NOVA SCOTIA HOUSE OF ASSEMBLY
Wednesday, November 29, 2017
November 22, 2017 Report of the Auditor General
Printed and Published by Nova Scotia Hansard Reporting Services
Public Accounts Committee
Mr. Allan MacMaster (Chairman)
Mr. Gordon Wilson (Vice-Chairman)
Mr. Ben Jessome
Ms. Suzanne Lohnes-Croft
Mr. Brendan Maguire
Mr. Hugh MacKay
Mr. Tim Houston
Hon. David Wilson
Ms. Lisa Roberts
[Mr. Gordon Wilson was replaced by Ms. Rafah DiCostanzo.]
[Mr. Brendan Maguire was replaced by Mr. Bill Horne.]
Ms. Kim Langille
Legislative Committee Clerk
Mr. Gordon Hebb
Chief Legislative Counsel
Office of the Auditor General
Mr. Michael Pickup,
Mr. Terry Spicer,
Deputy Auditor General
Mr. Andrew Atherton,
Assistant Auditor General
Ms. Dianne Chiasson,
HALIFAX, WEDNESDAY, NOVEMBER 29, 2017
STANDING COMMITTEE ON PUBLIC ACCOUNTS
Mr. Allan MacMaster
Mr. Gordon Wilson
MR. CHAIRMAN: Good morning everyone. I call this meeting of the Public Accounts Committee to order. Today we have with us the Auditor General’s Office, and we will be speaking and discussing the November 22nd Auditor General’s Report. I’d like to remind everyone to ensure that their phones are on silent so we do not have interruptions.
We’ll start with introductions.
[The committee members and witnesses introduced themselves.]
MR. CHAIRMAN: Thank you. Last night we received some information distributed to committee members by email and I would like to ask members if it is their will that this information be made public so that it can be included in our discussion today. I will ask members if that is okay.
Would all those who are okay with that please say Aye. Contrary minded, Nay.
The motion is carried. The information received last night from the Department of Health and Wellness that was requested in camera last week has now been made public, and can be discussed at this meeting.
Mr. Pickup, I’m going to turn it over to you to provide some introductory comments.
MR. MICHAEL PICKUP: Thank you for having me and my team here today to discuss the results of our November 22nd report to the House on three audits in the health area. I have only a very short opening statement.
Firstly, I must say a big thank you to the 33 folks in my office who produced three reports with ten chapters in total to the House since October 4th. I am so grateful for the dedication and hard work of my teams who diligently commit themselves to meet the mandate given to my office as the independent auditor of government.
For the folks who are with me here today, and equally for our team members back in the office already working on our next set of audits, thank you so much and please know that you are appreciated and valued.
Secondly, I would like to share with the committee members and the public that I believe my office has a very successful and professional relationship with those we audit. In this case the CEO of the Nova Scotia Health Authority and her team, the Deputy Minister of Health and Wellness and her folks, as well as the people at the IWK, were absolutely 100 per cent co-operative, engaged with us, and professional in their relationships with us. This makes auditing much easier.
I can assure this committee that we’ve had an open and sharing dialogue and we received full co-operation. For that approach, I would like to say a big thank you on behalf of me and my teams. While audits can be a challenging process, the senior leadership of these organizations, in my view, have set an environment where their officials embrace us and welcome us as an independent voice. We provide assurance not only to the House but also to them on how the operations of government are indeed being administered.
Now for these three health audits - we made 21 recommendations that resulted from our examination of various practices related to family doctors and primary care, mental health services, and the home care support program. Our recommendations relate to improving various aspects of health care and were all accepted by each of the organizations that were part of the audit.
I take some comfort that the Health Authority, the department, and the IWK essentially told us that yes, indeed, our findings and recommendations will be helpful to them on the path that they have already begun to go down. Their responses to our recommendations in many cases show specific actions that are or will happen in relation to the recommendations. This acceptance of our recommendations and a solid response makes me happy because it should result in improvements to how the government is delivered to people.
We are here today to help the Public Accounts Committee in your use of our report as you work to hold the government accountable. We are happy to be here to discuss the reports.
Mr. Chairman, that concludes my opening comments.
MR. CHAIRMAN: Thank you. We will begin with 20 minutes of questioning from Mr. Houston of the PC caucus.
MR. TIM HOUSTON: Thank you for the opening comments. You referenced the value of the service you provide to the province. I wonder if, for the benefit of those who may not fully understand, you could explain the concept of a performance audit and why it’s important that your office conduct performance audits.
MR. PICKUP: Sure, I’m always happy to talk about our mandate. The mandate in the Auditor General, in simple terms, is to conduct financial audits and then to conduct performance audits. In performance audits, we’re really looking at the administration of government, if you will, be that economy efficiency or an effectiveness aspect as well. Performance audits are those that move outside of the financial sphere and answer the specific questions related to those audit objectives for a particular area or function of government.
MR. HOUSTON: So, really getting to the heart of the effectiveness of the operations of government, which is I think what most Nova Scotians are really interested in.
I took a review of your website over the last few days, and there’s an entire team at your office dedicated to performance audits. The team consists of an assistant auditor general, an executive director, four audit principals, four managers, three senior audit officers, and three audit officers, for a total of 15 persons. That’s not including yourself or the deputy auditor general or any support staff.
It seems that the performance audit group is a significant part of your team; it’s almost over 50 per cent of the entire staff. Does that staff ratio reflect the importance that performance audits play, in your view, of the job of the Auditor General? Performance audits are pretty important, right?
MR. PICKUP: I would put equal weight on our responsibilities related to conducting financial audits like the Public Accounts, equally to the performance audit portfolio as well. In simple terms, it is probably 60-40 per cent-wise in terms of the work that we do on performance audits compared to a financial audit. What I would look at as sort of a measure of that is, earlier this year we reported to the House in February on our follow-up of two years of performance audits. Over those two years, we found that over 70 per cent of our recommendations were implemented by government. I said at the time that that was a record high. I took that as an indication of the importance and usefulness of the recommendations that we make.
MR. HOUSTON: Who approves the budget for your office?
MR. PICKUP: Mr. Spicer might want to help me on some of the technicalities because I sometimes mix up all of the steps. We do go to the House Management Commission of the Legislature with the budget, and then it goes from there, I think, to Finance and Treasury Board, and they do their thing with it.
MR. HOUSTON: With such a percentage of your staff and your effort focused on performance audits, that would be a high percentage of your cost of your budget. Knowing the process that the budget goes through to get approved, should the government be surprised that your office does performance audits?
MR. PICKUP: I would go back to the approach to a performance audit and the auditing standards that we set out to follow and we do follow. In determining an audit area that once we look at it, like in this case, the three health care audits, we would go out and meet with the government folks, the people who we’re actually auditing, keeping in mind sort of under that accountability triangle, if you will. we have the Legislature, which gives the authority to government to spend and conduct operations and then us as a part of that triangle, as the auditor reporting back to the House to say what has been the result of our examination related to how government is doing their business.
MR. HOUSTON: It is on your website that one of your strategic priorities is to “Focus our audit efforts on areas of high risk that impact on the lives of Nova Scotians.” That is one of your strategic priorities. To my mind, the doctor recruitment situation and the situation with health care in this province would fall within the area of public interest. Is that the strategic priority that you had in mind when you selected this audit?
MR. PICKUP: When we select audits, we look at areas that are what we would consider likely higher interest, higher risk, whatever the term you want to use for that is. At the end of the day, we have limited resources as well. We can probably handle eight to ten performance audits a year, so we have to be very strategic in what we pick.
When I get out and talk to folks in government, be they deputy ministers or folks running these other organizations, I say I hope when we come to you and say this is what we’re going to audit, that you say good for you, that’s going to add some value to us. I take some faith in that. When we pick those areas, that’s what I want to hear, instead of oh, that won’t be any use to us.
I am convinced through these meetings that we have and through these interactions that yes, we select what we want to as the independent auditor, but the feedback that we’ve received in this case from the three organizations has been very positive.
MR. HOUSTON: I noticed that. The government knows that you have a mandate to do performance audits; it knows that you have a large portion of your staff to conduct performance audits. In those you have a strategic priority to focus on areas of public interest, so I wouldn’t think they would be surprised that you were going to focus on health care and specifically doctor recruitment. In fact, they’ve known for quite some time - I know in this committee that this coming audit has been discussed a number of times, and also outside this room.
My question for you is: Prior to the Premier’s comments last week in response to your findings, had any member of the government expressed any concern to you about the fact that you were doing this audit?
MR. PICKUP: Just to roll back and to clarify for folks, in terms of who did we meet with and was there any sort of pushback as to the why or anything like that - I find it can get confusing in audit as to who we’re auditing - keep in mind in this case the audited organizations, if you will, are the Health Authority, the Department of Health and Wellness, and the IWK. We would have met with them early on to say we’ve selected these areas - and there was no pushback. Then we would have, as part of audit standards, gotten their acknowledgement on the audit criteria. The audit criteria are what are the bars we’re going to use to judge you, to measure you, to do the audit on - and we had complete agreement from all of those organizations.
MR. HOUSTON: So, there wasn’t any pushback that you were doing this. The pushback came with what you found.
MR. PICKUP: I want to be clear in case I haven’t been - the three organizations that we audited, if you look at their responses, including on Page 18 of Chapter 1 - the responses have been very encouraging from these organizations to say we accept, this helps us on the path that we’re on, and this is consistent with the direction we’re heading. I take a lot of faith in that - that our audits are useful to the people that we’re auditing, in addition to us serving the House primarily.
MR. HOUSTON: I do want to talk about the communications plan. In your reports - 1.11 - you reference a number of communications plans that were created around the doctor recruitment strategy. The report references one plan from July 2017 and others from 2015 and 2017.
In reading that, it sounds like there were really three communication plans in total, but none of which the report says were actually implemented. Is that a correct summary - that there were three plans developed, but none were implemented?
MR. PICKUP: I think that’s fair and I think I would draw you to Paragraph 1.12. I know on December 13th you have the deputy and the CEO from those two organizations, and I think 1.12 is what we would have been told as to the reason for that. I think that probably would be an interesting area of question for those folks when they come, as to the Paragraph 1.12.
MR. HOUSTON: Did your audit indicate whether these plans were the result of - well, did you know any more additional details about these plans or just that they existed? Were they drafted but never approved, or were they approved but never executed? Do you have any of those types of details?
MR. PICKUP: Sure. What we reported was that at the Health Authority they told us that they needed departmental approval on various aspects of redesigning health services before they implement the communication plan. When we asked the department about that, they indicated they were having ongoing discussions with the Health Authority about the approvals and they’re going to continue to work with them on moving the plans forward. Beyond that, I can just speak to what we’ve reported in these two paragraphs. I think it would be up to them to answer the extent of conversations and the whys beyond that.
MR. HOUSTON: So the Health Authority developed the plans, probably approved them internally, sent them to the department and they never heard back, so they just sat there - or didn’t hear back in the sense of approving them anyway, maybe some back and forth.
MR. PICKUP: I don’t know that it would be fair to say they didn’t hear back. I think it would be fair to say they were having ongoing discussions about it but they weren’t comfortable yet to the point where they thought that should be released. Beyond that, I think in terms of specifics, it’s probably better addressed to those organizations.
MR. HOUSTON: In terms of the development of the plans by the Health Authority before they were sent to the department for approval, do you know if they were developed by internal staff resources or did they hire external consultants? Would you know that?
MR. PICKUP: I think where we focused was on the fact that they weren’t in place and that they were working on it. We focused less on how you got to the draft points. As much as I hate to always give this as an answer, it’s probably better addressed to those officials when they do come in.
MR. HOUSTON: We really don’t know how much it costs taxpayers to develop these plans. I guess given the fact that they cost something, either on internal staff time or external consultants, there was definitely a cost to taxpayers for three plans to be developed, which I’m assuming didn’t get developed in an hour each and I’m assuming there was probably a lot of back and forth, so more and more times.
These were probably pretty expensive plans to be developed and approved by the Health Authority but never actually implemented. Is there any scenario where you could say that was a good use of taxpayer monies, the development of three plans that sat on somebody’s desk somewhere?
MR. PICKUP: I can’t comment on exactly how much it cost because we didn’t sort of take that approach to look at the actual cost of it, we were focused more on the outcome, on the result aspect of it. That wasn’t part of the audit objectives so it would be difficult for me to comment on that.
MR. HOUSTON: I do want to table a letter from Health Authority staff - I have some copies here and I have provided a copy too. I just want to - this is a letter from the Site Lead, Department of Psychiatry, Cape Breton Site. It’s to family physicians and nurse practitioners in Cape Breton. It’s dated October 30, 2017.
I want to direct you to the very last paragraph of this letter which says, “One last note. A letter outlining these issues was to be sent out last October but our department was forced to wait for a letter from the appropriate Provincial Public Relations department.”
This is a letter that went out a couple of weeks ago to family doctors in Cape Breton that was actually drafted and ready to be sent out an entire year ago but wasn’t because the signatories were waiting for approval from the provincial public relations department. I assume that’s the same thing that was happening with the overall communications plans that you found. When they said they were waiting for the department to respond back to their plan, were they actually waiting for the public relations department, do you know, or was it the Department of Health and Wellness?
MR. PICKUP: In relation to this letter, just to clarify, we wouldn’t have looked at this letter as part of the audit. This letter is dated October 30, 2017, and that is well past the audit report date.
On the communication plan, I’ll have to keep with the point that we made that while they were drafted, the indication was there was back and forth between the department and the Health Authority but they never got to a point where they were ready to go, where the department was comfortable with it now. All the rationale behind that and the whys and the explanations, I think, are better addressed to the deputy minister.
MR. HOUSTON: Sure, I appreciate that, thank you. But if I was to characterize your report as Exhibit A, inside Exhibit A there’s three examples of communications plans that were drafted, approved, sent for final approval, and went nowhere. Then this, I think, is Exhibit B of a letter that was meant to be sent out to inform family physicians and nurse practitioners, that sat for an entire year waiting for approval.
The wheels of government have ground to a halt in terms of explaining the health care crisis to Nova Scotians. I think that’s the only conclusion I can make because I’m only aware of Exhibit A and Exhibit B but I would suggest that there’s probably hundreds of other similar exhibits.
This letter, that final paragraph, is consistent with what you found in your audit. Would that be a fair summary, that it’s consistent?
MR. PICKUP: Again, I can’t go into the details of this letter and what might have been beyond that because it’s one specific thing that we didn’t look at, so I’ll have to stick to the communications plan that wasn’t done. But in terms of the communication plan, I would draw your attention again to Page 18, the comments from the Health Authority at the end of Paragraph 3, where they indicate - the Health Authority says, “[We understand] our responsibility to communicate with and give Nova Scotians an opportunity to understand and provide input . . . We are developing and implementing a new multi-phased communications and engagement plan to provide Nova Scotians with a better understanding.”
That is their response, agreeing to that finding and this audit. They understand their responsibility. They agree that they have more work to do, and that these are some of the things that they are planning to do. I think that beyond that, I would suggest asking those folks when they’re here.
MR. HOUSTON: And that’s from the Health Authority.
MR. PICKUP: Those were additional comments from the Health Authority, but in relation to the communication plan itself, the department said they agree that communication is very important. They said:
“The Department has been engaging in communications planning with the Nova Scotia Health Authority related to improving access to primary health care. The Department is currently working with the NSHA to develop and implement complementary communications plans that inform Nova Scotians as NSHA enhances access to primary health care services . . . Elements of the plan will be implemented before the end of 2017 . . .”
So presumably you could ask for an update, I suppose, when they are here on December 13th, and recognize that those efforts will be ongoing. That was the department’s response specifically to Recommendation 1.1 of that audit.
MR. HOUSTON: Sometimes when my kids text me, they put a little winky-face icon at the end of their statement. There didn’t happen to be a little winky-face icon at the end of that? They could have made that exact same statement a year ago - “working on,” “developing,” “implementing” - they’ve been doing that, and the Health Authority is exactly accurate in what they said, that they’re working to implement it. They have been doing that, and they would point to a plan they have that they’ve asked for approval on. Approval never came.
I think in light of your actual findings, we have to take those types of boilerplate department responses with a grain of salt. But the end of 2017 is not that far away. They will be here, and we will ask them. I do appreciate that.
I want to talk about the doctor recruitment strategy. Your report is short on details of the actual recruitment strategy, but it does note that there is one, that it’s need-based, and that there could be some clarity around physician incentives. But there is really no detail on the tactics used to recruit doctors, which I suspect there probably wouldn’t be, in a report like this.
If you stand back from all of that, did the auditors have a sense or any opinion on whether the strategies that are in place for recruiting doctors are effective?
MR. PICKUP: Sure. What we said, I think, in recognizing the practice of audit and also the reality of the fact that we were nearing the end of this audit in Spring 2017, and that’s around the time the strategy was coming in. So there wouldn’t have been time at that point to assess the effectiveness of it.
In fairness, in reality, I think you’ve got to give some time for something to happen before you come and audit it. It was a bit premature.
MR. HOUSTON: Did you happen to notice - it was developed, it was coming into effect, it hadn’t really had a chance to roll out - if there was any process in the strategy to allow third parties to recruit doctors? Or is all of the recruiting done by the department and Health Authority staff?
MR. PICKUP: We didn’t get into that level of detail in the report. I think, in fairness to these organizations, perhaps you can ask them when they come.
MR. HOUSTON: Thank you.
MR. CHAIRMAN: We will now move to the NDP for 20 minutes. Ms. Roberts.
MS. LISA ROBERTS: Thank you very much. As one of the newest members of the Public Accounts Committee, let me just express my appreciation for the work that goes into these performance audits and for the assistance you provide us in doing our job as Members of the Legislative Assembly. It is better the know the issues that are coming up in the systems that Nova Scotians depend on so that we can fix them.
I’m going to first ask questions about the recruitment part of the audit related to family doctors in particular. The Premier has said in the past that family doctor recruitment is an issue in pockets of the province. Based on your audit, do you believe that is a fair assessment - are there only pockets where doctor shortage and recruitment problems exist or would you say that it’s more widespread?
MR. PICKUP: We didn’t look at the effectiveness of the recruitment strategy, given that it was just coming in. We looked at things like, have you set what success would look like and have identified that? Then we’ve indicated that there are recruiters for each of the four zones that the Health Authority has set up. The specifics of how many people they’re actually looking for - perhaps the Health Authority and the department will be able to get into that more when they are here.
We have indicated in the report that there is planning beyond that in terms of identifying the long-range planning numbers that are needed. So we do point out that those things are happening, but in terms of a particular region or zone in the province and what a recruitment need may be, we didn’t look at that in the audit.
MS. ROBERTS: In Recommendation 1.3, the report notes that there is no process to identify and assist Nova Scotians with serious health issues in search of a family doctor - essentially there is no triaging of patients who need a family practice registry.
We know that family doctors are independent contractors in the majority across the province, and when I look at the responses to that recommendation from the Department of Health and Wellness, the responses are fairly general - “We will look at our options” and “We will continue to work with the Department of Health and Wellness to identify interim strategies to increase access to primary care for Nova Scotians.”
Given that most family doctors currently working in Nova Scotia are essentially independent contractors, did you leave this audit with a sense that there is a way, that there is a mechanism, or that there is a realistic step-by-step plan towards ensuring that Nova Scotians with serious health conditions are able to access a family doctor?
MR. PICKUP: There are two aspects of your question that I would focus on. One, the recommendation obviously is based on the conclusion that this is not happening in terms of the registry itself. There is acknowledgement to that.
I would also point you to Paragraph 1.19 where we have indicated that they did have a discussion with us, that the Health Authority is looking at what other provinces have done in dealing with this issue and they’re working with the department to find a way now. Their response to the recommendations say that they’re going to work on this and look at interim strategies.
My suggestion again would be - not to have a theme on my answers and I’m trying to talk to the report - but the details of what that will mean in terms of what they’re looking at with other provinces, what the interim strategies might be, how they’re going to deal with that through their responses, really those questions will have to go to the department and to the Health Authority to talk to.
MS. ROBERTS: A concern that I have in a really overarching way is that progress on many of the recommendations that are made in this audit actually rely on some degree of goodwill and intact relationships between the bodies that you audited and other organizations - other agencies and other groups outside of government. For example, in the case of doctor recruitment - Doctors Nova Scotia. I think we’ve seen over the past eight months, and particularly this Fall, real evidence that that relationship is damaged and that it will be difficult to move forward in a collaborative, all-hands-on-deck, let’s-figure-out-the- solutions fashion.
I’d have to say as well that in that point of connection between the Department of Health and Wellness and the Nova Scotia Health Authority, what I hear from medical professionals who are in the system and frustrated, is that many things get lost in between there. Many things are kind of bouncing back and forth between the Nova Scotia Health Authority and the Department of Health and Wellness instead of a forward motion happening on the problems that we need to be addressing.
I would welcome your comments, based on the access that you had to really what is just one part of the relationship that is crucial to us making progress in this province in terms of addressing these very important issues.
MR. PICKUP: To be honest, there are a lot of places I could go with the answer to that question. I think I will try to focus it a bit, and if I’m not focusing as well as I should for you, just sort of maybe put another question back to me, okay?
One of the things that I’ve realized, if I didn’t fully realize before, is health care is fairly complex. There are a number of parties involved here and what shows that to me in this audit, and these three audits - probably of the 21 recommendations, as an example, the Health Authority has a role in 19 of those. Some of those are just for the Health Authority but they have at least a part in 19 of them, even when they are directed to the IWK or to the department. It is a complex relationship, I think, as is the topic.
Now having said that, I think we’ve given a few indications here in these three reports there we’ve brought you a tool to hold the government accountable. We’ve pointed out some observations. For example, I would bring you to 1.12, in terms of the communication plans and the back and forth with the department and the Health Authority. I’m bringing that up because I think it’s worthy of a question to have some understanding on, right? So why not have the deputy minister and his CEO talk to why that is, to help understand that and what is behind that, rather than just working under the conclusion that that is a bad thing. I would point that out.
We do give a couple of other examples on some of the other audits, as an example. The one that really sticks in my mind is the Together We Can strategy. That was the mental health strategy adopted in 2012, for 2012 to 2017. There were 26 items in there. Two of the items, the department and the Health Authority each thought the other one was responsible. So obviously nobody wants to see that happen so I think that is probably a specific question that can get asked to them, to say why is it that two of the items each thought the other was responsible for.
The final example I would give you on that is actually in the other audit, the home care audit, where the department acknowledges that because of the change in responsibilities and the Health Authority having some responsibility or the responsibility related to client assessments - for example, home care. The need for the department under the accountability structure to have oversight to see how effectively that is being handled. We made a recommendation on that; it may acknowledge that.
I am better with specifics, I guess, and right there I’ve given you sort of three specific examples from three different audits where I think it’s worthy of some discussion. This is a tool, these reports that we bring to you to help you question folks in government as part of accountability. I hope these three reports will serve that. I’m hoping that sort of got to your question.
MS. ROBERTS: In 1.30, you report that the Health Authority indicated that as of November 2017, there are 50 teams. These are primary care teams, collaborative family practice teams, 50 teams in varying stages of implementation and that they ultimately plan to have a total of 70 to 78 full teams in place within the next six years.
We noticed in our caucus that that’s the first time we’ve heard the term. We’ve heard six years as a time frame that we’re now aiming for, for those collaborative practice teams.
Does your office know where these 50 teams are? And what does that mean, “varying stages of implementation”?
MR. PICKUP: Where the 50 teams are, we haven’t reported that, but I’m sure if you pose that to the Health Authority or the department, they could get that for you. I don’t have the information as to where the 50 teams are. The “varying stages of implementation” was really an information piece, from what they acknowledged to us and told us to say they’re at. Obviously some are further along than others.
MS. ROBERTS: I’d say that, in fact, it has been very difficult to get that information, which might show the proof in the pudding of the challenges around communicating with Nova Scotians around how we’re addressing physician recruitment. I have no idea where those 50 teams are. I also don’t know if the existing community health centres that are across the province, and fairly well distributed, are considered as some of those collaborative primary health care teams, or if we’re looking at expanding those or investing in them in any way. Like I said, proof in the pudding.
In Recommendation 1.4, you say, “The Nova Scotia Health Authority should define and measure performance indicators for its physician recruitment strategy and report regularly to its board of directors on the indicators.” Was the Health Authority able to explain why this had not been happening already and why there were no regulations in place from the beginning?
MR. PICKUP: The recruitment strategy came in in Spring 2017. We just reported what was not happening and then the response as to what they were going to do. Clearly they’ve already put a process in to start implementing a quarterly reporting system. We haven’t audited that. That was post the audit. They indicated that that started in October. But the why - why the delays, if you will, or why only occurring at that point in time - I would suggest asking the CEO of the Health Authority when she’s here.
MS. ROBERTS: A last question on this part of the audit. If a family doctor is not able to be recruited by those physician recruiters, does the Health Authority for example have the flexibility to reallocate funding to add a number of family practice nurses to existing clinics to or hire a nurse practitioner? Or is physician funding frozen in a budget line only for family doctors? Do you know?
MR. PICKUP: That would have be outside some of the scope that we had on the audits, so here I go again: you could pose that to the department and to the Health Authority.
MS. ROBERTS: I’m going to jump to the home care audit. Was the department able to explain why some of the recommendations that had been made by your office a number of years ago had not been implemented?
MR. PICKUP: One of the things I think we try to do in audit is develop audit criteria to say what we’re looking at and then to go seek evidence to whether something was met or not met, and then make a recommendation that flows out of that. It’s a little bit more challenging, I think, to get something auditable as to why something didn’t happen. I’m always a bit leery to try and speak for others, in terms of explaining whether that was a resource decision, a priority decision, a management decision, or what exactly happened. I think it’s best left with the deputy minister to explain the whys.
MS. ROBERTS: On home care, your office notices a risk of fraud because there is insufficient reporting on whether service providers are actually living up to the terms of its contract. In part because I’m so aware of this situation on the ground in my constituency, I feel like I need to at least say, in this format or in this venue where I know it will be recorded by Hansard, that there are many risks in the way we are doing home care in Nova Scotia right now.
One of the risks is that we don’t pay CCAs a living wage and so we have CCAs working for less than $15 an hour. There are high incidents of leave due to work injury, they are not paid for the time it takes to travel between clients, and they’re not even provided a bus pass.
I think there is a lot more that could be unpacked and explored under what you’ve summarized in 3.39 in terms of the providers raising concerns about the funding arrangement right now. Effectively, Nova Scotia is relying on various home care providers to delay and replace more costly admittances to nursing homes. That is the strategy and, in fact, the reduction in wait times for nursing homes is largely as a result of home care being added, but it’s not being added in a way that actually allows the people who we are relying on for that work to support their families.
I just want to say that here so that at least the people working in that field and the providers know that I am aware of that.
Can you give examples of the kind of non-compliance with contract terms that you noted in the course of this audit?
MR. PICKUP: Do you want us to focus in on a specific paragraph?
MS. ROBERTS: You noted that there were concerns about non-compliance with contract terms and performance issues so yes, I would like some examples of that. I think that was covered under Recommendation 3.4.
MR. PICKUP: Specifics of the examples that were supporting that, we didn’t choose to elaborate on. I think the point was made that globally that wasn’t happening and the recommendation was made to address that. You could ask the department themselves, and the Health Authority. I just want to note on your earlier comment, in Paragraph 3.39, the Health Authority management also expressed concerns with the approach to funding and the need to work with the department on the approach to funding going forward. So the Health Authority has obviously expressed their concerns to us. We didn’t go into detail as to what the concerns were, but you’ll have the folks here to question.
MS. ROBERTS: In the course of the audit - I know that there has been some discussion in this House and there has been some analysis done in earlier years about the workforce and whether, in fact, we are doing the work that we need to ensure that we have trained people to do the work of home care. Did you get a sense from this audit where we are with that?
MR. PICKUP: One of the recommendations of the previous audit - and we’ve included it as Appendix 1 on Page 59, “The Department should identify the future demand for home care services and determine the level of various home care staff required to provide these services.” That was not complete. The department did do an assessment of future demand, “. . . however they have not determined whether the availability of health professionals will be a limiting factor to meet future demand.”
That remains not complete and is one of the eight recommendations from that audit that we’ve identified as still being not complete.
MS. ROBERTS: Have they looked at what future demand is likely to look like?
MR. PICKUP: We’ve indicated that they have completed an assessment of future demand, but they haven’t looked at the supply side, I guess, to see whether they’ll have the staffing levels to meet that demand. Essentially, to boil it down, they looked at one side of the equation and now they have to look at the other side of the equation.
MR. CHAIRMAN: Order, the time has expired. We’ll move to the Liberal caucus and Ms. Lohnes-Croft.
MS. SUZANNE LOHNES-CROFT: Welcome back. It’s always good to have you here and get first-hand information.
Can we have clarification of the dates that the particular audits took place - the mental health, the physician recruitment, and the home care audits, when they started and when they ended?
MR. PICKUP: Sure. For the family doctors audit, the audit planning would have been early Fall 2016. What we would call the field testing - an audit term for our folks getting out there, doing the examination work, actually getting out and looking at things - that would have started in Fall 2016 and would have been completed in summer 2017.
The final phase of the audit would have been drafting the report that you saw, clearing the report, the back and forth - that would have happened throughout Fall 2017. That’s the family doctors one.
I’ll go through the three of them. Is that helpful? Okay.
On the mental health audit, we would have done the planning phase - Phase 1 of the audit - in Fall 2016. Then the field work, that audit testing stuff, would have been winter 2016-17. I’m now essentially calling that “last winter.” Then the report drafting and clearing, which I think is important, was in Spring 2017. We only report it now, but that part of the audit really took place in Spring 2017.
The final one on home care, for the three phases of the audit: the planning was in Spring 2017, the audit work would have been done in summer 2017, and then the report drafting and clearing would have been in Fall 2017. It’s almost like three times three, so three audits with three phases each. That’s the outline.
MS. LOHNES-CROFT: Can we just talk about the process that you go through to do an audit? Although I’ve been sitting on the Public Accounts Committee for four years, and I’ve gone to Public Accounts conferences, I’m not quite sure how you go about - you talk about the planning and the field and then the sort of wrap-up and going back and forth. Can you run us through how you do an audit?
MR. PICKUP: Sure, I would be happy to. I’m always happy to talk about how audits work, so I’m excited by that. Essentially, when we pick a topic and we look at, okay, what’s happening in the world, the first thing we do is at a senior level. The folks who are with me here today - who, between us, scarily have over 100 years of audit experience, which sounds really sad, I guess, in some ways.
We pick the audits that we’re going to do by following a fairly open process. Then we go meet with the folks to say, here’s what we’re thinking of auditing. When I say the folks, I mean the senior folks, whether it’s the CEO and the VPs or the deputy ministers. We say, here’s what we’re thinking of looking at, at a high level. First we have a discussion around, does this make sense to you? We may still look at it, even if somebody says, oh, we’d rather you didn’t. But I try to make sense and be reasonable, to say, is this the right time for an audit? Will the audit add value? Are we hitting the right area?
Frankly, if I go and see a deputy minister or a CEO and they say, yes, please audit that area - you’re going to find nothing, it’s working perfectly, it’s not that important - then why would we audit it? We have that discussion initially to make sense that we’re auditing something that is going to be of value. That’s our first pick on that.
Then we come up with what our audit question is, what question we want to answer. That is a question that essentially is geared toward the implementation and the administration of government policy. So we pick the audit objective to say, is there a recruitment strategy in place, and is it effectively working? We come up with an audit question and we share that and we have a discussion with the organization we audit.
Then we pick the audit criteria. The audit criteria are essentially the measure, the bar which you’re going to audit against to say, do you pass that or do you not pass that? We come up with the audit criteria. Criteria in this case might be, do you have a plan in place? So you have the audit criteria. There might be three or four of them.
You sit down with the places you are auditing, the organizations you are auditing, and you come to an understanding at the planning, before you start any of this exam work. Here is what you are going to be judged against. Do we agree? Is there a mutual understanding as to what the audit criteria are? In this case, in the three audits, we had a complete understanding and agreement on the criteria.
Then we go about to actually do the audit work, the testing, so we can answer those questions to say if that criterion was met. If the objective was, you should have A, B, and C, did you have A, B, and C? That’s the examination phase. During that, we would obviously be meeting with people and obtaining audit evidence.
Then we would have some clearance discussions to sit down with the organizations before we start writing these reports. Once we finish gathering evidence, we say, here’s what we’re finding. Here’s a chance for you to clear facts, to see if we have missed anything on the facts, and to see if we have it right. Before we start drafting anything, we have to make sure that the test results are correct. We do that.
Then once that is done, it’s time to start report-writing. We start drafting these reports, and then we go back and forth. Not to put a fine line on it, but it probably takes six to eight weeks to go back and forth with the organizations we audit to get clearance - for one thing on facts. We cannot have any facts wrong in a report.
Then we have a discussion around interpretation. For example, do we agree that as a result of those facts, you did or did not meet the audit objective? That’s where you go back and forth and you get an understanding.
Then from that we develop the audit recommendations, and we leave the audit recommendations with the organization for a few weeks so that they can talk about it and see if they make sense. We will sometimes have back and forth because frankly the recommendation may be something where an organization says, we’re never going to do that, that doesn’t make any sense, it’s not going to happen.
We may still have the recommendation if we really think it’s important, but in 99 per cent of the cases, the organizations we audit say that recommendation makes sense because we have worked with you to get to the point where the recommendations are feasible, they’re relevant, and they’re meaningful. They give us a response, and we include that.
Then they get to see again the final report, and if they want to add comments like the Health Authority did, we’re open to that as well. Then we have the report essentially ready to go.
When I became Auditor General, we started to have a press release that we issue. We invite the organizations that we audited in probably for three or four days - not to negotiate, but to say, here is the press release and we want you to be prepared. I think people should be prepared to know how you’re going to answer to an audit. Also, is there anything in there that they think is factually wrong?
It’s not a negotiation, if you will, in terms of points that I make in the news release, but we can’t have any factual errors. We started that when I came in, to invite these organizations in. We sit down, and we say, read the news release, tell us what your reaction is, and frankly, go be prepared for report day. You know what we’re going to say. You know what the press release is going to say. I want people to be prepared for that day.
I know it’s a long answer, but I really want people to realize - particularly the public - that when we get to an audit report, there’s no surprises in here for anybody. Everybody has been through it. The folks have been through it.
As well, I always offer to meet with the clerk of the Executive Council if she wants to meet and talk about the reports. We provide her with copies of them. I’ll be available to chat with her if she wants to chat about the report as well. Sometimes she takes me up on that. Sometimes she doesn’t feel the need to. I think we’re pretty upfront. We’re pretty open.
I think sometimes that’s a misunderstanding that folks may have in the public. Does that report come as a surprise for people when we table it in the House? No, when you look in the report, the responses to the recommendations are there. Everything is there. This is not a surprise or a gotcha. This is the result of quite a process.
I knew it would be a long answer.
MS. LOHNES-CROFT: That’s all right. There’s time to collaborate a little bit on the recommendations?
MR. PICKUP: At the end of the day, if we felt strongly about something, and we have reached a conclusion, and we’re going to make a recommendation, and if somebody disagrees, that’s fine. One of the signs I take that we’re doing relevant work is that 99 per cent of the recommendations when we do the audit and even when we go follow up continue to be agreed with. We’re not in a big fight with the organizations that we audit. We have a great relationship. We’re trying to see change happen.
I think an indication of that is, when we did our follow-up this year, it was the highest implementation rate of recommendations - not thanks to us, but thanks to the government folks who are responsible for implementing these things. But that does tell me the recommendations are relevant and mean something. When we now have over 70 per cent being implemented within two years, I think that’s a good thing.
MS. LOHNES-CROFT: And it gives goals for departments to improve.
MR. PICKUP: Right. It’s one of the things departments have on their plate among many things - the Auditor General’s recommendations and dealing with the Auditor General’s recommendations. I know for us this is our reason to exist and, for the organizations we audit, it’s one of the things and it’s part of the reason why we do the stand-alone follow-up report, because it’s up to the deputy ministers, the CEOs, to come in here and explain to you. If they decide not to do one of our recommendations because they want to do something else, those are management decisions - those aren’t ours. That’s for management to decide, but it’s for them to explain to you folks as to why they make those choices.
MS. LOHNES-CROFT: When you do the two-year performance audits, checking in with departments to see how they are doing on the recommendations, you said there were 70 per cent - the outcomes are very positive.
How much collaboration is in that process? How often do you check in with the department to see how they’re doing with the recommendations? Do departments reach out and say we’re really struggling with achieving this, and come back to you? Is there any talk between the time the report comes out and the performance?
MR. PICKUP: One of the things that we do - and part of it was a result of some work with the Public Accounts Committee over the last three or four years - is we do the stand-alone report now to the Legislature, where we actually do a dedicated report that follows up on the audits two years after we made the recommendations.
This year in the winter, we will be reporting on all of the audits that we did in 2014 and 2015. Our view is - and this is a judgment call - you make your recommendations, you hope the organizations are working on it, and hopefully they come to Public Accounts Committee for a discussion. We give them two years and we say we’ll be back in two years, and everybody knows that; we have an understanding on that. We say that when we come back in two years, our hope is that 80 per cent of the recommendations have been implemented, and where they haven’t been, that the story is told around why they haven’t been.
We started producing the stand-alone report to the House two years ago, and we’ll do that again this winter - that just deals with follow-up. So two years of audits, two years after the fact, what has happened.
MS. LOHNES-CROFT: But there’s no communication in between?
MR. PICKUP: Organizations like, for example, the Health Authority, the Department of Health and Wellness, we’re in with those folks all the time on other audits and other things. We do the financial audit, for example, at the Health Authority. I don’t know that a month goes by that we’re not having some sort of interaction on something.
But I don’t want to leave you with the misunderstanding - we really have come to an agreement and understanding, an acknowledgement, that once we make these recommendations, we need to give organizations some time - we’ve landed on two years - to say take some time and then we’ll come back. That doesn’t stop the organizations from coming to the Public Accounts Committee, for example, to talk about where they are with the actions that they’ve promised.
MS. LOHNES-CROFT: I’m an educator and we say the process is more important sometimes than the product. We know some children will not achieve the product of the outcome, but the process - what skills, what improvements have been made in the process of achieving that goal.
I look, for example, on Page 41 or your report - I like that chart on the Together We Can strategy. I note that you did say that they’ve moved up - that one has not been started, and there were several in progress, and most were completed. How important is progress in situations of achieving some of these goals? Of course, we all want everything completed, but do you discuss the items that are in progress when you’re doing your back and forth of putting a report together?
MR. PICKUP: On the Together We Can strategy, as an example of those that have started and those that haven’t, the biggest thing on those - and the department has responded favourably - is to say there’s probably time. Given that this was a 2012 to 2017 strategy, it’s probably time to go back and look at these items to ask if they’re still relevant. I don’t think any of us would want to be so stubborn to say, well you had this strategy, you had these items, they should be done.
I think now is probably the time to go back and ask if they’re still relevant. Then, on top of that, take all these actions and say, did they actually work? Evaluate them to see what has worked and then put that into your new planning to say okay, what are you carrying forward, what are you not carrying forward, what is relevant?
That is more to me like the heart of the discussion we had with them on this Together We Can strategy, because I don’t think any of us want to say okay, go do Item No. 18, we don’t care if it’s relevant or not any more. We tried to bring it up one step above that to say determine if it’s still relevant and then see if it’s actually working. The department and the Health Authority accepted that makes sense.
MS. LOHNES-CROFT: I was going to refer to Paragraph 3.40 on home care. A lot of the recommendations came from 2008. I don’t have that report but I’m just wondering, are some of the recommendations there now outdated? That is quite a number of years; it’s nine years. You just spoke about that, that sometimes in discussions you have to go back and ask if these are really relevant, especially in health. Science is always making progress, treatments and things are always changing.
Is it realistic that when you do go back in and do performance audits, the two-year ones, that maybe some things should come off the list?
MR. PICKUP: Sure. Our methodology and how we approach this, just to give you an example, on the 2017 February report to the House on follow up, for example, we looked at the whole basket of recommendations that we made over a two-year period over 20-plus audits. Our starting point is to get from the organizations we audit to say, to start with, categorize those recommendations - do you think they are complete? Do you think they are not complete? Do you think it’s relevant, but you don’t plan to implement it, or do you think it’s no longer relevant?
Let’s start with a discussion around whether something continues to be relevant or not, and that’s where we start now. I’ll remind you that when we started on that February 17th report, what the government folks told us is that 99 per cent of those recommendations continue to be relevant, we want to implement them, we intend to commit to our action that we had indicated.
Now sometimes the actions will change, but I think of prescription monitoring. They say yes, we’re still going to implement; we’re still going to do something on that recommendation. It may be different than what we originally planned because things have changed. Well that can make sense, right? But 99 per cent of those recommendations, they still say are relevant.
I think you are absolutely correct, that the starting point would be let’s have a discussion around what continues to be relevant.
MS. LOHNES-CROFT: I want to go with the dates. The report was drafted in the Spring of 2017 and in the Spring of 2017 we had a budget with some health care additions - I’m thinking mental health in particular. We had an election and a second budget that came out this Fall that was passed.
I’m just wondering, there have been some things implemented, especially in mental health, that I think are relevant to what the government is doing to make improvements and make things better for Nova Scotians. If I could table this, it’s a press release that the Minister of Health and Wellness did on October 10, 2107, with some of the new investments in 2017 and 2018. We would need copies to pass out.
It seems like new - past the date of this report, so you didn’t consider any of these investments? This report was done up and ready for print, so these are not considered at all in your recommendations?
MR. PICKUP: The short answer is we cut off at a point in time to say okay, this is based on audit work done up to this period, now let’s do reporting.
Again, I would make the point that one of the things I was pleased with on these audits is the responses from the Health Authority and the department.
MR. CHAIRMAN: Order. I’m sorry, time has expired. We’ll move back to the PC caucus and Mr. Houston.
MR. HOUSTON: Your report indicates that there is a province-wide head recruiter for physicians and that there is an additional recruiter in each of the four zones. Did your audit find any instances where two recruiters were in competition for the same doctor or did you look at any of the actual recruiting that’s taking place?
MR. PICKUP: The point we made, which I think may answer your question is, the department and the Health Authority should look at the roles and responsibilities in relation to some incentives to make sure it’s working efficiently - that there are no delays in terms of dealing with potential candidates on response to questions. I think that’s as close as we probably came in answering I think where your question leads to.
MR. HOUSTON: So you wouldn’t have seen if they were competing for the same doctor or if one recruiter was trying to recruit another doctor from another area of the province?
MR. PICKUP: That wasn’t the point of the audit that we make on the recruitment strategy and the room for efficiency is not related to that.
MR. HOUSTON: So nothing about the actual efficiency of the structure. So you don’t know whether that’s happening or not happening. It wouldn’t have been part of the audit?
MR. PICKUP: That would not have been part, no.
MR. HOUSTON: Your audit indicates that the department and the Health Authority are collecting recruitment data, but they haven’t given themselves any clear metrics or targets for the recruitment strategy. So they’re collecting data, but they don’t have anything to judge themselves against - I guess that is the point that’s being made. It would be important that they would have some metrics to judge themselves against, would it not?
MR. PICKUP: Right, the point was that you need to have performance indicators, not only after the fact - so not only collecting to say, here is what the result was, but setting it up front to say, here is what we expect, here is what success would look like - so what are your five or six indicators of success.
MR. HOUSTON: In terms of that, you did recommend that they create some metrics, as you just said, and then the Health Authority responded in October that they reported to their board with six key indicators. So I guess after the fact they kind of said, we did do that.
I’m just wondering about the dates because the Health Authority said in October that they reported the key indicators. I believe your final cut-off date was November 6th, and then the report came out on November 22nd. I don’t know if I have the dates exactly right, but it just seems to me that the recommendation was to create some metrics - they said, now we’ve done that, but your report doesn’t incorporate that. Are you aware that they’ve created any metrics?
MR. PICKUP: In the responses, when they are outside of the examination period - so we would have finished this exam work over the summer - we don’t go and then roll forward to try to audit what’s in the responses if the dates are outside of the audit period. So these dates would be outside of the audit period.
MR. HOUSTON: Based solely on your report, it seems that the Health Authority and the department have a recruitment strategy, but they won’t release it. They have a communications plan, but they won’t implement it or have it implemented. They have metrics to judge themselves against the recruiting that we don’t know. Is there any way that any Nova Scotian could read your audit report and have any comfort that the government is effectively recruiting doctors?
MR. PICKUP: I think I need to probably start this with saying, while we indicated there is a recruitment strategy, it only came in in the Spring so we weren’t able to realistically then assess the effectiveness of it because frankly it had just started. As time goes by, I assume even this committee could question the Health Authority and the department on how effectively that is happening.
For us, we were finishing up this audit over the summer - the strategy just came in so it really wasn’t realistic from an audit perspective - or in fairness, a time perspective - if something was only in place a month or two to try to audit it.
MR. HOUSTON: I don’t take comfort that they know what they’re doing, but others may, I guess.
I do want to move on to mental health. In Paragraph 2.5 of your report, it states that March 2016 was the deadline for a mental health services plan. Of course that deadline came and went and no plan was presented. It has actually been a year since that deadline and still no plan presented. It further stated that then the plan was expected in the summer of 2017, even though your audit was conducted in winter 2017.
Do you know if a plan for mental health services was actually released yet, or in the summer, as expected? Or did they miss another deadline?
MR. PICKUP: I think I would have to go to the responses to the recommendations and what the responses indicate. In the response to Recommendation 2.1 they indicate that, “Informed by planning to date, initial priorities . . . have been identified . . .” When you go through some of those responses they indicate what will be happening but we haven’t gone back to look to say if it’s in place now.
MR. HOUSTON: You don’t know if they planned yet or not?
MR. PICKUP: No.
MR. HOUSTON: Based on what you found in your audit, if there are two Nova Scotians in different parts of the province who are encountering similar mental health issues and were seeking help, are there policies in place that would allow them to expect equal access to treatment? Two people in the province needing the same treatment, is there any policy in place that would lead you to believe that they would get the same treatment, the same access to treatment?
MR. PICKUP: We made a number of points, observations, conclusions, and then recommendations related to the need for policies in the province. An example would be a transfer policy as an example, so due to the lack of a transfer policy there could be issues.
We also point out as an example the Dartmouth General and the emergency department there and the way that works, as well, in terms of the differences of services and the issue of a transfer policy there. What happens as a result of a lack of transfer policy, hospitals may develop their own across the province in terms of transfers, so you may end up, as we point out in the report, with doctors and nurses calling around the province to see if they can get beds, as an example. There are differences in availability of hours.
The audit identifies what some of those differences are and some of the lack of policies and some of the potential issues because of that.
MR. HOUSTON: I’m going to summarize that and you can correct me if I’m wrong: There are no policies in place to suggest to you that two Nova Scotians in different parts of the province, needing the same treatment, would have equal access to that treatment. There’s no policy in place.
MR. PICKUP: I think we were clear in terms of the lack of provincial policies in some issues result in different services so I think I would sort of stick to that as my summary.
MR. HOUSTON: If there were two Nova Scotians in the same part of the province who were encountering similar mental health issues and seeking treatment but seeking help on different days, are there policies in place that would allow them to expect equal access to treatment?
The first question was, two Nova Scotians in different parts of the province, is there any policy to see they get the same treatment? The conclusion is no.
Now I’m asking, if there are two Nova Scotians in the same part of the province, just on a different day - is there any policy to suggest that they would have equal access to treatment?
MR. PICKUP: I think what we have pointed out is that there are, in some cases, lack of policies, for example, where in some cases service may be between Monday to Friday, 9:00 a.m. to 5:00 p.m., whereas in other cases it may be different than that.
I think what we were pointing out is that it’s not for the auditor to suggest obviously what those times should be or what the plan should be but the need for some policies on these things and the need to deal with some of the planning.
If you look at some of the responses to some of the recommendations here, I think the responses are fairly detailed, including, for example, related to wait-time standards, which I think is very important.
MR. HOUSTON: The recommendation is to kind of get some policies in place to make sure that people have access to treatment but that may or may not happen, but the fact that there are no policies is the real point, I guess, to me. It’s surprising.
MR. PICKUP: I would draw your attention, as an example, if I could, to the response to Recommendation 2.3. We recommended that, “The Department of Health and Wellness, the Nova Scotia Health Authority, and the IWK should determine and clarify wait times standards for initial and subsequent appointments . . .” In their response, the Health Authority agreed and said they’re implementing it. They said:
“The first priority will be to establish and monitor wait-time standards for Child and Adolescent Services. This should be in place by early 2018 with the implementation of Choice and Partnership Approach (CAPA) model and the enhancement of our capacity for provincial reporting. Establishment of standards for Adult Services is targeted for mid-2018.”
MR. HOUSTON: Mid-2018.
MR. PICKUP: That’s for adult, and for the children and adolescents, it should be in place in early 2018, it says.
MR. HOUSTON: I think that would be four years after the creation of the Health Authority, would it not?
MR. PICKUP: The Health Authority starts year four on April 1, 2018.
MR. HOUSTON: So four years after the Health Authority has been created, somebody is going to get around to trying to get some policies in place to make sure that people have equal access to treatment.
MR. PICKUP: Just to clarify, so I wasn’t misunderstood, the Health Authority is in year three. They end year three on March 31, 2018, and start year four on April 1, 2018.
MR. HOUSTON: That doesn’t make it a whole lot more comforting.
Since you’re talking about the wait times, there are no policies in place to expect that people would have equal access to equal wait times across the province. But those are the wait times that you’re referencing, that they are going to try and start to look at that.
I think that’s what has come out of this letter that I tabled earlier. I think my colleague from Sydney River-Mira-Louisbourg, Mr. MacLeod, initially raised this letter. In this letter, they talk about the inequality of the number of resources available in Cape Breton. In Cape Breton they generally have 16 psychiatrists, and they currently have seven - seven adult and one part-time.
Those are the types of things that if you don’t have a policy to strive towards, then you’re probably not going to have a plan to have the resources to meet the policy, and it just kind of goes on and on. That was my kind of conclusion from that.
I guess how I would leave this section is that our caucus - and I believe my colleagues in the NDP as well - have been saying for some time that health care in the province is in crisis, and we have maintained that mental health care in the province is in crisis as well. I wouldn’t ask you to weigh in on whether or not it’s in crisis, but I would ask you this question.
Based on your audit and your assessment of the province’s mental health system, do you feel confident that the department and the Health Authority have the information and infrastructure in place to accurately know if the system is meeting the needs of Nova Scotians? Can they possibly tell you that the system is meeting the needs of Nova Scotians based on what you have seen about how they operate?
MR. PICKUP: I think the answer to that for me is really about specifics. I see for example the IWK response to Recommendation 2.3, where they say, there is not a provincial wait time standard for child and adolescent mental health services, but they’re committed to work closely to establish these wait times. This audit points out a number of things that are not happening, and then the commitment is there to do something.
I think we have given you this tool, if you will, this report to help you do your job. To say, here’s what we have noticed and pointed out things that are not happening and then to question the Health Authority and the department when you have the opportunity, on what that means going forward.
This audit points out a number of shortcomings. It indicates things that are happening, yes, and points out things that aren’t. All I can say is that there is no disagreement. The government agrees, and the people we audit agree with this. They have indicated what they are going to do. Now it’s over to you folks as the Public Accounts Committee and the Legislature we report to, the House, to do with it what you see fit in terms of holding these folks accountable.
MR. HOUSTON: I’ll just finish with one question on the home care supports. That whole chapter reminded me of the Department of Environment audit we discussed a couple of weeks ago where we’re faced with a department that has certain responsibilities and is obviously failing to live up to them.
I want to ask you specifically whether the lack of contract management that you noticed in your audit around home care is due to a lack of priority on the department’s part or a lack of resources. Could you tell whether it was just not properly prioritized or whether they didn’t have enough people to do it?
MR. PICKUP: The very quick answer, because I think I have very limited time, is that when we set the audit objective, we said, here’s what should be happening. We went and looked, and we said, this is not happening. In the responses, I see nothing on resources or limitations. It’s focused on what is going to happen. The whys, I think, are better posed to the deputy minister of the department.
MR. CHAIRMAN: Time has expired. We’ll move back to the NDP caucus and the honourable Dave Wilson.
HON. DAVID WILSON: Thank you for coming in. I, too, want to associate myself with my colleague’s comment thanking you for the work that you have done, not only you but also your staff. In your opening comments, you thanked a number of groups - I think all the audit identities that you did, your staff on their response and their interaction with you.
I have to ask, since it hasn’t been asked yet, what were your thoughts on the criticism that the Premier stated about your performance audit? I would think that that might have caught you off guard by any means. Do you have any response to that?
MR. PICKUP: My only response in general is that any time anybody starts looking at the work that we do and talking about the audits that we’re doing and the recommendations that we make and there is interest in our work, I look at that as an opportunity. If we have work to do to talk about the mandate, to talk about what we’re doing, that’s fine.
But most important to me on all of this is the recommendations that come out of these three audits. The fact is, we have 100 per cent agreement from the people we audit that these things make sense, and they are going to do something about it. I take a lot of comfort from that.
This is a complex area, and I get that, but again, I use any of these things as an opportunity to talk about the work that these folks with me and those who are back in the office do and, most importantly, the results of that work.
MR. DAVID WILSON: I would suggest that the criticism wasn’t warranted, in your opinion, on the mandate of your office? You’re fulfilling the mandate of what your office is supposed to do when it comes to audits of services here within the government.
MR. PICKUP: In terms of the work that we’re doing, I have zero concern or worry that we’re outside of mandate. Clearly, we are inside of mandate. This gives me an opportunity to engage in that discussion with you folks or Nova Scotians or people in general. When people are interested in audit, I’m happy, because hopefully that will help see the recommendations implemented.
MR. DAVID WILSON: Are you running in the next provincial election? (Laughter)
MR. PICKUP: I can 150 per cent guarantee you that will never happen. If you want me to sign something, I’m prepared to sign something. (Laughter)
MR. DAVID WILSON: I thought I would ask.
I do want to go to an area that is of deep concern, and not only for our caucus. I believe a number of Nova Scotians and the Opposition caucuses have been trying to shed light on access to mental health services here in the province. When I read through the audit, I was concerned about the lack of planning and a concurrent strategy. Of course, you have mentioned the Together We Can strategy, which was released in 2012. I would think and hope that that would continue on no matter who was in government.
Would you agree that strategies that are publicly put out there keep a government to account to a certain level? I would agree with your earlier comments that you have to be able to adapt and modify them. But a strategy overall holds a government to account no matter what political Party is in power. Would you agree to that?
MR. PICKUP: I would agree that something that is very important about a strategy is reporting against it and evaluating against it to, (1) to see if it’s being accomplished, (2) to see if it’s still remaining relevant, and (3) to make changes and tell the story around the changes that you’re making and the actual achievement that you have obtained. Performance reporting is about telling a story around where you are, what has happened, and where you are going. It’s not a numbers game. This is not about getting 25 out of 26. It really is about what the story is around all of this.
MR. DAVID WILSON: I think you can direct the public to, here’s a strategy, here are recommendations that might help you when an issue comes up, when mental health especially is such an issue that I think most people are extremely concerned. I think strategy goes further than ensuring that on World Mental Health Day the government puts out a news release about all the money they’ve spent. If there’s a strategy to back up this, then I think the public would say listen, the government is on the right track, they’re going in the direction that hopefully will meet the needs of Nova Scotians.
I know in your evaluation there was no final evaluation plan for the strategy, but when Recommendation 2.8 came out I read the response from the Nova Scotia Health Authority, the IWK, which both indicated they’d be pleased to work with the Department of Health and Wellness because this needs to happen, I believe through the direction of the Department of Health and Wellness because they are the holder of the strategy.
It concerns me that there was no plan for it, but I would think now that with that recommendation and the acceptance of it and maybe you could clarify that the department will do an evaluation of the strategy - did they indicate any time line on that evaluation of Together We Can?
MR. PICKUP: Of course, you will have them here in a few weeks, but yes they did agree now to complete a final evaluation of the strategy and for the three parties to work together - the department, the Health Authority, and the IWK.
But as a general point on that, this is a 2012 to 2017 strategy so it’s probably a good time now to take a look at this in conjunction with planning, which is what they indicate. I would hope the government across organizations - not this department - when they put these strategies in place, to go to your point, this one was put in place in 2012. I think those things should be built in at the beginning, to say there should be an evaluation, an ongoing evaluation as this happens and, in this case, that wasn’t put into the strategy.
I hope government will take from that, let’s build that in. Again, it really is about telling that performance story around what is happening, not a numbers game or that type of thing.
MR. DAVID WILSON: I would agree and I was part of the government that introduced the strategy. I’m very proud of that. I know at the time the concept was that now the province will have a plan to go forward. Unfortunately, maybe that numbers game would have come up if that was one of the reviews after the five years. I wish that was in there; I wish I could go back and make sure that was in there.
I hope the government is genuine on doing this because I have to tell you, I go home at night often just hoping that people who have contacted my office get the service they need. There are huge gaps when dealing with mental health. For many, many years, under many, many political Parties, mental health had been on the backburner, and with that strategy I think people within the province recognized that maybe they’ll get the attention they need as we go forward.
Out of the report one of the other concerning areas, and I do have some knowledge of it being a paramedic and transferring patients to the Dartmouth General, the fourth largest emergency department in the province, or fourth busiest emergency department in the province - it does not have a psychiatric emergency, or is without a crisis response service or no psychiatric support for the emergency department itself.
The response from the government - was it adequate, do you think? When you looked at the numbers - 1,400 patients I think in 2016 - seen at the ER in the Dartmouth General presenting some type of mental illness or mental health crisis, are you confident that the government is going to respond adequately to that finding in your audit?
MR. PICKUP: That is a good question and a good example and an opportunity, I think, for me to demonstrate in terms of the recommendations and where we go with recommendations. Our recommendation wouldn’t be so specific and particularly policy-oriented on that type of issue that it would be that at Dartmouth General you should do A, B, C and D. That’s not what the audit says.
What we’ve said is that the Health Authority should ensure there’s a well-defined, evidence-based model of care, including an evaluation process as to how that works. The response on that was that they agreed with this and then they indicate the details of doing that.
I think the point is about always looking at these things and whether that is how you want to be delivering services, versus me saying you should do this at Dartmouth General or you shouldn’t do this at Dartmouth General. That’s not what the recommendation says.
MR. DAVID WILSON: Did you look at any of the services offered at Mount Hope across the street from the Dartmouth General? Any relationship between getting patients from the Dartmouth General maybe to Mount Hope instead of having to wait for those transfers in the QEII to get the assessment or further treatment?
MR. PICKUP: We didn’t look at the transfer policy between those two or what happens as a result. What we did report is some of the discussion we had with folks at the Dartmouth General in terms of potential delays that may be caused in relation to ambulatory services or matters related to that. We reported that. Then their concerns from staff that were raised that they weren’t confident that that care is always patient focused as a result of some of those things. That was as far as we went in terms of what we looked at there.
MR. DAVID WILSON: If I recall correctly, psychiatric support used to be across the road. It’s my understanding now that’s not happening. Where did that breakdown or change happen? We know with the amalgamation of the district health authorities a lot of things were put on hold, and there is no hiding behind that. So you’re not aware of that support that used to be there some time ago around those health care providers who work across the street from the Dartmouth General?
MR. PICKUP: In terms of implementing an evidence-based model of care, if you will, in terms of specific questions or how that actually rolls out in terms of those areas, I wouldn’t have that information and that wouldn’t be part of the audit. I haven’t said it in a while, I guess, but you’ll have the folks here in a few weeks time and that may be something you wish to ask them.
MR. DAVID WILSON: You mentioned about transfer policies, especially concerning the fact that patients will arrive at the Dartmouth General. As a medic, if you were presented with a mental health crisis - if you were listening to the radio - you would see where the busiest hospital was if there was backup, and you would go to Dartmouth General. The catchment area at the Dartmouth General is huge, so paramedics do bring patients to the Dartmouth General.
With your work around not finding a transfer policy, did you have any correspondence - did you look at the Cobequid Health Centre, for example? That facility has an emergency department but it closes at a certain time. A lot of the criticism I hear and concerns I hear from staff in the Cobequid Health Centre, plus on the ambulances, is that often they stay much later than they’re supposed to be open because they can’t transfer a patient into the QEII or the Dartmouth General. So did you look at any of that transfer policy that affects Cobequid when it closes?
MR. PICKUP: We don’t specifically comment on any particular hospital or any particular location or facility other than the Dartmouth General because it was one of the nine regional ones, but if you go to Paragraph 2.36 we indicate that “. . . staff across the province told us . . . the hospital will attempt . . .”, and the differences in the hospital. So we were more global in terms of what’s happening at the various locations and what we’ve been told versus any particular or unique facility - other than the Dartmouth General because it was one of the regionals.
MR. DAVID WILSON: Definitely recruitment and retention of health care providers - I know physicians is a deep concern for many in the province who don’t have a physician, but we see closures around the province because of a lack of a certain health provider. Health providers are a very mobile group, and we’re competing globally - mostly in North America - to the recruitment and retention of those health care providers.
Morale has a huge role to play, I believe, in attracting new health care providers. Are you concerned? Do you think your findings in the audit will play a role in the morale of health care providers? I don’t know if you can answer that or if it would be better to ask the department. We are concerned about what you’re finding, especially in health care. Would your report have an effect on the morale of health care workers in the province and will it hurt the ability to recruit and, more importantly, retain health care providers in Nova Scotia?
MR. PICKUP: I think you’re right indicating that’s probably a better question for the Health Authority folks or the departmental folks. I go back to something I said earlier - I would hope that with the openness and transparency that these three organizations gave us in terms of accepting our recommendations and indicating actions to take, that would help encourage and promote a system that is open to that independent auditor coming in and having a look and making suggestions, and an organization acknowledging that while they’re on the path, they have things to do.
So I’m hoping that if anything that could be used as a sign of openness and modernness that an organization welcomes the outside auditor with open arms to say, come have a look, and then doesn’t fight the auditor on the actual recommendations and gives pretty specific responses. I’m hoping that they can actually use that to their advantage, but that’s up to them to answer in terms of recruitment.
MR. CHAIRMAN: Thank you. We will move to the Liberal caucus, and this time we’re gong to go to Mr. MacKay.
MR. HUGH MACKAY: Thank you for the continuing excellent work that the Office of the Auditor General provides on behalf of this House of Assembly. I was certainly very pleased to hear in your introductory remarks that you were talking of the successful and respectful relationship that you have with the Nova Scotia Health Authority, the Department of Health and Wellness, and the IWK. Certainly, as government we’re particularly pleased that those organizations are moving ahead with all 21 of your recommendations. I think that speaks very well to the relationship that you have noted and we hope that continues.
I would like to focus a bit on communications, and depending on time allowing, I may be passing off to my colleague from Hammonds Plains-Lucasville in a moment.
You have said the department and NSHA are not adequately communicating with Nova Scotians, including resourcing of family doctors. The examples to this are the communication plans - three communication plans not implemented. As you noted in the conclusion, draft communication plans not used. In my 30-plus years in the private sector, if a draft communication plan was implemented before necessary discussions and approvals of all concerned parties, whoever started implementing a draft communications plan would be hauled up on the carpet.
I think that the use of draft communication plans not being implemented as an indication of inadequate communication is a very poor baseline for conclusions. I’m curious, if I have the baseline wrong, what you might have been using as a baseline rather than draft communication plans.
MR. PICKUP: The point on the draft communication plans was that they weren’t finalized and then put into place - the idea would have been that this had been ongoing since 2015 and therefore they ought to be put in place.
To the substance of what that would mean in terms of the communication plans not being finalized and put in place, I think I would draw you to the response to Recommendation 1.1, where the Health Authority indicated what’s left to be done:
“We are developing” - so that means it hasn’t been put in place - “a multi-phased communications plan that is being implemented in partnership with the Department of Health and Wellness to provide Nova Scotians with an improved understanding of collaborative family practice teams and how the health authority is working to strengthen the primary health care system. Tactics to address these two areas will be implemented by December 31 and include enhancements to the NSHA website on collaborative family practice teams and doctor recruitment as well as other digital and social media opportunities. A series of stakeholder conversations across the province will begin in November/December 2017, followed by community conversations in 2018. Content on the NSHA website has been enhanced . . .”
The point of not having the communication plan in place and moving from draft to final was that that meant that these things that were going to be done weren’t actually done as a result of not having the plan finalized.
MR. MACKAY: Thank you for those comments. As you’ve pointed out in earlier statements, the audit really is a snapshot in time. It’s not like a motion picture that is continually monitoring something; I think we all have to keep that in mind. I think some members of the committee might misinterpret your conclusions as indicating that these processes are not working or not being implemented when in fact many of them are working very well.
You mentioned social media just now, and in my communications with my constituents, that is certainly taking ever-increasing importance in communicating what I’m doing on behalf of my constituents. I suspect that similarly, the department and the Health Authority are using social media in a similar manner.
Speaking of not adequately communicating, did you look at statistics and consider the number of events, the number of news releases, the posts on social media, speeches and debates, and everything else that was being done, as part of your audit?
MR. PICKUP: What we were looking at here - just one step above that, as to whether indeed a communication plan had been put in place. No, we didn’t look at all of those details. Part of what we relied on is that the Health Authority themselves identified that the website needed work, as well as other digital and social media opportunities as well.
We got agreement that the plan had not been finalized, that the plan had not been put in place, and then an understanding of where they intended to head post-audit, some of which refers to November, December, and ongoing. That was the basis for where we ended up.
MR. MACKAY: It’s a concern that Nova Scotians will misinterpret the effectiveness of communications from the department and from the Health Authority when we do not include a number of these other media for communications. For example, when we announced the addition of I think 22 new nurses into the primary care teams, the first Facebook post we did on that reached over 61,000 people. That would seem to be fairly effective communications when you’re reaching 61,000 people in Nova Scotia with one announcement.
The news releases that are put out, the department alone does 80-plus news releases each year. In fact, there were 88 in 2015, 83 in 2016, and we’re around 60 already this year. That doesn’t even include press releases done by ministers, the NSHA itself or the Premier himself.
Then there are media calls. We field hundreds of media calls annually that provide information back to our news media, which then responsibly reports back through their channels to the public. So there are a great amount of communication vehicles and channels for disseminating the information on health care to Nova Scotians. We believe that if the concentration is done strictly on the framework of the audit, that could be misleading to the public, who may not understand the purpose of the audit or the mechanisms of the audit and will obviously be used for political points by some members of the committee.
In Paragraph 1.34, you suggest that there’s a good job being done of communicating with key stakeholders. You mention a number of them, including Doctors Nova Scotia. Certainly, if the Health Authority and the Department of Health and Wellness are engaging in good communications with key stakeholders, we also anticipate and expect that they would then disseminate that information to their constituent membership - Doctors Nova Scotia being a case in point. We would expect that when we provide information to them, they are then providing informed information back to their membership.
I’d also like to comment that as government, recently reformed of course here through the summer, the new Minister of Health and Wellness immediately toured the province. He met with over 70 stakeholder groups, and while that might be outside the remit of your audit report on that, I think it’s another very good indication of the excellent job that the government is doing in parallel to the work being done by NSHA and IWK and the department as far as informing the public through as many channels as possible, the media, while the draft communication plans are finalized and introduced.
Did you speak to some of the other key stakeholders about communications with the public and what they’re doing? You mentioned some key stakeholders in Conclusion 1.34. Did you actually interview them and get their feedback - Doctors Nova Scotia, for example?
MR. PICKUP: We met with some stakeholders.
MR. MACKAY: Can you recall which stakeholders?
MR. PICKUP: Doctors Nova Scotia and the college.
MR. MACKAY: Since you made the comment that suggest a good job communicating with key stakeholders, I’m concluding from that then Doctors Nova Scotia and the college confirmed that they were having good communications with the Health Authority and with NSHA.
MR. PICKUP: There, we were looking at the communication on the need for family doctors, as we indicate in Conclusion 1.34 - keeping in mind we weren’t auditing these other organizations. It was really just to get out and have some level of discussion.
MR. MACKAY: I’m sure the public will find some reassurance that Doctors Nova Scotia does say that there’s good communication with the groups. How would you actually judge success of communications from the Health Authority and from the department? What would be your measurement of success?
MR. PICKUP: I think what I would go to here is if the Health Authority had wanted to present information different from what they’ve actually responded. If we look at their response, the Health Authority themselves say:
“. . . many Nova Scotians do not understand what a collaborative family practice team is, the range of services available, and how this team provides accessible, comprehensive, coordinated, continuous and community-oriented care. NSHA understands our responsibility to communicate with and give Nova Scotians an opportunity to understand and provide input into the future of the primary health care system. We are developing and implementing a new multi-phased communications and engagement plan to provide Nova Scotians with a better understanding . . .”
If they could have indicated that these things were in place through their communication, we would be having a different discussion, but they acknowledge themselves in terms of what I just said in terms of outcomes that aren’t happening and that they’re developing a plan to address this.
I take a lot of faith in that the organization that we audited have indicated themselves in terms of the work they have to do and what’s not happening, and that the communication plan is meant to address these things.
MR. MACKAY: Knowing that they’re moving forward with your recommendations, I think we’re all very hopeful that we will meet and hopefully exceed the 80 per cent expectation on the recommendations when you come back to in two year’s time.
But, as you say, it’s a snapshot in time and I think what we’re seeing is that many of these things are already being acted on. The communications plans are moving forward, but as they are still draft these organizations have not just stood still in the water. They are making many efforts, through news releases and through other channels - social media and so forth - to communicate with the public while the draft is being implemented.
MR. CHAIRMAN: We’ll move to Mr. Jessome.
MR. BEN JESSOME: I guess on the subject of collaboration, we’ve referenced today the work of the Auditor General, government, the IWK, NSHA, and the Department of Health and Wellness. I would say that everybody can get behind the concept that there are many hands involved in improving service delivery in this province.
I know that the SchoolsPlus program predates our government. Our government has made significant strides to try and improve the reach, touching all school boards at this point in time, to expand that program. I know there was an announcement in Spring of this year which, as I understand it, would fall within the timeline relevant to your report, to hire more psychologists in our schools through a partnership with Mount Saint Vincent University.
I’d just like to ask you, in that essence of collaboration - was the SchoolsPlus program, which is an important service to mental health of all youth Nova Scotians, was that considered as part of this audit?
MR. PICKUP: That individual aspect of one - that may be one part of service delivery of mental health services wouldn’t have been examined by itself.
MR. JESSOME: Okay, with the time that I have, I guess I would also indicate or reiterate that this is a snapshot in time and that government has made significant strides since being re-elected to try and address a number of the recruitment, mental health, and home care challenges that we have in this province.
We truly value the role of the Auditor General and seek to collaboratively take the scrutiny that your office has presented us. I think all sides of the floor would agree that we all have a role to play in ensuring that we deliver quality health services across the board, and I appreciate the opportunity to be part of that dialogue here today.
MR. CHAIRMAN: Order. The time has expired. Thank you.
The time for questions has expired. Mr. Pickup, would you like to provide some closing comments?
MR. PICKUP: I have even shorter closing comments than the opening comments. In closing I want to say thank you to the committee for having us here today. It is very rewarding, as the independent auditor of government, to have our reports considered by such an important body as the Public Accounts Committee.
As you can tell, we take our work very seriously as we audit key areas of government’s operations in order to provide assurance and comfort both to the Nova Scotia Legislature and to all Nova Scotians on how government is being administered.
Health care of course is complex and these three audits that we discussed today indicated that while many positive things have been done in the three areas we examined, there is of course more work left to be done. I am please to hear that on December 13th, the Public Accounts Committee will be holding a meeting with folks in the organizations that were part of these audits, to discuss the reports.
My office conducts a number of performance audits each year, in addition to the financial audits that we do. The number-one question that I get asked is: What happens then, does government do anything with the recommendations that you make? I want to remind the committee that earlier this year, as I mentioned earlier, we reported on our follow-up recommendations in 2013 and 2014, across some 20-plus audits, and found that over 70 per cent of our recommendations had been completed.
This is a positive sign to me that the government is taking actions they commit to, to improve the delivery of government to people. This also makes me hopeful that the 21 recommendations that we have brought forward in these three audits will be acted upon, as agreed to by the organizations that we audit. Thank you, and have a nice day.
MR. CHAIRMAN: Thank you, Mr. Pickup, to you and your colleagues for your work.
We have one item of committee business. It is a piece of correspondence from the Department of Internal Services. It was information requested at the October 18th meeting. That has been distributed to members. Are there any questions on that correspondence?
Hearing none, our next meeting is on December 6th with the Department of Fisheries and Aquaculture to discuss seafood exports.
Is there any further business to come before the committee?
Hearing none, this meeting is adjourned.
[The committee adjourned at 10:55 a.m.]