Question.

Regarding a question of attitude, the Standing Committee on Agencies, Boards and Commissions is concerned that, to a large degree, the problems which surround the debate over board autonomy, accountability and role appear to have arisen as much from differing attitudes among key officials as they have from the historical and legislative factors expounded upon earlier.

Throughout the review, the standing committee heard that departmental officials working in Yellowknife were perceived by boards and their staff as being reluctant to accept input, possessive about information and, at times, condescending. The sum of this perception has been that some senior public service managers within the Department of Health may be presenting impediments to effective board function, simply through the approach they are bringing to their interaction with board officials.

The standing committee is concerned about the considerable evidence before it which suggests that there is too much central control. Members heard about a situation in which requests for medical technology were denied by headquarters but direction was provided to spend the money on a floor polisher. Boards related repeated instances in which needs had been identified and dollars has been found to support new programming, but the process was halted at departmental direction. It has seemed to the standing committee that the Department of Health has crippled itself with an inability to accept that health and hospital boards are capable of carrying out important responsibilities and is now unable to stand back and allow regionally driven initiatives to proceed as they should.

This, to be fair, may be a consequence of the lack of definition surrounding board roles. Once the MOU is finalized, it will be important for the Minister of Health to motivate a shift in outlook among her senior officials. The department must realize that goals can be better achieved if the central authority moves away from trying to "run things" in the regions and moves instead toward a process where it assists boards to best achieve their own priorities.

Where it is not possible to shape these new attitudes through staff inservice training and supervision, the standing committee would urge the Minister to take more final action. Clearly, it is the opinion of the committee that the current posture within headquarters operations at the Department of Health must change. If the change cannot be achieved with current personnel, then the replacement of officials should be contemplated.

Legislative Review

The Standing Committee on Agencies, Boards and Commissions has confidence that the establishment of an MOU will contribute greatly to the correction of existing problems. However, the committee is concerned that this will not necessarily go far enough.

During the 11th Assembly, the previous Standing Committee on Agencies, Boards and Commissions brought forward a report in October 1990, which recommended that the Territorial Hospital Insurance Services Act should be repealed and replaced with one "that better reflects the government's philosophy of supporting regional autonomy."

Although subsequent amendments dissolved the Territorial Hospital Insurance Services Board, a major overview and shift in legislative framework have still not been undertaken.

At the present time, the standing committee does not wish to recommend specific changes to the legislation. These will be more appropriately identified through the consultation process between the Department of Health and the boards.

The Standing Committee on Agencies, Boards and Commissions believes, however, that legislative review and amendment, when identified through consultation with the boards, should not be delayed.

Mr. Chairman, I move that the Minister of Health should seek advice from health and hospital boards with respect to amendments that should be made to the Territorial Hospital Insurance Services Act or other health legislation in order to better reflect a philosophy which supports board autonomy;

And further, that the Minister of Health bring forward recommended amendments to the act by the fall session in 1993.

That concludes my section, Mr. Chairman.

Question.

Thank you, Mr. Chairman. I will continue with the report, Mr. Chairman.

Barriers To Effective Administration

Throughout the review process, matters were brought to the attention of the Standing Committee on Agencies, Boards and Commissions as issues which were hindering the effective administration by health and hospital boards.

Absence Of Territorial Planning For Delivery Of Health Services

The standing committee heard many comments, for instance, about the lack of an overall "strategic plan" for health services. Health and hospital boards described a sense of continuing uncertainty about the directions which should be taken in the design of new programs and services, priorities for the enhancement of existing ones, and responsibilities for addressing emerging needs. This was summed up at the November 21 consultation sessions by the chairperson of the Inuvik regional health board who pointed out that:

"I think the first roadblock is no plan. I think everybody is working in isolation. We are all working for the betterment of the health of the people of the Northwest Territories and, yet, there is no plan."

The same concern was echoed by all the boards and was well described in the written submission received from the Kitikmeot regional health board as, "...a lack of territorial vision and direction to guide the focus of hospital and community board expenditures and services."

This deficiency was noted, as well, by the Auditor General of Canada who stated that: "Without a plan, NWT health care has no clear sense of where it is going or how to get there."

Health Planning Occurs In Isolation

The standing committee did observe that, almost without exception, each health and hospital board had developed its own process for regional planning. During the November consultation sessions, for instance, the Stanton Yellowknife board of management outlined for committee Members the ambitious and very promising measures it has undertaken to examine the facility's role and needs up to 1995. Larger planning processes will build on this to review current programs, assess the potential for further repatriation of services and assess global space needs.

Similarly, the Keewatin, Kitikmeot and Inuvik regional health boards have also mounted comprehensive planning initiatives to identify regional needs and to develop workable approaches to meeting them. The board of management at H H Williams Memorial Hospital has been actively assessing current space parameters to identify new potential for increased utilization of the facility. And, representatives of the Baffin regional health board outlined a model that would be followed during a regional needs assessment study, scheduled to commence in November, 1992.

While the Standing Committee on Agencies, Boards and Commissions was very impressed with the various initiatives that have been undertaken by the health and hospital boards themselves, Members were concerned that these activities have been pursued largely in isolation and were confined to a regional perspective. There seemed to have been relatively little sharing between the boards with respect to the design and implementation of planning exercises.

Mr. Patterson, could you slow down a bit, so the translators can keep up with you?

Yes, thank you, Mr. Chairman. Departmental involvement was described by some board representatives as attempting to exert a controlling or delaying influence.

There was also concern over the observation that there is no system which channels the results of the excellent planning exercises which are taking place at the regional level into an overall framework for the delivery of health services in the Northwest Territories. Regional planning exercises often seem to be regarded by Yellowknife headquarters as "competing" with the overall approach which the department wishes to follow, yet that departmental framework has not been articulated.

The standing committee was concerned that this absence of direction has created a barrier to administrative effectiveness throughout the system. Without a well developed vision for health care delivery and health promotion, it has been difficult to coordinate such aspects as capital planning, program goal setting and community participation.

Further, the absence of a planning framework in this area worsens the role confusion which predominates the territorial health system and risks inefficiency through the duplication of services. This was pointed out by the Kitikmeot regional health board in the written submission provided to the standing committee in February, 1993:

"The KHB would add that the lack of territorial vision has also led to role confusion between hospital boards, health boards and the department -- hospitals appear to be expanding outside of the provision of acute care services, into continuing community care. This area is now serviced by health boards. We question if it is cost efficient and effective to duplicate community care expertise that currently exists in health boards and the department. Such duplication further compromises the department's ability to allocate scarce resources."

In addition, the lack of health planning has been an impediment to the appropriate allocation of human resources throughout the Northwest Territories. This was highlighted in the Auditor General's report:

"Getting the right kind of health care people to the places where they are needed across the territories is a major challenge requiring effective resource planning. All the parties and the people should know exactly what they can expect. From our survey results and press reports, we noted there was confusion about health care delivery in the regions, and residents are not sure what to expect.

When the Standing Committee on Agencies, Boards and Commissions took all this evidence into account, it found that a clear need exists for a comprehensive, easily understood territorial plan for the delivery of health services.

Planning Must Be Regionally Driven

At the same time, the standing committee wishes to emphasize that territorial planning must be based on the unique needs and priorities which exist within the regions. These are best identified by the health and hospital boards.

Planning cannot be an activity which is imposed. Right from the earliest stages of needs assessment, there must be a recognition that the people who live in the regions of the territories are the ones who best know what is necessary to have healthy families and communities. As the chairperson of the Inuvik regional health board pointed out:

"I also believe that if we have a department-run needs study, then we have a department-run answer and I do not believe that is what we want."

The Standing Committee on Agencies, Boards and Commissions was concerned to hear health and hospital boards express opinions that planning exercises have not involved a sense of "partnership" with the Department of Health. They have been seen as processes which have been developed in Yellowknife and implemented from a "top-down" perspective.

Over the past year, the Department of Health has devoted considerable attention to developing a process for a "health facilities and services review." A framework for this process was developed and included stages for: identifying key participants; collecting and verifying profiles which show population and service user characteristics; identifying opportunities to improve effectiveness and reduce costs; developing options and strategies; preparing action plans and evaluation criteria; and, assessing progress and reviewing plans.

Concerns were expressed to the standing committee that, even though the procedures called for consulting with "key participants" at each stage, the design for the review had been drawn up in headquarters and imposed on the regions.

For this reason, there was considerable initial concern over the process, especially in the Deh Cho region, where it was felt that the community had no control over the type of review that had been undertaken -- and in the Keewatin, where there were concerns that this approach would conflict or compete with regional planning efforts which were already farther advanced.

The Standing Committee on Agencies, Boards and Commissions is of the opinion that the time has passed when this government can say "We are going to study what the communities need ... this is how we are going to do it ... and this is the point at which the 'key participants' we identify are going to become involved." That centralized approach is too reminiscent of a previous era, and it is not likely to be accepted in the future.

A Territorial Plan For Health Services

During the Fort Smith hearings on January 22, 1992, the NWT Health Care Association, which represents all health and hospital boards, made a presentation which included the following recommendation:

"That the Department of Health take immediate steps to consult the health and hospital boards to implement shared planning programs for effective and efficient health services to the respective communities being served."

The Standing Committee on Agencies, Boards and Commissions agrees that it is essential for a plan to be developed. While the committee considers it the Minister's statutory and administrative responsibility to coordinate inter-regional planning, the content of any plan can only be developed through a partnership between her department and the boards. Health and hospital boards should have direct input, not only into the substance of the plan, but also into the process through which the plan will be put together.

I will now turn this section of the report over to Mr. Antoine, Mr. Chairman. Thank you.

Thank you, Mr. Antoine.

Inadequate Information Systems

Thank you, Mr. Chairman. Without exception, all health and hospital boards indicated that the current state of information processing within the health system was a serious barrier to effective administration.

The standing committee was dismayed by the degree to which incompatible and inadequate systems exist. Equally disconcerting has been the apparent inability of the Department of Health to take a lead role in correcting these deficiencies.

Board staff have had to cope with a myriad of systems that are apparently incapable of exchanging information and do not meet administrative or planning needs. For their part, the boards appeared to have done their best in coping with the current situation, as many have successfully developed their own internal procedures for re-entering data or designing intermediate reporting formats. However, this has resulted in a system in which neither financial nor statistical information can be communicated and reported with efficiency.

The Standing Committee on Agencies, Boards and Commissions is aware that the Auditor General's report deals with the matter of health information systems at some length and that this has been a subject of considerable attention by the Standing Committee on Public Accounts.

Because this item fits more properly within the Public Accounts Committee's mandate, the Standing Committee on Agencies, Boards and Commissions does not intend to make a specific recommendation on the matter of information systems at the present time. However, it should be recognized that Members of this standing committee are of the opinion that specific corrective action should be considered a government priority.

Departmental Requests For Information From Boards

Health and hospital boards expressed a continuing concern, over the course of the review, with respect to the frequency and type of information demanded on a regular basis by the Department of Health. Board representatives found that the department, over the past several years, has forwarded numerous requests for administrative information, line-by-line budget substantiations and service delivery statistics. Without exception, the boards found departmental demands for information to be excessive and unnecessary.

During the November consultation sessions, for instance, the chairperson of the Keewatin regional health board pointed out that:

"We spend inordinate amounts of time justifying budget expenditures on a line to line basis that are five per cent over the budget item amount. In some cases, these are budget line items of $300 or $400, yet we have to justify a five per cent variance for those items. It is ridiculous when we are dealing with $20 million and $30 million budgets, to be worrying about $5 and $10. I am not saying that we wish to be financially irresponsible. I am saying we have to review the system and look at what it is we are attempting to do."

The Baffin regional health board described departmental monitoring procedures as "excessive" and a "constant irritant," while the chairperson of the Inuvik regional health board commented that:

"The control of the Department of Health line-by-line budget is also one of our greatest concerns... I think that, as boards of management we should be allowed to manage. If we are not boards of management, then please tell us so."

The standing committee is concerned that these demands for more and more detailed reporting represent a hindrance to effective administration at the regional level. Board officials have found that it is often difficult to complete activities that have been established as regional priorities, because of the time that has to be spent preparing reports for Yellowknife.

The chairperson of the H H Williams Memorial Hospital board astutely noted that, in addition to detracting from effective administration, this also has the potential to divert attention away from patient care, itself:

"I have been involved with health care in the Northwest Territories for 28 years now, off and on. I have seen such an incredible change that has taken place from the days when patient care seemed to be ultimate. Now we hardly ever hear the word. Patient care almost always gets forgotten in pursuing all the other things that have to be done, the documentation of what we do."

The Standing Committee on Agencies, Boards and Commissions is aware that certain information requirements are imposed on the Department of Health by the Financial Management Board and, in some cases, the standing committees and Members of the Legislative Assembly. Further, certain sections of the Financial Administration Act require the department to take responsibility for appropriate over-all fiscal management of the health system and this, in turn, requires departmental officials to access information from the boards. Upon reviewing examples of the number and type of requests, though, the committee has formed the opinion that the department's demands for budgetary details and the frequency of specific requests for statistical and administrative reports are, in fact, excessive.

To a large degree, the root of this problem may lie with the aforementioned inadequacy of information systems. If appropriate, well-working systems were in place, information could be centrally accessible without imposing additional reporting requirements on the boards.

Just as inadequate information systems are contributing to this problem, so too are departmental attitudes and procedures. The Standing Committee on Agencies, Boards and Commissions is of the opinion that the excessive line-by-line monitoring by departmental officials reflects a headquarters perception of health and hospital boards as incapable, undependable management bodies. There appears to be an unwillingness at departmental headquarters to stand back and allow the boards of management to manage.

This is further compounded by information flow procedures within the Department of Health. Currently, departmental demands for information about board operations are generated in a number of divisions and are forwarded from a number of staff levels.

Directors, associate directors, analysis, consultants, administration officers, medical officers and a range of other mid to senior-management officials in Yellowknife frequently pepper board administration with demands for information related to their latest internal work assignments. Often, information is required on relatively short notice. Sometimes information demands by one headquarters division appear to duplicate or overlap those made by other divisions. And, in a majority of cases, board administration is provided with very little understanding of why the data are required.

It is hoped that the aforementioned "master memorandum of understanding" (MOU) between the department and the health and hospital boards will clarify requirements that the boards must follow in forwarding information to the department.

Until the MOU is finalized, however, the Standing Committee on Agencies, Boards and Commissions is of the opinion that information flow between the boards and the Department of Health is in definite need of senior-level coordination. Members of the standing committee are of the opinion that this coordination should be achieved by channelling all departmental requests for board information through the office of the deputy minister of Health.

By establishing the deputy minister as the single coordinating source within the department, the standing committee believes that overlap in the content of information requests could be eliminated, better consideration could be given to reasonable time lines for board response, and headquarters information needs could be vetted to ensure that they were essential to the operation of the health system.

In summary, the Standing Committee on Agencies, Boards and Commissions believes that the number of demands for detailed information currently placed on health and hospital boards by the Department of Health are constituting a serious barrier to effective administration. While this situation will likely be addressed by an improved information system and role clarity achieved through the MOU process, the committee is of the opinion that senior coordination of information requests is necessary at the present time.

Therefore, I move that this committee recommends that all requests from the Department of Health to health and hospital boards for budgetary, statistical and other administrative information should be made only by the deputy minister of Health;

And further, that information requests should be limited in number and scope to only those which are essential for the efficient and effective operation of territorial health services;

And further, that the time frame for board response to departmental information requests should be reasonable and established with due consideration to other priorities which have been identified at the regional level. Mahsi.

Thank you. The motion is in order. To the motion.

Question.

Question has been called. I do not believe I have a quorum. Mr. Clerk, please ring the bell.

Thank you. Question has been called. All those in favour? All those opposed? The motion is carried.

---Carried

Mr. Koe.

Inadequate Funding Base

During the standing committee's review, board representatives frequently noted that the original health funding base transferred from the federal government has proved inadequate for meeting either current or future needs. Representatives of the Baffin regional health board, for instance, pointed out that currently there is no base funding to cover annual leave and sick leave of community-based nursing personnel, so these dollars must be drawn from other areas. Several boards mentioned that training opportunities for health care professionals are restricted by shortages in the funding base.

It was suggested by some health and hospital boards that a system of standards should be established to dictate levels of service to be delivered in the various health care disciplines to communities and hospitals within the regions. Dollars could then be allocated according to the real cost of meeting the defined standards.

The standing committee is of the opinion that the Department of Health should consider ways of accepting the challenge to establish a system of standards that are comprehensive enough to meet communities' potential needs and at the same time are realistic, in light of current fiscal pressures on the health system. Because such global issues were somewhat beyond the scope of the current review, it was felt that the Special Committee on Health and Social Services might find it fruitful to explore issues surrounding the inadequacy of the funding base for health services and, specifically, might examine possibilities for funding allocations based on a more systemic set of service delivery standards.

Lack Of Incentive For Successful Management

During the course of the standing committee review, representatives of health and hospital boards pointed out that they have made significant strides in improving internal control and management procedures over the past several years. They expressed concern that this does not appear to have been recognized by the Department of Health. To a large degree, the same control directives and budget allocation procedures have remained in place since the transfer.

The standing committee heard several boards advocate for new block funding approaches and a system of global budgeting. It may be difficult to implement such approaches on a system-wide basis, until all health and hospital boards are on a par with respect to management resources and expertise. Development of the concepts involved should be initiated now, however, with a view toward possible implementation of block funding procedures within the next three to five years. Principles related to these new approaches to board funding should emerge as a result of discussions between the department, the health and hospital boards and other stakeholder organizations. Perhaps some of the analysis now being undertaken by the Special Committee on Health and Social Services will add to this process as well.

As a more immediate observation, though, the Standing Committee on Agencies, Boards and Commissions noted a need for some consideration of a surplus retention policy, which would apply under circumstances in which health and hospital boards have clearly demonstrated appropriate management performance.

This need was outlined in a written submission which the standing committee received from the Board of Management at Stanton Yellowknife Hospital:

"As boards and their staff work to maintain financial stability, there is currently no reward in the present funding system. Boards should be able to keep a percentage of surpluses generated, in recognition of the work they have done. This money could then be used for specific projects which fall within the board's mandate, but perhaps do not receive priority in funding."

Similarly, during the November consultation sessions the chairperson from the Board of Management at Hay River's H H Williams Memorial Hospital commented that,

"Our hospital has a pretty good track record when it comes to staying within our budget. I hate what happens, and not just in our department but in all government departments, when it comes to the end of the year--about mid-March--and we have to spend the money that is there because if we do not spend it we will lose it. I would love to have the opportunity to direct the board and the hospital in using funds in a very responsible way and getting a little bit of recognition for it."

Perhaps the most illustrative comments in this respect were brought to the standing committee's attention by the Inuvik Regional Health Board. Facing a chronic under-utilization of hospital bed spaces and an increasing need for fiscal restraint, the board closed a 19-bed ward in 1991-92. This was accomplished without staff layoffs or major capital renovation costs and has resulted in a significant increase in percentage utilization of the facility.

Yet, there has been virtually no recognition of the very appropriate management approach taken by the Inuvik regional board, in fact, when she appeared before the standing committee in November the chairperson expressed frustration with the way the effected savings have not been allowed to improve health services in the region. She stated that,

"We have certainly taken a big bite out of the amount of money that was required to run health services in our region, with the understanding that we are closing an entire ward in our hospital and losing 19 beds. I think we have done our part.

"What bothers me about that is when we asked the Department of Health for a speech pathologist, what happened to our 19 positions? Why can we not take these resources and use them as we see fit? We have done our part, now please, in reciprocation, please allow us to do what we feel is necessary for the needs of our region."

The Standing Committee on Agencies, Boards and Commissions believes that there is much merit in the notion that where health and hospital boards have effectively demonstrated appropriate fiscal management resulting in year-end surpluses, that they should be able to retain a significant portion of the surplus for regionally identified priorities. Any policy to this effect, however, would need to be developed through a joint consultation process between the department and the boards. Surplus retention policy should not be developed within the Department of Health and imposed on the health and hospital boards.

Some cautions may be in order. It is wrong to assume that a surplus in one budget category is an automatic indicator of appropriate spending decisions; surpluses should never be generated by cutting back below basic service delivery levels maintaining periods of critical staff shortages and so on. Further, boards must be mindful of the fact that the retention of surplus dollars is best regarded as a source of one time only funding and that they should be careful not to create later year funding shortfalls by using this money to support ongoing programs or services.

The Standing Committee on Agencies, Boards and Commissions is of the opinion, however, that these limits should be easily reflected in a well written policy directive and that, in balance, the advantages of a surplus retention incentive far exceed the risks.

Mr. Chairman, I have a motion. I move that this committee recommends that the Minister of Health consult with the health and hospital boards to develop policies and strategies which allow surplus retention under circumstances in which boards clearly demonstrate appropriate fiscal management. Mahsi.

Thank you. Your motion is in order. To the motion.

Question.

Question has been called. I believe I do not have a quorum. Clerk, ring the bell. Thank you. Question has been called. All those in favour? All those opposed? Motion is carried.

---Carried

Mr. Koe.

Human Resource Development Within Health And Hospital Boards

I would like to talk about human resource development within health and hospital boards. The Standing Committee on Agencies, Boards and Commissions took special note of the needs which exist with respect to human resources within health and hospital boards. The committee was

concerned with the current state of professional resources within board operations and also with the manner in which board members themselves have been recognized and developed as human resources.

Personnel Administration Within Health And Hospital Boards

The standing committee was aware that the report of the Auditor General of Canada has provided a fairly extensive treatment of the prevailing approach to "Managing People" within the health system, including some aspects of human resource management by health and hospital boards. The committee also understands that this has been one of several points on which the Standing Committee on Public Accounts has focused during its current review.

Accordingly, comments in this report will not be comprehensive but, rather, will touch on those areas which Members of the Standing Committee on Agencies, Boards and Commissions have identified as important for the purpose of the current review.

I will now ask Mr. Lewis to continue.