Thank you, Mr. Chairman. Mr. Chairman, there have been a number of reports, dissertations, studies, opinions and comments on the Department of Health over the last year. I know that I have been slow in responding to reports, et cetera. I want to apologize to the House for being slow, but I did not want to come to this House and respond to any of those reports unless you had up-to-date information and I was reasonably sure that what I was reporting to you was, in fact, fact.
With regard to the report, Mr. Chairman, I must admit that I am going to be fairly lengthy in the Department of Health opening remarks, and I apologize for that, but there are things that need to be reported.
Mr. Chairman, the department has studied and acted to implement recommendations included in the reports that I had mentioned before. The responses to these reports have been provided to the respective committees, as follows:
1. The report of the Standing Committee on Public Accounts, including the NWT health human resource plan and the north of 60 special initiative, which is the report on the national health research and development program;
2. The report of the Standing Committee on Agencies, Boards and Commissions;
3. The report of the Auditor General on the Comprehensive Audit of the Department of Health.
Also, Mr. Chairman, as I have said before, there is a joint response to the report of the Special Committee on Health and Social Services being developed by the Departments of Health, Social Services, Education, Culture and Employment, and Justice is involved as well, and it will be tabled by the Premier during this session.
Board Issues
First of all, Mr. Chairman, I would like to deal with board issues because that has been a matter of some contention over the last little while. I have made reference at the last session to a proposed meeting that was going to occur in late January with the boards. That meeting did not occur until February 1 and 2.
Mr. Chairman, I met with the boards on those dates and reviewed with them many of the issues which have been raised through committee reports, and directly by boards. For the first time, Mr. Chairman, representation was included from Dogrib, and from Deh Cho communities, and agreement was reached that representatives of professional organizations, including the NWT Medical Association, the NWT Registered Nurses' Association, and the Canadian Public Health Association, would be invited to attend the next meeting, which I proposed should be held in April in Taloyoak -- the second of four meetings to be held each year. This year, there will be three more meetings of this group.
I should explain that the NWT Medical Association, the NWT Registered Nurses' Association and the Canadian Public Health Association will only be there for part of the time. We will then deal with issues that concern all of us, which is the health of people in the Northwest Territories, the delivery of health in the Northwest Territories and our common interest in pursuing good health policy in that area. The rest of the time, it would be merely myself or the deputy minister and the boards discussing issues that concern our territorial Department of Health and the board chairs. There will be four meetings from now on until we get down to ironing out many of our differences. Then, we may be able to cut it back to three meetings a year, and then two. I certainly wouldn't want to go below two though, Mr. Chairman.
I indicated, at that meeting, my intention to invite the federal Minister to the meeting, in order to acquaint her with the unique nature of our land, our population, and our health problems, and the means through which we attempt to deal with them. I say that, Mr. Chairman, because I believe that, again, with the Department of Health federally, there is a lack of understanding about the difficulties that we face here in delivering health care and just really what a good job those nursing stations and health centres do under some very trying conditions, weather conditions, being away from major hospitals, et cetera. I notice that, in provinces these days, they are looking towards the same kind of system that we have. I think it is important that we try and get the federal Minister up here so that she can be more aware of what we are trying to do.
The agenda included discussion of the following matters:
1. Planning the health system's, general approach, the operational planning process, and the capital planning process:
In 1994-95, efforts will continue toward the completion of an NWT Health Plan. This will be pursued through coordinated efforts with health and hospital board chairs, and representatives of the medical, nursing and public health professional organizations. Efforts will continue on the development of community and regional profiles to determine health needs, health service resources and use, and the options for improving service arrangements. These activities will take into account the planned consolidation of community- based programs, including mental health, alcohol and drugs, aged and handicapped services, in the Department of Health.
I think I mentioned, during the capital budget, Mr. Chairman, that with any new facilities we will be looking at trying to incorporate alcohol and drug centres into those new facilities so that we are getting a one-stop shopping, if you will, although there would be a division in the actual physical building.
I think I reported to the House last fall that we would also step up the call letter for capital budgeting for the boards. I think that has been done, Mr. Chairman;
2. Out of NWT support services - specifically, we discussed the proposal to enter into an agreement with the Royal Alexandra Hospital (RAH) in Edmonton:
The initial agreement is broad in scope, permitting an extensive range of collaboration and flexibility to meet the specific needs of individual boards. Specifically, the arrangement authorizes:
a) establishing a northern health services program within RAH, and the RAH as the prime, but not the exclusive, referral centre for the Western Arctic, and that also includes the Kitikmeot;
b) relocating nurse coordinators now operating out of Larga boarding home to the RAH, but we would preserve a close link between RAH and Larga;
c) developing detailed plans to:
i. coordinate patient referrals;
ii. provide patient services information;
iii. provide traditional healing support;
iv. provide consultation services in Edmonton, and in the NWT;
v. support continuing education for health professionals in Edmonton and in the NWT through live and interactive telecommunications;
vi. provide backup arrangements for physicians;
vii. coordinate Edmonton based medevacs; and,
d) identifying additional areas for future action.
Mr. Chairman, I think we will ultimately be successful in making this arrangement and we would intend to pursue similar arrangements with the Keewatin Board and Winnipeg and the Baffin region and a hospital in either Montreal or Ottawa for services to that particular region.
I should explain that there are many people saying to me, how can you be making this arrangement with the hospital in Edmonton when Premier Klein has the health care system in an uproar down there? We are pursuing this arrangement because we have already spoken to the health people in Alberta at the deputy minister level. I have spoken to the Minister. They have told us of their plans and what they intend to do in Alberta, so we are very familiar with what they intended to do. We went down and said, "Look, this is what we intend to do with doing business with your hospital, Royal Alexandra." They said, "Go right ahead, because that is one of the facilities that is going to be there. You will be giving them patients and a better basis upon which to work," et cetera, so it worked out for both us and the Royal Alexandra Hospital and Alberta, in general.
4. The memorandum of understanding, which was the subject of some questioning by Mr. Koe at the last session, and we understand that it was the subject of a two-day meeting of board chairs, CEOs and department officials on February 3 and 4:
Mr. Chairman, the MOU project is a joint undertaking of the Department of Health and the NWT Health Care Association to review the current arrangements between NWT hospitals and health boards, and to develop a document which clearly defines the roles, responsibilities and authorities of the boards and the department, within existing directions of Cabinet and the Financial Management Board. Mr. Chairman, I should point out that boards are asking us to go further than we can at the present time simply because of the legislation that is in place in the NWT right now.
The theme of the MOU is based on the development and operation of an NWT health system through collaboration and cooperation. This working together is based on the assumption of four stakeholder groups, all operating in the public interest:
a) Boards, whose special roles are to plan, organize and manage services at the community level;
b) Professional groups, who participate in the management of the system in addition to providing direct services;
c) The Department of Health which defines services, establishes and monitors standards;
d) The Social Policy Group, consisting of the Departments of Health, Social Services, Education, Culture and Employment, operating under a memorandum of agreement, to plan and coordinate programs and services which exceed the mandate and capability of individual departments; and,
e) Government, including Cabinet and the Legislative Assembly, which sets policy for and finances the operation of the system.
The project is guided by a steering committee consisting of the deputy minister of Health, or delegate as chair, the director, Hospital and Health Facility Operations, and three delegates named by the NWT Health Care Association, on behalf of health and hospital boards. An outside contractor, Western Health Planning Associates, was engaged to assist in the preparation of the document.
Discussions were held on the report of the consultant, and on a draft document prepared by the steering committee. The assembled materials will now be further refined, and reviewed at the Minister's next meeting with chairs and CEOs this spring.
5. Functional Review Of The Department
I had not been able to recall the name of the consultant. It has come rushing back to me that it is Coopers Lybrand, Mr. Chairman. This review of the department offers an opportunity to respond to several areas of concern noted by the Auditor General and the SCOPA in their reports, including planning, policy development and human resources development, especially the aim to increase aboriginal representation in the department at all levels. The final report of the consultant will be provided to the joint department/FMBS steering committee by the end of February.
6. Financial System
Over the past year, extensive consultation has been undertaken with boards through the health board financial systems project to deal with problems arising from the use by boards of three different financial charts of accounts and three different financial information systems. The resulting lack of consistent coding procedure has undermined the credibility of financial reporting, weakened submissions for supplementary funding, and frustrated managers at all levels.
A working group of board and department financial officers was struck to review financial systems being utilized by the various boards and to propose a plan for a common, integrated financial system that would use the same accounting methodology and chart of accounts. This working group has undertaken the standardization of the charts of accounts, accounting guidelines and financial systems, and has unanimously recommended a financial system package. The package has been tested, and a financial system implementation plan is now under way. At the meeting, board chairs agreed to the proposed financial management system. Implementation is scheduled for completion by the fall of this year.
7. Board Appointment Process
A number of concerns have been voiced about the board appointment process. At the recent meeting with board chairs and CEOs, I invited their input into further streamlining of the process so that boards are fully involved in the selection and appointment of health care trustees.
At a meeting held with board chairs in February, it was agreed that a review of the composition of the Stanton Yellowknife Board would be jointly undertaken in the next six months. Mr. Chairman, I hope to do that review quicker than six months. I would like to aim probably for four weeks from today. Some 50 per cent of the people who are treated at Stanton Hospital are from outside of Yellowknife. What I proposed to board chairs, and I think I have their agreement on it, is that we would place upon the chair of the Kitikmeot Health Board, the Inuvik Regional Health Board, the H.H. Williams Memorial Hospital in Hay River, the hospital in Fort Smith, that there would be a representative from Deh Cho, and there is already a representative from the Dogrib Nation on there and that we would look at the issue of Lutsel K'e, which derives its hospital services from the Stanton board as well. If we can bring those people in to the board, and I think we can -- I think we have agreement from Stanton right now on that issue -- then they would make up 50 per cent of the board. The remaining 50 per cent of the board would come from this area. I think, then, we would be seeing a continuation of the issues and the concerns from different boards in whatever region of the Western Arctic and Kitikmeot that you might care to mention, taken up with the hospital that is delivering service to their constituents, their patients, to the people who live in their area. I hope that will take place very quickly, Mr. Chairman.
8. Orientation Of Board Members
The department is collaborating with the NWT Health Care Association on an update of the trustee orientation manual and on the establishment and funding of an ongoing orientation and trustee development program. The NWT Health Care Association sponsored a day long meeting of board chairs and CEOs on February 5 to discuss the intended approach.
Program Issues
1. Non-Insured Health Benefits
The Non-Insured Health Benefits Program (NIHB) applies only to Registered Indian and Inuit residents, and provides drugs, dental, vision care, medical supplies and equipment, and some travel benefits. This program is administered by the department on behalf of Health Canada under the terms and conditions of a contribution agreement.
Each service component is bound by a separate appendix to the agreement, and may be provided only under specific contracts. For example, optical services are provided under separate contracts, obtained through competitive bidding, for Baffin, Keewatin, Kitikmeot, Mackenzie and Inuvik. Only successful bidders for a regional contract have access through the program to the Yellowknife market. Others can provide the service but may not bill the program directly. This current agreement expires March 31, 1994. For those Yellowknife MLAs who have been lobbied in this regard, I realize that we have a problem in this area and I will move to correct that problem before we let the next contract, Mr. Chairman.
At the request of the department, Health Canada has convened a meeting with aboriginal organizations and health board representatives on March 2 to review the proposed terms for a new agreement which will take effect in April 1994.
2. Extended Health Benefits
The Extended Health Benefits (EHB) program provides assistance to eligible persons for health services beyond insured services covered by the Health Care Plan. This program is separate and distinct from the NIHB program. Benefits of the EHB program apply to Metis and non-native residents, and include drugs, dental, medical and surgical supplies, some institutional care, and travel associated with accessing benefits.
The major beneficiaries, Mr. Chairman, of the program are seniors, defined as 60 years of age and older, irrespective of medical condition or income. Other beneficiaries are those with designated medical conditions. The list is drawn from what was originally developed by Health and Welfare Canada to represent chronic diseases, but it has been modified over time on an ad hoc basis to its present form. Currently, Mr. Chairman, it contains 41 conditions. In 1992-93 claims were made in relation to only 29 of those 41 conditions. It is apparent that all beneficiaries of the program have unusual needs. It is equally apparent that there are others without benefits who need them.
In other words, what I'm saying Mr. Chairman, is there may be things on the list that are no longer required and there are certainly things off the list that are required, so we want to look at it.
We've started a review of this EHB program, with the assistance of a contractor knowledgeable in this area, Mr. Stan Remple. The aim of the review is to develop options to place the program on a more rational basis. One major benefit to doing so would be to provide a mechanism for dealing with problems where both medical and economic needs are evident. The insured services program cannot provide complete coverage, but it can provide basic benefits, and a means for dealing with the extraordinary events that undermine the fundamental aim of the program.
3. Specialist Services
Access to specialized services is a continuing problem in the NWT, especially in smaller communities. For medical specialists, this need has increasingly been met through expansion of capabilities at Stanton Yellowknife Hospital and through arrangements with facilities in southern Canada. We expect further improvements as a result of the new arrangement with Royal Alexander Hospital in Edmonton.
Dental specialist services are more problematic, and we remain dependent on tenuous and very expensive arrangements with southern-based specialists. Further, it appears that access to service is not based on consistent criteria nor closely related to need. Orthodontic and periodontic services must become more accessible, and on less inequitable terms and conditions to all NWT residents. As such, it is our intention to develop a dental speciality services program for orthodontics, periodontics and oral surgery that will:
a) identify these major specialty treatment needs;
b) provide a mechanism for the detection, prevention and early intervention of orthodontic and periodontic problems;
c) coordinate the access to northern-based treatment programs;
d) make use of the most appropriate therapies for treatment of these conditions in the NWT; and,
e) ensure that there will be equitable access to these programs.
In relation to denturist services, we have examined the current situation elsewhere in the country and consulted with national, provincial and territorial professional organizations. Mr. Chairman, I am attempting to schedule a meeting this week with the NWT Dental Association and the denturists to pursue the matter.
4. Dental Therapy
The state of dental health in the NWT, Mr. Chairman, is poor, as evidenced by a 1990-91 study of children across Canada. Our situation is the worst in the country and may have actually grown worse amongst the very young since the last similar study done in 1988-89. We believe the findings would have been much worse without the extensive dental care provided in small communities by dental therapists. In order to reverse the deteriorating state of dental health among children in the NWT we will be more aggressive in preventing dental decay earlier in life. Mr. Chairman, we're getting those children in school now but we have to get them before they get to school. That's what we are going to attempt to do.
The first school of dental therapy was established in Fort Smith in 1972 and many of you will remember that in 1982 it was moved to Prince Albert, Saskatchewan, with the expectation that there would be increased access to young patients. This has not occurred. In the past year, Health Canada has been reviewing existing training arrangements and solicited our views on the future of the school. We have responded with a request that the school be returned to the NWT. We will be pursuing this possibility further this year, in collaboration with and with the full support of the Department of Education, Culture and Employment and Arctic College.
Health Promotion/Disease Prevention Issues
1. Health Status Indicators
Most of the major improvements in the health of the NWT population over the past 30 years have been achieved through better housing, better nutrition and sanitation, widespread immunization and improved care for children, infants and pregnant women. Most of these improvements have been recent and are not yet fully established. In addition, a new set of health problems has emerged, arising from the dramatic change in lifestyle of many aboriginal people. This has been well documented in a recent report on the people of Igloolik in 1971, 1981 and 1991, describing the significant change from traditional patterns of life and the accompanying loss of fitness.
Mr. Chairman, the increased use of processed foods and the reduced exercise levels carry the risks of obesity, diabetes, cardiovascular disease and cancers. The major cancer risk, however, is from smoking. More people smoke in the NWT and at an earlier age than anywhere else in Canada. Death rates from lung cancer are also higher, especially for women.
The following are highlights of the health status of NWT residents and other important health indicators drawn from the most current available statistics:
a) A total of 30 per cent of deaths between 1984 and 1990 (62/217) were caused by injury and violence, many of which were related to alcohol abuse;
b) Lung cancer is the most common cancer. The NWT rate for "years of life lost" is twice the Canadian rate for males and four times the rate for females;
c) A total of 62 per cent of students aged 15 to 19 smoke cigarettes, the highest rate in Canada;
d) Mortality among Dene and Inuit infants is more than twice the Canadian average;
e) The twofold gap between native and non-native perinatal and infant death rates is increasing;
f) The NWT suicide rate is consistently higher than the Canadian rate. There were 19 suicides in 1992;
g) Tuberculosis is increasing among Inuit and Dene. The rates are comparable to third world countries;
h) Confirmed gonorrhoea rates for ages 15 to 24 are six times the Canadian rate;
i) Dental cavities and missing teeth rates for children are the highest in Canada; and,
j) The average number of persons living in a house is the highest in Canada. This is an indication of the inadequate number of houses and the increased risk of infectious disease.
2. HIV/AIDS
There is a growing concern internationally about the general lack of success in promoting safe sex. Repeatedly, population surveys indicate a considerable awareness of the risk of HIV infection and how it may be prevented. But there is little evidence that people are willing to change their high risk behaviours. In the NWT a special effort is being made, in collaboration with the federal Laboratory Centre for Disease Control to learn more about sexual practice among aboriginal populations and how it might be influenced. Specific health promotion and disease prevention activities will be enhanced, focusing on oral communication and television/video approaches, rather than written material.
3. Tuberculosis
Tuberculosis remains a serious problem in the Northwest Territories. Compliance with drug treatment is a particular concern. Once a patient begins to feel better, there is a tendency to take prescribed anti-tuberculosis drugs intermittently or not at all. The frequent result is recurrence of the disease and the unnecessary and avoidable infection of other people and, again, I go back to the crowded housing that many of our communities face, Mr. Chairman. Mr. Chairman, in order to avoid treatment failures and new infections, it is now the practice to ensure that prescribed drugs are taken by direct observation. A general review of the tuberculosis control program is being conducted to ensure that all effective measures are in place to control the disease.
4. Tobacco-Related Illness And Death
Mr. Chairman, since the 1994-95 budget was developed, an additional demand has been created for a tobacco control strategy, as a result of the ill-considered move by the federal government to reduce its tobacco tax. It has been demonstrated that increasing cigarette taxes and prices discourages smoking. Data from the USA indicate that for adults, a one per cent increase in price lowers the consumption of cigarettes by 0.42 per cent. But, for teenagers, a one per cent increase in price produces a 1.4 per cent decrease in consumption. This assessment has been confirmed by experience in Brazil and the United Kingdom.
The federal program, the announcement that was made in the House, Mr. Chairman, does include $200 million, or thereabouts, over three years to support anti-tobacco use programs. It will be insufficient to counter reduced tobacco prices, but we will make the best possible use of it. I have advised board chairs that this funding, our share of the $200 million, will be made directly available to them to use as they see fit. But, I will be seeking a commitment that some funds will be used to support initiatives which might serve all residents. So in other words, Mr. Chairman, I am saying that we will give you all of the money and you can spend 75 per cent of it in your regions to deal with how you feel you can counter tobacco use and point out the risks of tobacco use. But I would like you to provide 25 per cent of that and put it in a pool so that you can put together some ads or campaigns across the territories that apply to everybody.
5. Skin Cancer
Mr. Chairman, with regard to skin cancer, concerns have been expressed regarding the increased risk of NWT residents to the increased penetration by ultraviolet light as a result of depletion of the ozone layer. Specifically, the issue of availability of protective sunscreens has been raised. Recently, the issue has been complicated by information from the United States indicating the ineffectiveness, or worse, of some sun screens. In other words, Mr. Chairman, some of the products that have been on the market may not only have been ineffective, they may have been worsening the effect of the ultraviolet rays upon peoples' skin. We are reviewing the matter right now because this is recent information, and we will provide, in writing, to boards and others the current information on this subject, and we will get that around just as soon as we can, Mr. Chairman.
6. Nutrition
With regard to nutrition, Mr. Chairman, we continue to recommend and support the use of aboriginal foods in the Northwest Territories. The known benefits to Arctic communities and residents of traditional foods outweigh the known adverse consequences of contaminant intake associated with the traditional diet.
We also support the provisions of traditional foods for patients in health care facilities, whether within or outside the Northwest Territories, and are encouraged by the responsiveness of institutions to meet the nutritional needs and wishes of our aboriginal and other Northwest Territories residents.
Budget Proposal For 1994-95
Mr. Chairman, with regard to the budget, the Department of Health's proposed O and M budget for 1994-95 is $178.008 million. The department's proposals reflect a continuing effort to improve the health of NWT residents and to improve the access to and quality of health services while maintaining expenditures at a predictable and acceptable level. This is a realistic expectation that can be achieved:
1. through further judicious patriation of services from the south to permit care closer to home and, of course, we will save on the travel costs;
2. by monitoring the use of services to determine whether there are equally effective or better ways to provide care with fewer resources;
3. through negotiated arrangements with southern providers of care in the interest of better patient management and, of course, we save on their per diems in the hospitals, then;
4. through the establishment and application of protocols, guidelines and procedures appropriate to northern clinical practice; and,
5. through the management of payment methods for service which encourage good practice and provide predictability of costs over time.
During 1993-94, four major efforts have demanded priority attention by the department:
1. the development of a memorandum of understanding governing roles and relationships between the Department of Health and hospital boards;
2. conducting of a functional review of the Department of Health;
3. the review and revision of health legislation. I think, at the last time I counted yesterday, there were 19 or 20 pieces of legislation governing health in the Northwest Territories, and that would be, specifically, the Public Health Act and the Medical Profession Act, Mr. Chairman. These things are both now obsolete and impediments to the further development of the NWT health care system. Legislative proposals are being prepared and will be sent to Cabinet later this year; and,
4. the decentralization of the health insurance services division to Inuvik and Rankin Inlet, involving the recruitment, training and relocation of 20 staff, the acquisition of space and equipment and the development of new systems to support multi-location operations. The Inuvik office opened November 15, 1993, and is now fully operational. The Rankin Inlet office will open, as scheduled, on February 21, 1994.
One significant task deferred from last year, as a result of these preoccupations, is the consolidation in the department of management of medical travel benefits to GNWT employees,
now within the mandate of the Financial Management Board Secretariat, and that will occur this year, Mr. Chairman.
Mr. Chairman, I know that I have taken a long time but I wanted to try and set the record straight in a number of areas.
That concludes my opening remarks, Mr. Chairman. Thank you.