July 18, 2018
The
Committee met at 9:30 a.m. in the House of Assembly Chamber.
CHAIR (Brazil):
Okay, ladies and gentlemen – Ms. Rogers, if we could get started. We have
Hansard doing the recordings for us.
I want
to welcome everybody to the Public Accounts Committee hearing with Health and
Community Services on a number of topics, but the primary discussion at the
beginning of the hearing will around the road ambulance recommendations put
forth in the AG's report.
I'd
like to welcome everybody to this session which is taking place July 18, 2018 in
the House of Assembly. I would like to ask the Members of the Committee if they
would introduce themselves and then we'll ask the Auditor General's staff and
the staff from the Department of Health and Community Services also to introduce
themselves, then we need to swear in a couple of individuals who haven't been
sworn in, in previous hearings.
I'll
start with Mr. Reid, an introduction of who you are and your district, please.
MR. REID:
Scott Reid, MHA for St.
George's – Humber.
MR. KING:
Neil King, and I work for
the good people of the historic District of Bonavista.
SOME HON. MEMBERS:
Hear, hear!
MR. KING:
I am stealing your line,
Gerry.
MS. ROGERS:
You stole my line. That's
good. It means I am having an influence; I like that.
MS. P. PARSONS:
Pam Parsons, the District of
Harbour Grace – Port de Grave.
MS. ROGERS:
Gerry Rogers, and I work for
the good people of St. John's Centre, and anybody else who call me.
MR. FINN:
John Finn, Stephenville –
Port au Port.
MR. PETTEN:
Barry Petten, MHA for CBS.
CHAIR:
I'm David Brazil, Chair of
Public Accounts and Member for the District of Conception Bay East – Bell
Island.
I'll
ask the Auditor General.
MS. MULLALEY:
Julia Mullaley, Auditor General.
MS. RUSSELL:
Sandra Russell, Deputy Auditor General.
CHAIR:
Oh, and I go to the ADM – or
the DM, sorry.
MR. ABBOTT:
It's John Abbott, Deputy Minister of the Department of Health and Community
Services.
MS. HANRAHAN:
Heather Hanrahan, ADM, Regional Services.
MR. HARVEY:
Michael Harvey, ADM, Policy Planning and Performance Monitoring.
MR. CAMPBELL:
Cameron Campbell, Director of Primary Health Care.
CHAIR:
Welcome to everybody. We
have three individuals that need to be sworn in: Ms. Mullaley, Mr. Harvey and
Mr. Campbell.
I'm
going to ask our Deputy Clerk if she'd do the swearing in, please.
Swearing of Witnesses
Ms.
Mullaley
Mr.
Harvey
Mr.
Campbell
CHAIR:
Thank you, Elizabeth.
Now
I'll explain the formal process that we'll use here. I'll ask the deputy
minister to first do a synopsis or an overview of particularly the road
ambulance recommendations or the findings and the response from the department
as to the action plans that are in play. Then I'll start with Mr. Reid, giving
each Member 10 minutes to ask questions relevant to that particular topic. They
don't have to use the whole 10 minutes as we go through it.
If a
Member feels the questions have been answered that they had, they can skip. Then
afterwards, if the road ambulance process has been completed and the Committee
are happy with the findings or at least the information that's been requested,
we can move to any other issues around the AG's report for the Department of
Health and Community Services.
So I'll
ask Mr. Abbott to start for us, please.
MR. ABBOTT:
Thank you, Mr. Brazil.
Since
the release of the Auditor General's report on the Road Ambulance Services in
November 2016, work has been ongoing to implement the recommendations. The
department, along with the regional health authorities, recognize the importance
of optimizing the ambulance program. We have made significant strides in
improving the monitoring of ambulance operations, ambulance professional skill
development, internal communications and policy and procedure development.
To
address recent concerns over ambulance staffing and response times, Western
Health, on behalf of the four health authorities, engaged Grant Thornton to
carry out a staffing and payroll review of the 48 private and community
ambulance operators. The report was made public. The review's findings raised
concerns over insufficient staffing of ambulances and the operators' use of
funds provided by government.
As a
result, the department is continuing to contract with Grant Thornton to carry
out forensic audits of several operations. The firm has also been contracted to
establish a monthly staffing and payroll reporting system to ensure operators
are meeting their contractual commitments.
Eastern
Health has constructed and moved into a new ambulance dispatch centre. The
Eastern Health authority is in the process of customizing, testing and training
dispatchers on computer dispatch software. Once the centre is fully operational
in October of this fall, Eastern Health will have the most up-to-date technology
to dispatch and monitor its ambulance operations.
The
department continues to develop options for the establishment of a central
medical dispatch centre for the province that would allow for a province-wide
ambulance dispatch system and oversight. The department and the four regional
health authorities are reviewing a proposal to acquire electronic patient care
records, referred to as an ePCR system, as part of a larger acquisition of new
defibrillator monitors for road ambulances. The ePCR system will not only
improve quality assurance for patient care, but will also track ambulance
staffing.
The
department has hired an advanced care paramedic within the department to aid us
in better defining appropriate attendant skill levels and to begin planning for
the introduction of advanced care paramedics in rural regions of the province.
The department and the four RHA paramedicine departments have formalized a
communications process to ensure the department's performance objective and
information needs are communicated to the RHAs –
CHAIR:
Excuse me –
MR. ABBOTT:
Yes.
MS. ROGERS:
(Inaudible.)
MR. ABBOTT:
Oh, I'm sorry. Yes.
MS. ROGERS:
Great. It's such good
information; I don't want to miss it.
MR. ABBOTT:
Okay. I can provide this
later for sure.
The
department and the RHA paramedicine departments have formalized a communications
process to ensure the department's performance objective and information needs
are communicated to the RHAs and through the Provincial Medical Oversight
office. The department and the four RHAs have revised the ambulance program
policies and procedures and standards manual, and the revisions will be
implemented as part of the new service agreement with the operators.
Finally, on the 12 recommendations from the Auditor General, one has been fully
implemented to date, 10 are partially implemented and one has not been
implemented to date. That's our summary right now, Sir.
CHAIR:
Okay.
Thank
you, Mr. Abbott. I appreciate that.
I'll go
right to Mr. Reid and we can start with your questioning.
MR. REID:
Okay.
Thank
you for your update and the information there. I have some questions as I go
along. Some are sort of general to get some more information so that I better
understand how the system works and things like that. It's more of a general
sort of knowledge that I want to get about how it works and, as we go on, we may
get into more specific sort of things.
But in
terms of the training for ambulance operators, that was one of the things that
came up in the AG's report, can you tell me a little bit about the training
requirements, where the training is done, who offers the training, those sort of
things, how extensive it is and how we compare with other provinces in terms of
training?
MR. ABBOTT:
Okay. I'm just going to lead on that, Mr. Reid, and then maybe I'll ask Cameron
Campbell to also add to that.
One of
the things, as a general sort of overview comment, is we realize that we need to
enhance training right across the board. So we have the ambulance attendants, as
it were, and we have the paramedics and the advanced paramedics. Our intent is
to expand training for paramedics so that there are more ambulances right across
the province. So we're engaging both public and private training facilities to,
in fact, do that and to up our skills.
One of
the things we have done is bringing an advanced paramedic into the department to
help us define those training needs with more certainty. We're also engaging
with the paramedics and the attendants in terms of how we should move towards
regulation of that occupation. Again, that will help us increase and improve
standards, and part of that would be to expand training.
Right
now, the operators are really responsible whether they are private, community or
hospital-based. Operators are responsible for making sure the training is
provided and/or the attendants are, in fact, trained. We've seen that as a bit
of a challenge for them and we recognize that, but at the same time the public's
expectation is those who are on our ambulances are meeting the basic skill sets
that are needed.
With
that, I'm going to ask Cameron if there's anything specific he wants to add.
MR. CAMPBELL:
Sure.
John
had touched on the fact that we've brought some advanced care paramedics to the
department that are working with us, and with a group across the regional health
authority where we've first targeted that, to look at how we would go about
spreading the advanced care paramedic model across the province. It's currently
concentrated in a couple of areas, primarily, in and around the St. John's area.
Of course, advanced care paramedics are able to work at a higher scope of
practice. We're looking at how we spread that in the rural areas where it could
be quite a valuable care tool for people.
I think
as well, kind of speaking specific to your question around where does training
happen and how does that compare to other areas of the country, locally we train
what we call EMRs, or emergency medical responders, and primary care paramedics.
Primary care paramedics are trained at the college level. That happens both in
our public and private college systems. The EMRs, or emergency medical
responders, is a shorter training stint. Those are the individuals who are
referred to as our ambulance attendants. They are not paramedics and do have a
much smaller scope and are often utilized in areas where it can be hard to
retain primary care paramedics.
Recently, the department has been working with the community paramedicine
operators association. They've paired up with a company called Training Works to
look at how we upscale existing EMRs that are working primarily in our rural
communities so that they have the opportunity to become primary care paramedics,
while still working and ideally doing that remotely. That's one of the major
initiatives that's been moving forward, and we're certainly paying a lot of
attention to, because of the ability there to potentially upscale a number of
our current attendants.
We've
also been working as of late with our Provincial Medical Oversight office, which
is housed within Eastern Health, to update the process of registration for
paramedics. In particular, linking back to the AG's report, we're looking at how
we ensure that we have adequate continuing education and ensuring that we update
the number of hours required to maintain licensure in the province. I think
that's an important step to make sure that we are increasing the level of
oversight and ensuring that appropriate education is available and required for
those currently working in the profession.
I'd
also note that in terms of how we compare across the country, our paramedics
have to complete what we call a COPR exam which is an exam that's organized at a
national level. It allows for labour mobility across provinces, but it also
ensures that we have paramedics that are on par with those in other regions of
the country.
MR. REID:
In terms of the recent study
that came out, the Grant Thornton study, that focuses mostly on sort of
financial accounting matters and how the money is spent. So in the future you
plan to do more of an assessment of what training people have to get a better –
is that the plan moving forward?
MR. ABBOTT:
So going forward, the Grant Thornton report lays out a number of recommendations
and, on top of that, we will be negotiating with the operators in terms of,
again, how we how we skill up and make sure that those who are on the ambulances
are meeting the standards and then we make sure that we have the supports in
place to do that.
So
that's all to happen relatively shortly because the agreements expire in
September and we have to engage them very shortly around that.
MR. REID:
Yeah, so that's an
opportunity there in terms of the contracts and when they expire.
MR. ABBOTT:
Yes.
MR. REID:
In terms of requiring additional training and having a plan as to how to achieve
it.
MR. ABBOTT:
Yes, and we're doing that, both using that as that opportunity to really bring
more attention to it, but also, as Cameron Campbell said, to continue to plan
and put the supports in place. We've been talking to the regulator as well in
terms of how to move forward to bring our EMRs and our paramedics into a
regulatory regime so that we can enforce the standards as well.
MR. REID:
Yeah.
You
mentioned the professional association. In some cases, I think the professional
associations for some other medical professions play a large in developing the
training and developing the certification.
Is that
the case with the association for people –?
MR. ABBOTT:
Yes, they're fully engaged. Again, they're evolving as an association. There's
new leadership, so again we're back at the table with them to help them to help
their members.
Part of
the challenge is not all those that are in the practice, shall we say, are
seeing the benefit of more training, regulation and those kinds of things. It's
a learning process, as well, for everybody.
MR. REID:
Yeah.
The
report, I think, showed that a lot of the – in terms of the way people were
paid, they weren't paid the required amount, I think 32 per cent or something
like that in Grant Thornton.
MR. ABBOTT:
Yes.
MR. REID:
Is that related to training? These
people weren't able to find someone who didn't have the training to justify a
certain pay level? Or why is that?
MR. ABBOTT:
Not in and of itself. I think part of
this is there was a negotiated agreement; monies were put in to really help the
operators attract and retain the attendants and paramedics. The question then or
the issue, obviously, that Grant Thornton has found is that some of that money
has not gone where it should have.
MR. REID:
Yeah.
MR. ABBOTT:
We realized we have to do more work on
that. Part of it is an administrative function within each of those operations.
There have been
some complaints made by different individuals and that's helped us focus where
we should get Grant Thornton and others to focus their efforts. But in and of
itself, we would disconnect the two.
MR. REID:
Yeah.
Okay, I think my
10 minutes are close to being up there.
CHAIR:
Okay. Thank you, Mr. Reid.
I'll move to Mr.
Petten now, if you want to ask some questions to the witnesses, please.
MR. PETTEN:
I might be repetitive because I'm
having a lot of trouble hearing most of the questions. I don't have an earpiece
either.
MS. ROGERS:
(Inaudible.)
MR. PETTEN:
I don't even think I have one there,
actually.
In 2015 the
province had 769 registered ambulance attendants. What is that number today?
MR. CAMPBELL:
Right now it would be just shy of 800.
I'd have to confirm the exact number because it does change on a day-to-day
basis.
MR. PETTEN:
Right, so that's pretty close to being
that same ballpark.
At the time when
the AG report – Eastern Health operated an ambulance service in St. John's and
Carbonear and provided oversight for another 15 private operators and six
community care operators. The AG report examined the skill levels, response
times and oversight of the RHA and other ambulance services.
Would you say the
department has made sufficient progress in each of these areas?
MR. ABBOTT: Mr. Petten, I
would say we are making significant progress but we know there are still gaps
that we are needing to address, and that's been the focus literally since the
AG's report has been out. As late as, literally, this week we are continuing to
focus on improving the quality of the services, making sure we have more
paramedics on our ambulances, that they are meeting the training standards
required by the program and working closely with the oversight office to make
sure that they are supported and have the skills there to move that whole
service forward.
We think, certainly, central dispatch is going to be a
critical part of that so we know where the ambulances are, who are on those
ambulances both in terms of staff and obviously in terms of patients, and that
we provide really sort of a national-class service for the residents.
That's where we are and we'll be continuing to discuss
those issues with the various associations, as well as in the department with
the health authorities, obviously, making sure we can get the funding to meet
the needs that we're finding as we go forward.
MR. PETTEN:
Recently, I know it was in the news, the Southern Shore region, Bay Bulls to
Bauline region, their issue was response times for ambulance service in their
region and apparently a new ambulance operator was approved. So has that worked
out yet? Again, about response times, is that issue still ongoing or is there
any resolution?
MR. ABBOTT:
We've been having discussions, obviously, with the proponent and with Eastern
Health. Our data would suggest that the response times are not the issue that's
been made public. That's why we are reviewing all of that data to make sure, in
fact, that the services are meeting the needs. It has not been, for us or
through Eastern Health, the issue that has been out in the public at this point.
MR. PETTEN: So,
just to be clear, the department questions those response times that have been
made public, the numbers that the public spoke of.
MR. ABBOTT:
Yeah.
PETTEN: You
don't agree with those numbers?
MR. ABBOTT:
Well, we're reviewing them. They brought that data forward. Again, it wasn't
coinciding with the data we had, so we were obviously going to review that. We
obviously owe that to the
communities involved to do that.
MR. PETTEN:
Okay.
Also in
the report the Canadian industry, the best practice for training – and I don't
know if this question was already asked by my colleague, Scott, there. Has the
department skill level standard been raised to match the Canadian industry best
practice?
MR. ABBOTT:
That's where we want to go. We're
working with the operators and with those staffing them to, in fact, move there.
As Cameron Campbell said, in terms of the paramedics, they are tested and
licensed based on national certification and testing. We would want to bring all
our attendants, their skill level, up as well.
MR. PETTEN:
Okay.
And the same then,
will the same thing will be expected of the private operators as well? It's not
–
MR. ABBOTT:
Oh yes, absolutely.
We don't make a
distinction between community, private and those operated by the RHAs directly,
so we want to make sure the whole system is meeting national service levels.
MR. PETTEN:
But that's where the gap appeared to
happen because from our base hospital it seemed to be running – their record is
much improved, St. John's and Carbonear, as opposed to our private and community
operations there. That's where the big gap seemed to – it seemed to be almost a
three-tier system when you look at …
MR. ABBOTT:
Yeah and some have described it that
way. We're trying to make sure it's as level as we can. The hospital-based
services, it's easier to attract skill, the paramedics. They are directly
funded, obviously, by government. They have the latest technology and we need to
bring everybody up to that level.
MR. PETTEN:
Also, in the AG report they found that
Eastern Health's own operators in St. John's are not meeting the response time
benchmarks. Has this issue been dealt with or is it being dealt with or is it
approved?
MR. ABBOTT:
Again, that's going to be just an
ongoing issue that we have to address with Eastern Health or any of the
operators, is to meet the response times. Part of that, again without getting
too technical, is sort of the immediate response time which we call the chute
time. The time the call comes in to the time the ambulance is on the road should
be 10 minutes max and then the question is 10 minutes or longer to get,
obviously, to the point where the pickup, shall we say, takes place
and we monitor those response times. We have the technology now to know where
each ambulance is and their response times. We monitor those very closely.
So if
you recall last year, there was a significant issue up in Labrador, in the Happy
Valley-Goose Bay area, and the operator was having trouble, repeatedly, meeting
both the chute time and then the response times. So through that review, we
determined that operator was not going to be able to provide the service we felt
was needed. So we then had the health authority take over that service so that,
in fact, we could meet those response times.
That's
how we monitor each of the services across the province. If there's an issue or
complaint made, we'll investigate. We'll work with the operators, whether it's
the hospital – because, again, the same thing applies. We've reviewed all of
their operations as well. We don't have double or triple standards here. We try
to have one for the province. But, as you can appreciate, a rural area, it's
going to take a little bit longer to actually get to the scene than in an urban
centre. But urban centres are matched against other urban centres across the
country so that the level of service is comparable.
MR. PETTEN:
Okay.
The AG
also found that the department wasn't providing effective oversight. Has there
been any changes made within the department now to improve upon that or –?
MR. ABBOTT:
Well, we have, in terms of – the simple answer is yes. We've provided more
support, resources to that. We have our director here, Mr. Cameron Campbell, to
oversee that work. We have brought in, as I said, an advanced care paramedic to
work with us on training. We have ongoing and regular meetings now with each of
the RHAs and ongoing meetings and discussions with each of the operators and
certainly their associations.
So we
are monitoring much closer the activity out in each of the regions and the lines
of communications have certainly been improved so that we can get – and
technology has allowed us to know where the ambulances are. So we are able to,
in real time, know where the ambulances are and that certainly helped us in
terms of any discussions we've had with both the public when complaints come
forward, certainly with the RHAs and then the operators themselves as to meeting
the standards expected of them.
MR. PETTEN:
Okay.
CHAIR:
Thank you, Mr. Petten.
I'm
going to go to Mr. King next.
MR. KING:
Mr. Abbott, you talked
about, when you did your introduction, you had a number of the recommendations
implemented partially and not. Can you go through which are done, which are
partially, which are not and the reasons why?
MR. ABBOTT:
Okay.
The first
recommendation was: “The Department of Health and Community Services should
evaluate its basis for road ambulance attendant skill level policy, which is
below Canadian industry best practice, and determine whether it is sufficient to
ensure quality care.”
We feel right now
that's partially implemented. Since we reported last year – and I'll give the
update as of March 2018 and then this month, so it will give you some sequence
of activity – we continue to work with the training institutions and industry in
an effort to address the primary care paramedic supply issues.
The department and
representatives from the RHAs and industry are developing a strategy to place
advanced care paramedics in rural regions of the province. As late as this
month, as I've said, we've seconded an advanced care paramedic from Eastern
Health to work with the department to better define appropriate attendant skill
levels, and aid us in planning for the potential placement of advanced care
paramedics to rural areas of the province. That work will continue. We don't
have a specific end point at this point.
In terms of the
second recommendation, that the Eastern regional health authority should ensure
that the road ambulance services provided by private and community-based
operators for the region meets the skill levels required by the department – and
it continues on – based on where we were in March from when we last reported,
the department and the four RHAs have developed a strategy to address best
efforts, issues and are waiting for the new service agreements to discuss a
change in the best efforts clause with the ambulance industry.
We are currently
planning for – again, we replaced some of the ambulance operator service
agreements that expire in September and we intend to address this issue in these
new agreements. That's in terms of the operators making sure that they have
those that are skilled to meet when there is a shortage.
The third
recommendation: The department should ensure that
its policies and procedures and the Ambulance Operations Standards Manual are up
to date, are being enforced, et cetera. Again, they updated in March. The
proposed changes to the policy and procedures manual have both operational and
financial impact on ambulance operations, which have to be discussed with them.
We'll be discussing that through the renegotiation of the service agreements. We
are also waiting to move forward on those with them. We've been developing the
changes, internally, but we now have to sit down and negotiate some of those
with the operators.
The
issue before us – and we approached Cabinet on this – is that we feel that we
really need to have new emergency service legislation for the province and that
these operating standards, in fact, then become either statutory or regulatory
and that they're really not a negotiated item, as we do in other areas. So
Cabinet has approved us moving forward with drafting legislation. We will be
doing consultations this summer and into the fall to develop that legislation.
The
next recommendation was that we should evaluate its basis for dispatcher
training and determine whether it's sufficient to ensure quality care. That one
has not been implemented and we are waiting on the results of Eastern Health's
central dispatch and how we can learn from that and move that service right
across the province.
We felt
it would be, sort of – I wouldn't say wasted effort, but we felt that once we
knew what we were doing in terms of central dispatch because we want them
focused on the training for those dispatchers than for looking at this dispersed
across the province.
The
next recommendation is the department should set ambulance response time
targets, giving consideration to Canadian industry best practice for response
times. Again, partially implemented, and I sort of referred to that in some of
my previous answers.
We have
now automated vehicle locator system in each of the ambulances so we, in fact,
know where each one is at any point in time, when it's either parked or on the
road. This has allowed us to gain better information and it's used by the
paramedicine staff and ambulance operators to track and audit ambulance
operations so we know then what response times are and then we can monitor
those.
As a
result of that, we've been able to figure out if there needs to be any change in
both location and response times.
MR. KING:
Sorry, just a quick question on that one: Is that on private ambulances as well?
MR. ABBOTT:
Yes.
MR. KING:
And to be cognizant of the
time –
MR. ABBOTT:
Yes.
MR. KING:
– just go through the Health
and Community Services. I know there are a lot of recommendations.
MR. ABBOTT:
Yes, the next one in terms of the department ensuring it is providing effective
oversight of the road ambulance program; as mentioned, we believe that is fully
implemented based on some of the responses I've given earlier.
The
next one: The department should ensure that contracts with the private and
community operators are negotiated and renewed in a timely manner. Again, we are
at the point now and we will be sitting down with the operators very shortly to
look at the future of those agreements, and we're looking at the options for how
to renegotiate those. We think there's sufficient funding in the system to allow
us to move and make the changes we need to see happen.
The
next one is the department should monitor the road ambulance program to ensure
intended results are achieved. Again, that's ongoing work so we say it's
partially implemented. And the Grant Thornton report was a major piece of work
we did this year to really get a better handle on what is happening out there in
terms of the system, who is delivery what and who is getting paid for what.
The
next –
MR. KING:
Oh, that's why those – I was just looking through the Health and Community
Services, what you folks have been doing –
MR. ABBOTT:
Okay.
MR. KING:
– I know each health
authority would be based on what you guys would dictate to them.
MR. ABBOTT:
Yeah.
MR. KING:
Just getting back to the
third recommendation here about Health and Community Services ensure that
policies and procedures and the Ambulance Operations Standards Manual –
MR. ABBOTT:
Yeah.
MR. KING:
You talked about emergency
service legislation in consultations. What type of consultations will you guys
be looking at?
MR. ABBOTT:
Again, we'll be going out to the communities across the province. We'll be
meeting with, obviously, the operators and their associations. We'll be meeting
with municipal leaders and the public if they're so inclined, so interested. We
will then be pulling all of that together and going forward in the fall to
Cabinet.
MR. KING:
Thank you, Mr. Abbott.
CHAIR:
Ms. Rogers.
MS. ROGERS:
Thank you very much.
This
may seem like an odd question, but if we were to sit down and have a beer, John
–
MR. ABBOTT:
Who pays?
MS. ROGERS:
I'll pay.
MR. ABBOTT:
Okay.
MS. ROGERS:
I'll pick up the tab for that.
If you were to
just tell me in a nutshell – these are the real challenges for our ambulance
services in the province – to sort of give us a global picture of what's
working, what's not working and what are the challenges. What we're doing is
we're looking at some of the very specific issues, but if we get sort of a
global picture of what you're really up against.
MR. ABBOTT:
I think from the department – and as we
look at these issues on a regular basis and as we sit down and address the
challenges – for us we think we, collectively, can still better manage the
ambulance service in the province. We look at what's happening across the
country and we see no reason why we can't have similar standards and quality.
It's getting
acceptance by all players, the operators, the staff and government, to agree
that, one, we want to improve the quality of the service. In doing that, we need
to provide better management; we believe a central dispatch so that we, whether
it's on a regional or provincial basis, can improve response times. Then, within
that, we need to make sure we have, on the ambulances, the appropriate
professionals to provide the standard of care.
If that is done
properly, obviously, the quality of care and survival rates, particularly in
severe incidents, is improved. It allows those paramedics to work to their full
scope of practice, and they become active as opposed to passive in terms of
supplying care.
We know all those
elements and we now just need to bring those together. We believe there's
sufficient funding in the system to allow us to do that. Again, on the whole, we
get complaints but we don't get a lot. I think both community and private
operators are doing a very good job in responding. We have, as I said, those
chute times. They have to meet those 90 per cent of the time and they generally
are.
When
we do see a problem, I think
the department, with the RHAs, are then in a position to move because we
understand the business and we know what is acceptable and what isn't. I think
the government wants to make sure wherever there's a gap that we're going to
fill that in. On a go-forward basis, we'll sit down with the operators to work
through, then, the detail as to how that gets done.
MS. ROGERS:
What you've talked about is
really where we'd like to see the service elevated to, but what are some of the
challenges of getting there? When I look at it, the dispersion of our people,
the geographic situation where population is widely dispersed, seniors, money –
one of the things we hear about is from people out in rural areas, in either
community or private operations, is the disparity of work-life balance and
payment for staff, people who are staffing the ambulances. What are some of the
challenges to get to where you really want to go?
MR. ABBOTT:
Looking at the dispersed population –
so, again, the call on the system is not significant. In some cases, an
ambulance may not move for a day or two, so retaining and attracting skilled
paramedics for that service is going to be challenge, both – well, in the first
instance will somebody want to work on that service and, then, will they stay,
and will they be able to work to their full scope of practice and remain
proficient in that. That's going to be – as we speak and going forward – our
biggest challenge. We want to skill up. Then, in doing that, it's going to be –
that's our biggest challenge.
The money, we say,
is there and will be there to meet that. We can do better. We can be more
efficient around some of the services so that we can make sure their response
times are a bit better and the dollars are better spent. Technology is there and
we need to apply that and use that regularly.
If I was to flip
it around, I think the expectation of, say, our urban centres, whether it's the
greater Northeast Avalon, which is a metropolis, and the standard of service and
expectation there is
high and we have to meet that. So we have to be comparable to whether it's
Halifax or Moncton or what have you in both the quality of care and response
times and things like that. They're probably under as much pressure, if not
more, than some of our rural operations.
The
other aspect is around the operators, generally, and certainly the community
operators. Many of those are still relying on volunteers.
MS. ROGERS:
Yes.
MR. ABBOTT:
We know that in rural Newfoundland that's going to be a challenge based on just
availability of volunteers. So we're going to have to look and monitor that very
closely. The default then is either a private operator and/or a RHA-run service
will be the result.
So
we'll be looking at that closely, but that's going to be the biggest challenge,
I think, for the community operators. We know they're very active and embedded
in their communities, in their regions and we support that, but we have to make
sure they can also provide the service that people expect.
MS. ROGERS:
What about an aging
demographic, how does that affect the operation of ambulance services?
MR. ABBOTT:
Today, or in the short-medium term, we're not seeing that from the supply side,
but it's the demand on the system and that's why we want to see paramedics and
advanced care paramedics in the service because then they can support seniors in
their homes, in the communities, in their personal care homes so that we don't
have to bring those citizens into the acute care system when they can be
serviced at home.
We are
working now on the West Coast in having an advanced care paramedic program
embedded in the community so that, in fact, the so-called ambulance service is
actually going to provide care in the community.
MS. ROGERS:
That's great.
Cameron
was talking about upscaling and training. So how do you see that being done
particularly in rural areas? My understanding – I don't know if these numbers
are correct or not – Eastern Health employees get about $26 or $27 an hour.
They're on call 12 hours a day. Private operators get about $21 an hour. They're
on call 24 hours a day, a number of days in a row.
How do
we address the disparity that we see, for the workers themselves, in rural and
urban? If we want to upscale – I love this idea of again using that full scope
of practice – how do you operationalize that when we see such a disparity in
payments and hours? How do you make that attractive? How do you make that
possible without it just being on the backs of the individual workers?
MR. ABBOTT:
Well, part of what we do is we scan right across the province and certainly
across the country to make sure we are going to be competitive in what we pay.
MS. ROGERS:
Uh-huh.
MR. ABBOTT:
That's a given and we work then through the negotiations with the operators to
make sure that what we negotiate – and this is the whole basis of the Grant
Thornton report, is we negotiated agreements, we put money in to address the
exact issues that you're referring to, but we found that some of those monies
weren't going to where they should go.
MS. ROGERS:
Okay.
MR. ABBOTT:
So that's really the basis of the Grant Thornton report. That's why I think we
feel confident and we say look, we think there's money in the system to allow
and to bring both the salaries up and, in doing that, we also want to make sure
we bring the skill levels up. If we have to pay more, we're prepared to pay more
to meet – and that there aren't the gaps that you refer to.
We
believe as a department, and I think within talking to the paramedics and others
themselves, that professionalizing that service, professionalizing the work they
do as a regulated occupation is something that we support. That way the
standards can be enforced and it doesn't become optional. Operator A can say
yes; the operator B says maybe. No, everybody has to operate at the one level.
So
that's the course we're on. As well, we just had a meeting this past week with
the licensing authority to talk about that and how we get to the next step.
That's going to require some development with the paramedics and the EMRs to
make sure we can get them to that stage, whether it'll be within a year or two
but that's where we'll make the biggest difference, we think, going forward.
MS. ROGERS:
Great.
My time
is out. I have more questions, but I guess I'll have to wait.
CHAIR:
Okay, when you come back.
Ms.
Parsons.
MS. P. PARSONS:
Good morning.
My
question is in regard to the response time benchmarks. As outlined in the
Auditor General's report, the Eastern Regional Health Authority has established
a 10-minute ambulance response time benchmark for its own ambulance operations
in the metro St. John's area. However, it has not established a response time
benchmark for its Carbonear operations.
This is
of particular regard and interest with the people I represent in the District of
Harbour Grace – Port de Grave.
MR. ABBOTT:
Yes.
MS. P. PARSONS:
Also, the Department of
Health and Community Services and the Eastern Regional Health Authority have not
set any ambulance response time targets for ambulance services outside of the
metro St. John's region.
I
guess, why is that and what is the latest and the status with regard to, I would
say, fixing this or improving this?
MR. ABBOTT:
Okay, just one second.
I'm
going to ask Cameron Campbell to respond to that.
MS. P. PARSONS:
Okay.
MR. CAMPBELL: We
have looked nationally at what benchmark targets do exist and whether or not
there's an ability to apply those. So I think there are kind of two key parts to
the question here: One is that in order for us to even monitor our benchmarks,
we knew that we needed to have technology in place that would allow that to
occur. So up until the point of this review, we would not have had any of the
automatic GPS-based systems that would actually allow us to monitor any
benchmarks that are set, with the exception of Eastern Health actually being an
initial earlier doctor of that technology, which has allowed them – particularly
in the urban setting – to try to establish those targets.
We can say at this point what we have done is put in place
a system across the province – and we spoke about this earlier – around
automatic vehicle locator. That allows us to start to trend and track what our
timing is currently. I think, to be fair, before we get to a point where we're
willing to set a benchmark, we need to make sure that's not arbitrary and that
it does fall within the realm of what is realistic within the current
configuration of the system.
Over the last year or so, we've begun to collect that data.
In addition, Eastern Health has led the way in now establishing its own central
dispatch. The department has been working quite closely with them. As part of
that, we are putting in place what is called a computerated dispatch system.
That will serve all of the Eastern Health current assets,
including those outside of St. John's and the Carbonear ambulances. That
computerated dispatch system is designed to automatically provide the best
possible routes, but also select the ambulances that make the most sense, and to
keep our ambulances in a state of – what we call – dynamitic positioning where
when an ambulance is responding to one call maybe on the eastern side of a zone,
those on the western side of that zone would begin to shift over to make sure
that we still retain ultimate coverage across the region.
I think back to the question around the benchmarks in
particular, it has certainly been more challenging for us to determine how we
would go about setting response benchmarks in rural and remote areas of the
province. And in some ways,
we are not comparable to many areas of the country because of our very dispersed
population. If we look at other areas, the road networks are not nearly as long
and the distance between homes are not nearly as long. We will have to account
for that and I would think that may change our actual response times going
forward.
What we
can control at this point is that piece around our chute times, which is making
sure that when a call comes in that ambulance is leaving as soon as possible.
The deputy, John, had referenced that we currently aim for a 10-minute chute
time within 90 per cent of the time.
MS. P. PARSONS:
Okay.
It has
been made known to me of an incident, in particular, a year ago, February past.
It was obviously the winter and road conditions perhaps played a factor in this.
A call was made. The patient died, unfortunately, not because of – I don't think
the response time in this case, but it was made known that the response time, by
the time the ambulance got there, was significantly long. That was a major
concern by family.
It
happened in the community of Spaniard's Bay and Ridge Road in particular. I
would think this would be covered by Moore's Ambulance Service there. Just to
make that known to you.
Also, I
want to move now with regard to the contract. Moore's contract is said to be
operating on the 2008-2012 contract. Is this a fact? Why is this happening? When
can employees in this particular area expect that the contract will be signed in
the 2014-17 contract? What can you tell us about that?
MR. ABBOTT:
The contract is with the lawyers now to
finalize; we've gone back and forth. We've been hoping that this could be
resolved any day and it's taken a bit longer between the lawyers for both
government and the operator. We think we have pretty well all the terms sorted
out but yet to be signed.
MS. P. PARSONS:
Yet to be signed. Okay.
Also, employees
have raised concern about the retro pay.
MR. ABBOTT:
Yes.
MS. P. PARSONS:
I guess that would be all part of that.
I often get asked that question to look into this on behalf of them. When can –
a ballpark – employees expect to receive that retro pay?
MR. ABBOTT:
I think we're familiar with those cases
and we're monitoring that. Once things are signed, then we can make sure those
funds are paid out.
MS. P. PARSONS:
Okay.
In closing now, as
you're aware of course, there was a $5-million announcement recently down at
Carbonear hospital. Probably about a month ago – well, in June there and
that's to include a new ambulatory service to be operated out of Carbonear
General Hospital.
So can
you just shed some light on that and just give some details on exactly what that
means?
MR. CAMPBELL:
If I'm not mistaken, you're referring to the infrastructure that would be
updated at the Carbonear site?
MS. P. PARSONS:
Right.
MR. CAMPBELL:
So I don't have a whole lot of detail on that, but I do understand that part of
that infrastructure funding was to update the ambulance bays that would be
located at the hospital to bring them into a more modern stage. It's part of a
broader infrastructure redevelopment that has an impact on the emergency
department there. So it's one of many sites where we've been continuing to do
that over the last number of years.
So when
we've been making those updates at sites, we're making sure that, if there is an
ambulance base there, it is appropriately placed, it's close to the emergency
department and that allows us to do a couple of different things, including to
better utilize our paramedicine staff. So if they're not waiting to respond to a
call, they could be inside of the hospital helping to provide care services as
well.
MS. P. PARSONS:
So we can expect, of course,
for services to be enhanced and improved, obviously based on this. Right? Okay,
thank you.
That's
all for me for now.
CHAIR:
Mr. Finn.
What
we'll do after Mr. Finn, we'll take a short 10-minute break, if anybody needs to
go to the washroom or make a phone call.
Mr.
Finn.
MR. FINN:
Excellent. Thank you.
Good
morning, folks, my colleagues – I guess the benefit of going last – have done an
excellent job in terms of being very thorough, as you have with your responses.
So I just have one question and you just hit on it, Mr. Abbott, and this was
around the piece on the West Coast with some training and trying to have the
paramedics provide more services in the community.
I've
had conversations with the minister previously and, I believe, yourself. So it's
certainly something very exciting. So in addition to having made significant
progress, I believe, on your recommendations, I'm just really curious about that
one particular piece.
MR. ABBOTT:
Well, we're anticipating an
announcement on that shortly and, again, it grew out of the community coming
forward to say we think we can do this. Working with the Western Health
Authority and the department, the pieces have come together to allow the
ambulance/paramedic service then to engage in providing further services in the
community.
It's
based on what has been happening across the country, in Nova Scotia, in
particular, and we've been monitoring that. I'm not going to say we're using
this as a pilot in the sense of what we want to do is learn from this and then
how we expand that across the province.
It's
certainly suited for this province in terms of the rural nature, the isolated
nature and where we have an ambulance service, it can then add to the primary
care service in that region. The paramedics, if we have them work to their full
scope of practice, then they can be as qualified then to provide initial
response and care.
To Ms.
Rogers's point, for seniors in the community, they then can go in and help – get
diagnosed and be first responders in providing service, and through technology,
going back to the dispatch to the hospital to say with the state of this
particular patient, what else can we do to maintain this patient in her home
and/or community.
We also
want to bring that in to our personal care homes. We are seeing that we have
seniors who are leaving the personal care home to come by ambulance to an
emergency room only to be told: Yeah, here, and now you can go back. We're
saying we want to bring that service in to the personal care home sector as
well. We're going to learn from what we do out on the West Coast and then apply
that across the province. But the fact that the community wants to do that has
been the critical part here. We haven't imposed it.
MR. FINN:
Excellent, looking forward
to it.
That's
all for me. Thank you very much.
CHAIR:
Okay, if we want to take a
quick 10-minute break. Then, if we head back here at 10:45, it would be good.
It's a bit different on your phones; I think it's three or four minutes, so say
10:50 by your phone. We're all on 10:38 now. We're good?
Recess
CHAIR:
Okay, ladies and gentleman,
we're going to reconvene again.
I'm
going to go to Mr. Reid to continue the question process.
MR. REID:
We'll start again.
I'm
going to continue with some questions on the road ambulance. Again, I have a few
general questions. Part of it is to get some background and to get a sense of
where the department is going in the future and where you see the problems.
I'm
just wondering about the urban-rural challenges in each of these areas. You
mentioned the pilot project on the West Coast, how that could work and what
information that might provide. I'm just wondering: Has the department looked at
other possibilities in rural areas, especially co-operating with fire
departments or things like that, in terms of road ambulance service. Are those
models used in other provinces and other jurisdictions? Is the department
exploring options in that regard?
MR. ABBOTT:
What we are looking at is, from a principle review is, obviously, how we can
improve the service, make it more effective and be more cost effective in doing
that. An example of what we're looking at, and it started basically on the West
Coast, is we're providing the same ambulance and attendants on the ambulance if
it was – quote – an emergency or if it was inter-facility transfers, those kinds
of things.
We are
reviewing, with the health authorities, what is most appropriate there. Western
Health had started that a little over a year ago and has found that they can
provide more responsive service, a more cost-effective service by changing the
nature of the ambulance in responding to those different types of calls. One is
an emergency call, fair enough; the other is a call made between a facility,
say, in Corner Brook, Western Memorial, and up in one of our facilities on the
West Coast if we're moving patients between facilities.
We can
schedule those and what have you. We've looked at that. We're then seeing how
other health authorities can do that because it takes pressure off in the true
emergency and the ambulance service, so that then we can be more responsive and
have better wait times.
That's
an example of where we're looking at. The other thing is around central
dispatch. Eastern Health now is just putting their centre down in the Miller
Centre because they had some space that they could use in that facility. That
will be operational in October. I think we will learn from there the central
dispatch for all of their assets and how we can get better information, better
response times and better coordination.
We have
the automated vehicle locator now on all – again, that's relatively new – our
ambulances; get better data on how we manage those. The intent there is that
data then can go into a central dispatch to know if you are actually returning
from a call – and, particularly, we have a lot of calls that are ambulances
coming from rural into urban. We have ambulances coming from the Bonavista
Peninsula in to St. John's or from the Southern Avalon coming in to St. John's.
They're going back. If there's a call, can they be redeployed?
It
would make sense, have faster response times and, certainly, better utilization
of their vehicles. It then becomes more cost effective. So we're looking at all
of those possibilities as we move forward. The industry is, I think, supportive
of that. We just need to make sure we have more conversations in how we do that
and how they get compensated appropriately.
MR. REID:
In terms of the rural-urban
issues, are there more challenges in terms of rural areas of the province in
terms of keeping trained people in those areas? One of the recommendations
relate to monitoring the system and things like that. Do you have a sense of how
things are going in rural?
MR. ABBOTT:
Yeah, I mean it is a challenge, as I
said earlier, about recruiting and retaining the emergency ambulance attendants
and, in particular, when we want to move up to paramedics. Dare I say that's a
challenge in all our health services; the further we're away from a regional
centre, then the more difficult that is becoming for us.
It's the
attraction part of that and then it's just the availability, in the first
instance, of young people really wanting – are they there and do they want to
come in to this service. It's incumbent upon us to make it as attractive as
possible. We think having it as a regulated profession will give them more sense
of professional identity and support as they go into this.
It's going to be
an ongoing challenge for us, there's no doubt about that. We see that in other
services. In other
areas we're putting bursaries, we're putting return to service agreements, those
kinds of things. We haven't done that in this particular area yet, but I can see
that's going to be something we may have to turn our attention to as well.
On
distance, obviously, in the response times and things like that, we're providing
the physical vehicle and the equipment. That's the easy part. The training
that's going to be required, we're committed to, but it's going to be the
recruitment – it's just the HR issues that we face in health care, generally,
are going to probably play out quite significantly in the ambulance side of
things.
So
that's why we want to come up with new models to make it more attractive. Again,
as we're doing on the West Coast, on the Port au Port Peninsula, is that we can
make that more wholesome, sort of, experience as a paramedic, and not only are
you going to be on the ambulance, you are also going to go into people's homes
to help them provide care. That, we think, will be part of the solution.
MR. REID:
Yeah, and you mentioned
legislation and how that relates to professionalization and the, sort of,
statutory requirements. So there's no legislation now in terms of –
MR. ABBOTT:
No.
MR. REID:
– that establish those
things?
MR. ABBOTT:
No.
So
we're really the only province, I think, that hasn't gone down that road. We've
talked about it for some time. So this spring we did go to Cabinet to say: We
think time is – we're overdue on this. That was accepted and we're out
consulting.
I guess
the benefit of being the last in here is that we can look at best practices
right across the country, which we're doing, to support the legislation when it
comes forward.
MR. REID:
Yes.
Okay, I
think that's all I have on the ambulance stuff. I may have something else later
on.
CHAIR:
Okay, perfect.
Mr.
Petten.
MR. PETTEN:
Thank you.
Back to
the skill level. I know the AG found the department skill level policy was
outdated. I know we've talked about various improvements being made and things
being worked on. I guess my question is more of a broader question from the
common sense point of view that we all live in this province, we know the
dynamics we deal with.
I said
it earlier when I spoke first – and I want to go back to it – the three-tier
system. I'm not saying there's a three-tier system, maybe there is, but it's a
job to deny that there appears to be a different level of service. My community
operates under private ambulances, but I'm fully familiar with the community
system as well.
If I go
to the Health Sciences Centre, ambulance operations at the Health Sciences
Centre are first class compared to what I've seen. That's not diminishing the
other private and community care – or community. But it's obvious to anyone –
the common sense point of view when you look at it – there is a stark difference
in the professionalism and the equipment they have. Everything about the
operation is totally different
I'm
going to ask a really broad question: How does the department deal – I know it's
nice to say in theory and it sounds good publicly to say we offer the same
service to a rural community to the urban centre. That would play well. Being in
politics, I get that totally.
In
reality, how does the department – how can you tackle that issue? Training the
proper number of paramedics, skill levels, you name it, the geography,
everything, to bring this to an acceptable service for all involved – because I
don't think we'll ever meet across the board standard, as hard as we may try. I
don't know if you have any commentary on that.
MR. ABBOTT:
If you look at the options – and,
obviously, we've had lots of conversations in the department to the questions
you ask. In the way the service has evolved, it really started, in many cases,
in the community; it wasn't a top-down kind of a service. The community
responded. That's why we have the community operators and there are volunteers.
We will ensure
they have the equipment they need, but then staffing and training. Unless it
becomes – and until it becomes – mandatory, you're going to see variations. So
we would like to move to making sure the skill sets that are mandatory – you
won't be able to operate an ambulance unless you have the right people on the
ambulance and that are fully skilled to the level.
We want to make
sure there are paramedics, ideally, on each of the ambulances. That's going to
take some time but that will raise the standard. That's where you will see the
difference because the technology now – we have to know where the vehicles are,
how quickly they respond and make sure we have electronic patient records, all
of that tied in.
Until we get a
mandate and get to that level – so legislation will help us, regulating the
profession will help us. That will be the key drivers to get that equilibrium
across the province.
If you
look at the dedication and the commitment in the community side – and,
certainly, even on the private side – we have a lot to work with in moving
forward. As the population changes within the province we'll probably see more
concentration and more pressure on our urban services, certainly on the
Northeast Avalon, out in Grand Falls and Gander and Corner Brook and Happy
Valley-Goose Bay, to make sure that those services are probably even at a – I'll
call that an urban standard. Fundamentally, it's response times and the quality
and skill of the people on the ambulance. Those we have a fair bit of control
over.
MR. PETTEN:
In keeping with that, rules
can be in place for whatever and in government there are lots of rules. But
enforcement is probably just as important as the rule.
How do
you police this? How do you ensure those community ambulance operations and
private are up to scratch? Do you have regular inspections? I know you make
things mandatory, but unless you see something happening sometimes you'll never
know it occurred.
MR. ABBOTT:
Again, the health authorities are pivotal to that because they have a role to
oversee each of those ambulance operators and the contracts and service they
provide. We rely on them to do that, again, I think when we get to making sure
we have the legislative standards.
Right
now we negotiate these elements. I'll say, you violated – no, I didn't, and you
get into that kind of conversation. But if we have legislation and regulations,
which are definitive, then either you did or you didn't and there's no
discussion around that. I think that will be very helpful to all of us, both us
as overseers of the service and then for those who are actually delivering.
We work
closely with the health authorities, and through the associations, for the
operators to make sure we are moving the standard forward and that the quality
of the service is moving forward. We do get complaints around response times. If
we do get an issue, generally, in terms of a complaint, it's around the response
times.
Right
now, at least we have the systems in place to track the ambulance, where it was
and where it wasn't, so it's not debatable anymore. That has improved our
ability to respond to when there are problems. Ms. Parsons mentioned an example.
We're able to go back and track and have that discussion. If there's an issue
with that operator, as we found out in Happy Valley-Goose Bay, then working with
the health authority we are able to go in, intercede and either fix it or we
have to replace you.
The
minister has been very firm on that. With that resolution, we're able to then
improve all the services going forward. Part of that is making sure our
oversight is – we, in fact, do our part. That's what we're certainly committed
to doing.
MR. PETTEN:
Thank you.
One
other point to that, too, is in rural Newfoundland sometimes you're increasing
the rules and regulations, you're tightening, you restrict. We call it cracking
down, enforcing, making sure things are keeping a proper standard. Sometimes the
pool will shrink for qualified or interested people that are in that small
geographic area that's willing or capable of carrying out the service as
mandated by the department. I guess that will be something that will be a
challenge.
MR. ABBOTT:
Yeah, there are definitely those considerations. We definitely want to work with
the operators that are there, but they have to have both the willingness and
capacity to improve what they're doing. If they can't or they won't, then we
obviously have to have a separate conversation of how we deal with that.
Again,
using the Happy Valley-Goose Bay scenario, we had conversations but we felt we
had to move. I think we will do that and you will see some changes going forward
– nothing specific at this point – where larger operators may take over smaller
operators, or the health authority may have to take over some operators or
operations if they can't meet their requirements.
We've
got that from a contingency point of view. Now, of course, the sector is
becoming unionized. Fair enough. Then if there's withdrawal of services and
those kinds of things, we have to have backup plans and contingencies there.
We're always trying to keep an eye on what is happening on the ground. We have a
very good information basis to help manage any of the scenarios that are likely
to happen over the next five to 10 years.
MR. PETTEN:
I have a final one before my
time wraps up.
The AG
referenced the patient care reports. A lot weren't completed. There was some
post – after the patient was transported. They were altered after the fact. Has
the department figured out what happened there? Are there any mitigating things
put in place to prevent this from being a regular thing?
MR. ABBOTT:
Well, what we find if we're
using manual systems, then we're going to run into those problems. They're not
acceptable but they're a fact of what is happening. We will be now moving to
automated reporting. That then will take out that challenge or that gap in
service. Then it becomes automatic, the reports are logged in electronically and
they follow the patient into the hospital.
As we move in with
our electronic medical record system and other electronic systems, then it will
be all integrated. That will be one less challenge going forward. The bottom
line here – and I think some of them I answered – technology is really helping
us and will help us with a lot of these operational issues that we've had in the
past.
MR. PETTEN:
Thanks.
CHAIR:
Thank you, Mr. Petten.
Mr. King.
MR. KING:
Thank you for the detailed overview
here this morning. Great questions by my colleagues; it's pretty much covered
off everything that I've had marked down.
Thank you.
CHAIR:
Thank you.
Ms. Rogers.
MS. ROGERS:
Great. Thank you very much.
Central dispatch
in Eastern Health, we're going to see that fully operational by October?
MR. ABBOTT:
Yes.
MS. ROGERS:
When will we see a central dispatch
that will cover the province?
MR. ABBOTT:
We're looking at a couple of options
there. Right now, we are going to see how Eastern Health's plays out. We're
going to monitor that very closely and then one of the options is whether or not
we can bring that system or equivalent across the province. Then it would be
either a public-operated system either out of Eastern Health or however we
manage that.
Some jurisdictions
have a private provider for a central dispatch, so we've had discussions there.
That's an option. Or we can continue to rely on a mixed system here, both public
and private. Some of the private operators obviously have their own dispatch and
we can work more closely with them. I think the Eastern Health piece will help
us determine, over the next number of months, which way we should go.
MS. ROGERS:
Do you mean that if – oh, it is 11:11 –
Central Health's experience, then you would have more than one central dispatch
then? Eastern Health will have theirs and then are you –
MR. ABBOTT:
Yes. So we're looking at Eastern Health
having theirs. Do we expand that model and that system then across the province?
MS. ROGERS:
Yes.
MR. ABBOTT:
That's one option. The other is do we
have – quote, unquote
– three or four for each of the health authorities having their own. Do we go
contract with a private operator to have it province wide, which is done in Nova
Scotia and New Brunswick, or do we just built on with the private operators in
the province right now that have their own – quote, unquote – dispatch? Do we
try to enhance that and tie it into, say, each of the health authorities?
We're
trying to figure out which of those options we think makes the most sense for us
going forward.
MS. ROGERS:
You would even explore a
private operator province wide.
MR. ABBOTT:
Yes.
MS. ROGERS:
Then they would take over Eastern
Health as well.
MR. ABBOTT:
Yes.
MS. ROGERS:
Are you in negotiations or discussions
about that now?
MR. ABBOTT:
No, we just did some fact-finding,
based on we knew what was happening in those two provinces, but that's as far as
we've gone on that.
MS. ROGERS:
Okay.
Do you have a
timeline for that, John, in terms of …?
MR. ABBOTT:
We were hoping to have something by
now. Because Eastern Health was working with their model, we've slowed down a
provincial one until we see how theirs works, how they plan to deliver, and then
can we leverage that for the rest of the province rather than have to reinvent a
new system.
MS. ROGERS:
So you don't really have –
MR. ABBOTT:
No, and we think what they have – in
terms of the infrastructure they put in place, it probably can meet with some
additional staffing for the province as a whole.
MS. ROGERS:
Have you looked at what are the
benefits or challenges with a private versus public dispatch system?
MR. ABBOTT:
One is just the experience, really, was
what we saw in New Brunswick and Nova Scotia. Medavie provides the service
there, so they have the experience. It's certainly state of the art.
That was one of
the options. If we could contract through a public proposal process, somebody
could come in and put that in place literally right away, as opposed to us
building it piece by piece. That was really the attractiveness of looking at
that particular option.
MS. ROGERS:
Okay.
The automated
vehicle tracking system, is that province wide?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay.
So you
have new data, then, on response times?
MR. ABBOTT:
Yes.
MS. ROGERS:
Can we have that?
MR. ABBOTT:
Yeah, we can look at any particular period and …
MS. ROGERS:
Great.
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay, because I think that's
something that has really been identified, like the Fitch report and that. It
would be great to see what you folks have solved with that.
MR. ABBOTT:
If I may, then we can have a conversation with your office as to what period you
would be interested in or …
MS. ROGERS:
How long has it been effect?
MR. ABBOTT:
Cameron?
MR. CAMPBELL:
It came into effect about a year ago. Although some of the data would have been
not so clean in the very beginning, in terms of needing to narrow down a
specific request; one issue that we would still have. There is a fair bit of
work involved in looking at specific response times.
We need
to then pair that with 911 data. Then, of course, there are still some gaps in
cases where a private or community operator is contacted directly. So it makes
it difficult for us to know what the contact time was versus the movement of the
vehicle.
MS. ROGERS:
Right.
MR. CAMPBELL:
We have all of the movement
data. It's just when you're looking at a certain period how do you then pair
that up with your 911 or your call data.
MS. ROGERS:
Yeah.
I would
think it wouldn't be just my office, I would think the Public Accounts Committee
would really like to see what has happened again, because that's been identified
as such an issue with the Fitch report and then what we hear anecdotally as
well.
I would
think that to be able to get some of that information – what have you found
yourselves now? Have you got a bit of a picture? Since you've been able to do
some of that tracking, has it told you anything?
MR. ABBOTT:
The general finding is that we are being responsive within what we've targeted
as reasonable response times. So we're looking at a 30-minute max kind of thing
for most regions in terms of where the ambulances are located. There are
variations in some regions just because of geography.
We
haven't seen any significant issues outside the issues that arose in Happy
Valley-Goose Bay. Then to have conversations with specific operators when we see
and hear, or a complaint of a specific delayed response as it were, we'll look
at that. Now we have the data. Again, it's done in real time and we can monitor
that as we speak.
What
we'll do is we'll develop a report for the Committee and table that here.
MS. ROGERS:
Okay.
Thank
you very much. That would be great.
With
the Grant Thornton audit, some operators have reviewed the latest audit and are
telling us there are many mistakes with numbers off, the issue of not being able
to replace staff because of the requirement for different levels of training.
They find there's a major problem with some of the calculations.
I'm
just wondering, have you been getting that kind of feedback from operators where
they feel it really hasn't accurately reflected the challenges they have been
dealing with?
MR. ABBOTT:
I mean we have heard some criticism. As
a matter of fact, probably not as much as we probably thought we might because,
again, the report finds significant issues around use of funds, payment and what
have you. That's why we ask an independent auditor to do that because that's
their business. Each of the operators are then free to have that conversation
with the auditor and correct, if there are things to be corrected. At the end of
the day, we have to stand behind whatever that auditor finds and then go from
there.
Part of that is
just going to be some conversations. We're being careful going to the next
stage, based on the recommendations of the auditor where we need to do further
audits. The numbers are significant where there's a variation of 25 per cent,
which is, you could argue, a high threshold. Because of some of the reasons, we
know it's not a perfect system there. We will then do further audits of those
operators and see what needs to happen on those.
That's the basis
of the audit. Not everybody would agree, but as we say, the facts are the facts
as we know them. They had done a fair bit of time – we thought this audit would
take a couple of months; it's taken longer than that for some of those reasons.
Some of the operators did not keep good records. They weren't as compliant in
the first instance, those kinds of things. So they really had to work hard to
get in to get access to that data.
MS. ROGERS:
I wonder if I could ask for leave.
CHAIR:
Oh yeah, go ahead.
MS. ROGERS:
I only have two more questions left on
this, on ambulance.
CHAIR:
That's fine.
Mr. Finn, yeah,
and Ms. Parsons.
MS. ROGERS:
Some operators are telling us – and I
don't know how accurate this is – that the minister said he's not renewing their
contracts, there's no meeting scheduled to start the negotiations and many
operators and their staff are kind of unsure of their future. I'm just wondering
what the department is doing to quell those fears?
MR. ABBOTT:
We will be continuing to provide road
ambulance service after September. The audit piece was – because it was slightly
delayed (inaudible) results. We wanted to wait for that before we went to the
next stage with them. We will be conversing with them very shortly as to what
the next stage of the negotiations will be for those agreements.
MS. ROGERS:
Okay. So you are going to meet with
them and –?
MR. ABBOTT:
Yeah. We don't see, obviously, in a
short period that there's going to be any significant change here, but we need
to work through that now with this report in hand.
MS. ROGERS:
My last question. I know there have
been some real challenges around folks who may have a mental health crisis who
need transportation to a facility. How is that going? What has been done about
some of those issues?
MR. ABBOTT:
We are working with the health
authorities to make sure how we respond to any emergency is done in a more
appropriate and sensitive fashion. This area we haven't really explored a lot
yet and it's something we know we need to do. That's something we have on our
work to do further on that, working with the paramedics and the operators to
make sure that those issues are fully recognized and addressed, as you put it.
MS. ROGERS:
Yeah, and because I know the RCMP in
some rural areas have said they're not going to do that transportation.
MR. ABBOTT:
Yeah, we have not had that. Again,
we're working with the RNC and the RCMP on that.
For them, it is
training and making sure the right people are in those situations. It's not
perfect, certainly, as we know it, but as we've seen with the mobile response
with the RNC, they have stepped up significantly. They've set a higher bar for
the province and we, the RCMP, the ambulance operators and everybody else will
have to move in that direction.
MS. ROGERS:
Okay.
Thank you very
much.
CHAIR:
Thank you, Ms. Rogers.
Ms. Parsons.
MS. P. PARSONS:
No, that's everything for me.
Thank you.
CHAIR:
Perfect.
Mr. Finn.
MR. FINN:
Yeah, just one actually.
Mr. Abbott, you
mentioned once or twice that you felt there were sufficient funds in the
department for some of the implementation of a variety of the recommendations.
With respect to the Grant Thornton report, were there any cost savings realized
or any areas where you could –?
MR. ABBOTT:
Well, I'm taking the report at face
value, and based on that, if you – because they just looked at one quarter. If
you pro-rated that
across the system on an annualized basis, there's over $2 million to be
addressed. That's a significant amount of money within that program. That gives
us some comfort to say all right, we need to figure out how we redeploy those
dollars. But we do need to sit down with the operators to figure out how we do
that.
It's
going to be a potentially heated type of conversation because that money that
was intended for a very specific purpose hasn't happened. We need to know why
and we need to know why on an individual operator basis how they're going to
change that going forward.
MR. FINN:
Okay, excellent.
Thank
you.
CHAIR:
I'll go through again to see
if there are any further questions.
Mr.
Reid.
MR. REID:
On the road ambulance –
CHAIR:
Road ambulance, yes.
MR. REID:
(Inaudible) the Fitch
ambulance review, there were recommendations related – medium- and long-term
recommendations. I'm not familiar with that report. I think it was done a number
of years ago.
MR. ABBOTT:
Yes.
MR. REID:
What were these
recommendations and where are you in terms of those?
MR. ABBOTT:
It was done under the previous administration. It was really looking at the road
ambulance program in its entirety. There were a series of recommendations but it
really focused on how to improve quality, skills training, central dispatch and
those kinds of things, things that the Auditor General has also hit on in the
report.
MR. REID:
Yeah.
MR. ABBOTT:
We have taken that report
and are working with industry to make sure we can implement those as quickly as
possible; central dispatch was certainly a significant one, the need for
legislation and those kinds of things. We're looking in tandem with the Auditor
General's recommendations to implement those.
It was
a very well-done report and I don't think anybody had any fault with it. Part of
it then was making sure we got consensus with the all the operators as we start
to move forward with implementing those recommendations.
MR. REID:
Yeah.
When
was that report, just so I can locate –?
MR. ABBOTT:
2013.
CHAIR:
2013.
MR. REID:
2013, okay.
MR. ABBOTT:
Yeah, because that's five years.
MR. REID:
I should have a look at that because it
still seems to be some of the same issues, maybe, that you're dealing with now.
MR. ABBOTT:
Yes.
MR. REID:
Okay, that's it for me.
CHAIR:
Thank you.
Mr. Petten,
anything further?
MR. PETTEN:
No, I'm good. Thanks.
CHAIR:
You're good?
Mr. King, you're
good?
Ms. Rogers, you're
good?
MS. ROGERS:
(Inaudible.)
CHAIR:
Ms. Parsons and Mr. Finn.
I'll just have a
few concluding remarks on that one. I do thank and appreciate everybody. It's
been a very thorough discussion.
It did, from my
perspective and, obviously, the Committee will have more discussions later on
about – appeasing is probably not the right word, but at least relieving some of
the concerns we had. That's why we called for a second hearing on this one.
In comparison to
some of the other responses that we had received from the department, there was
less of an uptake on ensuring that compliance was adhered to in this case, and I
do realize for a number of factors: you have a three-tiered or three-approach
system here when it comes to road ambulances and how you provide the service;
you have regional health authorities who may do things differently and you have
a different hierarchy or bureaucracy that has to be followed; and different
geographic challenges, no doubt. Knowing that the Grant Thornton was one part of
a report that was in play may have played a part in waiting to see where that is
and what impact it may have on certain things there.
The discussion
here from my perspective – and I think from the response from the Committee –
seems to alleviate some of the concerns we have. No doubt we'll have an
opportunity, after we review discussions and we start to formulate our report
for the fall, we may have some recommendations around how you move that forward.
One of the big
concerns by all on the Committee was time frames because, obviously, your
ambulance service is your primary first responder call that anybody relies on.
Particularly, how do you provide those services in remote and rural areas? How
do you provide an adequate service in heavy-demand areas like the Northeast
Avalon and urban centres?
I do give credit,
you've outlined at least a plan is in play to make that work and there are going
to be contingents that may have to change along the way. Obviously, the biggest
concern that we've had over a period of time is always asking if it's resourced
properly. I know even from Grant Thornton, being able to look at the finances is
one side of it, the training is the second side and the implementation process
is the third component.
I'm happy to say
from my perspective that there's a plan in each one of those. Some may take a
bit longer than others; some might actually literally have to change the process
of moving resources to make it happen. It may have to change being a little bit
more creative on the model that gets implemented in a particular area. I do
appreciate that and representing a district that's urban from Paradise, Portugal
Cove-St. Philip's and then having the challenges on the ambulance service on
Bell Island, I can appreciate the uniqueness. So do my colleagues here who come
from rural and represent rural and remote and
city-oriented districts that
there are different challenges there.
I will
say, and I apologize in advance, I say it tongue-in-cheek, but I have to ask you
a question I asked eight years ago in Public Accounts to a deputy minister from
a different department but in a similar circumstance. At the time it was with
the Department of Education. We had different school boards and I asked would it
be easier, more fluent and more consistent if there was one authority that
oversaw the whole process from a department point of view.
Being a
former bureaucrat here in the building, I know sometimes when you're trying to
juggle how one works where, and you've got 10 components coming at you versus
having to deal with regional health authorities – and I'm not putting you on the
spot –
MR. ABBOTT:
No.
CHAIR:
– but I do recognize the
challenges, and we did in Education at the time. I'm hopeful that the new plan
in education has to be fluent and has been working with the one school district
because we seem to have an even flow of access to particular services in various
regions, even with some of the challenges.
So I'll
just throw that out to you. You don't have to answer, but I would appreciate if
you'd just say, or just your concept, it would be easier if there was one or a
set policy that was umbrella for everybody.
MR. ABBOTT:
Well, I think for us in the department and we've accepted – we have the four
health authorities and for the reasons they were set up I think they're still
valid. As I say, trying to respond to a health issue or whatever in Labrador
from St. John's –
CHAIR:
Becomes a challenge.
MR. ABBOTT:
– is a big, big challenge.
So that
health authority, as an example, are able to deal with their issues, I think,
quite effectively. What we are doing as a department is that we want to ensure
that we have provincial standards and legislation to back that up if need be,
but certainly provincial standards and policies that then are to be consistently
applied across the province no matter where you are, reflecting that there are
going to be some contacts there. Obviously, road ambulance in Labrador is going
to be slightly different than road ambulance on the Northeast Avalon.
That's
really where we are, whether it's ambulance service, cardiac, speech language,
we want to make sure we have provincial policies and that we're not just relying
on four individual sets of policies, or even more, around the province. So the
same with ambulance, we've really focused on making sure we have consistent
policies across the province and then on a go-forward basis with the legislation
and new agreements, I think we'll get closer to that ideal.
CHAIR:
Good.
So do
you feel you've got good co-operation between the four regional health
authorities when it comes to road ambulance particularly?
MR. ABBOTT:
Yes, absolutely.
CHAIR:
Okay.
They
bought into rectifying, improving and finding the models that work and
supporting it?
MR. ABBOTT:
Yes.
CHAIR:
Perfect. Okay.
The
norm at the end of part of a session before – and we want to continue in
to some of the health ones. I'll get a
little time frame here and we'll have a little chat about that in a second.
I would like to
ask the Auditor General, after sitting here – and I know it's a report to your
predecessor, but you're very in depth into this report after discussions that
we've had in meetings. From what you've heard, do you feel that they're
adequately approaching and addressing the recommendations to your review in a
year or so, that you'll be confident that they're compliant to a point where
they've improved exactly what the standard of ambulance services should be for
the people of the province?
MS. MULLALEY:
I guess I certainly can comment that
I'm encouraged to hear the progress that's happened over the last few years. I'm
certainly encouraged of some of the initiatives that are underway.
From our office's
perspective, we monitor reports three years after the issuance. This particular
report would have been issued in the 2016 time frame, so we will actually do
some formal monitoring next year to the House of Assembly and the public on a
further status update on that. I think that will also beneficial because I think
many of the initiatives we heard here today will be further implemented in that
regard. I think that will be an appropriate time frame then to update the House
of Assembly and the public on progress.
CHAIR:
Okay. Perfect. Thank you.
Mr. Abbott, I just
ask that if we have some follow-up questions down the road when the Committee
gets together, that we can send an email to you and you can respond with
information. I know, as Ms. Rogers had noted, some information, but if you could
share any information that you shared with either one of the Committee Members,
you share it general, to everybody. You can either send it to myself or
Elizabeth and we'll ensure that it gets part of people's packages.
As you know in
hearings, we're taking notes and that, but there may be something that we may
think we have an alarm out. You may have already answered it and got the detail,
or it may be something that we neglected to ask that may be pertinent to when we
put together our recommendations. We do ask that if you share with one Member of
the Committee, you share with all.
MR. ABBOTT:
Sure.
CHAIR:
Because then that's pertinent to our
discussions when we complete our report for the fall.
I thank you on
this part of it. As we noted, we wanted to take advantage while we had you guys
here, rather than call other hearings in this. This was one that warranted it
because of the fact that compliance wasn't at the level that we had thought it
was.
We had agreed as a
Committee that we'd probably spend an hour or so – and we'll probably have to
take a break for lunch at 12 p.m., for a quick break, and then we'd come back.
My plan would be that we'd have everybody out of here between 1:30 and 2 p.m.
I know everybody
has busy schedules as part of that, but there are some general ones there, I
know, going back over what was in the AG's report. Particularly, I have a couple
later on, on the personal home care. A lot of information you had shared with us
and we had the debate and the discussion last year. But as part of just
follow-ups, rather than us have to go through a whole hearing process again, we
may be able to knock
that off today and not have to worry about this and have it in our report of the
fall.
I'll
start with Mr. Reid. We're going to continue. Around five to 12 we'll break for
lunch for half an hour, and then we'll come back and try to conclude. So I do
ask – there may be a couple there. We don't want to get generally into the same
thing we did last year, but because there's been a lapse of a year, there may be
a couple of things that have popped up; I know a couple on some of the policy
changes in personal care home approaches there.
There
may be something that we can knock-off, have done, and then when we do our
report we'll have a more fluent, thorough report for the House of Assembly in
September. I think we're all happy with that.
Dose
that work for your time frames?
MR. ABBOTT:
Yes.
CHAIR:
Yes, we'll plan to get
everybody out between 1:30 and 2 p.m. for sure. We'll give you a break for half
an hour at lunchtime at 12 to go make a call, get something to eat, these types
of things.
I'll
start with Mr. Reid, if you have a few health-related questions.
MR. REID:
Yeah.
Are we
going to start with any particular area or just general?
CHAIR:
No, no, if that's okay with Mr. Abbott.
MR. ABBOTT:
Sure.
MR. REID:
Yes, okay.
CHAIR:
All the ones relevant to the
AG's report that you responded to eight months ago.
MR. REID:
Okay, I'll just ask a
general question first about the nutrition in long-term care facilities. There
were some issues raised about that in the AG's report. I'm just wondering how
the implementation of those recommendations are going?
MR. ABBOTT:
As you know, the AG provided 10 recommendations; two specific to the department
and the remaining eight to the regional health authorities.
In
terms of the two that apply to the department directly, they've been partially
implemented. I can just speak to those in a moment here. One second.
In
terms of “The Department should conduct a formal review of the Operational
Standards for Long Term Care Facilities in Newfoundland and Labrador,” we have a
working group from the health authorities, as well as ourselves, to review and
revise the standards. That's ongoing.
To
date, approximately 90 per cent of the standards have been drafted. To get the
full implementation, the working group needs to complete the remaining
standards, begin a review process with the stakeholders and gain approval of the
manual. That's sort of standard process. When we do that kind of work we want to
ensure in this case, obviously, the health authorities, the nursing homes and
others are fully engaged in the final approval. Our plan right now is to have
all this work done, completed and implemented this fall. That's where we are on
that particular one.
Then
Recommendation 10: “The Department and the RHAs should establish benchmarks for
performance indicators, review and monitor actual financial and statistical
data,” et cetera. The department has identified financial and statistical
indicators. We've done that work. We're in the process of validating those with
the regional health authorities. Again, we are consulting with them and the
Centre for Health Information on the benchmarks.
Through
our system we have different operations, different delivery models, size of
facilities, et cetera. So we have to take that into consideration. We're
comparing those against national comparators where we can find them. There are
not as many there as one would think.
We hope
to have that work fully implemented by the end of the summer. In essence, give
it another month or so and we should have that work completed. The RHAs – for
those that I'm aware of – are in the same mode in terms of implementing or
partially implementing the recommendations specific to them. I have some updates
on those as well.
MR. REID:
Yeah.
Okay, I
think that's good for me for now.
CHAIR:
Okay.
MR. ABBOTT:
If I may, just on that.
MR. REID:
Yeah.
MR. ABBOTT:
What this AG report has
highlighted is an area that really was sort of under the radar; we were talking
about it. It's really brought heightened attention by the department and the
health authority. So it's been very helpful, us honing in on that particular
area.
There
are industry standards, there are comparators that we know we should be and
could be using. That's been very helpful in focusing the work.
CHAIR:
Okay.
Mr.
Petten.
MR. PETTEN:
Thank you.
The
AG's report on the personal care home regulations; I know myself and my
colleague, actually too, for Ferryland, have a fair number of personal care
homes in our districts. I know I do, as well as himself – community care homes.
I've
come back to this report, actually, when I've had questions and talked to the
different home care operators. It appears to be inconsistent, and I know Keith
is finding it in his district as well. It's gone from we're working with you and
there's a bit of give and take – and they're not slack, but they were used to a
certain level. Now we've gone from one end of the spectrum to the other. They're
finding themselves going to non-compliance or getting sanctioned or getting
warnings for almost any infraction out there.
We've
gone from probably being a bit too easy on these homes, for want of a better
word, to now – it's gone from one extreme to the other. This is home owners in
two different districts altogether, two unrelated groups. We've gotten the same
message.
My
question is being that I know the department, obviously, tightened up on a lot
of this with the regulations and I have no problem with that, but how much has
the department done in consulting with these home owners? A lot of the home
owners find they're getting very little consultation. They're being told there
are changes coming, these are the expectations, we need this and we expect this.
Then someone is coming in, walking in unexpectedly – which is fine, a surprise
inspection – and they're getting wrote up.
I had
one home, one person and they had a resident. They had everything prepared and
the resident was on their way. In mid-transport it was cancelled due to some
infraction. They pushed back, kicked up and questioned it and at the end of the
day it turned out to be a non-issue and it was solved. They feel they're
constantly under siege now as opposed to before, they probably weren't under
siege enough, if you know what I'm saying, but trying to find that balance.
Is
there a concerted effort? I know there must be but has the department given any
consideration to probably being more collaborative with the home owners to try
to bring them in to compliance and to bring them to the new age. I understand.
There are 13 in my district and there are all levels from there to there. I
agree with improving but I'd like to see more of a …
MR. ABBOTT:
I hear you. So just a couple
of things, if I may.
In
terms of inspections and then conditional licensing; there are two components
of, I'll call, an inspection. Service NL will go in to look at the physical
premises and preparation of food, those things. That falls within their mandate
based on current legislation and regulations. Then they can issue a report and a
conditional licence, or pull a licence if it's not safe. Then we have the health
authorities that go in obviously to monitor care in the facilities and depending
on what they find, can provide conditions on the licence.
It's
not done lightly and it is done based on standards, protocols and best
practices, what have you, that the operators are fully knowledgeable about.
Harking back to our conversation earlier about road ambulance, once we go to the
regulatory side, and if a standard is set, then they must meet that standard.
They are funded to meet that standard.
In
terms then of consultation, we have a working committee with the personal care
home operators. We meet on a regular basis. We are reviewing, currently, the new
operating standards and we are going page by page with the operators to make
sure they understand and can support those changes.
The
working relationship with the home operators has generally been good. There have
been issues at times where things might not have gone as well as both parties
would have liked but, certainly, under the current minister we are working quite
closely and meeting on a regular basis, including myself, as needed and the
minister also, as needed.
We
think the working relationship is quite good, but as the standards change and
the expectation – and the expectation of residents is changing – then the
operators are sometimes finding that a bit of a challenge. The market has
changed and what have you. For them to – quote, unquote – keep up, will require
them to invest and invest in the training and what have you.
That's
where we're finding, at times – and it's not happening on a regular basis but
there are, and I suspect I could probably guess who some of those operators
might be – that they're having a difficulty to keep in with the change in
business practice and expectation. There's really nothing we can do, other than
have more conversations with them.
We
know, in particular, the small home operators – say with 25 beds or less as a
case in point – some of them have been around for quite a while. We are working
and have committed to working with them on their finances and what have you,
because in certain locations they need to be there. We need them there because
they're the only operator in a large geographic area. We will work and are
working closely with them as well.
That's
sort of where we are on that as we speak. There is a table for them to bring any
and all issues and our doors are definitely open to hearing those.
MR. PETTEN:
I guess it goes back to with
those – because I do have a pretty good knowledge. I know all the operators; I
know a lot of their issues. They've been around for a long time.
MR. ABBOTT:
Yeah.
MR. PETTEN:
I know a lot of those homes
were operating under some form of a committee as opposed to individuals. There
was a committee, a personal care and community care home group that dealt with
the department or their RHA on different issues.
MR. ABBOTT:
Yes.
MR. PETTEN:
I'll go back again to say
that there seems to be a lot of confusion. I know that the department are
probably trying to work with these home owners. This confusion doesn't seem to
be – I'm just wondering is there a better way the department could address this
issue? It's not like one issue here or there, I've gotten it pretty well from
right across the board and I know Keith has in his district as well. He met with
groups in the last week.
No one
is saying we're opposed to change. It's just the expectations and they're
overwhelmed. The expectations have gone from there to there and they feel they
have no support. I know I've talked to several home owners and they feel
helpless. I mean one I was trying to – I'm waiting to hear back, actually. I
tried to set up some sort of meeting with the department to go in and have a
face-to-face because they were struggling. There was a lot of stress on them, a
lot of financial responsibility because most of the homes in my district are the
20-25 beds or less.
MR. ABBOTT:
Yeah.
MR. PETTEN:
They're the small operators
that have been around forever. I'm speaking on behalf of a lot of people in my
district and these are real concerns – and Keith's district as well and I'm sure
others.
You may
not realize because they're dealing with the RHA, but this is a lot of stress to
those home owners. They're not opposed to doing change, but they want more help
and more guidance in helping them attain the proper change. It's a lot of
investment for these small homes. It's a lot of financial to keep up with the
criteria, but it's their livelihood as well. They obviously don't just run the
homes, they work there. It's part of who they are. They're family operations
that have gone on for a long time.
MR. ABBOTT:
Yes, and I think, Mr.
Petten, certainly with some of the homes that are in your district, they operate
slightly different in that they really work under the RHA, the Eastern Health
Community Supports Program, usually for persons with mental health and other
challenges.
We have
been just talking recently around how we to need to re-engage with those
operators with the focus on how we support the residents in there and,
consequently, the operators to meet that. We're committed to engage further with
them and with Eastern Health.
We may
need to have a separate conversation with you and some of those operators if
their voice isn't being heard to the degree you've enunciated that. But we have
flagged that in the department as a specific issue as late as this past week
that we need to do along the lines that you've set.
MR. PETTEN:
Okay.
Thank
you very much.
CHAIR:
Okay, just looking now that
it is 11:52, if we could break for lunch just to give people an opportunity to
get lunch and make some calls. Then we'll come back at 12:30 and spend an hour.
It gives each to the five who haven't – their 10-minute opportunity to ask a few
questions. Then we can be out of here by 1:30 or so.
Is that
good for everybody?
Okay,
back here at 12:30 sharp, please.
We're
out in the Speaker's Boardroom. Yeah, we are. We can have a chat on a few
things.
Recess
CHAIR:
Okay, I want to welcome everybody back, and as we committed to, we'll try to
conclude this within the hour. We've asked people to – any questions that are
outstanding or something new that's changed, particularly around health care,
while we have the officials here that we could have a little discussion around
that.
Okay.
Mr. King, you're next.
MR. KING:
Okay. The only question I
have is related to communities, environmental care facilities (inaudible).
Around this time last year when we met we had just rolled out the new system for
food. I forget the name of the –
WITNESS:
Steamplicity.
MR. KING:
Steamplicity; I just want to
know how that's working out. Has it improved food quality, and are patients
happy?
MR. ABBOTT:
It's been operational now for – give or take – four to six months, fully
operational in Eastern Health. The initial response has been positive. The
quality of the food is better, timeliness and what have you. They're monitoring
and will be reporting to us on those issues as we go forward. We'll be sort of
monitoring that approach and whether or not then we should obviously roll that
out to other hospitals down the road.
MR. KING:
Yeah.
MR. ABBOTT:
It is early days. The
promise is of a better system, so we're now going to monitor for that.
MR. KING:
Yeah. From what I've heard
of it, it's been very positively received. Is this in long-term care facilities
here locally as well?
MR. ABBOTT:
No, just in the hospital.
MR. KING:
In the hospital, okay.
You're evaluating it right now and you're looking at possibly moving it out,
too.
MR. ABBOTT:
Yes.
MR. KING:
Okay.
Thank
you.
CHAIR:
You're good?
MR. KING:
Yeah.
CHAIR:
Thank you, Sir.
Ms.
Rogers.
MS. ROGERS:
I'd like to ask a few
questions about acute care bed management. It's still such a big problem, hey.
Can you
give us an update on the state of the art of what's happening? There are so many
recommendations here for different regional health authorities. I know there are
working groups, program team looking at the lean process, improvements, patient
flow, task force priorities.
Can you
just give us an update on what's happening with acute care bed management?
MR. ABBOTT:
In terms of the 16
recommendations – and they apply obviously across all the health authorities –
10 of those have been fully implemented and six are partially.
We have
a working group in place. They've taken these recommendations quite seriously.
We know we have beds that are underutilized or – quote, unquote – over utilized
in the sense that there are people in them, patients in them that really should
be discharged earlier, discharged home or discharged to long-term care or
personal care or what have you. We've been looking at that.
I just
want to give you – I won't say it's an anecdote because it's, in fact, the case.
In recent months in Central Health, we've had 17 cases where people have been in
long-term care and we were able to move them actually back home.
MS. ROGERS:
Oh, great.
MR. ABBOTT:
All of this sort of ties in,
when we look at what we call the alternate level of care beds, as people who
clinically can be discharged but have nowhere in the first instance to go. They
will obviously remain in the hospital bed. We're really focused on bringing
those occupancy levels down considerably.
We have
adopted a Home First approach, which basically looks at those, and said: What do
we need to do? What supports to we need to put in place in addition to our
existing programs and policies? We have home support, we have this, we have
that, but is it working for that particular client? It is an individualized
approach at the end of the day. We're finding a lot of success with that and
we've only really been rolling that out over, literally, the past year.
That's
been the focus. That will help us with the management of the acute-care beds.
The working committee involves the department that's overseeing that with the
four health authorities. They have a work plan that's in place and we are
striving to meet and implement all of these recommendations. Given the nature of
the work involved, they're meeting on a monthly basis to drive that work.
MS. ROGERS:
Is that just Eastern Health
or is that province wide.
MR. ABBOTT:
No, that's the province as a whole.
They're
taken and they're going through each of those recommendations, as well as
looking at some other issues that need to be addressed as we go forward.
One
thing that will be addressed in recommendations is what's the policy or plans to
support any of the changes we need to make. We're developing the performance
indicators to make sure they make sense and monitor those. There's a lot of good
national data that we can use. We're applying those to the Newfoundland and
Labrador context.
We are
looking at, obviously, early discharge planning. So when you come to the
hospital there's to be, at that point, a discharge plan already developed for
you. Based on your case and your acutely, et cetera, it should take three days,
four days, five days, what have you. A discharge plan is put in place and then
you're monitored against that. That's to help manage the patient as well as the
resources.
There's
a whole series of those initiatives that the RHAs are working on and monitoring
for that, comparing results against the benchmarks and then making the changes
that are necessary. Obviously, it requires the full co-operation of the nursing
staff and the physicians that are involved in the care, but sometimes it's
simply down to making sure that when a patient leaves the bed, that the support
staff that are put in place are available to make sure that bed and that room is
cleaned appropriately to admit somebody shortly thereafter.
We hear
of backlogs in the emergency room to get up to the floors. Again, that all ties
in to that. If you look at the number of beds we have on a per capita basis,
relative to the other jurisdictions we're again on the high side. Part of it is
geography but part of that is that we need to utilize those beds a lot better.
MS. ROGERS:
The work plan, is that a
public document?
MR. ABBOTT:
It's just a document that's used by the committee itself.
MS. ROGERS:
Is that available to us?
MR. ABBOTT:
I think that can be made available, yes.
MS. ROGERS:
Oh, that would be great.
Thank
you very much.
What
are some of the blocks and barriers, because I think there's still – is there?
Has it changed in terms of the amount of people who are medically discharged,
but still in acute-care beds, the data around that? Has that changed the
numbers?
MR. ABBOTT:
It is improving.
MS. ROGERS:
Yeah.
MR. ABBOTT:
It's still higher than we
would like, but we needed to have a response to that. The Home First approach;
we knew the issue, we knew what some of the solutions were, but we weren't
making the changes because we were dealing with established policies and
processes.
What
we've done now is set teams up in each of the health authorities so that it will
not only have somebody from the Community Supports Program but from the nursing
program, the OT and what have you, to say for this particular patient, for him
or her to now go home, we need to make sure we have these things in place. Now
they have a process to address those. It's a collaborative team approach there.
Again, a very simple concept but it wasn't happening.
MS. ROGERS:
Yeah.
MR. ABBOTT:
Now we have put that in
place. We've allocated some additional dollars to fill in the gaps. The federal
money from last year's Accord was targeted to support that.
MS. ROGERS:
What do you see as some of
the main blocks, barriers and challenges to get people out of those beds?
MR. ABBOTT:
Part of it will be, maybe, needing some more additional home support hours
upfront. From a process point of view we were waiting to do the financial
assessment before we allocate the hours. We're saying that can be done in
tandem. The need is there, put the service in place and we'll address the
financial assessment so, again, an example.
But I
think providing home nursing hours, if needed, and adding those where it's
needed, making sure there's either OT or PT services in place, connecting back
to the family physician and those kinds of things – so, as I said, it's
case-specific and each case has had a different solution.
MS. ROGERS:
John, where are we with the
financial assessments in terms of eligibility, ceilings and what we ask people
to pay in relation to the rest of the country?
MR. ABBOTT:
Yes, again, our Home Support Program, in terms of the level of subsidy we
provide, is probably one of the more generous in the country. We have looked at
that, but, again, how we can improve because there are still people who are not
getting access.
We have
gone recently to Cabinet to look at some changes and they have been approved and
will be announced in short order; again, to get at some of the barriers that we
see there, particularly for the liquid assets issue and then adults with
disabilities who are working. We recognize there are sort of two areas that we
can improve on and we can make it more administratively – we can simplify the
process.
The
income ceilings, I know we're not in a position to change those because we're
not in the overall fiscal situation to change those at present.
MS. ROGERS:
But in a number of provinces
there is no means test. People don't pay out of pocket for home care, right?
MR. ABBOTT:
Yes, but we won't be changing that certainly in the foreseeable future.
MS. ROGERS:
Okay.
Are we
still facing wait-lists for long-term care beds?
MR. ABBOTT:
We do have wait-lists waiting for beds. Again, we've added capacity. We just
opened up the beds in Carbonear; that will relieve pressure. We've expanded –
MS. ROGERS:
Is that full now –
Carbonear?
MR. ABBOTT:
Yes, it should be, or if not we're just phasing that in over a couple of weeks'
time. We've expanded – again, through Home First some home support hours were
needed, so that's taken some of the pressure off. The numbers haven't increased
significantly. I should say they've actually improved and we monitor those on a
monthly basis.
CHAIR:
Okay.
Ms.
Rogers, I'm going to go to Mr. Finn.
MR. FINN:
Actually, I'm fine now. I
was curious about the acute-care bed management. I know there are a few nuances
there and I think you've addressed what Ms. Rogers was referring to. Obviously,
we want to get people out of the beds and into long-term care or back home with
a level of care. I know that's a constant challenge, so that's really all I had,
Mr. Chair.
Thank
you.
CHAIR:
Okay, thank you.
Mr.
Reid, anything further?
MR. REID:
Yes, I just had a couple of
questions. I guess I'll ask them both at the same time. One is related to the
Newfoundland and Labrador Prescription Drug Program and I just want to get a
sense of how that's working out and if there are any changes in practice. Are
there any savings based on the implementation of the program?
MR. ABBOTT:
Sure.
The
provincial Prescription Drug Program, we have roughly 130,000 people registered
for that program. In any one year we may have between 105,000 and 110,000 people
who actually use the program. It's administered out of our Stephenville office.
Administratively it's, I think, fairly simple in terms of access.
We
continue to add new drugs to the formulary based on Health Canada and the
Canadian Agency for Drugs and Technologies assessment and then we negotiate a
pricing agreement with, say, the generics or others. We're relatively fairly
current on that.
The
biggest challenge we have right now administratively is the special
authorization. Some drugs need that to be authorized by our pharmacists in the
department. Because of increased demand and some staffing issues, we're having a
few challenges there, but we think we're close to catching up on that.
The
income ceilings are such, in the way the program is structured, that there are
more people looking for assistance than we can provide access. We are optimistic
that the national discussions on pharmacare with the federal government will be
a solution to that particular problem.
The
other challenge is – and all governments are facing and anybody in the business
– that the new drugs and therapies that are coming on are quite expensive. It's
not uncommon now to hear that based on a new therapy developed by a
pharmaceutical company that's gone through the approval processes that you're
talking at $400,000, $500,000, $600,000, $700,000, $800,000 per patient.
That's
going to be the biggest challenge we face going forward, just from a cost point
of view. That's why we think the pharmacare discussions are going to be very
instrumental in allowing us and all other provinces to deal with that.
Technology and science are really going to be our biggest challenge going
forward.
CHAIR:
Are you good?
MR. REID:
Yeah, that's good.
CHAIR:
Okay.
Mr.
Petten, follow-up questions?
MR. PETTEN:
I don't have much else
either. I'm just kind of curious overall with the AG report – we want a chart of
what's been implemented partially, fully and not implemented at all on all the
recommendations. I know that the Prescription Drug Program, according to us,
most of the recommendations are 100 per cent done, but where are we with the
other ones?
I know
that acute-care bed management, nutrition in long-term care and salaried
physicians we're probably a little over half fully implemented – the
recommendations. What is the goal of the department to reach – where do you
figure it will be to max out in completion percentages or where are you with
those things?
MR. ABBOTT:
If I may, just as a whole, we are working diligently on all the recommendations
for all those areas and we anticipate – for those that are remaining to be fully
implemented, like in terms of the physician's one, for example, over the next
number of months we should have those in place, the same with acute-care
management. So we've got working committees and processes in place to get us
there. We don't feel substantively that we're very far off in meeting the intent
and spirit of those recommendations.
Now,
there's one in the Drug Program in terms of a technical piece that we can't put
that in place. It's cost prohibitive and it really is not going to solve the
problem. It's not for the sake of looking at that seriously and in terms of
trying to get close to what the recommendation was trying to get at.
Where
it is at all feasible, we are striving to get these recommendations in place.
MR. PETTEN:
Okay.
That's
all I have to ask, Mr. Chair.
CHAIR:
Okay.
Mr.
King.
MR. KING:
I'm good.
CHAIR:
You're good?
Ms.
Rogers.
MS. ROGERS:
Yes.
Back to
acute-care bed management, because I know it is very complex – what are the
recommendations? Is that work ongoing to ensure that policies are in place
throughout all areas to support acute-care bed management? Can we see those
policies? Would it be possible to see those policies?
MR. ABBOTT:
Yes.
MS. ROGERS:
And I know it's all very,
very complicated and I know that a number of facilities do have people in
acute-care beds that need to move on but that it's difficult.
And so
we see that Labrador-Grenfell Health has not implemented yet, in this last
report that we had an update – “Regional health authorities should identify
and/or establish performance indicators related to acute-care bed management and
ensure national benchmarks are identified or hospital targets are established
for each performance indicator.”
The
last update we had was that Labrador-Grenfell Health has not implemented this to
date but are arranging for a group to commence this work within the next several
weeks. Has that happened?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay, great.
MR. ABBOTT: Of
those indicators, they have five in place and four they're working on. We also
now have a new CEO in place who will be driving that change.
MS. ROGERS: And
that's happening in all the regional health authorities, is it?
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay.
MR. ABBOTT:
Heather's telling me that all the others are fully implemented.
MS. ROGERS:
Okay, great. Great.
For the
provincial Prescription Drug Program, the ceilings for eligibility, have they
changed at all? If not, how long has it been since they've changed?
MR. ABBOTT:
Those, Ms. Rogers, were put in, roughly in, I think, 2006.
MS. ROGERS:
Okay.
MR. ABBOTT:
And we, I don't think, have changed those for that period.
MS. ROGERS:
Yes, because I'll tell you
why – 2006. I hear from so many people, particularly seniors, whose income, OAS
and GIS, has really not changed; yet, their cost of living has skyrocketed,
particularly rent. And how many seniors come to us saying: I can't afford my
drugs – who may not be right at, you know, they may just be above the
eligibility rate.
I'm
hearing also from doctors. I'm hearing from people in emergency departments
about people coming, particularly again seniors, who are not taking their meds.
It's anecdotal, but it's real.
MR. ABBOTT:
Mm-hmm.
MS. ROGERS:
Or cutting their meds in
half, taking them only every second day, which I think probably ends up being a
cost down the road to our health care system. It's a problem.
MR. ABBOTT:
Yes. I think certainly the department and the government recognizes that. Right
now, because of our government's fiscal situation, not really able to move to
expand as much as I think people would like. But that's part of the argument and
rationale moving towards national pharmacare so that there is a level playing
field right across the country, and access to the expensive drugs as well.
That's where I think we're pushing with Ottawa to move this forward.
MS. ROGERS:
I don't want to argue with
you, except I believe that probably the cost down the road is greater if people
are not able to take their medication as prescribed.
MR. ABBOTT:
Mm-hmm.
MS. ROGERS:
Have we really come to the
point in our history where we can't afford, until we get pharmacare, to ensure
that people have the medication they need to stay well and keep them out of
hospital, keep them well and not sicker.
MR. ABBOTT:
I hear and I understand that
perspective for sure.
MS. ROGERS:
Okay.
It's
not on the recommendations and issues that were raised by the Auditor General,
but I was wondering how is it going with the cut in the Adult Dental Program?
What have been the unintended consequences of that?
I'm
hearing from many, many doctors – and from different emergency rooms – the
number of people that are presenting with infections and cellulitis due to poor
dental care, even working people saying they can't afford dental care. They end
up at emergency; they end up with expensive IV treatments.
Has
there been any tracking of the rollout of the effects of cancelling that Adult
Dental care program in terms of the additional expenses because people can't
access proper dental care?
MR. ABBOTT:
I don't have that data and
we haven't been monitoring closely. Now, at any point in time we can track that
data. We've been staying close to the dental world, through our director of
dentistry with the department, to monitor – and we've just negotiated a new
agreement with the dentists' association.
Again,
because of cost in the first instance, the government had to backtrack on that
particular part of our program. I don't think anybody said we won't move in that
direction at some future point but, right now, we're in a holding pattern.
MS. ROGERS:
Is there any intention to
track it, to evaluate what the rollout has been of that?
MR. ABBOTT:
As I said, that's something
that is not active.
MS. ROGERS:
Yeah.
MR. ABBOTT:
If cases come forward and
need attention, we will make sure we'll assist that individual as required. But
we have not seen any wholesale evidence of that, but to be fair, we haven't been
tracking closely either.
MS. ROGERS:
Yeah. It's kind of
interesting hearing from an emergency department to say it's increasing,
increasing, increasing and the great cost just because of poor dental care.
The
other thing again – it's outside of this – can I get a status on the bus pass
situation that's now moved from AES to community health. I'm hearing multiple
situations where people repeatedly have to go to the doctor to get notes in
order to get a bus pass. Can you tell me what the policy is and where that's at?
MR. ABBOTT:
The program is yet to be transferred.
MS. ROGERS:
Oh, I see.
MR. ABBOTT:
Yeah, it's almost any day now. I'm not in a position, really, to answer that. I
know that it is an issue that is coming to the department, but we have not been
engaged on that one yet.
MS. ROGERS:
When people come to me and
they can't get a bus pass, it's not Health that they are negotiating with, it's
still AES?
MR. ABBOTT:
Yes.
MS. ROGERS:
Oh, okay.
MR. ABBOTT:
Literally for the next couple of weeks and then …
MS. ROGERS:
Okay.
I mean
I'm sure you're concerned. Everybody is concerned the number of times people are
going to doctors. Doctors are telling me as well the number of times people have
to go to a doctor to get a note. Then the note is just not quite right, so they
have to go to the doctor again and again, and the cost to our health care
system.
MR. ABBOTT:
Yeah.
I guess
what we're seeing, and one of the rationales for moving the program over, is to
address those kind of issues so we can align with our – because we have the
data, the MCP data. When a client or patient presents, we can connect those
stories right away and say, yeah, this is legit. We'll be looking at all those
processes once they are within the Health and Community Services domain.
MS. ROGERS:
Are you developing a new
policy around it?
MR. ABBOTT:
We will be.
MS. ROGERS:
That's not developed yet, is
it?
MR. ABBOTT:
No, no.
MS. ROGERS:
Okay.
Is it
possible to get a copy of that policy once it's developed?
MR. ABBOTT:
Absolutely.
MS. ROGERS:
Great.
Thank
you very much.
CHAIR:
You're good, Ms. Rogers?
MS. ROGERS:
I could ask a million
questions.
CHAIR:
We all could go for hours on
health care. That's good.
Any
other questions before I conclude with some questions? No? I appreciate that.
I have
a few and some are statements.
Oh,
yeah, go ahead, Ms. Rogers.
MS. ROGERS:
There's issue of – I know
that my colleague asked a question. Salaried physicians; can you just give us
sort of a – because there were so many concerns that were raised, the fact that
some people weren't working with a contract, and not being able to really
implement the contract after someone has been working for a long time.
Can you
just give us sort of a ballpark of the state of the art around so many of these
issues that were raised and where we are with salaried physicians?
MR. ABBOTT:
Yes.
MS. ROGERS:
I was also surprised – no,
that's fine, if you could just give us a sense.
MR. ABBOTT:
Again, in light of the Auditor General's recommendations in that particular
area, we've been working quite extensively with the health authorities to put
the contracts in place, align our policies right across the province and look at
how we manage and approve new positions. All of that is working.
The
area that's still a bit of a challenge is getting physicians, who have been
working in the system without a position description and a contract for an
extended period, to see the value of doing that. But, certainly, anybody new
that's coming in – and there's a lot of changeover – we are slowly but surely
making sure we'll have full compliance.
We are
still trying to work with all physicians to make sure they are clearly given a
position description, they know what's expected of them and that the pay
obviously follows that. We've re-established the Salaried Physicians Approval
Committee. That's something that we've now put in place over the past year.
We're looking at locum coverage – all of those things – so that we get the best
value for the dollar we're spending.
We're
making sure we align the physicians that are needed in the communities where
they are needed. There are some indicators we use, and the reference of one
physician for roughly 1,500 citizens. In some cases we have a lot more than
that, and some we have a lot less. When we're looking at requests for filling or
replacing, we're bringing that data together.
Obviously, we've added nurse practitioners to the system.
MS. ROGERS:
Yes.
MR. ABBOTT:
They have to be considered
in that equation as well. As we graduate more, we want to bring more into the
system.
Again,
we're looking at other practitioners – paramedics as well – for a role to play
so that we have a full complement of fully trained professionals to deliver the
care. All of that is playing out there. We've seen significant improvement in a
relatively short period of time in how we're managing the salaried physician
resources in the province.
MS. ROGERS:
Meeting with family practice
residents – many who are from the province and want to stay in the province –
have talked about more of an interest to be salaried rather than fee for
service.
MR. ABBOTT:
Yeah.
MS. ROGERS:
But then, also, the
Newfoundland and Labrador Medical Association has talked about – is it
co-capitation?
MR. ABBOTT:
Yeah, sort of a blended
model.
MS. ROGERS:
The blended – yeah.
MR. ABBOTT:
Yes.
MS. ROGERS:
So where is the department
–?
MR. ABBOTT:
I think we will be starting
negotiations in the near future with the Newfoundland and Labrador Medical
Association. I think that will be certainly one of the topics for discussion.
They put out a discussion paper just recently – or their 10-year plan –
MS. ROGERS:
That's right.
MR. ABBOTT:
– in how to move in that
direction. We're in alignment with that approach; we just have to figure out
together what is the best model and the payment model. Different jurisdictions
have tried it; some with varying degrees of success. We have a finite series of
dollars that we pay to the physicians and we see that we should be able to come
up with new approaches within that budget.
MS. ROGERS:
Okay.
My very
last question: The issue of health care provision within our justice system.
MR. ABBOTT:
Yes.
MS. ROGERS:
Where is that at? What can
we see?
MR. ABBOTT:
We have our team in place;
we have a team lead in place. We've started the discussions with the Department
of Justice and Public Safety.
We are
already providing services within several of the facilities across the province.
We will be going into the penitentiary here in the city providing similar
services, as we do in the community. We're working with Justice in how to
accommodate that, both facility-wise and in terms of the relationship with
corrections staff and their policies.
The
minister was interviewed and quoted recently, within the year, that there will
be the full transition. We're working towards that. I think it's certainly top
of priority for me and several of our staff to move there and the Department of
Justice is fully supportive of that. Again, we're talking different languages.
Even though we're talking is it an inmate or a patient and getting the language
sorted out when we sit down and talk about that.
MS. ROGERS:
When you're saying that
you're already providing some services, what would those be?
MR. ABBOTT:
The single session; we're
also providing counsellors out in Central and up in Labrador; and the psychiatry
services in the Eastern region are provided out of Eastern Health.
MS. ROGERS:
When you're saying single
session, so folks who are incarcerated can avail of single session –?
MR. ABBOTT:
Yes, so we want to move –
MS. ROGERS:
That has started?
MR. ABBOTT:
Yes, and we want to make
that applied right across the system.
MS. ROGERS:
Yeah.
MR. ABBOTT:
There's a little bit of a
challenge here in timing and resources, but we're committed to doing that.
MS. ROGERS:
Is it someone from Eastern
Health who is providing a service in the facility?
MR. ABBOTT:
Yes, and we're going to be
working to make sure there's somebody in place any day now; it's just a
logistics matter.
MS. ROGERS:
Okay, because I've just
visited the facilities and nobody talked about that.
MR. ABBOTT:
No.
MS. ROGERS:
Okay, so it's like brand
new, brand new.
MR. ABBOTT:
Yes.
MS. ROGERS:
Okay. That's good to know.
That's good to hear.
I know
that the minister has said within a year. Are you hoping to be able to do
something about the psychiatric services sooner than a year or …?
MR. ABBOTT:
One of the things we've
committed to doing is doing a clinical review. We approached Eastern Health to
do that, so that as we embark on that we take the latest best practices and
apply them right from the start.
MS. ROGERS:
Doing a clinical review of
the current services?
MR. ABBOTT:
Yes, and compare that to
best practice. Then design what we think is the best approach, given our
circumstance going in as we take over the service.
MS. ROGERS:
Okay.
What do
you see as some of the real blocks and barriers? Are there ones that …?
MR. ABBOTT:
Again, at the end it's going
to be a resource issue but we're committed to making the dollars available. Then
we just need to obviously identify the clinicians that can come in and support
our patients in the correctional facilities.
MS. ROGERS:
Great. It's good news.
Thank
you.
CHAIR:
Thank you, Ms. Rogers.
I had
one about the blended pay-for-services model. You've answered that and,
obviously, I've been following what the Medical Association is proposing.
MR. ABBOTT:
Yes.
CHAIR:
There are some unique
opportunities and probably some unique challenges within the whole system. I
look forward to see how that unfolds in the negotiations.
While
we're on the doctors, we hear on a weekly basis at least that doctors are coming
and leaving for various reasons. Are we monitoring how many doctors? Have we
added new physicians to the system over the last number of years?
MR. ABBOTT:
Yes, we have. We were at the
highest again that we've ever had. We had some vacancies right across the
province in the specialities, and we monitor that daily and weekly. There are
pockets where there's more concern than others. Certainly, when we see – out in
the Conception Bay North area there were several family physicians who had
finished roughly at the same time for different reasons. We knew that was
starting to happen so we went in to assess what services we need to put in place
to accelerate the recruitment.
Part of
it is a distribution issue and part of it is work-life balance issues for
physicians now. How we practise today is different than how we practised five
years ago, 10 years ago, so we have to factor all of that in our planning.
We are
also undertaking a physician resource plan for the province. That will help us
guide this for the next 10, 15, 20 years. That's the intent here. On the whole
we are doing quite well, but there are some issues that have cropped up.
CHAIR:
Do we have that data? Can we
track –?
MR. ABBOTT:
Yes.
CHAIR:
I realize the demand areas,
that there may be two doctors who leave in remote central areas, but you've
probably added four doctors in an urban area because of the demand and numbers.
MR. ABBOTT:
Yes.
CHAIR:
If we could get a copy of
the tracking.
MR. ABBOTT:
Sure.
CHAIR:
We've had a lot of
conversations around physicians in different areas. How do you compensate to
ensure there's a provided service? You're not going to be able to provide the
same service to everybody. If we're recruiting doctors, how do you engage them
to go to rural remote areas versus the urban centres? That would be a piece of
information if you could share it with us, I think we'd all – there would be a
value to that.
I have
a concern that's coming up in my district and maybe it's across. It's purely
health related but I don't know if it's the health authority as such. We've been
noticing – I don't know if it's because of budgetary restraints or not – that
social workers are doing very inclusive audits, for want of a better phrase, on
their client services. We've had, I know in my district – and we've had a
discussion about one particularly. Services for home care services,
particularly, have been dramatically decreased based on what they call an audit
reassessment.
In some
cases, where it's becoming alarming to me in my district, we've had home care
services cut for developmentally delayed special needs adults. The unfortunate
thing – and we're talking minimal amount of home care; they were receiving 10
hours a week, two hours a day to help with preparation for meals and ensure that
they showered that day and everything was safe in their home. When they lose
that, they lose their allowances and they lose any other special supports and,
in some cases, supports to go to a special needs program that was inclusive for
a taxi cab or a bus pass, for example.
Those
are my two concerns, keeping in mind – and I'll say this publicly – I was a
bureaucrat for a number of years and I was with AES. The review process
internally, I've always said, was a sham. I've never ever, of my 26 years, seen
somebody overturn a co-worker's assessment internally. I didn't see it in AES; I
didn't see it in Health. That's just the reality.
Then
you take it to the next level – and I had this discussion with the supervisors
and I've taken it to the next level about the discussion. The alarming comment
made to me was that we've been over-servicing people. I challenge that
because I said you're over-servicing with two hours a day for a special needs
adult who was living with their mother who passed away and then her brother, who
was younger than her, passed away. She's still developmentally delayed. That's
not going to change. The environment doesn't change from there.
The supportive services that have been in play for nearly
20 years going to a particular program, that's a volunteer-run program, but her
ability to go because the taxi is paid for. Keeping in mind she's at an age
where I can see the next step. If these services continue to be cut, she will be
in hospital. She'll be a ward of the state forever and a day at hundreds of
thousands of dollars for the sake of if we're paying 10 hours at $150 a week.
That ensures her safety and her well-being from a health point, not counting her
mental well-being. I have an onslaught of emails from this individual and her
family saying these are automatic supports. It's a minimal investment.
The concern becomes is it – because now we're saying go
back and really scrutinize the files that we had going for years to find a way
to save money. When people make the comments we've over-serviced people for too
long, define over-service. If you only need one car, you don't have three cars
in your driveway, unless you have people to drive them and unless you're
collecting them.
These people who have these particular needs were assessed
somewhere along the way by a qualified social worker or a psychologist to need
these types of services. Now that we're finding – and I just thought maybe it's
a couple in my district and they're unique because it could be a unique social
worker, it could be a unique day, but I'm challenging them. I'm getting the
impression – I'm being told that there's a full-fledged push towards the social
workers at the grassroots level to do complete audits with the intent of saving
money.
That's alarming to me because it's going to have a major
impact and it's not going to save us money. I know in the three I have I can see
in a year, if we don't reverse some of these, you're going to see them in
long-term care at the hospital on Bell Island, or you're going to see them
having to be getting some supports out of the Waterford here. You're going to
see ambulances on a daily basis leave. We just talked about road ambulances,
what it will cost for Fewer's to drive ambulances from Bell Island constantly
over and these type of needs.
I put that out there. I don't know if the department can
have some influence with the regional health authorities. I suspect it's not
only happening in my region. I do know it's happening more on the Avalon and
maybe it's Eastern Health that pushed it. I know one of the targets have been
special needs adults and I
will tell you that. It's alarming because I know these cases and I say that
coming from my background.
Knowing
the minimal investment to improve their quality of life, their health care and
their safety is nowhere near what it's going to cost the minute we pull those
services. That's an alarm –
MS. ROGERS:
(Inaudible.)
CHAIR:
Yeah, I'm putting that on
record, knowing a year down the road we'll talk about hundreds of thousands, if
not millions of dollars, extra having to be put into the system for a handful of
clients, because we didn't spend nickels and dimes on services that were being
provided, because somebody had assessed it under their professionalism that
these services need to be provided.
I don't
know, John, exactly what response you may be able to make because it's different
from a regional health authority.
MR. ABBOTT:
Yeah.
CHAIR:
It's alarming to me and I
want it on record just for a discussion point.
MR. ABBOTT:
In terms of that issue – I'm
just sort of working backwards – from a policy end, we have done a review of the
Home Support Program, and done right from all aspects of it. We are looking at
the assessment process and reassessment process to make sure it's right and the
people doing those assessments, all professionals in their own right, have the
skills to do that and they're applying consistently to the degree that that's
possible.
As part
of that process, we have asked the health authorities, on their assessment and
reassessments, to make sure they apply the appropriate tools to that assessment.
There are very regimented tools to allow them to do those assessments. We leave
it to the social worker or the community health nurse, or whoever does those
assessments, to make sure they're done right and we have to rely on that.
There
will be cases – and I know you and I talked on one of those – where the
reassessment suggests less hours of care that is needed. Those then are reviewed
by others in the health authority. They can be reviewed and appealed, as it
were, to make sure they're done right.
We want
to make sure people are getting the right amount of support, the right amount of
hours and support. That's where it is. It is not a fiscal issue as far as the
department is concerned at all because the money is set aside for the program.
We know there will be cases on either side of this – some will get some more
hours of support, some will get less – but we've left it to those doing the
assessments to get it right. Where there are some of the examples you've used –
and for those that we're made aware of – we will ask the health authority and
we'll go to senior management to make sure those cases are given a second
review, or third review as the case may be, to make sure they can stand behind
those assessments.
CHAIR:
Fair enough.
I can
understand a reassessment; if somebody is coming out from surgery, for example,
and you need X number of hours and then it gets reduced because their mobility
issues have improved. But a developmentally delayed 55-year-old lady who is 280
pounds and is four-foot-one, who can't reach a stove, has phobias galore and has
a 65 IQ level; 20 years later it hasn't improved. There's no intervention we've
done other than she's still socially in the program she's been in for the last
15 or 18 years which has been her social life. It's been her support mechanism.
It's actually been even an educational component because they're trying to teach
basic skills and this type of thing. She's now been diagnosed or acknowledged as
being over-serviced.
My
concern is I've gone through the social worker, I've gone through the social
worker's supervisor who did a review, I've gone to the director who, before she
reviewed the file, said to me: Well, you know, David – and this is somebody who
I had worked with in a previous life which said – we've been over-servicing a
number of clients. Then my natural bias – and this is a person who I would
consider a colleague at times and a friend who's making comments like that. I'm
thinking maybe the process itself is still not independent enough to make the
proper decisions.
I have
a real concern on this one, and this one I'll follow up, but I'm glad you put it
on the record that there hasn't been a notice to Eastern Health or any of the
health authorities to start cutting money in home care, other than the
reassessment for the process, which I can live with that. We have to have checks
and balances to ensure people get the service they need. Sometimes there's an
increase. Sometimes it's less because their circumstances improve.
I do
have concerns when there's a clientele group who their circumstances are never
going to improve; they're going to be the same. So we have to maintain at least
an adequate service that has, for want of a better phrase, kept them coherent
and inclusive as much as possible and happy, safe and healthy to the best degree
that we could. I just wanted that noted because it's one of the few things that
I'm adamantly upset about – that I don't think there's been enough real thought
gone into it – where I think a small group of our society got bottlenecked into
another big group and they're going to end up reaping the negatively from the
process.
Other
than that, I do want to thank officials and the Auditor General's staff. I will
ask the Auditor General again, from what you've heard there – and I know I go
back and reiterate that it's a report from a previous Auditor, but you're
obviously reviewing the response for it – nothing alarming that the deputy
minister or his officials had noted that would bring up. We've already talked
about the road ambulance but some of the issues that we've brought up since
then?
MS. MULLALEY:
No. No particular concerns.
From my
perspective, I want to thank you just for the opportunity that these meetings
present. I think they are very important meetings and an opportunity to hear
about the implementation of the recommendations.
As I
mentioned earlier, our office will be issuing a report this fall. That would be
with respect to reports issued in 2015. Of the six reports that were discussed
throughout today, three of those: The Prescription Drug Program, the Nutrition
in Long-term Care Facilities and the Personal Care Home Regulations will be
included in the report in the fall.
CHAIR:
Okay.
MS. MULLALEY:
Thank you again.
CHAIR:
Perfect. I appreciate that.
With no
other further comments, can I ask for a motion to adjourn?
So
moved, Mr. King.
All in
favour signify by saying 'aye.'
SOME HON. MEMBERS:
Aye.
CHAIR:
Opposed, 'nay.'
Again,
I want to thank everybody. I want to thank Ms. Murphy, the Table Officer, for
taking care of us. We look forward to any follow-up information that you have to
share with us.
WITNESS:
(Inaudible.)
CHAIR:
Without a doubt. She has
more knowledge than most of us.
Thank
you.
On
motion, the Committee adjourned
sine die.