Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 6 - Evidence - November 2, 2011
OTTAWA, Wednesday, November 2, 2011
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:12 p.m. to examine the progress in implementing the 2004 10-Year Plan to Strengthen Health Care.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[English]
The Chair: Honourable senators, I call the meeting to order.
[Translation]
Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I am Kelvin Ogilvie, a senator from Nova Scotia, and I am the chair of the committee. I ask my colleagues to introduce themselves, starting on my left with the deputy chair of the committee.
Senator Eggleton: Art Eggleton from Toronto.
Senator Martin: Yonah Martin from Vancouver, B.C.
Senator Dyck: Lillian Dyck from Saskatchewan.
Senator Merchant: Pana Merchant from Regina, Saskatchewan.
Senator Demers: Jacques Demers from Quebec.
[Translation]
Senator Champagne: Andrée Champagne, also from Quebec. Good afternoon.
[English]
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: I would remind everyone that today we continue to examine the progress in implementing the 2004 10- Year Plan to Strengthen Health Care in Canada. This is our eighth meeting, and the topic today is access to care in the North.
I welcome our witnesses for today's meeting. From the Government of Yukon, we have Stuart Whitley, Deputy Minister, Health and Social Services; and Sherri Wright, Assistant Deputy Minister, Health and Social Services. From the Government of the Northwest Territories, we have Debbie DeLancey, Acting Deputy Minister, Department of Health and Social Services; and Robert Dana Heide, Assistant Deputy Minister, Operation Support, Department of Health and Social Services.
From the Government of Nunavut, our scheduled witness, Peter Ma, unfortunately had to cancel at the last minute.
I invite our witnesses to present their joint submission. We will start with Mr. Whitley, followed by Ms. DeLancey.
[Translation]
Stuart J. Whitley, Deputy Minister, Health and Social Services, Government of Yukon: Thank you for the opportunity to appear before you this afternoon. Unfortunately, we did not have enough time to prepare a presentation in French, so I will continue in English.
[English]
Each senator will have received a deck of materials in two parts. The first part is "Access to Care in the North," a short presentation that is an overview of what we will cover this afternoon; and a separate deck from each of us will speak specifically to some of the issues in our respective jurisdictions. If you care to follow me along, I will refer to this deck by page number.
"Access to Care," at page 2, indicates that we were to have three specific presentations but for the unfortunate absence of Nunavut. Following two presentations, we will go to a more interactive discussion with members of the committee.
On page 3 we make the very important point that without the Territorial Health System Sustainability Initiative, THSSI, we could not have made the progress we have made with respect to access to care in the North. On page 4, we briefly make the points that in addition to the supply of funding from the federal government toward access to health care, we also manage our base budgets as effectively as we can, which we will demonstrate in the presentations to come, to ensure that access to health care for Canadians in the North is increasing. We also want to acknowledge the important point that Canada has long recognized the need to assist the North with respect to its health care funding arrangements going back as far as 2003, in particular the 10-year accord and the Territorial Health System Sustainability Initiative, which initially was a three-year arrangement and then a two-year arrangement, which takes us to 2014.
I will move to page 5. Over the course of time since 2005, THSSI funding has provided $30 million per year shared between the three territories. That funding has played a critical role in the development, implementation and delivery of innovative and transformative health services in the North. It bears repeating that we are hugely grateful for the final extension of THSSI until 2014.
Over to page 6, the goals that were stated at the outset as agreed upon by the territories and the federal government were that we would reduce reliance over time on the health care system — and we will come back to that with some force when we speak specifically to what is going on in the territories — strengthen our community level services, and build self- reliant capacity to provide services in the territory. They are huge goals that in many respects present enormous challenges.
Over to page 7, the three funding components of the territorial funding would address key priorities, including support for medical travel costs. As you might expect because of the nature of our geography and the nature of our modest infrastructure, we rely heavily on medical travel to outside jurisdictions for the purposes of augmenting our health care delivery services. That includes our pan-territorial projects, which we will speak about during our discussion, mass media collaboration, support for the Arctic Health Research Network, mental health first aid, and medical travel program evaluation, which is an ongoing exercise.
Over on page 8, the federal priorities that are communicated to us frequently by the federal government rest upon the Northern Strategy. There are four pillars there, and I will not run through them all, but you can see that these have been now referred to many times by the Prime Minister as priorities for the federal government.
Probably one of the most significant concerns of the federal government is cost containment, as it is for all our three governments in the North. The increasing costs of health care impact our programs exponentially in the North, and it is in all our interests to contain costs.
Over to page 10, headed "Health is a Strategic Federal Investment," the North presently is experiencing an economic boom. All three territories now are in the process of experiencing considerable economic investment and considerable investment in the effects of global warming, of which there have been several announcements by the federal government in respect of sovereignty issues in the North. All of these are not possible to develop fully without healthy people and healthy communities. In respect of that, the funding that is available to us under THSSI is a significant means by which we not only improve the health of northerners but also help to manage the cost curve, which, of course, is affecting all jurisdictions.
Over to page 11, headed "Current Northern Context," probably every member at this table will be aware that we have significantly poorer health indicators in the North, particularly for Aboriginal and Inuit people. We have higher costs because of our smaller communities, our vast distances and our reliance on the infrastructure of other jurisdictions to deliver our services. We have health care human resource challenges because of our remoteness and the smallness of our communities. It significantly impacts our recruitment and retention. Our small populations mean a smaller tax base. We are hoping that will change, as, indeed, the indicators are starting to show. We are starting to generate more and more in the way of resource-based royalties. We are now in the process of experiencing population growth in the Yukon and Northwest Territories. Unfortunately, not all of that growth in the territories is of a permanent nature. Many of the exploration-type activities involve in-and-out labour groups, who nevertheless will depend upon our services but who do not actually live here so they can affect the funding formula or the tax base.
For the first time in the history of the territories, we are starting to see, particularly in Yukon and Northwest Territories, people retiring in their home communities, which has put an additional burden that we have not experienced up until now. It goes without saying that there are limited economies of scale.
I think two of us, if not Nunavut, have had scrutiny from the Auditor General of Canada, and we always welcome pointers on how we can do things better, even if they are a little harsh in the observation. They have said to us, in the course of their performance audits, that we need to strengthen recruitment and retention. Well, hallelujah, we agree with that. We need to improve our systems performance measurement and monitoring. We completely agree with that. We agree in the Yukon, at least, with all of the recommendations of the Auditor General. However, it means that we are looking at a major investment in systems to bring our capacity to do the kinds of evaluations, tracking and trend predictions that they want us to do more easily.
Finally, I would point out that the Truth and Reconciliation Commission, which has worked its way through the North now, has really peeled the scab off a serious social ill. All of you will know what that it is, the scale and scope of it, but to have it come to our communities and to have the multi-generational nature of that impact exposed in a way that this inquiry did has put significant burdens on our health care system as well as our social services system. We point out, I think as is appropriate, that the largest group of survivors and descendants of survivors is in the North.
On page 13, headed "Stability in Health Care Funding," the point we want to make here is that health care system transformation takes time. Elsewhere in our background materials that you were provided with yesterday, and I am sure most of you would not have had the opportunity to review them as yet, the point we make is that often — I quote an Australian prime minister just last year on this — governments are obsessed with "short-termism." In other words, if we invest now, will we have a product or something to show at the end of our mandate? That is putting it somewhat crassly; nevertheless, we see that in the funding arrangements. When THSSI was given to us for five years, first of all it took a year for the money to start running, and for four years, we were gradually building up programs, accounting for some missteps, looking at the results we were getting, and by that time, we had to think about how we could continue this. Then it was extended for another short period of time. That process started all over again, and we had to recruit people who thought it was going to end and they were going to leave. It is a bit of a mess when it is not taken as a given that transformation of health care systems does not occur overnight, that is, long-term, stable, permanent kinds of transformations.
We also make the point on this slide that the present funding arrangement is not adequate, and I know that this committee is not aimed in that direction, if I can put it that way. Nevertheless, we think it is important to put a marker on that point as well.
Finally, an important point that we in the Yukon will dwell upon is that health care funding is not a stand-alone issue: The social determinants of health must be taken into account. As long as we continue to look at health care as a siloed activity, as an activity that is primarily driven by the acute care system, we will never make significant changes in a way that will permanently impact its cost.
I have done the 100-yard dash through our overview. I will turn it over to my colleague, Ms. DeLancey, from the Northwest Territories.
Debbie DeLancey, Acting Deputy Minister, Department of Health and Social Services, Government of the Northwest Territories: Thank you, Mr. Chair. We also have a slide deck from the Northwest Territories. We are appearing with a pan-territorial presentation, and, of course, the three territories do have many similarities, but we also have our own unique challenges. We will each try to speak to those. I will quickly walk you through some of the unique challenges we have in the Northwest Territories, some of the progress we have been able to make, in part, because of the investment of federal funding, and some of the challenges that still lie before us.
On slide 2, you will see a map of the Northwest Territories, which shows you the eight health and social services regions that we use to deliver our services.
To pick up a little more detail on some of the points that my colleague from the Yukon made, we have a population of just over 43,000 people spread across a large land mass, 33 communities — many of them remote — and the majority of them with no year-round road access. This creates not only issues of distance from services but also the need to duplicate services. If you had a population of 43,000 people in a southern municipality, one health centre or hospital would do the trick. We need to duplicate some level of infrastructure in every one of those communities.
Our population is about 50 per cent Aboriginal. That group faces some unique health and wellness challenges. We have 12 distinct Aboriginal groups that are negotiating self-government. This drives us towards perhaps 12 different arrangements for jurisdiction over some elements of health and social services. It is a complex system. We are trying to deliver it in 11 official languages. We have cultural and linguistic barriers that drive cost and present challenges in access to services.
Most of our communities do not have resident physicians. When people from the North hear that having access to a family physician is a big challenge in the South, they sometimes laugh. Only six communities out of 33 fund resident physicians. Of those six, we are only able to recruit and retain resident physicians in two communities. In effect, we have 31 communities with locums and visiting physicians.
These are to provide some context.
On slide 3 we have listed some of our key challenges. I will touch briefly on each one. We feel that overall our residents have access to a reasonably well-delivered range of programs and services. We have 90 per cent positive feedback on our patient satisfaction surveys. However, we recognize the system is not keeping up with needs, demands and challenges in the area of health human resources. One of the key issues we face is that it is difficult to recruit to remote communities. We have a lot of vacancies and a lot of turnover. Professional staff, physicians and nurses like to live where they have a professional community. It can be challenging and sometimes scary to be alone with just perhaps one other practitioner in a remote community, needing to deal with the whole range of acute care issues.
We do have to fund and provide specialized training for our community health nurses, because in 26 communities they are the sole practitioner. Being trained as an RN often is not enough for people to go into our remote communities. We hear from residents that their quality of care suffers from the turnover and lack of stability from having a revolving door of casual nurses and locums.
As you can imagine, medical travel is a huge cost driver for all of the territories. We have about 23,215 scheduled medical travel trips per year. Over and above that, we have a huge number of unscheduled medical evacuations. These are costly and often can provide risk or some level of discomfort for patients.
Our delivery model is a challenge. We want to provide an equitable access to a range of basic health and social services to all our residents. That is hard to do when you do not have the resources to have the full range of practitioners in every community. We have developed an approach that we call an integrated service delivery model, which relies on community health nurses. It is a nurse-led model. Those community health nurses usually will have a community wellness worker or health worker. We have certain services that we provide only in regional centres, certain services provided only at our territorial hospital and some services we have to send people out for.
We try to use a mix of health practitioners and be as innovative as possible — recognizing how difficult it is to recruit physicians — through the use of nurse practitioners or midwifes, but those bring their own challenges in terms of training, certification, and retention.
My colleague from the Yukon touched briefly on population health status. We call it a bit of a wellness crisis in the Northwest Territories. We have higher rates of chronic diseases, obesity, smoking and heavy drinking than the average across Canada. Our population reports lower levels of physical activity, less likely to eat a healthy diet, and lower levels than the Canadian average for self-reported health status and mental wellness. These are cost drivers. We have great demands and great needs, and these are spread amongst all our remote communities. It is very difficult to respond to those.
I will not talk a lot about governance and structure. The point I tried to make with that first slide is that we do face complexities with the cultural diversity and number of Aboriginal self-government tables being negotiated. Our delivery system needs to accommodate that, while being as efficient and effective as possible.
Accountability is an emerging issue in health across the country and was an issue identified by the Auditor General of Canada in the recent review of our system. As a small jurisdiction with eight different authorities that have different data collection systems, staff and ways of operating, we have been very challenged to start putting accountability measures in place. This is an area where we know we have a lot of work to do.
Finally I will note that there are fiscal pressures on our system, many of which are shared across Canada. Every health system in Canada is facing the costs of an aging population, rising costs of pharmaceuticals and the cost of complying with new standards. Of course we have some that are unique to our jurisdiction, like the huge use of medical travel. Hopefully that gives you a flavour of some of what we see as what we are struggling with.
Moving on to slide 4, we feel we have had some successes and are making some progress. The federal funding has been instrumental in allowing us to make some of the investments and do some of the research necessary to try to turn some of these issues around.
In terms of the human resource aspect, we have been able to develop training programs for community health nurses. The feeling is that when these folks go into remote communities with a level of confidence and a level of skill, they are more likely to stay and provide stable service. We have been able to start deploying nurse practitioners and midwifes in a few of our communities. We are lucky to have a physician community that is very open to seeing different allied health professionals supporting them. They are very open to saying, "Do we really need to have a doctor in this region when we might have two nurse practitioners?" We have been able to start implementing some of those different arrangements. We have also been able to invest a little more in physician recruitment and trying to come up with a full complement of physicians.
In terms of medical travel, there is dedicated THSSI funding to support the direct cost, which has been hugely helpful to our territory. With the other territories, we have also been able to invest in looking at how we can improve our administration of medical travel and manage the process more effectively. With some of the management and administrative changes that have been made in the Northwest Territories we feel we have we have actually been able to bend that curve, and in the last two years our medical travel costs have remained stable. We are not sure we will ever see them go down, but if that line is not going up every year, we consider that a success.
In terms of access to basic services, we are seeing some accomplishments. The advent of telehealth — e-health, electronic medical records, teleconferencing for counselling and diagnostic consultation, sending digital images from one community to another for an X-ray consultation — is starting to have an impact on our system. We are starting to see people in small communities have faster access to services without having to travel. We still have a lot of work to do there.
We have been able to put some program enhancements in place with the support of THSSI funding. One example is an expanded dialysis program for a small investment. It has had a huge change in the quality of life for patients who now do not need to travel out of the territories for that treatment. Some of our human resource initiatives that I already talked about are starting to result in stabilization of services that our communities are seeing.
Another success that we should mention, and I will pick up on our overview presentation, is the establishment of the Arctic Health Research Network. All the three territories now have established a research capacity that is starting to support us in looking at accountability and performance measurement and starting to be able to match territorial research needs up with researchers and academics from the South to address some of our unique challenges.
On page 5, we talk briefly about some of the priorities. This is the work that we still need to do. There is still a lot to do to make improvements in our system. We need to continue to improve access to the range of basic services for our residents. We are looking right now at our service delivery model. I talked about the use of midwives and nurse practitioners. We are doing a review of how we can be more creative and what the best deployment of those health human resources is to provide service to the greatest number of people.
We continue to roll out e-health initiatives. We are lucky that in the Northwest Territories, almost all of our physicians are on salary. We are able, therefore, to roll out a common electronic medical records system across the Northwest Territories, which will be hugely helpful in terms of taking advantage of some of the e-health technology that has become available.
We are looking at setting up a virtual call centre for our community health nurses and staff out in the regions so there is a 24-7 staffed centre with all the e-health technology. When they have a patient in a community and they need someone to help with a diagnosis or to determine if that person needs to be medevaced or treated in the community, there will be dedicated staff available to do that. To date, this has happened on an ad hoc basis and often we get patients flown into a territorial hospital simply because a community health nurse was not able to find a doctor to assist with that diagnosis.
The Auditor General has recommended that we need to do a comprehensive five-year plan for health human resources in the Northwest Territories. That is a big project. That is something we will look to THSSI funding to help us undertake.
We are also looking at improving how we manage chronic diseases. Seventy per cent of our hospitalizations are due to chronic diseases such as type 2 diabetes, heart and lung issues and mental health and addictions-related issues. We know that if we make the proper investments in helping with early intervention, such as giving people self-management tools and the support they need at the community level, we can prevent a lot of those situations from reaching the stage of needing acute care or needing to be medevaced to the hospital.
I have talked about medical travel; while we have made improvements, we feel there is a lot more that can be done. We are looking at our policy right now and looking at a way that we can centralize dispatch and triage so there is one coordinated medical travel, flight control and air traffic control for the whole Northwest Territories.
In terms of accountability, I mentioned that we have a lot to do. We are looking at moving all of our authorities onto shared financial systems so that we can implement system-wide performance measurements and have performance agreements with them. We are moving towards putting all the physicians onto one electronic medical record, and that will support our ability to do tracking of outcomes and reporting at a territorial level.
The last slide speaks to what we think are some of the benefits of a continued investment in health care in the Northwest Territories. We have seen that we can contain some of the increasing costs by using economies of scale and new approaches to delivering service. We have also seen that we can improve access to service for our residents. It is a wonderful thing when someone in a remote community who requires psychiatric counselling can receive that on a weekly basis through video conference rather than having to fly into the hospital and stay in a psych ward for three months. That is a reality. Those things are happening now.
We are working in partnership with our health care providers to improve our risk management, quality assurance and performance measurement. This is all key because we heard from my colleague in the Yukon about the economic activity in the territories. We need to be able to have our population take advantage of that, and a healthy population is a healthy workforce. It is in all of our interests to ensure that people are healthy and well enough to take advantage of what is going on.
We feel that the federal funding has helped, both through direct investment in those tough areas like medical travel, but also in helping us to find our way to solutions. We hope to be able to continue to rely on that funding to do so.
The Chair: Mr. Whitley, I gather you will sum up?
Mr. Whitley: Yes, I will sum up after I speak to the Yukon's particularity.
The Chair: Could you move that along with some alacrity?
Mr. Whitley: I will take your advice.
Before I do, I just point out that although Nunavut is not present and I do not presume to speak for Nunavut, I think it is important to make the observation that many of the issues that confront us in our jurisdictions in the Northwest Territories and the Yukon are equally present, if not more seriously so, in Nunavut.
I will try not to repeat the points that were made that have applicability to the Yukon as I work through this short deck. This is about Yukon access to care in the North. I am starting on page 2.
I saw the illustrations that my colleagues put in here for the first time on the plane on the way down here. If any of your questions have to do with the illustrations, it may be more of an iterative exercise than I thought.
With respect to the illustrations on page 2, it struck me that the smallest illustration to the right is the three premiers of the territories when THSSI was renewed for the last time.
On page 3, I will just point out, in addition to what you can read there as well, there are about 34,000 people in the territory. We think that is quite under-counted at the moment. It is probably closer to 36,000. About 23 or 24 per cent of those are First Nations, and of those First Nations there are 14 separate languages and First Nations themselves.
I mentioned medical travel. On page 5, there are a few illustrations there. What you cannot read with respect to the document shown on the one page is boil water advisories. That is more frequently the case in rural Yukon than not. The others refer to poor dental health and poor housing, all of which are serious issues for us.
With respect to what we have done in relation to access to health care, in terms of the expectation that we will manage our own affairs, we did conduct an extensive community review and consultation around our health care system. To summarize that review, people are happy with our health care system; they do not want us to take anything away from it and there is not a strong groundswell to actually pay for it in the way of direct user fees. I do not think that reaction is much different than anywhere else in the country. Certainly that is what we found.
I also want to point out — you have it in your package of materials — that the health behaviour study in school-aged children is quite possibly one of the most dismal documents you will ever read. It speaks to the high-risk behaviours that a majority of our kids are engaging in, particularly kids in rural Yukon, which have to do with smoking, drug use, bullying, depression, dropouts, dysfunction in the home and hunger. All of these issues have huge downstream effects for our acute care system.
As a result of a couple of unfortunate deaths in our facilities, we struck the Task Force on Acutely Intoxicated Persons at Risk, the recommendations of which you have in your package, again, presenting us with enormous challenges in terms of resources for a very small constituency, although desperately in need.
You can read the portion on medical travel for yourselves. It has to do with the astonishing escalation in costs for medical travel and the reasons for that.
Page 8 details the kinds of thing we have done with THSSI funding to increase and improve access to health care on a number of fronts.
On page 9, one of the things that we are investing heavily in, in terms of resources, is a wellness strategy, fully recognizing that you cannot boil the ocean. We are focusing on children and youth. We are also looking at how we can target populations within the Yukon to improve their overall wellness. This is predicated on the working assumption, which I think we all intuitively understand, that we cannot make an impact on the acute care system unless we make an impact on the overall health of citizens, and that includes the social inclusion strategy as well. We are looking at issues like housing, education, mental health and the kinds of supports that people need so that they are well. As part of the social inclusion strategy, we are looking at aging well, and we are developing a health human resource strategy so that we can ensure a continued supply of medical professionals.
I will not go through page 10. You can read that for yourselves. There are ways in which we have now improved, in a very direct way, access to care as a result of federal assistance.
I want to point out that the last bullet on page 11, the dental health program, is not something that we had before without the THSSI funding. With that, we were able to implement a dental health program for children. I think everyone understands that dental health is the gateway to overall physical health. In many instances, as one of the illustrations portrays, the state of dental health in rural, particularly Aboriginal, kids in the Yukon is atrocious, and we must do something about that.
The interesting thing is when THSSI was coming to an end and we were just getting this program started and then the news came that we no longer had the funding to continue it and the minister mused about the problem with that in the house, there was a hue and cry about the urgency of maintaining a program like that, the urgency of maintaining a program of early psychosis detection, which we heavily invested in with THSSI funds. Yet, somehow we are supposed to find money from the highways branch or the department of education to fund for programs that continue to bloat the health care budget.
Slide 12 speaks to the important relationships that we have continued to foster in the Yukon, the First Nations partnerships in particular. Although it refers to the specialist community there, we also have to acknowledge with gratitude the relationships that we have with the big hospitals in Vancouver, Edmonton and Calgary.
I do not think it can be sufficiently underscored how grateful the territories are for the funding that we have received to date so that we can do this kind of innovative and forward-thinking work.
In summary, we are small and complicated — maybe the word "complex" is a better choice of words — in the sense that we are diverse in our population. We are scattered and remote. We have ethnic diversity. Our geography is vast. As you all know, we are all experiencing incredible changes — demographic, social and climate — and all of us are working very hard to address our needs to take into account these kinds of issues, as well as the needs of our population. We think we are getting results. There was the 50-yard dash through the Yukon situation. I turn it back to you, Mr. Chair.
The Chair: Thank you very much. I will now open it up to my colleagues for question.
Senator Eggleton: I was interested in the difference in the presentations between the Yukon and the Northwest Territories, even though you say things are much the same. Mr. Whitley, in your comments, you said the THSSI funds had significant impact. You also said that it stopped. I believe in Budget 2010 some money was recommitted for it, so it is still going. You can answer that along with the rest of the question. You say it has made a significant difference in the Yukon.
Ms. DeLancey, you used more modest words when you talked about the successes. In fact, you used the word "start" two or three times. Has it been a little different in the Northwest Territories? Is there much of an impact noticeable on the ground amongst the population in terms of the use of these funds for improving programs and services?
Mr. Whitley: The initial agreement was for five years. Into the fourth year, the message was that it would not be renewed and that we would have to start winding down the programs and extracting ourselves from any kinds of commitments. We were not able to guarantee people employment or assure the communities that we were going to continue with these programs simply because there was no alternative source of funding.
As that edged on and the negotiations ramped up, that changed, and ultimately it was extended for a further two years. All that did was take us back into the same situation that we were in before. It got started, it stopped, it got started, and it stopped again. It was not a very good way to run some of our programs.
Ms. DeLancey: I would refer back to Mr. Whitley's opening comments about how fundamental reform in the health system takes time. I certainly did not mean to understate the value that the Northwest Territories has gained from THSSI and from Canada Health Transfer funding, both in terms of helping with some direct pressures, like medical travel, but more important, starting to do that analysis of where we can actually accomplish change.
In terms of the start, a number of studies were done. There have been a number of reviews, for example, medical travel, which has started to point us in the direction that we need to go, but there is still work to be done in terms of applying the results of those reviews that we have done. In terms of health human resources, we have been able to test out the effectiveness of nurse practitioners and midwives, but there is still a lot of work to be done to figure out how extensively we can afford to deploy those other allied health professionals and what the mix of providers looks like. When I said it is a start and talked about modest success, I certainly did not mean to imply that we had not made great progress as a result of the funding. However, I believe we do feel, and I think we have heard it from our colleagues in the Yukon, that we still have a ways to go. In terms of THSSI funding, we have a fully developed work plan for the next two years for moving forward some of those one-time investments that hopefully will change how we deliver services.
Senator Eggleton: Do your populations feel that there is a difference? Do they notice a difference in the application of this funding?
Ms. DeLancey: I think it would be more accurate to say they would notice a difference if the funding were suddenly withdrawn, for example, a government that did not have enough money to cover medical travel budgets. Again, we do not see changes in population health outcomes at this point. There are some minor areas. For example, the feedback we have had on the nurse practitioners and midwives, where we have been able to fund those positions, has been very positive, but they are only in three or four communities at this point. They are not universal across the Northwest Territories.
Senator Eggleton: Mr. Whitley, in your presentation you talked about the social determinants of health and the critical need to address that issue. If there is a successor to THSSI, or a continuance of THSSI funds beyond 2014, would you like to see some of it put into that area, into social determinants? If so, what would they be?
Also, what should be the focus if there is a continuing THSSI? What program or programs should be the focus of it?
Mr. Whitley: There were a couple of questions in your comments. The first one has to do with the continuation of THSSI, whether it should in some way be directed to the social determinants of health. The short answer to that question would be yes, but what does that entail?
The issue of the relationship between public health and public disease, if I can put it that way, is one that is just starting to get some traction across the country. In meetings with my colleagues, we talk about how important it is to consider issues like housing, education and poverty in relation to the impacts on health that those things are going to have.
For us, at least in Yukon, we need to get a better understanding of what that relationship is. That is why we are developing a social inclusion strategy, as well as a wellness strategy.
The problem of poverty is intractable. In some discussions, I heard some political people say it is beyond solving, that there will always be some sort of poverty somewhere. I am not entirely sure that is correct, although experience suggests otherwise.
Nevertheless, we need to understand much better how those determinants relate overall to the impacts on health. We know that they do; but, for example, will ensuring everyone access to a home have an impact on the health care system? That is a pretty big jump to make. I am not even sure we could do that. We have some people in Yukon that are hard to house. Every place we put them, they seem to have difficulty and end up back on the street.
What can we do about that? We are working right now with the Yukon Anti-Poverty Coalition on a social inclusion strategy. They are involved to a lesser extent in the wellness strategy. We are getting the advice of the community on how this works. To me, that is a first step. We could not do this work without the THSSI funding.
To answer your question as carefully as I can, it would be unwise to set aside funds for addressing the social determinants of health without understanding what that relationship is and how they can be most effectively deployed. In my view, money always follows a good idea, and we are at the stage where we have good ideas about how to fix things like poverty.
However, again, I said that we cannot boil the ocean; we have to target our activities. I would say that we have good technical solutions for many problems. We have things as simple as condoms. If we could simply increase condom use in Yukon, we would slow the increasing rate of sexually transmitted infections.
We have a fairly active campaign now, but that does not seem to be doing the trick, as far as we can see. There is a problem. People are not using a very simple technique to avoid sexually transmitted diseases, which have considerable downstream consequences for many people in Yukon.
We have good technical solutions for disease eradication, yet we do not have better than about 60 per cent take-up on vaccines. Why is that? Part of it has to do with education; part of it has to do with lack of awareness; part of it has to do with poverty and marginalization. We need to understand how we can more effectively communicate to those groups.
Sorry, I am going on at length.
The Chair: I was listening very carefully to your answer because I listened to your comments on social determinants. It is a complex issue. The idea of just trying to solve it with a task force on acute toxicity is not getting at the overall issue. I think your answer to Senator Eggleton framed it in a larger context. It is hard to get a handle on that total issue.
Senator Merchant: I thought your presentation was sympathetic and empathetic, and a plea for continuity. I thought you spoke from the heart; it was a very engaging presentation that you gave us.
I have a question, following a little bit on the previous questioner: Do you find that sometimes the traditional approaches for the population that you serve may also complicate things a little bit? With your aging population, how do you handle that? Are you able to put people in homes or do they prefer to stay with their families? How do you handle that when you have a small population spread out over such a wide expanse?
Ms. DeLancey: I would refer this question to Mr. Heide.
Robert Dana Heide, Assistant Deputy Minister, Operation Support, Department of Health and Social Services, Government of the Northwest Territories: We try to incorporate traditional practices in how we deliver services, particularly for elders and people living a traditional lifestyle.
We have taken a strategy around developing home care and home supports in small communities, and developing as much capacity as possible to keep elders in their homes. We also have a strategy within our housing corporation to reduce seniors' rents in public housing to the point where they can afford to stay in their homes and still eat well and survive well.
In our regional centres, we have long-term care facilities. They also try to reflect traditional practices and traditional ways of being. We encourage and train local correct language speakers to be in those facilities. However, at the higher level of registered nursing and physician supports, we struggle with providing that. To answer your question, yes, we incorporate as much traditional lifestyle and practices as we possibly can.
Senator Merchant: It would be difficult to yank someone from their family and community and send them off a great distance to be in one of those facilities. You have to go to them rather than pull them toward you.
Mr. Heide: You are absolutely right. Our last option would be moving someone out of a community. One of our innovative ways of using tele-medicine is to reconnect families through the telehealth system for Sunday visits. You will see elders and people who have been placed in a regional centre visiting with each other via telehealth on a Sunday afternoon, very much like people would visit. That family connection is maintained as much as possible.
Senator Merchant: I think Mr. Whitley mentioned telehealth and e-health. That was an important part of the 10- year plan.
Recently Senator Sibbeston spoke in the Senate about the value of a fibre optic link along the Mackenzie Valley to improve these services. I assume you have some difficulties in extending these kinds of services and information technologies to remote northern communities. Could you tell us to what extent information technology is used in your territory to meet these health care needs, and what needs to be done to make better use of these technologies?
Mr. Whitley: If it is the Mackenzie Valley, I will defer to my colleague. I can speak to that after she does.
Ms. DeLancey: I did note that we are using telehealth more and more in our jurisdiction. We are certainly finding great benefits, but we are challenged by the availability of bandwidth. For example, we have put video conferencing telehealth facilities in 26 communities. There is a partnership with the department of education so we are constantly vying for who has access to the bandwidth and whose uses take priority. For telehealth to be fully utilized, we need a more reliable access. Our physicians and practitioners are very excited about the potential, but they have all experienced situations where the technology has not worked as well as it should, and they become reluctant to fully utilize it.
Certainly, the fibre optic cable is something we hope will make telehealth, access to education and some of the more creative uses of e-health, such as what Mr. Heide talked about, more effective in the territory.
Mr. Heide: We are very proud of our advancement in our electronic health record system and our overall e-health system. We have digital X-rays in all communities, so that physicians in the regional centres can support clinician nurses in the communities, often avoiding medical travel by being able to diagnose and instruct the community practitioner in how to move forward.
Ms. DeLancey talked about our partnership with education. We are providing speech language therapy, where in the past there was no access to speech language therapists. We have installed the telehealth system in all the schools and provide distance speech language therapy, which is having amazing results in the elementary schools.
Mr. Whitley: We have much the same as Mr. Heide just described. We have televideo with real-time diagnostics by doctors in Whitehorse working with nurses in remote communities. We have access to lab data and we have teleradiology in all communities. We are a bit different from the Northwest Territories and Nunavut in that all of our communities are road access with the exception of one. There is not quite the isolation that the other two jurisdictions have. I will ask my colleague, Ms. Wright, to speak to the point about home care.
Sherri Wright, Assistant Deputy Minister, Health and Social Services, Government of Yukon: As much as possible, we like to be able to keep people in their homes. With the THSSI funding we have been able to significantly expand our palliative care programs. We have a team that works with all of the health workers in the communities, so we can keep people at home longer.
In terms of traditional medicine and services, we have a First Nations health program that runs out of the Whitehorse General Hospital in our capital city. In our continuing care facilities, we do our best to offer traditional diets to elders from the various First Nations. Sometimes being small is a good thing. One of the neat, innovative things we have been able to do for one of our fly-in communities in Old Crow is to offer wintertime extended care to elders in the community of Old Crow. In the spring, when it is a little easier on them, they go back to their communities and live with their families on the land. That is something innovative we have been able to do as well.
Senator Dyck: Some of the issues that you have raised are actually quite depressing. I believe Mr. Whitley said that you cannot boil the ocean. If you do not have clean water to drink, good food and a house, you have a lot of strikes against you.
My first question pertains to jurisdictional issues. Does the THSSI funding allow you to address any issues that might come up with respect to access to health between the different groups? I believe that Ms. DeLancey talked about self-governing First Nations and the diversity within the different nations and languages. Sometimes funding for health care has provincial versus territorial issues. Is that covered by the agreements? Are there ways to optimize so that a particular patient does not fall through the cracks? Do they get the health care they need?
My second question pertains to wellness strategies. I think you were indicating that a lot of diseases probably could be alleviated by prevention. What are the sorts of things that could be done? For example, it was quite awful to see the dental suffering that might be due to the water system not being fluoridated or to a lack of dental care within the school system. What programming could help with that?
Ms. DeLancey: I will speak to the jurisdiction question first and, if I may, ask if Mr. Heide can speak to the wellness question from the Northwest Territories perspective. The THSSI funding is helping us to deal with some of the complexities in our jurisdictional setup. You may be aware that at one time many jurisdictions in Canada had moved to regional health authorities to try to get local involvement in decision making. The pendulum has swung such that many jurisdictions have gone back to one structure or health board per province.
In the Northwest Territories, because of the cultural and linguistic differences and many groups negotiating self- government, we are struggling to find a balance so that we can operate as an integrated system. Again, you made a very good point: Patients need to move seamlessly from one authority to another, when they need to reach a higher level of care. We need to respect that Aboriginal groups are negotiating some elements of jurisdiction over some of the social services and the promotion programs.
The THSSI has helped us to do some of these one-time investments in looking at how we can balance those off. For example, we had a study done that has come up with some concrete and practical recommendations, for example, how we might set up a back office or shared services for our different health authorities so that they could maintain some of their regional footprint and programs while sharing financial and laboratory services and recruitment and retention — all the services that do not touch a patient. We are now looking at using THSSI funding for the second phase to determine how to put that together.
The other area where we are relying on THSSI is to help us deal with the whole area of accountability. In a system that is as complex as ours, how do we work together so that we can agree on the important measures; and what are the important indicators that we should be tracking and reporting to the public? In fact, THSSI is helping us to deal with some of our unique jurisdictional challenges.
Mr. Heide: That is a great question. Prevention is where we need to get to. We do a significant amount of prevention in both messaging and health promotion on stop smoking; drinking; healthy lifestyles; and the wellness approach. We have oral health rooms built into the schools. Our issue is attracting, recruiting, and retaining people for the jobs. One strategy took local people out to be trained and brought them back to deliver those programs. However, when they leave the North, they are often seduced by the bright lights of the big city; and we have a hard time getting them back. It is a constant challenge to find people to provide good oral health.
We also have a jurisdictional issue around good dental care. When oral health is failing us, dental care in small communities is difficult to provide. It is based on dentists travelling into the communities; and they tend to come when there is a profit to be made. When there is no profit to be made, they often do not come in.
Mr. Whitley: A couple of comments, Mr. Chair, and then Ms. Wright will speak to the dental issue specifically.
In terms of the jurisdictional issues around THSSI, we just have not experienced them at all. We have had nothing but cooperation with our colleagues across the North and with the federal government. The department of health has worked with us in a very cooperative way. Even when it came to our concerns about renewal or non-renewal of the arrangements, our colleagues have been nothing but collaborative and cooperative with us.
Where the jurisdictional splits cause problems for us comes down to the social determinants of health. Clean water, access to nutritious food, housing — these issues have blurred edges around their jurisdiction. Whose responsibility is it? That is where we start to fall down.
If we need to drill a well on First Nation land, the question then is where do they get the money to do that? The federal government might well take the position that you have money, you decide how you will spend it, but we have given you what you need to have. Then they come to the territorial government, and the territorial government will take another position, which will perhaps be that the municipality has been funded appropriately, and if that is not enough for you, well, too bad.
There is a good deal of "siloism," if I can put it that way, around funding for what I would call soft needs, although they are in fact hard needs. Decisions are often taken that cause ripple effects for us in the North.
For example, the closing of the dental tech school in the Prairies. That was our sole source for dental techs. We had funding arrangements for students to go and get their training and then come back and work in our communities. Now we are scrambling. Where do we send our kids to learn these skills that will help us solve this problem? That decision was taken relatively at arm's length. There could have been more discussion about that. Again, this is not an exercise in blaming or finger pointing, but it illustrates the jurisdictional issue that the senator raised.
Ms. Wright: I want to talk a little bit about dental health in the North. I know you are all familiar with the problems we have with the dental health of children, and Yukon is no exception. One of the things that the THSSI funding has allowed us to do is it has given me and my colleagues time to pause and think about what we might be able to do to effect greater change in specific areas, and this is one of them.
One of the programs we were able to explore was something as simple as putting workers in daycares and teaching small children how to brush their teeth. When you have seen what happens with kids who have to be anaesthetized and put in operating rooms to have all their teeth removed at very young ages, we have seen great success with this program. It is a wonderful thing that we have been able to do with this program. I wanted to share that with you.
I want to echo what Mr. Whitley said about our relationship with our counterparts in the Yukon and the federal government, as well as the First Nations. I am very proud of our relationship and the way that we are able to work together. That is not to say that we do not encounter problems or difficulties from time to time, but the fact that our relationships are so strong really makes things a lot easier and more efficient for us.
Senator Martin: Thank you very much for being here. I think my colleagues have asked some of the questions that I had, but just going back to the word "focus," I thought I should really focus on a few things that have come to mind.
As you know, the committee is examining the progress that we have made in implementing the 2004 10-Year Plan to Strengthen Health Care, and specifically with your presence here, looking at the access to care in the North component of the 2004 accord. As a former educator, and talking about authentic assessment and how we evaluate the effectiveness of a program or whatever it is we are doing, I would like to hear from each of you — and perhaps it could be in a follow-up paper or document, or an answer this evening — how you would evaluate the 2004 accord, specific to the access to care in the North component. What specifically was effective in that accord?
In our recommendations we can then say these items and this language was very effective, we need clear targets, we need certain matrices in there. What helped you assess the improvements and success in the North in the delivery of health care?
That is a very big question, but maybe you can focus on one or two items that you felt helped you assess and allowed you to do what did you well effectively.
Ms. DeLancey: It is a big question. If I understand correctly, you are looking not just for where we would evaluate that we have had some success, but more what, in the way the accord was structured, was helpful.
I was going to flip through my binder to look for the document itself, but one thing that comes to mind is the fact that the accord took into consideration specific northern circumstances. For example, whereas in the South the focus was on wait times, there is specific wording in the North about improving access to services. In the North wait times is not our issue. That is one point that I would raise. That wording spoke specifically to what Northern challenges are and then opened the door to using that funding to tackle those North-specific issues.
Mr. Whitley: The issue of wait times is the example that I was going to use as well. That is to say, it is important that we have flexibility to address the issues that confront us in the North. Requiring us to show progress on wait times, for example, was not that helpful. As my colleague pointed out, wait times is not so much an issue for us in the North.
We would like to take you up on the opportunity to look at the wording and provide you with a document on what we think the wording might have been and how it might have been improved or what worked. We have done some work on that, but we will provide that to the committee.
The Chair: I think what Senator Martin focused on were the two aspects, the last one that you mentioned, and also to note any language in the existing accord that allowed you to do things specifically. You mentioned the issue around wait times and being different from access to health care. If you could identify some of those specific examples in illustrating the point, both from the past and language for the future, it would be most helpful.
Senator Martin: I know it cannot be simplified in this way, but sometimes I like to see the matrix and have the number value and I can look at it and say, in sentence structure, a five. Having specific language or grids or matrices could be helpful. I do not know if those are some things that you would like to see that would help you measure and help you improve the accountability in the medical system.
We have heard of that lack of accountability or the need for more accountability and very specific targets. What I heard you say is that having something specific to the North is important and that is something we need to do in our next accord.
May I ask one more question regarding staffing? I have heard from clinicians that, in terms of infrastructure, some state-of-the-art clinics do exist in remote areas, but that, as you pointed out, the retention and attracting staff to those facilities is an issue.
I am curious: What percentage of staff would you say are from the North? That would start early on in the education process, modelling and mentoring in order to ensure that the people you have there are culturally sensitive and committed. Do you have a figure or an estimate as to how many people of the North stay and give back to the community in that way?
Ms. DeLancey: I cannot give you percentages today, senator. We can say that we certainly are seeing an increase, and we could follow up. In some of our investments in human resources, for example, we have medical student bursaries with a return of service, so we do see some of our youth who are going away to medical school coming back to the North. These are, of course, small numbers at this point.
In Aurora College we have a registered nurse program. At this point, we try to guarantee graduates a position. We have so many graduates who have gone to work in our territorial hospital in Yellowknife that there are no more vacancies. We have stabilized the nursing pool in Yellowknife. Similarly, we have a social work training program.
However, it is slow progress. As Mr. Heide noted earlier, in some cases, when we invest in training, we have kids who go south to medical school, but then they want to become cardiac surgeons, and we do not employ those in the North.
We will undertake to try to provide you more specific data.
Mr. Whitley: The interesting thing about your question is that for many years, our recruitment efforts were focused on trying to get medical professionals from elsewhere. We would provide northern allowances, top-ups, perks and benefits that would lure medical professionals to the North. To an extent, that has been relatively successful, although the retention part has sometimes not been as good as it could be.
We have changed our strategy around that now. Partly, that is because the nature of the North is changing. It used to be that northern communities, except for traditional Aboriginal and Inuit communities, were fairly transitory. People would come, stay for a few years, have a northern experience, and then leave.
What we are finding now is that just as more and more people are retiring in the North, more and more of our young people are coming back to live in the North. Therefore, we have altered our recruitment strategy for physicians, for example, to encourage our own graduates to go to medical school. In fact, I think we have seven young people now in medical schools across the country. We have secured a permanent ongoing seat at Memorial University, which specializes in remote communities in their medical program. We have started an LPN program at Yukon College in Whitehorse to essentially grow our own.
It is early days, of course, but we are finding that the likelihood of retaining medical professionals now is much stronger than simply trying to lure someone from another part of Canada or, in fact, another part of the world. In many instances, our internationally trained physicians or international medical graduates come to the Yukon, qualify within a year or two, and leave. For a time, Yukon was almost a portal to the rest of Canada for IMGs. That does not serve us in the long run. We are hopeful that this new strategy will yield fruit.
Senator Champagne: I was wondering if there was some kind of financial interest for young nurses or doctors to go. For example, I remember my husband coming back from a concert tour in all the territories. They went all the way to Grise Fiord. They travelled all around and met young teachers in school. A young couple, man and wife, went there and said: Yes, food is expensive. Yes, we live with records and DVDs that people mail to us. However, the money is so good. When we go back home in three or four years, we can buy a home and we are set for life.
Is it the same situation for medical personnel, doctors or nurses, that they would make more money going up North for two or three years than they would be making down South? Will they be negotiating with any of your governments or with the federal government, or is it a regular fee for everyone? I know that for teachers, there was a big difference.
Mr. Whitley: There is a different model of funding, senator, in the territories. I will let my colleague speak to how they pay their doctors and nurses over there.
With respect to our physicians, it is a fee-for-service arrangement whereby they do the work and charge the Yukon territorial government for each actual service that they deliver.
I do not think it is an overstatement to say that doctors in our territory make a very good living. We have a fairly strong retention of doctors who come to set up practice in the Yukon. I am not talking now about the international medical graduates; I am talking about doctors who are Canadian-qualified and come to establish a practice in the Yukon. I am not sure they would be happy about giving you a range, but they do okay.
Senator Champagne: I was wondering if they were making a little more than they would be making down South, like the teachers do. That was my question.
Mr. Whitley: I have not heard any complaints, although negotiations are coming up.
Senator Champagne: Do you still have problems retaining them?
Mr. Whitley: Not so much. Again, not the IMGs, but the doctors who come to the Yukon to set up their practices are pretty much with us. Because they are reaching their late fifties and sixties and now, we expect to replace them with the cohort that is presently in medical school.
With respect to nurses, there is a recruitment bonus and a retention bonus, and their salaries are very competitive. I have never heard that they can work for two years and buy a house in the South, but maybe that is a secret I do not know about.
Ms. DeLancey: Our physicians are on salary. This is a move we made about 10 years ago, and almost all of them are on salary. Again, we are in negotiations, but I can say that their salaries fall in a comfortable range relative to the rest of Canada. What we really sell with moving physicians to salaries is lifestyle. We have found that we have actually been able to attract more physicians who are younger, who are interested in work-life balance and having parental leave and all those benefits of employment.
With respect to nurses, we are more challenged. We are not able to offer recruitment and retention bonuses because they are part of our broader union of government employees. Again, we do find that nurses respond to the lifestyle, the challenge of working in small communities, and the extra training that we provide them, and we do provide a number of educational incentives for nurses who are prepared to go into the remote communities.
I think the situation you have described with teachers does not exist in the Northwest Territories anymore, since we stopped paying for staff housing. The young teachers are now struggling in the North as well.
Senator Seidman: Actually, in an ongoing way, you have answered my question. You are really tackling a North- specific issue when you tackle the whole issue of human resources. Studies have shown that health outcomes are often improved when patients receive health care services in close proximity to their communities and to their friends and families, when they have their networks to support them, and when they have familiarity with the environment and the customs. This all helps in speeding up recovery. I am not sure if there is anything more you want to say about this because it is a very big issue.
I would like to continue talking about to what extent people from your local communities are meeting the demand for health care professionals, such as doctors, nurses, radiologists and lab technicians, anything that you might need for front-line primary care services and promotion of health. What type of incentives do you think could be most effective in promoting recruitment and ensuring that people stay there?
The Chair: Ms. DeLancey, could you focus in on the aspects of community health access that you have not touched on to this point?
Ms. DeLancey: Yes. Our biggest challenge in training community people to meet the needs is basic literacy levels and school success levels in the Northwest Territories, particularly amongst the Aboriginal population and the population in the remote communities outside Yellowknife and the regional centres.
It would be fair to say that to a great extent we have been successful. The non-Aboriginal kids who attend the regional high schools and do well are getting training and are taking advantage of our own programs and in many cases succeeding. In order to do a better job of getting more northerners, particularly Aboriginal northerners into the system, it is not something that we within the health department or the college system can control. It is really a basic educational achievement challenge, and it goes back to those inter-dependencies that my colleague talked about.
The Chair: Earlier you said something that sounded to me kind of like a staff physician character. Could you elaborate with regard to that? Is that a concept you are using in the Northwest Territories, a staff physician kind of position? Perhaps I misinterpreted what you said.
Ms. DeLancey: A staff physician?
The Chair: Yes.
Ms. DeLancey: Yes. Our entire complement of physicians are employees, except for three or four. They are on salary.
The Chair: That is what you meant when you said they are all salaried?
Ms. DeLancey: That is right.
The Chair: Thank you. I just wanted to make sure there was not a distinction. Mr. Whitley, did you have a follow- up?
Mr. Whitley: Just a quick addendum, Mr. Chair. We recently had a conversation with some of our professional staff, non-doctors, about needs and what attracts them to the Yukon. It will be no surprise to you that what we are finding is that young people are interested in variety. They are not interested in settling in a community for long periods of time any longer. They are interested in time off to explore their particular passions; they are interested in work-life balance; and they are interested in technology. In other words, everything that you would expect from young people now, in any realm of endeavour, we have to start catering toward that kind of persona.
The difficulty with that is that we have issues that relate to continuity of care. The idea of the family doctor or the local nurse that has been in a community for 25 years — I am not sure I should be saying this — is probably a thing of the past. I think in remote communities we will see more of a cohort that will supply care. We are thinking of that now in obstetric care in Whitehorse, that the person who actually sees you through your pregnancy may not be the person who delivers you simply because doctors are no longer interested in a 24-7 lifestyle that perhaps a generation ago was taken for granted.
We are looking at changing our approach at how we recruit nurses. On the other hand, we have to take into account the impact that will have on our traditional views of what health care is all about.
Senator Champagne: I was reading, and you were saying, that you are training nurses to be midwives, especially in the remote communities. In your presentation on the Yukon, you indicated that you have one main hospital and two cottage hospitals. We all know that in delivering a child, there is a chance that something could go wrong.
Is there a way — for example, from the cottage hospitals — that telehealth could be helpful? If someone was having problems in one of the cottages or something, would they be able to use a computer or television to get help from a doctor who might be on duty in the hospital? Is that possible?
Mr. Whitley: I think that is possible in the abstract. However, in the Yukon, midwives as yet do not practice, at least in a regulated way. They practice informally, but they are not regulated and are not funded by the government. It is a matter of ongoing discussion right now about credentials, regulation and funding.
I think midwives are active in the other two territories, so perhaps I can direct that question to my colleagues.
Mr. Heide: With respect to the use of telemedicine around birthing, with the peripherals around the telemedicine system, you can use ultrasounds and fetal heart monitors, which are all connected into the telemedicine system. It is a matter of practice and a matter of having the right provider on one end to deliver and the right provider on the other end providing support and advice to the person in the community. It is always a matter of balance.
Yes, there are some ways and some technologies to support out-of-hospital births.
Senator Champagne: Whatever this new accord can bring to facilitate this possibility as far as white band or whatever to ensure that it can be sent to a hospital where a doctor is on duty would be helpful, would it?
Mr. Heide: Yes.
Senator Braley: I have heard a lot of good and interesting things in the development of the health care system.
What role can the federal government play in the future? If you cannot answer that today, maybe you have to send in a bit of a written report for us to be able to help. What role can the federal government play in helping to manage your systems and your territories? It has to be simple so that everyone understands.
The Chair: Without attempting to solve the entire health care system in your answer, perhaps the senator is looking for a clear focus on something that stands out at this point and then to follow up with further thoughts.
Senator Braley: Exactly.
Mr. Whitley: The obvious answer is to continue to help fund what we do. I think even more important than that is the need to have the federal government lay out exactly where its role is in relation to health care. It is simply not helpful to say that this is a provincial-territorial responsibility and ex gratia we are helping out with the funding.
The fact is that health care is a defining plank in our citizenship as Canadians. There is not a Canadian, I think, on the face of this country that would consider himself or herself a citizen of this country without considering that health care is central to that identity.
For that reason alone, the federal government has a responsibility to lay out exactly where it stands in relation to health care. If we knew that, our partnership could move forward in a much more effective way rather than what appears to be from a distance a dance that does not seem to have an end to it until an actual drop-dead date is set.
The conversation that takes place between jurisdictions would take place in a much more rational and sensible way if we all knew what our roles were. We have the role of delivering health care services in our jurisdictions. We know that. That is clear.
However, when it comes to the federal government, if you take away the military, and First Nations to an extent, and other small pockets of clear federal interest, it is not so clear any longer. In my respectful opinion, and this is without consulting with my new minister, who actually has not been appointed yet, that is probably one of the most important things that the new accord could establish.
Ms. DeLancey: We would identify two things. The first is, on an ongoing basis, to recognize that our territories will continue to need some support with those high-cost areas over which we have no control, like medical travel, especially when the territories are so limited in our ability to raise own-source revenues. That is where Canada really can play a role over the longer term. In the short term, it is recognizing that the flexibility we get from a fund like THSSI has allowed us to do the research and to put in place some innovations and some one-time investments that will help change how we deliver services. That support is critical as well.
Senator Braley: Does travel get replaced if we had robotics and someone in Ontario doing the surgery on someone in your territory?
Ms. DeLancey: Actually, we are seeing the ability to reduce medical travel through the use of e-health and telehealth, and we are doing that to some extent right now. At the same time, there are some situations where medical travel is never going to be replaced, particularly as we have an aging population, a greater percentage of people who are seniors and have more acute needs and need to travel out. We also have an injury rate that is twice the Canadian average. There are some situations where we have no control. People will need to travel. We are seeing some changes, and I think it is safe to say that the savings we realize in medical travel by using technology and e-health may be offset by the pressures of an aging population.
Mr. Whitley: It is not a one-way street. It is not as if you give us the money and we take care of the delivery. I think it is entirely appropriate that the federal government insists on accountabilities in any accord that moves forward after 2014 — accountabilities in relation to cost containment, accountabilities in relation access to health care, and accountabilities in relation to innovation and creativity. All those kinds of things are as important. Even as sometimes we chafe under the restrictions that the federal government imposes, we think that is entirely appropriate in return for the continued support of the federal government.
Senator Braley: I still think it has to come from within. You tell us how we can help and the best way to do it, and then we can decide whether it is cost-effective or not and apply the basic principles or shuffle the responsibilities and the priorities around. There is only so much money, and it cannot grow if inflation is 2 per cent by 6 or 8 per cent a year. Rationalizations and cost-effectiveness have to be put in. That is why we need your help to tell you how to do it, and we will listen.
The Chair: I think the take-away, and where Senator Braley is going with that, if I can be so bold as to take it a little further, is that it is not just the issue of telling us that one level has responsibility overriding or another has a certain responsibility or the issue of money but, rather, what are the specific directions? What kind of focus can help with regard to an actual program? Money and general responsibility, in their own right, do not solve things. The actual action plans and strategies are required. I think Senator Braley was hoping that you might, as you leave here, reflect on that to some degree and further illustrate for us, if you can, some specific strategies.
With that, and in pulling the meeting to a conclusion, I would like to summarize a little bit here. We have actually heard some very interesting things today. We would have expected that. You represent a remarkable stretch of total territory, using that in the broad sense of the three regions that we are hearing from today, directly and indirectly. We are aware that you have to a large degree what other parts of Canada have to a smaller degree in terms of their population. You have illustrated a number of those issues.
From my own point of view, I have been pleasantly enlightened by your comments with regard to medically trained personnel and a number of other infrastructure issues. On the other hand, you have illustrated significant issues that are based clearly in larger social issues and community issues of a larger nature. The solutions to those will require looking at other than just how you deliver vaccines. They have to look at how you get at the social structure overall.
To come in to some specific examples, you have been very positive with regard to some of the applications to this point with regard to video conferencing, electronic access and so on. In fact, I think probably most people in the room have seen in the news over the last couple of years, in particular, fairly dramatic examples of the use of even television access through to specific situations that have occurred in the North.
When you are reflecting on your meeting with us today, could you think about the specific successes that you can identify in the electronic health record through the video access issues? Perhaps you could provide some examples there. In addition, is there anything innovative that you believe in this area that has facilitated something in the North that you are not aware of that you have seen in just the general literature on the use of technology?
Beyond that, I would like to come back to the concept of innovation and see if you can identify innovative delivery methods and programs, either that you have implemented and you think there is room for further application, or those things that you are aware of from elsewhere that you think might have real application in the North. We are seeing overall some narrow innovations that are not getting broadly applied, and innovation is only useful if it is applied in a broad sense. It really is not innovation until it gets beyond the initial demonstration site into the larger community. I have gotten the sense that you are willing in your areas to look at things in a slightly different way. Could you identify innovative practices for us that you think might hold promise or have shown promise? To come back to something I said a moment ago, if there are any truly innovative situations that you recognize, in thinking about it, that you have implemented in the North that might have broader application as well, it is a two-way street, hopefully, in the health care application.
With that, on behalf of my colleagues, I thank you for the very thoughtful and careful way you have responded to their questions. I think it would be fair to say we have gotten a very good insight into issues that you are dealing with, from a very positive and constructive point of view. I want to thank you for that in particular. Finally, on behalf of my colleagues, thank you for having attended. The clerk will attempt to identify specific questions where they occur. You have the sense to think more broadly and come back with things you may not have mentioned to this point, beyond the questions that were specifically asked.
(The committee adjourned.)