our colleagues at the national level. Thank you.
Thank you, Ms. Meade. Mr. Yakeleya.
Thank you, Mr. Chair. The comment from the deputy minister on looking at the delivery system in the Northwest Territories, because of this issue that we are facing here, would I dare say that are you looking at an overhaul in terms of how we deliver our health care in our communities or our regions in terms of coming to a centralized system of health care delivery as to what the regions and the communities want to see more health care delivery in their communities. I know there are some specialists that come in the regions on a rotation basis, doctors do come in on a certain rotation basis, and we would like to continue with that. However, I’m going to make the speculation that I don’t know what to expect from the health care delivery system in the Northwest Territories. I’m not too sure if that’s a fair question to ask of the deputy minister in terms of what does she mean by that.
So I am certainly not talking about moving away from community focus. In fact, I’m talking about how we better enhance it. But how you enhance it is what will be different.
Traditionally, everybody thought medicine was about seeing a doctor. It’s not. It’s about seeing a team of providers, and they can be connected many ways. If we look at pooling and using our physician resources centrally -- and that’s virtual, by the way, that’s not moving them -- they will be able to provide better clinical support to the health care units in the small communities and, I think, deliver better health care. But we have to accept, not just in the Territories but in general, that we are dealing with a full-time and a very large part-time base, and it means you deliver different and you manage your standards and accountabilities at the medical/clinical/decision level differently. That’s the kind of changes we make.
So I think it’s an enhanced focus on how we can better support the communities and people to be supported, but it may not be by seeing the whites of the eyes of a physician all the time. So how do you increase the mobile visits, but also how do you get physicians to be able to support through electronic health and through telehealth some of those community decisions. I think it’s going to be better care and better handover after somebody’s been in the South, to be able to manage their recovery back home better. Thank you.
Thank you. I certainly look forward to the day where I could see what the deputy minister is saying in terms of improved health care services in the communities.
In the description here it talks about recruitment and retention programs specifically related to health and social service professionals. I want to ask, in terms of the recruitment of the aboriginal wellness workers, aboriginal health care providers such as the community health representatives, you know, people in the communities that have been working in this field but they’re not recognized; some of the elders that we use or we go to for various reasons that could be deemed health issues or social services issues that recruitment of relying on our own people and not always relying on the outside. There are specific times when we need a medical doctor to come in, but there’s also recognition of the aboriginal medical, if you could call it that, wellness model, so that we can utilize the traditional knowledge of the elders in our communities.
I think, Mr. Chair, that the Minister, prior to this chapter, did make some mention of the Foundation for Change. I’ve been looking at this. So that’s what I wish to see. That’s my vision, that our own people could be at the health centres or they can be going into the different houses in the communities to talk about prevention, to talk about the use of the traditional medicines from the land, medicine they have from the animals, medicine that could be used. People have a choice in terms of their well-being and the prevention of diabetes, prevention of heart disease, prevention of a lot of other things that we haven’t yet given prudence to the aboriginal view on how we can work on this. A lot of it we rely on the model of the western concept of illness, and that is something that’s good for some reasons but not for everything. So I hope, through the recruitment and on the whole health and social services, that this here looks at a balanced view of how health could be looked at in our communities and regions. Those are more comments to the department here and that’s my wish, I guess, to see how this program should be, could be, and hope to be implemented in this department. Mahsi.
Thank you, Mr. Yakeleya. If I had a billion dollars... Minister Lee.
Thank you, Mr. Chairman. I just want to advise the Member that much of what he’s saying is something that we have been discussing and working with and it’s part of the Foundation for Change plan in that we understand that we need to work on the larger framework, like the governance and delivery models but the focus in delivery needs to still be at the community level.
As mentioned earlier by the deputy minister, the recruitment and retention of physicians, registered nurses, nurse practitioners, for example, we have 68-plus positions and we have about 20 vacancies. While we are trying to recruit and retain, we understand that will continue to be a challenge because of the fact that not only are the residents and clients aging, but our health care professionals, by and large, are aging as well. So we are going to see increased demand for service but decreased number of people who could do the job.
This is why, under the Foundation for Change, we need to look at the overall system and do much of what MLA Yakeleya is saying, that is, to look in each community and see what is the team of care providers that we can establish in each community and region. They may not be the conventional health care people. We go to doctors when we need doctors here. We go to nurses and those people when we need them, but there are a lot we can do on prevention, promotion, as well as working with people as they go through their illness or their questions about their health issues or managing their cancer care afterward, because we know that lots of people can live a pretty good life afterwards from cancer treatment as long as they are looked after. So that is short. I will conclude there.
Much of what he is saying is part of our Foundation for Change action plan, understanding, though, it will take a long time for us to go to every community and work it out. So we are looking at first regional dialogue and we are looking, as the fund permits, to bring people together and have a dialogue about how do we take ownership of our own health care and what can we do from the ground up to make this work for us. That is part of the plan. Thank you.
Thank you, Minister Lee. Next on my list I have Ms. Bisaro.
Thank you, Mr. Chairman. I want to follow up on a question I asked yesterday. It doesn’t technically belong in this section. I think it does apply, because I am talking about the provision of physician and clinical services and so on. I asked yesterday about reciprocal billing and what we receive from Nunavut for the services that we provide to people in Nunavut communities. I understood the answer, but Ms. Meade stated that the agreements and the contract in place are in place verbally and that they are finalizing the language. I am considering it a second time. I thought, oh, my. That is a little alarming that we have a verbal agreement. I am reading it again. I am pleased to hear that we are finalizing the contract, but my issue goes more to what is included in that contract. I wondered if I could get a bit more of an explanation.
When, for instance, we send Nunavut patients out to Edmonton for treatment, they use the services of Larga House, I believe, in Edmonton. They are assisted with their travel. They are assisted to get to their appointments and so on.
Another example is that we have a doctor in the ER generally who is on call and will take calls from nurses in Nunavut communities.
Another example is I gather that we send travelling clinics which go to Nunavut communities, the eye clinic for instance who is one and there are other ones as well who go into communities and do clinic work there.
Those are three examples of things which I don’t imagine are covered in our reciprocal billing. Are those sorts of things covered in this contract which is currently verbal and which language is being finalized into a firm contract? Are those sorts of things considered in this contract? Are they in there or are we getting repaid for those kinds of services which are kind of under the radar and somewhat minor but it all adds up in the end? Thank you, Mr. Chairman.
Thank you, Ms. Bisaro. I will turn to deputy minister Meade for that response.
Thank you. The current contract is between Stanton, although it is on behalf of the government, and it covers basically the Stanton and extension, but there is a difference around how the territorial government also gets funding back should there be under FNIHB or under this particular agreement. So there are a couple of pockets of pooling. Not all things are under the reciprocal billing. Basically those are hospitals, drugs, doctors, services under kind of the original Canada Health Act.
One of the things that we are working on with both Yellowknife and the Greys with the physicians, some of it we capture because of the reciprocal billing around physicians and the mobile clinics, but not all. I have to tell you that we aren’t the first line of defence for that part of Nunavut. Actually, they are on call. They have a contract for on-call services where their nurse’s first call is actually a physician in Manitoba and one of their health authorities and then the call is made to the physician in the Stanton emergency if, in fact, the decision has been for a medevac and for some kind of treatment. That physician may also... Because some cases fly over us and go directly to Edmonton. I haven’t given you enough. I would say we are getting most of it. We have flagged and we want to look at the whole agreement after this one, but better to get this part signed, and so you are quite right. It is a matter of just getting the final ink from Nunavut agreements there, but there is a next round for the next agreement that talks about what are the other services and, quite frankly, do they still make sense for us and where should Nunavut be planning. It is a larger discussion. Some things came out even in H1N1 planning that will now guide some of our discussions. It’s on my agenda. We are already working with the CEOs.
Mr. Chairman, thank you to the deputy minister for that explanation. I guess I am glad to hear that this is an issue that is going to be looked at in further detail. To me it sounds as though this is a logical approach to look at the big picture, figure out what we should be doing and what we shouldn’t be doing and then go after the funding for those things that we are doing that aren’t now covered. Is it possible for the deputy minister or the Minister to give us some indication of timing on sort of when this work might be completed, when we might be amending the agreement to sort of be able to say we are capturing all of the expenditures that we are incurring on behalf of Nunavut communities and citizens? Thank you.
Thank you, Ms. Bisaro. Minister Lee.
Mr. Chairman, the agreement that has been agreed to has been worked on for quite a while. That contract is closed, basically. The negotiation has been going on and that is done. As the deputy minister had indicated, there are some other things that we want to be able to prove, but that would involve larger discussions between not only the DMs but myself with the Nunavut government. This contract that we are finishing off is basically dealing with a situation where there had not been any solid agreement before and we are closing that part of our relationship with Nunavut. So we will have to engage in a bigger conversation with Nunavut. That could take a while to get there. We are more interested in getting this part done and then to build on the next phase. Thank you.
Mr. Chairman, to the Minister, I understand that the one contract, the current contract, is basically finalized. I know a long time is what she has mentioned, but I am talking about the things that are not being captured now. How long do we think it is going to take to get some sort of agreement in place so that we can capture those things? I appreciate that it is a long process, but what does “a long time” mean? Thank you.
Mr. Chairman, I could tell you that this is something that is of interest to us. It does take two parties to negotiate. We will continue to encourage Nunavut to come to the table on this issue. I will be talking to Minister Curley on this issue as the DMs have been working on it for the last while. Thank you.
Thank you, Mr. Chair. I guess without having any kind of a time frame I need to ask a general question. If we are not currently capturing the costs of providing services, some services to Nunavut patients, communities, et cetera, what sort of liability does that put out there for us? How vulnerable are we to spending money that we’re not going to recoup? Is this going to create a situation where we are going to be basically in debt because we’re providing services for which we’re not being paid? I guess I would like to know how much. But if the Minister can’t tell me when we’re going to be negotiating a new agreement, that’s probably not forthcoming, but to the question of vulnerability and what sorts of costs we are liable to incur. Thank you.
Thank you, Ms. Bisaro. Deputy Minister Meade.
Where the services provided are under the Canada Health Act, one of the positions in the Canada Health Act is portability. So this faces all jurisdictions. We have to provide service. The issue that goes beyond is what is the understanding of the agreement on devolution of what the Territories would provide and that’s part of this discussion. Of course, our other problem is health care changes so quickly that what was once service within a hospital is now moved out.
When the Minister says it’s a priority, it certainly is. Quite frankly, the issue is not necessarily Nunavut going to the table. We have their attention and while certainly under the portability act, I as a deputy can’t say I’m not going to take your client. That probably has come out a few times in the conversation with my colleague in Nunavut, saying you have to pay attention to this.
So the first thing is a long time, because it is a legal agreement and this will be an issue for them as far as affordability and where they may or may not get a better deal, i.e., Manitoba or elsewhere. But also, our own accountabilities as far as what we agree to and what some of our physicians or other clinical people may think they should be providing. The bottom line, there’s no liability, there’s more of an issue of if we refuse service under the Canada Health Act. The liability here is are they real dollars, are they some assumption, what actually was the agreement and what part of this is an extension of the contract.
So Larga, one thing the Member flagged, I think I’ll look into because my understanding is there are multiple agreements and Nunavut also has agreements in Edmonton with lodging. So is that our cost or theirs? It’s a bit more complicated, but I’m comfortable and I’ve said that to the Minister, around liability, but we do have a requirement under the Portability of Canada Health Act. Thank you.
Thank you, Ms. Meade. Minister Lee.
Thank you. Beyond that I would just like to add that we have had a situation of not having a written contract between Stanton and Nunavut and it was important for us to make sure that we conclude that so that we settle the outstanding receivables and we have made some gains on that. So that’s why it was important that we conclude this and any newer issues that we need to be bringing to this we will deal with that in the next phase.
Also, I think it’s important to note that while Stanton has been experiencing a deficit, it is not correct to think that this is contributing to the deficit to the extent that it might suggest. That was just one part of that. We are doing lots of other work through the Foundation for Change and such, to address that issue.
I think it should also be noted that Stanton has been having capacity issues in their finance section and this budget includes some investment in that area, because it’s not clear cut we collecting everything that we need to do with Nunavut. Of course we will do that and we would not be wanting to provide services where we’re not getting paid for it, but there are lots of other issues where we needed to put some resources in there so that we catch up on what was falling behind and we are doing that through this budget. Thank you.
Thank you, Minister Lee. I’d like now to call on Mr. Beaulieu.
Thank you, Mr. Chairman. I just have one quick question in the area of health and social services authorities, agency administration and there’s an increase of about $760,000. I’m wondering if that’s the area that home care comes out of and if that’s an increase to home care. Thank you.
Thank you, Mr. Beaulieu. Minister Lee.
I’m sorry, Mr. Chairman, are we still on 8-17?
That’s correct; page 8-17. Is that correct, Mr. Beaulieu?
That’s correct, sir.
Thank you. Minister Lee.
Mr. Chairman, the home care service, the money is provided to each authority under our primary care. Thank you.
Thank you, Minister Lee. Anything further, Mr. Beaulieu?
No, no more questions. Thank you.
Thank you, Mr. Beaulieu, and I’d like to turn now to Mr. Krutko.
Thank you, Mr. Chair. In regard to the area of community health nursing, I know you’ve heard me many, many times talk about the nursing situation in Tsiigehtchic and I think that there’s motions passed, like I said, in the Gwich’in assemblies, passed in the Dene assemblies and this issue has always been an issue in regards to the health and the well-being of the community.
Like I stated earlier, if you look at the budgets going back to 1998-99, prior to division, if you look at all the smaller communities, you can see the amounts of dollars that were spent in regard to the different care, from nursing care to social programs. The majority of the smaller communities, in which their population is under 200, had all those services being provided and being expended to those communities based on the funding allocations. I think since then there’s been a real decline in regard to actual dollars being expended from physical bodies, service providers since that.
So I’d just like to ask the Minister, I know that there has been an issue about nursing care. I’ve spoken to the Minister several times on this matter and I was hoping that February 1st there was going to be a nurse in Tsiigehtchic, because that was my understanding. I’ve raised that issue with the chief and the community and mentioned to them there was going to be nursing care in the community effective February 1st. So I’d like to ask the Minister how soon are you expecting to have a nurse full-time in Tsiigehtchic?
Thank you, Mr. Krutko. Minister Lee.
Thank you, Mr. Chairman. There are a couple of issues that the Member raised. The first one about how services were better back in the ‘80s, I do not have information to either accept that or dispute that. I believe, by and large, this government is able to keep records from basically ‘99-2000, because it’s just hard to make comparisons when we’re talking about information prior to division. Anecdotally, I used to work as an executive assistant of the Minister of Health and Social Services for the entire NWT and I think there were as many issues back then as there are now.
On the issue of nursing coverage in Tsiigehtchic, Mr. Chairman, I need to say once again that it is not accurate to say that there is no nurse service in Tsiigehtchic. I understand that the Member is passionate about seeing a permanent nurse there. I have given him the information about the nurse coverage that the Beaufort-Delta Health and Social Services Authority is providing. For the community of 170 people, last year Tsiigehtchic had 14 weeks between the breakup and freeze-up and another 20 weeks of service I believe. So that’s 34 weeks of service, which is a little over half a year. That is what the authority is able to do within the current regime that we have and the Foundation for Change action plan, and some of the strategic work that we are doing is looking at the entire service delivery model as well as the governance and we will be putting focus on concentrating on small communities and how to better work out a team of care providers that MLA Yakeleya has mentioned earlier. So that is the plan and that is the work that we are trying to do.
However, I need to state, once again, that Tsiigehtchic does have nursing services. We service that community in the way the RCMP services are provided in Tsiigehtchic, which is what the MLA had asked me to do. I had committed to do that last February in the spring and summer sessions last year and I am committed to continue to work on that. Thank you.
The community of Tsiigehtchic appreciates what the Minister is providing. The community is requesting a full-time nurse in the community. That’s what they are requesting: full-time. Not six months, full-time. So that’s where I am coming from in regards to providing those services full-time in those communities.
Like I said, the community has done everything they can. They’ve purchased a housing unit so that they can’t use the excuse we don’t have housing for nurses in the community. They did that on their own. They’ve done that through their charter community. They are working to try to find ways to get policing in their communities by allowing them usage of facilities they have in the community which can accommodate the RCMP to stay overnight. The community is trying to do everything they can to attract everything to their communities, but what we need from this government is a commitment that those people that they do get there, they are going to have a care provider that is constant. That you work out that relationship between yourself and the provider, so you know who the elders are, you know who George Naditchie is or you know who these different elders in our communities are.
Again, I request from the Minister, is it possible to have a full-time nurse in Tsiigehtchic in a short time frame, knowing spring is coming forward? We know there will be a nurse there during breakup and freeze-up. I am requesting if that is possible to have a full-time nurse in the community in the immediate future.
Thank you, Mr. Chairman. The way our system is set up, the authorities get the funding to provide services to the communities. They work as one entity and they distribute their resources in the best way possible. I understand and I have heard, and I have met with the community about the desire of the community to have a permanent nurse physically there all year round. The issues are the Beaufort-Delta Health Authority is stretched, not only in terms of dollars, but in terms of available nurses. They have the obligation for all of the Beaufort-Delta communities to spread their nursing resources around.
The second thing is our labour law requires that there needs to be at least two nurses and it would be difficult to have two nurses in a community of 170 people. I’m not talking financially, but just it would not be enough work for two nurses for 170 people unless the 170 people went to the health centre every second day.
I understand health care is very important. Health care includes doctor’s service, nursing service, community health rep, wellness worker, people who can take care of the elders, including home care workers, including people who talk to people about how to prevent diabetes, take care of diabetes, see if they have it, cancer prevention. There is a whole basket of health care services that our communities expect. Health care doesn’t mean having a physical health care professional necessarily sitting there because we feel healthy if we see a doctor sitting in our office or nurse. Maybe that’s how some people feel, but that’s not how we can continue to deliver health care services.
Just like the RCMP, we don’t have two RCMP stationed in Tsiigehtchic, but the government has made the move to hire extra resources in McPherson so they can increase patrols in Tsiigehtchic, which is a great advance. That’s what we are trying to do for the nursing coverage until such time as we have different ways to address that. I don’t know how else I can put into this, because nurses need to keep up with their skills as well. They need to be able to do the work that is necessary to do and all of the practice guidelines will say being a full-time nurse in a community of 170 people may not give them the kind of work that’s required to keep up with their credentials.
I just want to state again that I am committed to working to enhance health care services in our communities, but they come in different shapes and sizes. Thank you.
Thank you, Minister Lee. Mr. Beaulieu.
Thank you, Mr. Chairman. Mr. Chairman, just a follow-up on my last question again. I had asked about the money for home care and the Minister indicated that was under primary care. There’s, like, half a million dollar there to do all the functions under primary care. I just wanted to confirm that home care, along with all those things listed, come out of primary care.
Thank you, Mr. Beaulieu. Minister Lee.
HON. SANDY LEE:
Thank you, Minister Lee. Mr. Elkin.
Thank you, Mr. Chair. The primary care division is the headquarters staff who look at policy setting and program evaluation. The program dollars were later on in the main estimates.
Thank you, Mr. Elkin. Mr. Beaulieu. Back to Mr. Krutko.
Thank you, Mr. Chair. Mr. Chair, this government has tried to take strides in accommodating small communities by implementing health care providers in different areas; mental health position, alcohol and drug position, social worker. Nowhere does it say that you can have people in a community working in similar areas, so that you do have more than one person in the community. That doesn’t say you have to have two nurses. You could have a nurse and a mental health worker, a nurse and a social worker working out of the same office or same operation. But I think if you use the argument the Minister is providing, it’s just another excuse to do nothing. I think we’ve tried to find ways of accommodating communities with policing, by trying to find police for 10 communities that don’t have it.
A similar arrangement applies to the small communities. Maybe I will just read out for the Minister... This is prior to division. I will just use Tsiigehtchic for an example. It’s tracking expenditures that were done back in 1988-89. The Territorial Health Insured Services, $284,000 was spent in Tsiigehtchic; social assistance, $205,000 in Tsiigehtchic. It goes on with regard to hospital services outside the Northwest Territories, $110,000 for Tsiigehtchic. If you just look at those numbers alone, they were spending over $500,000 in Tsiigehtchic. From the last numbers I got from the Minister, it was $147,000. So if you tell me that services have gone down since division, I think that because we had a lot of small communities, we were part of Nunavut, there were 51 communities we were serving. We were able to accommodate 51 communities with regard to health care services before division, but it seems like after division, we’re at a situation where basically the so-called dollars expended to small communities has depreciated to a point where that’s why you don’t have services, because it’s being spent in the larger centres to provide at those new hospitals or dementia centres or walk-in clinics or whatever you want to call them Those things are taking up dollars that should be expended in those small communities.
Mr. Chairman, I will give the Minister a copy of this. Maybe she can get her department to look at the cost breakdown of what we had prior to division and the expenditures we have today, so she can see for herself. I’ll give copies to several Members of small communities so we can see how exactly our services have depreciated to the point that they are not expending the same money as they were prior to division.
