Question has been called. All those in favour? All those opposed? Motion is carried.

---Carried

Item 15, motions. Item 16, first reading of bills. Item 17. second reading of bills. Item 18, consideration in committee of the whole of bills and other matters: Tabled Document 2-12(3), The Justice House - Report of the Special Advisor on General Equality; Tabled Document 3-12(3), Report of the Commission for Constitutional Development; Bill 5, An Act to Amend the Social Assistance Act; Bill 17, Appropriation Act, No. 2, 1993-94; Committee Report 10-12(3), Report on Tabled Document 21-12(3): Payroll Tax Act; Committee Report 11-12(3), Report on the Review of the 1993-94 Main Estimates; Committee Report 12-12(3), Report No. 4, Talking and Working Together; Appearance by Members of the Commission for Constitutional Development; and, Committee Report 14-12(3), Report of Health and Hospital Boards with Mr. Ningark in the chair.

The committee will now come to order. When we concluded Friday, we were dealing with the Department of Health. Now what is the wish of the committee? Mrs. Marie-Jewell.

Thank you, Mr. Chairman. The committee would like to deal with Committee Report 14-12(3) of the Standing Committee on Agencies, Boards and Commissions. Then we would like to address the Department of Personnel. Thank you.

There is a request to deal with Committee Report 14-12(3). Do we have the concurrence of the committee to deal with the matter?

Agreed.

---Agreed

Thank you. The chairman of the Standing Committee on Agencies, Boards and Commissions, Mr. Koe.

Thank you, Mr. Chairman. As mentioned earlier, the Standing Committee on Agencies, Boards and Commissions has now completed its review of issues related to the operation of health and hospital boards established under the Territorial Hospital Insurance Services Act. The committee has before it a copy of the standing committee's final report on this 14 month initiative. This follows an earlier interim report which was tabled and dealt with on December 10, 1992. The introductory chapter of the standing committee's final report outlines the process that was followed as well as the reasons for the committee's review. It also comments on a context within which a review was undertaken.

These are important sections because they lay out the background and procedures used by the standing committee and describes some of the events that were taking place during the time of the review.

In the interest of being brief, Mr. Chairman, I would propose to let honourable Members review the introductory chapter on their own and instead, move right away into our presentation of chapter one, which deals with an overview of health and hospital boards. This will allow us to get into the meat of the report and will maximize the use of our time in committee of the whole today.

Proceed, Mr. Koe.

Before doing so, however, I would like to make two quick points. The first is a point of clarification about the Auditor General's report. As honourable Members are aware, the Auditor General of Canada completed a comprehensive audit of the Department of Health in October, 1992, at the request of the 11th Legislative Assembly. The report was tabled in this House on November 17, 1992 and has been referred to the Standing Committee on Public Accounts where it has been the subject of a public review.

The Auditor General audited the Department of Health and not the health or hospital boards. Accordingly, the Standing Committee on Agencies, Boards and Commissions has not carried out a systematic review of the Auditor General's findings and will not comment specifically at this point with regard to recommendations included in his report. That job has been referred to the Standing Committee on Public Accounts. We look forward to the results of their extensive public review of this document.

At the same time, Members of the Standing Committee on Agencies, Boards and Commissions do agree that the Auditor General's Report on a Comprehensive Audit is a very important document and is largely relevant to many of the subjects that have been examined during the review of health and hospital boards. Where findings made by our standing committee relate to observations made by the Auditor General, these are noted in the committee report before you.

The second introductory comment I would like to make, Mr. Chairman, is one of acknowledgement. Throughout this review the Standing Committee on Agencies, Boards and Commissions received a great deal of assistance, information and interest from representatives of health and hospital boards across the Northwest Territories. I am sure I speak for all Members of the committee when I express our thanks for the thoughtful input we received in public hearings and consultation sessions.

With that as a preamble, Mr. Chairman, I would now like to move on to consideration of the first part of our report which is titled "An Overview Of Health and Hospital Board Issues in the Northwest Territories." That section begins on page 10 of the report which is presently before Members. Mr. Brian Lewis will continue.

Mr. Lewis.

Overview Of Health And Hospital Board Issues In The NWT

Thank you, Mr. Chairman. This is an overview of health and hospital board issues in the Northwest Territories.

The Standing Committee on Agencies, Boards and Commissions wishes to express its dissatisfaction with respect to a very serious state of affairs which presently exists within the administration of the territorial health care system.

In an earlier report on health and hospital boards in the Northwest Territories, the standing committee commented as follows:

"When responsibility for health was transferred to the Government of the Northwest Territories in 1988, the decision was made to establish a system of health and hospital boards rather than centralizing authority for administrative affairs in Yellowknife. The goal was to ensure that communities and regions would be able to take responsibility for the administration and delivery of the health care services required by their residents.

"After approximately four years, there are strong signals that the entire scheme is not unfolding as it should. There is a real risk that, unless significant adjustments are made in the prevailing approach used by the Department of Health, the development of a community-based foundation for the administration of health care services may be headed for failure.

"Members of the Standing Committee on Agencies, Boards and Commissions were dismayed by the degree to which conflict between the health boards and the Department of Health is exerting itself on our health care delivery system. When one regional health board chairperson was asked by the committee to identify the 'biggest stumbling block' to meeting the health care needs of her region, she responded clearly and simply 'the Department of Health.'"

The Standing Committee on Agencies, Boards and Commission has noted that, although some preliminary steps have been taken to define respective responsibility, concerns about the status and role of health and hospital boards have continued to characterize the territorial health systems in the interim report tabled two months ago. Perhaps to expect otherwise would have been, unfortunately, unrealistic. The specific problems are too numerous and too rooted in a history of poor communication and inter-organizational mistrust to allow an easy solution.

The Standing Committee on Agencies, Boards and Commissions was dismayed by the amount of evidence it received describing relations between the boards and the Department of Health as strained and unproductive. A number of very specific areas of dissatisfaction appears to arise from the interaction between boards and the Department of Health. To a large degree, however, each of these reflected two common factors: role confusion and overly centralized control.

Some of the information that has been brought to the attention of the Standing Committee on Agencies, Boards and

Commissions over the course of its review has been particularly illustrative.

For instance, at the November 21 consultation session in Yellowknife, a representative from the Baffin regional health board noted as follows:

"Between 1982 and 1988, the Baffin regional health board made sound progress, and only after the total health transfer in 1988 was there more centralization. This eroded the board's ability to have greater flexibility in resolving regional issues.

"Health boards are a common factor in managing hospitals everywhere in the world, but this has not always been appreciated by the department in the NWT, who are not aware that this is not a new process."

At the same meeting, a representative from the Inuvik regional health board offered the following view of relations between the Department of Health and the boards:

"I think the boards really are trying to do their best, but somehow, for some reason, we do not seem to be able to get our needs identified by the Department of Health. I really believe that. This is not a Department of Health bashing either. I believe that the people in Yellowknife do a great amount of very good work, but I think what they do not understand is that they have never lived out in the satellite communities. They do not know what it is like, nor do they understand that my needs in the western Arctic are very much different than the Baffin's needs or Keewatin's needs."

A written submission received from the Keewatin regional health board in June, 1992, summarized the problem in the following terms:

"There has been, and there continues to be, confusion on the part of the Department of Health regarding the role of health boards as an integral part of the delivery of health care services to the people of the Northwest Territories.

"This confusion on the part of the Department of Health official often leads them to intrude on the operating mandate of the health board.

"The partnership in the delivery of health care services is, for the most part, weakened when there is a continual conflict between the partners.

"In order for the health care system to fulfil its mandate to the people of the Northwest Territories, there must be the clear definition of the roles of the partners in the overall delivery of health care."

Board representatives, no doubt, have a vested interest in presenting a particular "side" of the story. However, similar objective evidence of systemic problems was found in the October, 1991 report of the Auditor General of Canada on his Comprehensive Audit of the Department of Health:

"The specific issue is the rivalry, sometimes bordering on animosity, between boards and the department. There appears to be a lack of trust, a one-way paper flow, poor communication and inappropriate control by the department. In our view, what should have been help and monitoring has turned into control. Monitoring is desirable and expected, but it needs proper information and performance system to provide the right kind of data. These have not been developed." Clearly, there are strong indications to the Standing on Agencies, Boards and Commissions that serious problems exist within the organization of the territorial health system, particularly with respect to the role confusion and control conflicts which surround the function of health and hospital boards. Thank you, Mr. Chairman.

Thank you, Mr. Lewis. Mrs. Marie-Jewell.

Placing The Issues In Historical Context

Thank you, Mr. Chairman. It can be argued that many of the issues confronting health and hospital boards today cannot be fully understood without considering the historical context in which the current system emerged. A summary of relevant background features is included as appendix C to this committee report.

The Standing Committee on Agencies, Boards and Commissions noted that the history of these problems was recognized by the former Minister of Health, the Honourable Dennis Patterson, in a September 21, 1992 addressed to the Northwest Territories health care association, when he stated that:

"It should not be surprising that there continue to be implementation problems. Many difficulties have arisen because the respective roles of government and boards had not been defined with sufficient clarify. The intentions were set out in the trustee manuals, but perceptions and expectations coloured their interpretation and applications. So, instead of concentrating our efforts in the last four years on developing a model and a strategic plan for the future, there have been debilitating skirmishes over alleged infringement or perceived excesses of board 'autonomy.'"

Similarly, the Standing Committee found it useful to review the following comments on the same subject, included in the very thoughtful written submission received from the Kitikmeot regional health board:

"From the beginning, it seemed everyone was struggling, no one was sure of who was to do what, and initially everyone did whatever had to be done, just to ensure service provisions continued. Quickly, the larger and stronger groups were able to take off on their own, and the various constituents began vying for power and resources."

While these perspectives place today's problems in the proper historical context, however, the Standing Committee on Agencies, Boards and Commissions knows that there is little to be accomplished by blaming past events and process. Instead, emphasis must be placed on identifying and correcting the various organizational factors which contribute to the perpetuation of these problems today.

Advantages Of Health And Hospital Boards

The Standing Committee on Agencies, Boards and Commissions recognizes that an approach which allows boards to act as the key delivery agents brings many strengths to the administration of health services. These were pointed out by several of the representatives who attended standing committee consultation sessions. They pointed out that health boards create a "closer-to-home" philosophy within the administration of health services and engender a sense of ownership in the community. At the same time, a board allows varying community interests to be balanced when making decisions about health programs and services.

Generally, health boards in the Northwest Territories have been able to provide the kind of structure that is open to community input and is reflective of other decisions that are being made by the community leadership. When appointments are made regularly and judiciously, it facilitates administrative continuity since it rarely involves the replacement of more than one or two board members at a time. As well, health boards can, and have, become adept at seeking out trustees with particular skills required for the operation of health care facilities and programs.

These views were not unique to the board representatives with whom the standing committee consulted. In his report on the audit of the Department of Health, the Auditor General of Canada pointed out that:

"Regional boards have many attractive features. They allow local involvement in key issues, they can be more responsive to the cultural sensitivities of the people, and they put the decisions and resources where the communities can be actively involved in deciding how to use them."

The standing committee noted that this has been recognized for many years at the national level, as well. In a 1972 brief to the Minister of National Health and Welfare, for instance, the Canadian hospital association commented that:

"The quality of patient care would inevitably be the loser if decisions were left entirely for the hierarchy in the Department of Health in the provincial capitals of the country, and in the offices of National Health and Welfare in Ottawa.

"This is not to criticize or condemn the good intentions of those in positions of substance and responsibility in those departments. The fact simply is that the control of quality patient care could not afford to come under the umbrella of bureaucratic jurisdiction. The community hospital board is the chain that joins together the patient and his needs, the community in which he lives and the government that, as paying agency, is certainly entitled to a hand in what must be a partnership endeavour."

The Standing Committee on Agencies, Boards and Commissions was of the opinion that a health system in the Northwest Territories must be delivered by bodies that are representative of the people who are served. In addition, a well-working system of health and hospital boards empowers communities and provides a sense of responsibility for the health status of people living within the region. Thank you, Mr. Chairman.

Thank you. Mr. Koe.

Initiatives By Health And Hospital Boards In The NWT

The standing committee was interested in learning more about some of the recent initiatives that had been undertaken by health and hospital boards, so asked each of the representatives participating at the November consultation sessions to provide an overview of some of the key projects under way in their respective regions.

The standing committee was impressed with the range of creative and responsible initiatives that were outlined. Without exception, each of the health and hospital boards were able to describe key activity areas which not only reflected the needs of the community but had potential to enhance the delivery of services and programs.

A complete listing of all the specific initiatives that have been undertaken by health and hospital boards across the Northwest Territories would be too extensive for inclusion in this report. However, the standing committee particularly noted the following projects as examples of the important work that has been carried out at the board level:

-In the Baffin region, for instance, the board has reorganized specialist schedules in a way that has actually increased the number of specialist visits to communities. This has proved cost-effective in reducing medical travel costs and has been welcomed by the residents of Baffin communities.

-In the Inuvik region, the board is spearheading a major strategic planning exercise and evaluating the potential for a palliative care area in the hospital to assist people who are terminally ill and their families.

-As well, the Inuvik regional health board is carrying out a major renovation of the transient centre.

-Suicide specialist services to the Inuvik region will now be delivered by the regional health board, through a contract with the Department of Social Services, and needs evaluation for speech pathology services has been undertaken.

-The Stanton Yellowknife Hospital board of management has taken on a strategic planning process to review the mission and goals of that health care facility, and is now moving on to a major functional review of current programs and services.

-The board at Stanton Yellowknife Hospital has also made considerable progress in implementing cross-cultural awareness training for hospital personnel, and is incorporating this as an integral component of resource management within the facility.

-In Hay River, the board of management for the H H Williams Memorial Hospital has been actively exploring potential avenues for delivering mental health care, aimed at meeting community and regional needs.

-The Keewatin regional health board played a key role in establishing a new dental clinic in Rankin Inlet which has created additional job opportunities and improved access to dental care.

-New contracts with the Churchill health centre have enabled the Keewatin regional health board to reduce costs for pharmaceutical and pharmacist visitation services while improving inventory control.

Upon reviewing the range of initiatives and projects mounted by the health and hospital boards over recent years, it became very clear to the Standing Committee on Agencies, Boards and Commissions that a lot of good work is being done at the community level. Clearly, these are not boards which meet often and accomplish little. The impression that was left with the standing committee was that health and hospital boards in the Northwest Territories have been able to achieve a level of maturity and operational effectiveness that is not recognized in their current working relations with the Department of Health.

Mr. Chairman, I would now like Mr. Whitford to continue.

Mr. Whitford.

Endorsement Of The Principle Of A Board-Managed Health System

Thank you. There is a motion on the floor, but I do not think we have a quorum. The motion is in order. To the motion.

I will try again, the microphone was not turned on. There was a question for the motion and Mr. Clerk will ring the bell.

To the motion.

Question.

Question has been called. All those in favour? All those opposed? Motion is carried.

---Carried

Mr. Dent.

Role Confusion In the Health Care System

Mr. Koe.

Memorandum Of Understanding

Thank you. Regarding the memorandum of understanding, the Standing Committee on Agencies, Boards and Commissions has already made note of the important initiative that is under way to develop a master memorandum of understanding between health boards and the Department of Health. The NWT Health Care Association has agreed to coordinate drafting and consultation activities and a contractor is to be retained to facilitate the process. Since bringing forward the interim report, the committee has noted that progress in this regard has been slow. The original time lines proposed by the former Minister of Health would have seen the substantial completion of this agreement by the start of the 1993-94 fiscal year. It is now unlikely that this target will be reached.

The standing committee is concerned that this process should not be allowed to become too cumbersome. The MOU is urgently needed.

The standing committee also noted that some board representatives were concerned that both the process leading to the establishment of the MOU, and the substance of the MOU itself, should not be defined by the Department of Health. There seemed to be an absence of trust, in at least some quarters, that the department would listen to, and work cooperatively with, the boards. Instead, there was some concern that the Department of Health would attempt to "impose" both a model and the content for the MOU upon participants. The Standing Committee on Agencies, Boards and Commissions is of the opinion that this cannot be allowed to happen.

Members of the standing committee are of the opinion that a "top-down" approach will simply not work in this case. The Department of Health must treat the health boards as equal partners in this process and not attempt to dictate basic content parameters. The MOU will only work if there is an equal sense of ownership among all the parties to it.

difficulties and returning the initiative to the fastest timetable the process will allow.

For their part, however, the boards must also assume a constructive approach to building the memorandum of understanding. It was Members' perception, during the committee's consultation sessions on November 21, 1992 that the boards were willing to approach this initiative as a collaborative and positive venture. That positive outlook will need to continue in order for the process to be successful.

In light of these considerations, the standing committee was concerned to learn that, at least in the early stages of the process, several board representatives reported that they had not been regularly advised as to progress on the MOU initiative. To reiterate the position previously taken by the standing committee in its interim report, this effort will not succeed unless it is based on ongoing information exchange and a collaborative approach. It is not enough for the department to rely on the information channelling capabilities of a voluntary organization like the health care association. The Department of Health must continue to play a role in ensuring that the respective parties to the MOU are fully briefed as to the status of the initiative.

The Standing Committee on Agencies, Boards and Commissions is of the opinion that, at this point, the initiative to establish a memorandum of understanding on roles and responsibilities within the health system will go a long way toward finally dispelling the uncertainty and confusion that has surrounded the status of health and hospital boards since transfer. This is essential to ensure the efficient operation of territorial health facilities, programs and services.