HEAL Committee Meeting

STANDING COMMITTEE ON HEALTH

COMITÉ PERMANENT DE LA SANTÉ

EVIDENCE

[Recorded by Electronic Apparatus]

Tuesday, November 18, 1997

• 1106

[English]

The Chair (Ms. Beth Phinney (Hamilton Mountain, Lib.)): I call the meeting to order. This is the fourth meeting of the Standing Committee on Health, on this Tuesday, November 18, 1997, 11 a.m.

I'd like to start off by saying that we will have a short session at the close of this meeting, for about twenty minutes. I notice it says here that our meeting goes from 11 a.m. to 1 p.m. It should say 12:30 p.m. So we'll try to close at 12:20, in order that we can have that short meeting.

I'd like to welcome our three witnesses from the department. Just before we introduce them, I'll just go through the procedure quickly. We give five minutes to the two lead oppositions, one minute to the government side, the other two opposition parties then get five minutes each, and then we go by fives.

I'll try not to cut off the first group too quickly this time. We just ask that the witnesses keep their comments as short as possible.

We welcome Mr. Cochrane, the assistant deputy minister. Maybe you could start off by introducing the two people with you.

Mr. Paul Cochrane (Assistant Deputy Minister, Medical Services Branch, Department of Health): Thank you, Madam Chairperson. With me today are Myra Conway, the director of programs, operations and co-ordination in Ottawa; and Dr. Jay Wortman, the director general of the non-insured health benefits program.

Madam Chairman, I am pleased to have been invited to appear before this committee today.

The Chair: May I interrupt you and ask you to call me the chairperson or chair, and not the chairman?

Mr. Paul Cochrane: Did I say “chairman”? I am sorry. Je m'excuse.

The Chair: Just say “chair”. That will be fine.

Mr. Paul Cochrane: Madam Chair, I am pleased to have been invited to appear before this committee today, and to have this opportunity to explain how Health Canada is responding to the recent Auditor General's report on first nations health.

[Translation]

First, I would like to state clearly that the department is committed to following through on the Auditor-General's recommendations and that most of them have been incorporated into our plan for a while already.

[English]

The Auditor General has highlighted the fact that the health status of first nations and Inuit people is significantly worse than that of the general population. I expect that in your travels, many of you have seen first-hand the great challenge that first nations communities face as they work to improve their health and living conditions.

The Auditor General recognizes that the causes of poor health status are many and varied. For instance, he mentions the poor socio-economic conditions that are a determinant of poor health among first nations people. This is clearly the case, and it means that the solution to the problem must involve the co-ordinated effort of all parties.

Health Canada is working closely with our federal colleagues—particularly DIAND and Human Resources Development—and with first nations themselves to maximize the impact of the resources directed to first nations needs. Where the opportunity arises, we are also working with provincial health departments. This is vitally important in order to avoid duplication of effort and to ensure that new and existing programs complement each other.

• 1110

In their entirety, first nations and Inuit health programs comprise over two-thirds of Health Canada's total budget. It is the policy of Health Canada that first nations may take control of their programs at a time and pace of their choosing. We believe the ability to take control of these programs, and to change them to better meet specific local and community needs, is an important step that will enable communities to improve their health status. At the present time, over 30% of all first nations communities are operating programs under transfer agreements, and an additional 31% are in some stage of transfer planning or negotiation. We are encouraged that the Auditor General has recognized the importance of transfer and has indicated this in his report.

[Translation]

The Auditor-General reported on all health programs concerning the First Nations and Inuits, but the comments that received the most attention dealt with the inappropriate use of prescribed medications resulting from the Non-Insured Health Benefits Program. I would like to take a few moments to discuss this.

[English]

The department clearly recognizes the seriousness of prescription drug misuse, and is working very hard to take any action we can to prevent this harmful activity.

In assessing possible solutions to this problem, it is important to bear in mind that as the payer of pharmacy claims, the non-insured health benefit program is but one of a number of parties involved in providing prescription drugs. Physicians, pharmacists, and the clients themselves all participate in any transaction that might result in the inappropriate use of prescription drugs.

The colleges and professional associations that govern physicians and pharmacists operate under provincial jurisdiction. Where criminal activity is suspected, there is a role for law enforcement, which is also often under provincial jurisdiction. Clients, and to a certain extent providers as well, are protected by legislation and regulations that limit the use of confidential medical information.

I make these observations not to deflect criticism but to emphasize the complexity of the problem of prescription drug misuse, and to illustrate why simple, easy solutions have not been forthcoming. Notably, though, we are currently installing real-time, point-of-service adjudication system for pharmacy claims. Currently, almost 90% of our claims are already flowing through this system, and we expect this to approach 100% of all claims by the end of this calendar year.

This is an important development, because the system is programmed to detect multiple doctoring, multiple pharmacy use, multiple prescriptions for the same drug, prescriptions filled too soon or too often, and other parameters that suggest drug misuse. When the system identifies one of these potential problems, it signals the pharmacist before the drugs are dispensed. The pharmacist must then determine whether or not the drug should be dispensed. If there is a legitimate reason for dispensing the drug, the pharmacist can override the warning. And we are also developing monitoring and audit functions to check on the effectiveness of the warning system and the frequency of overrides. When fully functional, we believe this system will be at the forefront of systems currently used in both public or private sector drug benefit plans.

[Translation]

We are also working on certain other fronts. We are producing educational materials for doctors and pharmacists as well as for the First Nations and Inuits. We are trying to give them a better understanding of what is involved in the most appropriate and effective use of prescribed medications and make them aware of the importance of recognizing and eliminating cases of poor use.

• 1115

[English]

We are increasing our review of the prescribing and dispensing patterns of physicians and pharmacists and have developed a protocol for follow-up with professional bodies when potential disciplinary issues arise.

In closing, I would suggest it is very important to recognize that prescription drug misuse, like other forms of substance abuse, is but a symptom of greater underlying problems for individuals and their communities. I hope you can see from my remarks that we take the problem of prescription abuse seriously. The Auditor General focuses on cases where there are problems, but these same figures also indicate that the vast majority of our clients appear to be receiving prescription drugs appropriately.

I thank you for your attention, Madam Chairperson and members of the committee, and would welcome your questions.

The Chair: Thank you.

Mr. Hill.

Mr. Grant Hill (Macleod, Ref.): Thank you for your commentary.

I sat and listened to a very similar commentary at the last Auditor General's report. I wonder if you could, for the benefit of the committee, point out the changes that were made the last time that you can document that improved the health status of natives in the ensuing three or four years. What things did you do in 1993-94 that we can say were successful?

Mr. Paul Cochrane: Thank you, Mr. Hill.

First of all, let me point out that in the 1993 report of the Auditor General, where we have followed up on recommendations, they commented that beginning in 1991-92 this program was growing at approximately 20% a year in terms of resource utilization. In the period leading up to this report, which we compiled at the end of 1996-97, the year-over-year increase in this program actually flattened out, and last year there was a negative increase in the absolute number of dollars that were spent in the program.

Mr. Grant Hill: It isn't growing as fast as it was.

Mr. Paul Cochrane: It has gone from a 20% increase to last year, when we closed our books and found the program had actually grown at minus 3%. So the actual dollars flowing through the program have decreased significantly. At the same time we have continued to provide a high level of benefit to first nations. Most, if not all, of the changes in managerial strategies we have utilized have been aimed at ensuring that appropriate medications or dental services are provided.

Mr. Grant Hill: Okay. You've answered part of my question, but there has been a reduction in the growth.

Mr. Paul Cochrane: There has been a significant reduction, I would suggest.

Mr. Grant Hill: What are you going to do about prescription charges for over-the-counter preparations such as aspirin? This is adding a huge cost, and in no other segment of society is this necessary or considered appropriate.

Mr. Paul Cochrane: Over the last three years we have actually looked at the cost of a dispensing fee being applied to what would be called an OTC, or an over-the-counter preparation. I think it's first of all important to point out why in the beginning a charge was in place. In essence, we were using the prescription as somewhat of a gatekeeper to the system. I think that's only fair to point out.

Based on the limited number of OTCs that are still available in our formulary, we have commenced negotiations and have successfully completed negotiations in several provinces. Notably in Saskatchewan and British Columbia we have now negotiated arrangements with the pharmacy associations and there will be no dispensing fee paid on OTCs. We are continuing negotiations with pharmacy associations in all other jurisdictions with the aim of eliminating dispensing fees on OTCs by the conclusion of our negotiations at the end of our next fiscal year.

• 1120

So we recognize the issue. We've moved aggressively on it. As I say, in two jurisdictions we've now eliminated it, and we continue negotiations with the other jurisdictions.

Mr. Grant Hill: The old provider, the old insurance company, has been fired, and you have a new company on stream. Are you convinced that the agreement with this new company is better than the somewhat shabby agreement with the old one?

Mr. Paul Cochrane: Let me first of all make it clear that we went through a competitive process that culminated in the identification of a new provider. The terms of the previous agreement had run its course, and in selecting a new provider, a different provider has been chosen.

That provider, I think it's important to note, came about as a result of the utilization of the aboriginal procurement policy, and resulted in a very competitive situation where we are now in position that a contract has been awarded to First Nations Health. That company will take over the provision of the automated service in the summer of 1998.

The specifications for this new contract are certainly more demanding and more stringent than the specifications of the original contract. We learned a lot over the seven years we dealt with the old provider. Hence, our statement of requirements is an enhanced statement of requirements, particularly in the area of audit, where we have increased the audit requirements.

Indeed, outside of that contract, we are working on a separate audit protocol to ensure that where we detect problems we will be able to have a broader base of audits so that we are ensured that the providers are aware of our requirements and adhere to our requirements.

The Chair: Madam Picard.

[Translation]

Ms. Pauline Picard (Drummond, BQ): Hello, Mr. Cochrane. I have the impression, like Mr. Hill, that I am hearing things I heard in 1993, and I have the impression that absolutely nothing has changed. We have heard about overlaps in community programs, data that is insufficient for evaluating the effectiveness of programs and the lack of supervision and program management. We have heard that Indian bands are poorly supervised and not qualified enough, and that some of them do not work the required number of hours. We have also heard about annual reports with no health-related yield measurements or indicators of program effectiveness.

Last year, the Standing Committee on Health conducted a study of child health. Aboriginal groups, particularly women's groups, told us they know of certain programs that could be helpful for them but the specific programs have never been set up in their communities. However, they knew that the cheque had been received by certain band chiefs.

I would like you to explain to me how it is that after four years, in 1997, the Auditor-General's evaluation of health programs concerning Aboriginals is the same as in 1993, and why these programs have the same flaws. Is this attributable to a lack of personnel?

You have just told us that there are things that will be put in place and that you will institute tighter measures. What will guarantee this for us? What guarantee do you have for me that, four years from now, the Auditor-General will not make the same observations he has made in 1997?

I find that there is a lax attitude. Why is it that we are not able to evaluate programs concerning Natives? A cheque is still sent, but there are no measurements and no information. I have been told that there are 30-year-old programs that no longer meet people's needs. They are not effective, but they are still there and a cheque is still sent for these programs, which do not exist for all practical purposes.

Mr. Paul Cochrane: Thank you. Allow me to answer in English.

[English]

If you review this Auditor General's report you'll find that in terms of the community health programs, the arrangements we have with first nations, indeed the Auditor General takes our arrangements and breaks them into two groups. It talks about contribution arrangements on the one hand and transfer arrangements on the other hand. Indeed, in terms of the transfer arrangements, it complements Health Canada on the transfer protocol and in the way we work with first nations in ensuring that the transfer arrangements are put into place appropriately and that accountability is built into those transfer arrangements.

• 1125

If there is a criticism in that area, it is that we do not follow up with an audit on each of those arrangements. As I indicated before, we deal with 630 first nations in Canada. It's not possible every year to follow up on every transfer arrangement. To do that, we would have to take resources that are currently in the hands of first nations at the community level and then hire a large number—I can't even estimate how many—of staff who would do nothing but monitor the situation.

We feel that the balance has to be made between investing the resources in the communities and allowing the communities to run the programs as they can within a transfer agreement, where they can make decisions that affect the programming at their level based on their membership. From time to time, we undoubtedly run across situations where we go in and audit, and then remedial measures have to be taken.

In our transfer agreements we have had very few— In fact, I cannot remember—and I've been involved in this program since the beginning—one major problem we have had with a transferred community.

On the other side of the equation, in our contribution arrangements, the Auditor General points out that we have goals and objectives in some of those arrangements that the communities are supposed to carry out. A contribution arrangement is more or less an administrative arrangement with the band.

Again, the major criticism is that we do not have the resources to follow up on as many program reports and contribution arrangements as we should.

If there's anything being criticized in the report, it's the regime that we have to monitor the arrangements. I can think of no occasion in this report in which there was any indication that anybody had found, throughout the course of this audit, any particularly outstanding difficulties with the delivery of health services in first nations communities.

We were asked to strengthen the audit capacity to ensure that the programs were being delivered in the appropriate fashion. But again, it's a balance between allowing the resources to flow to communities for programs or using the resources to become more diligent in our follow-up.

That isn't to suggest that we aren't diligent in our follow-up. Every region regularly visits communities to discuss their programs with the chief and council. Where a problem is detected, we're quite diligent in following up with those communities.

We do make audits every year. There's a random selection of audits on our key agreements to ensure that the terms and conditions are being followed.

The Chair: Thank you, Mr. Cochrane. We want to try to remember that we have larger committees this year, and everybody has a question they want to ask, so I wonder if you could also keep your answers as short as possible.

Mr. Myers.

Mr. Lynn Myers (Waterloo—Wellington, Lib.): Thank you.

Mr. Cochrane, in your initial comments, you said you were following up with respect to the Auditor General's point-of-service systems for pharmacies, dental contract changes, and controls in education and such. My question, first of all, is: do you have time lines for when you are doing this? How much money do you anticipate saving as a result?

Mr. Paul Cochrane: We do have time lines. I'll answer the first part of this question and then ask Jay to follow up.

We fully anticipate that we will have 100% coverage, or as close to 100% coverage as you can get, for point-of-sale transactions by the end of this calendar year As I indicated, we are now at 90% of all transactions flowing through a point of sale. So we'll indicate 100% by the end of the calendar year.

• 1130

In terms of some of the other strengthening of the systems, such as the new contract and its enhancements and the drug utilization review, I'll ask Jay if he could respond to that.

Dr. Jay Wortman (Director General, Non-Insured Health Benefits Program, Department of Health): Thank you.

As you heard earlier, our new contract becomes effective July 1, 1998. We have a team working now with the new contractor to put the terms of the new contract in place and fine-tune the agreement.

We're looking quite closely at the audit and the point-of-sale aspects of the new contract. We are in fact approaching our internal audit department now to get them to initiate a complete review of our audit requirements with a view to having recommendations from them and implementing those recommendations by the time we get the new contract in place.

I would also like to add a comment about the point-of-service system. We are currently rolling out a point-of-service system under the terms of our old contract. We negotiated an agreement with our old contractor to do that even though the contract is approaching its end, and we achieved that without any additional cost to us.

When we get into the new contract, because we're in a new system architecture, new client/server-based computer systems, we will have even more flexibility. We'll have a better system at that point than the one we're rolling out currently.

As for your point on what the anticipated savings are, that's a difficult question to answer. In fairness, I don't think I should even make an estimate. I can tell you that as a result of our drug utilization review activities in Alberta, which is the province where we've piloted most of the things we're doing, we've noticed a 7.6% reduction in pharmacy expenditures in that provinces and a similar percentage in reduction in actual claims in that province in the first six months of this year.

We are doing some analysis now to determine how much of that is a result of audit and drug utilization review activity and how much of that is a result of reducing the misuse of prescription drugs. To us, at first glance, it appears that we can have an effect in reducing misuse, and we do see it in the bottom line in terms of how much we spend in our pharmacy program.

Mr. Lynn Myers: A supplementary if I might, Madam Chair, on Alberta. On page 13-25, why is Alberta so high relative to the other provinces? I asked that of the Auditor General's office, and they said you were better placed to answer.

Mr. Paul Cochrane: Let me just put this table in context for a moment. Then I'll allow my colleague to follow up.

The fact that Alberta is high in terms of all three columns in this report certainly must be taken in context. If you look at the number of clients accessing this system during this quarter when the sample was taken, there were 257,000 first nations individuals who accessed the system in this quarter. The total number in the column where the Auditor General has pointed out excessive numbers of prescriptions is 710 individuals. That represents 0.001% of all the individuals who access the system.

The corollary of that is that 99.99% of people who access the system didn't fall in that column to begin with.

That doesn't mean we're not concerned about this column. And indeed, where the system permitted, we examined a large number of cases in this column. We found that some of them were appropriate. Some people were on medications that the physician was prescribing a small amount of for particular reasons, or there were other mitigating circumstances. Certainly that doesn't account for the vast majority in the column, but there were some.

But just to put it in context, one has to look statistically at what the 710 represents. In terms of why Alberta, even within that group, is higher than some of the other provinces, I'll ask Dr. Wortman to comment.

The Chair: Keep it brief.

Dr. Jay Wortman: We commissioned two studies last year to look at prescription drug misuse in our client population in the four western provinces, in which we compared our client utilization of codeine drugs and benzodiazepine drugs to provincial government plans, seniors plans and social services plans.

First, I'd like to point out that the utilization in our client group was about the same and in some cases less than the utilization pattern in these other provincial programs, but secondly, the thing we noticed was that Alberta had a higher rate of utilization of both types of drugs than the other four western provinces where our clients were concerned. We compared what we called the regulatory environment of prescription medications in those provinces and we found that we could make a correlation between the tighter regulatory environment and a lower usage of these types of drugs.

• 1135

Alberta, I think, has a more open regulatory environment, and I'll give you one example. Codeine-containing drugs are, in three of the western provinces, regulated by a triplicate prescription program—in Saskatchewan, right down to the 15-milligram level; in Alberta, codeine drugs up to 60 milligrams are not governed at all through a triplicate prescription program.

So I think what this tells us is that the provincial regulatory environment has a big impact on how much consumption of these drugs occurs in our population and, I would guess, in other populations as well.

The Chair: Thank you.

Mrs. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP): Thank you, Madam Chairperson.

I was pleased to hear Mr. Cochrane's comments, particularly his statement that the question of prescription drug misuse is but one symptom of far greater, deeper underlying problems pertaining to the higher incidence of ill health among the first nations and Inuit communities.

Indeed, again, I want to express concern that we as a committee with so little time have spent a lot of time on one particular problem facing aboriginal people when it comes to health and well-being. In fact, when we're looking at cost-saving measures and trying to deal with deteriorating health, there are so many more serious issues. When you hear about the incidence of TB, diabetes and other illnesses related to housing conditions, overcrowded living conditions, poor water and sewage arrangements, unemployment, lack of recreational opportunities, a tremendous suicide rate among young people, all of those facts beg questions and answers around the broader issue of health and well-being for first nations and Inuit people.

My questions would specifically be where are we at with respect to trying to respond to the Royal Commission on Aboriginal Peoples, with its very significant section on health and healing and I think some 25 recommendations? Are we at the stage of having addressed those concerns and working on them?

Second, is there a mechanism in the federal government for interdepartmental co-operation and work to get at the fact that we are dealing specifically with medical issues but also with many broad determinates of ill health? What is the relationship between the work you do with housing, with human resources and with all the other areas that are involved?

My third question is—

The Chair: We'll look at that after.

Ms. Judy Wasylycia-Leis: Okay, I'll save the third question. Thank you, Madam Chair.

Mr. Paul Cochrane: In terms of a government response to RCAP, it's my understanding that the government has committed to a response late this calendar year. I can assure that you at the officials level we have been working diligently since the release of the report to examine the large number of recommendations in the report. Certainly from a Health Canada perspective we recognize the value of the recommendation in the report about a healing strategy.

The complexity of issues that face first nations communities today really have to begin with healing individuals, and then you'll have healthy communities, and if you have healthy communities you'll have healthy nations.

So indeed over the last four or five years, other than increases in our non-insured health benefits program, which have now as I say basically plateaued, we have provided resources to first nations communities themselves to look at issues such as suicide and mental ill health. We see promise that once the resources are placed in the hands of first nations they can find solutions to problems, which as a government we just don't have the same sort of flexibility to be able to apply.

• 1140

In terms of working collaboratively, certainly this summer—again at the officials level, mandated by the government—we undertook a broad review of cross-cutting aboriginal programs. While I work in the Department of Health, I would suggest that this summer I spent more time working with officials from both DIAND and HRDC, looking at issues: with HRDC, training and jobs as they relate to the broader determinants of health model; and with DIAND in terms of issues such as housing, water and sewage, etc. We worked very closely with DIAND in terms of identifying priorities for water and sewage, because within Health Canada we have the environmental health officers who provide that expertise.

As for where all of this will lead, we hope we will see a significant response to RCAP. We know that this government has, both in the Speech from the Throne and in its red book promises, indicated support for initiatives such as aboriginal head start on reserves, the Aboriginal Educational Institute and other initiatives of that kind. So we're very hopeful that these will come to fruition.

The one I didn't touch on—and you're bang on—is diabetes. You're from Manitoba, so you would understand that the most debilitating disease now for first nations people, probably in western Canada but certainly in Manitoba, is diabetes.

Currently we indeed are working with the Assembly of Manitoba Chiefs, with Chief Louis Stevenson at the Peguis Reserve, looking at trying to establish a centre for diabetes at the Peguis Reserve. This will only be one step in addressing the problem of diabetes. We're looking for partners. The province has indicated that they are willing to participate and the university is willing to participate.

Certainly we recognize that a major initiative involving first nations in the area of diabetes is essential or we're going to have a whole generation of first nations people who not only have the disease but are probably debilitated by the effects of that disease.

The Chair: Thank you, Mr. Cochrane. Mr. Drouin.

[Translation]

Mr. Claude Drouin (Beauce, Lib.): Mr. Cochrane, first, I would like to know what advantages there are to the various types of transfer agreements. Certainly there must also be disadvantages, unfortunately.

Secondly, how are the extent and flexibility of transfer agreements determined?

Finally, what is expected from the various transfer agreements in terms of health care?

[English]

Mr. Paul Cochrane: Transfer has really two underlying pillars. The first underlying pillar of transfer is that we've now worked with first nations collaboratively over a number of years to improve health status. We've seen decreases in infant mortality rates and we've seen increases in life expectancy, but we now see a plateau in terms of the improvement in health status in many first nations people.

Transfer is about community development and community control of programs. Transfer allows communities to take on responsibility to develop their own expertise, their own cadre of health professionals, but at the same time it allows them to work in an integrated domain—in other words, health, social services from DIAND, environmental programs, housing programs from DIAND—to make choices themselves about how they utilize those resources to effect not only improvement in health status but improvement in education. So transfer has been a very successful tool in allowing for that self-determination and control.

As well, we have many instances where, once the control was in first nations' hands, jurisdictional problems that existed in the past—because there was a federal role, a provincial role and a municipal role—virtually disappeared. When you put it in the hands of local professionals working within a municipality or in a provincial system, it certainly simplifies and makes more effective program delivery.

• 1145

There are many communities across the country. I mentioned the Montagnais du Lac St-Jean band in Quebec, which is a perfect example of a community that has met all its obligations under its transfer agreement. It has submitted annual reports every year to all its membership and to Health Canada. They have completed their five-year evaluation. They are enthusiastically looking forward to the next five years in their transfer agreement.

There are other examples. I mentioned the Peguis Reserve in Manitoba, a perfect example of how, once placed in the hands of communities, the health program is more tailored, more specific to first nations' needs, and, I might also mention, it allows for a broader integration of traditional healing methods, if communities so desire, within their overall program delivery.

The Chairman: Mr. Elley.

Mr. Reed Elley (Nanaimo—Cowichan, Ref.): Thank you, Madam Chair.

May I suggest to all of us here on this committee and to those who have come as witnesses that we are sitting on a powder keg in this country. I've just come back from one week in the riding, where I held town meetings and talked with people. I am very concerned about the undercurrent of anger out there, particularly amongst the white population, about the way government handles aboriginal concerns. They mostly see it as a dollar factor. When stuff like what we see in the Auditor General's report becomes public knowledge, it begins to increase that anger level and the frustration many people in this country have about the whole concern we have about our aboriginal people.

I have a son who works for the British Columbia Ambulance Service. I have a son who works for a private ambulance service in northern Alberta. They both service reserves. They work with our aboriginal people.

The Auditor General's report said there is a real problem with the MSB's national transportation directives. They are unclear. They result in differing interpretations. I'm just reading here. Some ambulance companies inflate distances. Some bill for individuals not eligible for coverage. May I suggest that is not as much an aboriginal problem of abuse as it is of unscrupulous Caucasians who are abusing the system.

Very directly, how are you going to deal with, and how are you dealing with, for instance, ambulance services that abuse the system? It's not an aboriginal problem, it's a white problem.

Mr. Paul Cochrane: If I remember correctly, the significant problems with ambulance services cited in the Auditor General's report this year revolved around a situation in Saskatchewan.

Certainly where ambulance services are not insured in the province we have in place with ambulance associations contractual arrangements that lay out what we will pay in terms of trip rates or mileage rates or whatever. From time to time, unfortunately, as you point out, certain providers of services for one reason or another have decided they can manipulate a system to their advantage.

With the system in Saskatchewan, interestingly enough, when we have gone back and looked at the figures—in fact, we provided the figures to the Auditor General, or his friends—the vast majority of providers, whether they be first nations people, Caucasian or anybody else, provide the service in an honourable and professional manner. For those who don't—and we detected it— and I know cases in Saskatchewan where we have brought ambulance, where we have brought pharmacists—we have involved law enforcement agencies in trying to deal with those providers. In the case of providers such as pharmacists and physicians, we regularly use the colleges when we come across the information and when that information looks at variance.

We have an audit regime. Unscrupulous practices still happen. When we find them and detect them, we will prosecute to the extent of the law.

Mr. Reed Elley: Mr. Cochrane, it says directly in the Auditor General's report that national transportation directions are unclear. What are you going to do about it?

• 1150

Mr. Paul Cochrane: With transportation, in fact, we are deregulating it, if you will, as a national program. We have found that to try to run the transportation program as a national program doesn't make good sense.

If I can take the example of Ontario, ambulance services in Ontario, including air ambulance services, are an insured program. So the province provides it, and we provide supplements if required.

In other jurisdictions where it's not an insured program it makes much better sense to have local arrangements. So this year the department has gone to cabinet, cabinet has approved the removal of transportation as a non-insured health benefit, and has mandated that it be placed in community-based programs and that it be run as a local program so that it's best able to suit local conditions. In this way, as well, we will have a much more stringent ability to look at the provision of those programs on a local basis rather than having a national directive that tries to fit the norm rather than dealing with the situation in each region.

Mr. Reed Elley: Who's going to monitor that program at the local level?

Mr. Paul Cochrane: It will be monitored at the regional level and it will be monitored at our zone level.

Mr. Reed Elley: But who's going to do that?

Mr. Paul Cochrane: If the program is provided by the medical services branch, it will be the staff of the medical services branch. If the program is provided by first nations, it will be monitored through their contribution arrangements.

Mr. Reed Elley: Okay.

The Chair: Mr. Myers.

Mr. Lynn Myers: Thank you, Madam Chair.

I'm interested, Mr. Cochrane, in the non-insured health benefits program. I understand it's being transferred to the first nations as of April 1. Is that correct?

Mr. Paul Cochrane: If we get our framework in place—and we are working on that now in consultation with first nations—it will be eligible for transfer April 1. It will then be up to first nations to choose whether or not they wish to draw down that program under a transfer arrangement. So it will be eligible for it.

Mr. Lynn Myers: That actually is my question, what you term the “framework”. I'm interested in whether or not you agree that there are inherent systemic problems that need to be resolved before that kind of transfer takes place.

Second, is there a perception, either real or perceived, with respect to there being a rushing into this kind of transfer? Can you comment on that?

Mr. Paul Cochrane: I'll deal with the second question first, in terms of rushing into a transfer. Our policy is that first nations will have the opportunity to draw down programs under their control at a time and pace to be determined by them. We do not put a magic date on the table and say, “If you haven't taken it by December 15, 1998, or 1999, we're outa here”.

That is not the situation at all. Each first nation is presented with the information we have about all of our programs, about all of our expenditures, and they make the decision. If they choose to exercise control, we then enter into a negotiated agreement. If they choose to leave the program with the medical services branch, the program remains with us, and we continue as a provider. We continue to provide against our formularies and within our budget limits. So that choice belongs to the first nations.

In terms of a drawdown of transfer, right now some communities across the country have already drawn down transportation under transfer. We had authority from cabinet for up to 30 pilot projects. We are in negotiations for approximately 10 of those pilots across the country. Some first nations have indicated a real willingness to take down their dental program, their transportation program and their drug program and manage them against their program parameters but within negotiated financial limits.

So to say that the framework is complete is not the case. We are currently in discussions with the AFN and their membership across the country, trying to put together a framework that meets the needs of both Health Canada and first nations communities. This is not a “dump and run”, as the Auditor General has reported it; this is putting the information on the table and allowing those communities to make informed choices.

• 1155

Mr. Lynn Myers: Under the NIHB program, have you ever quantified, let's say over the past five years, the amount of public waste? Have you ever done that either in dollar terms or percentage terms? Has that ever been looked at? And if not, why not?

Mr. Paul Cochrane: I guess I would answer that question by going back to a statistic I provided before; that is to say that in 1991-92 this program was growing at an annual rate of 20%. By last fiscal year that growth had come down actually to minus 3% in benefits. Now, that was accomplished in an environment where this population is increasing slightly in excess of 3% a year in terms of natural growth, and the cost drivers associated with the program—transportation costs, dental costs, vision costs—are increasing anywhere from 5% to 8% in terms of cost increases alone. So although we're in an environment of pressures in the range of 8% to 11% for population and cost, the growth in costs have continued to decline.

I don't have a measure to tell you how much more efficient we are in delivering these programs today, but I would suggest that those figures indicate that our efficiencies have increased and that the programs are being delivered far more effectively today without any significant impact on the level of benefits available to first nations.

Mr. Lynn Myers: Thank you.

The Chair: M. Dumas.

[Translation]

Mr. Maurice Dumas (Argenteuil—Papineau, BQ): Mr. Cochrane, I am going to return to the issue of non-prescription drugs. The Auditor-General's report notes that the First Nations and Inuits can be reimbursed for non-prescription drugs under the First Nations Health Services Program if their doctor has given them such prescriptions, obviously. Is this still true? Is this practice common everywhere in Canada or is it limited to certain regions? Is Quebec in particular a victim of this practice?

[English]

Mr. Paul Cochrane: In all cases across the country prescription drugs are provided to first nations Inuit without a co-payment and without a deductible. The same thing applies in Quebec. Indeed, this year certain changes came about in the drug plan in Quebec whereby certain seniors had some of their benefits de-insured under the Quebec drug plan. We met with the chiefs of Quebec, and indeed we continue as a federal government to provide a full range of benefits to those first nations so they won't be disadvantaged by the changes in the Quebec program.

[Translation]

Mr. Maurice Dumas: I was speaking in particular of non- prescription drugs. I was thinking of aspirin, a drug that can be obtained over the counter. I was thinking about this type of drug.

Mr. Paul Cochrane: Over-the-counter medications?

Mr. Maurice Dumas: Are they reimbursed?

Mr. Paul Cochrane: Yes. The situation is exactly the same in all the provinces. We find it is more effective to use certain non- prescription drugs because prescription drugs are more expensive. In certain cases, drugs such as aspirin are useful. For that reason, we sometimes use non-prescription drugs rather than prescription drugs, which are more expensive.

[English]

The Chair: Ms. Wasylycia-Leis.

Ms. Judy Wasylycia-Leis: Thank you, Madam Chairperson. I'd like to pursue the issue of the transfer process around transfer agreements. I've heard what you've had to say in terms of the approach the department is taking with respect to ensuring enough time and flexibility in the discussions to ensure that it is done when aboriginal communities are ready to do those kinds of transfer arrangements.

• 1200

However, what I am hearing from the community itself and in discussions with members of the Assembly of First Nations is that it is their perception that what we are dealing with is very much a dump and run situation vis-à-vis the federal government. It is the aboriginal community who has used the term “dump and run”. It is members of the Assembly of First Nations who have said there is a sense of being rushed about the whole thing, that there's a bit of a threat around doing it as soon as possible while there's still some money on the table or it may not be there.

As I understand it, their understanding is that a framework for both medical services and non-insured health benefits across the board is to be achieved by April 1, 1998; that there are two discussion papers out in the field now that the first nations and Inuit communities must respond to by the end of this year in order to effect the conclusion of those agreements by April 1998. My sense from speaking to those people is that it's an agenda being pushed by the federal government. It is not to their liking or according to their needs, and they're very worried about it.

I would like some clarification on those issues.

Mr. Paul Cochrane: If you go to Manitoba or if you go across the country and talk to certain first nations leaders, there are some leaders who will certainly make it very clear that they do not consider sufficient resources are on the table to address all of the gaps in first nations' health. They believe that and they hold firmly to that point of view.

There are others who have decided that the resources that are on the table are sufficient and that, in their hands, those resources can be better utilized. As I say, there are first nations leaders on both sides of that discussion.

In terms of the framework document you were talking about, we have to go to Treasury Board with that framework document in the months leading up to April 1 because we, again, are receiving pressure, I would describe it as, from many first nations communities who say they are ready and want the framework in place. But there are communities that say this process should go more cautiously.

Again, we are trying to strike a balance between having a framework in place that will allow first nations to take control and, at the same time, address the needs of those who would like to go more cautiously. I'm not sure this is ever a completely win-win situation on either side of the coin, but those are the competing pressures.

It's interesting that the same groups—particularly in Manitoba—who are saying they want a more cautious approach are some of the communities with whom we are in the most accelerated negotiations in terms of the transfer of non-insured: The Pas Band, OCN in The Pas; the Interlake Reserves Tribal Council; the Long Plain First Nation; DOTC tribal council; Keewatin Tribal Council in northern Manitoba. So we have a number of active first nations participants at the table discussing transfer.

Perhaps I can just point out one: the OCN, Opaskwayak Cree Nation in The Pas. We had agreed with the Opaskwayak Cree Nation on a negotiator's arrangement for the transfer of non-insured. We were about ready to enter into an agreement. The chief and council went back and reviewed their negotiator's agreement; chief and council came back to me. I met with them in Manitoba about three weeks ago and they said to me, “Paul, the negotiator's agreement is not acceptable. We see that we are going to be jeopardizing service delivery in this area if we accept that negotiator's agreement.” They have withdrawn from that negotiator's agreement and have gone back to relook at the whole situation.

• 1205

We are not standing at the table saying to Opaskwayak Cree Nation, “You have to sign. We had a negotiator's agreement; you have to sign.” We are certainly respectful of the wishes of first nations and we will continue to deliver that service to Opaskwayak Cree Nation until such time as they decide they are in a position to accept it themselves.

Ms. Judy Wasylycia-Leis: I just wanted to first of all clarify that my comments were not based on discussion specifically with folks from Manitoba but in consultation with people at the Assembly of First Nations office, who I would assume would be in touch with a broad section of first nations and Inuit people across the country. Certainly they are concerned that there's a great deal of pressure and speed being applied to this whole process.

So my question is, has the federal government set a deadline of April 1 to conclude a framework agreements in both medical services and non-insured health benefits across the board? If in fact there are some differences of opinion in this country around timing of transfer agreements and the appropriateness of them at this point, is the government flexible, and is it prepared to delay the finalization of transfer agreements until the aboriginal people are ready to make that decision?

Mr. Paul Cochrane: First of all, I don't make the policy, I implement the policy, so I will respond to it as an official.

I have had discussions with AFN. I have had discussions with the new national chief. I have had discussions with the health technicians. In fact, I think you should be aware that at our management meetings, in which we bring together our regional directors from across the country to discuss issues, the AFN has a seat at that table. So what we're doing is no secret or no surprise to AFN.

I know they have had concerns. We had a meeting in Alberta where we brought the chief summit from Alberta to the table. We know there are two perspectives on this subject. There is no unanimous position in terms of first nations on this subject.

We are struggling with what is the appropriate timeframe—and I'm being somewhat repetitive here—to allow those first nations that want to move forward to do so and for those that are more cautious to delay. I should point out that if a framework is in place by April 1, it does not mean those first nations who wish to be more cautious have to step forward and accept transfer. We must differentiate between a framework and the ability or the willingness of first nations to come forward and work within that framework. We're not here to try to force a framework down anybody's throat, let me assure you of that, but we are trying to strike that balance between those who wish to proceed and those who wish to be more cautious.

The Chair: Thank you.

Mr. Myers, do you have a short question?

Mr. Lynn Myers: Thank you, Madam Chair. I wanted to get back to the over-the-counter products and the dispensing of them.

At our last meeting Mr. Hill, I think, mentioned the fact that in Alberta it's not necessary to have a prescription. Yet Mrs. Barrados seemed to be in conflict with that point. I wondered if you could clarify which it is.

Mr. Paul Cochrane: I'm going to ask Dr. Wortman to respond to that question, knowing that Dr. Hill has intimate knowledge of the system in Alberta.

Dr. Jay Wortman: Our policy across the regions, all regions, every province where we pay for over-the-counter medications, is that they must be accompanied by a prescription, otherwise we will not pay for them.

I studied the transcripts of the committee meeting where Dr. Hill raised this issue and I wondered whether there might be a different approach to provincial clients in Alberta that Dr. Hill has been following— and perhaps applied that to our clients. I think that in either case what we ask is that a doctor recommend the medication. I suppose if it wasn't necessarily a prescription from the doctor but a note or some other authorization from the doctor, we would accept that to pay for the over-the-counter medication.

But getting back to an earlier point, it is our policy—and we are being very tenacious with this policy in our negotiations—to remove the dispensing fee from over-the-counter medications. We will still require a medical authorization before we pay for those drugs, though.

• 1210

Mr. Paul Cochrane: Regarding the situation Dr. Hill referred to, we've followed up on it, based on the transcript from your session with the AG, and we still do not have a clear answer ourselves to specifically address the question.

But, Madam Chairperson, we are continuing to follow up on that, and I would suggest that we get our own clear understanding of the situation. I would be pleased to table that in writing with the committee, because I can assure you that we certainly do not want to be paying somebody for a prescription for an OTC—which we still do in Alberta—if that is not necessary.

So we want to clarify that, and we would like to respond to the committee in writing once we have complete clarification.

Mr. Lynn Myers: Madam Chair, as a supplementary, I don't understand what there is to clarify. Either you do pay for it, or you don't.

Mr. Paul Cochrane: The answer to the question of whether we pay for it or don't pay for it right now is that we do pay for it in Alberta at the moment.

Mr. Lynn Myers: If it's a prescription.

Mr. Paul Cochrane: If it's a prescription.

Mr. Lynn Myers: So where's the point of clarification?

Mr. Paul Cochrane: What I understood the discussion between Dr. Hill and the AG's office to be was that the practice in Alberta does not require a prescription, in some instances, to access an OTC. So if the practice in Alberta doesn't require a prescription, then we would want to conform with the standard practice in Alberta, because that would then eliminate the need for us to pay for the prescription so that the person could access the OTC. We do not have total clarity on that issue at the moment.

Mr. Lynn Myers: Madam Chair, it seems like this is an important issue, and I hope we get this sorted out.

The Chair: Thank you.

Mr. Vellacott.

Mr. Maurice Vellacott (Wanuskewin, Ref.): I note the fact that it has been acknowledged, in terms of monitoring the separate contribution agreement, that we've admitted that there hasn't been the adequate mechanism in place in advance for the monitoring of same.

With any of these levels of agreement, and particularly in respect to the separate contribution agreement, why would we get into not having some proper monitoring process in place in advance so we're getting the information? Is this typical? Why do we do that? Why are we getting into something where we don't have in advance a proper monitoring mechanism?

Mr. Paul Cochrane: We do have a statement of objectives. We do have a statement of budget, which is clearly a part of each contribution arrangement. Going into the process, there is no misunderstanding about what the expectations are and what resources are on the table to fulfil those expectations. So it's not as if we do not have a negotiation of expectations versus budget. That happens every year with the first nations.

What we don't have is 100% audit of each of the contribution agreements that exist across the country. I would estimate that we probably have in the range 10,000 to 12,000 different contribution arrangements in place across the country.

For us to have 100% audit, we would need—I could use the word “battery”—a significant number of auditors to audit each arrangement, and we just don't have that, nor do we feel that it is the right way to deal with the situation.

Mr. Maurice Vellacott: So it's not a matter of the kind of information; it's just that you don't do audits.

Mr. Paul Cochrane: We don't do 100% audit. It's not that we don't clearly state the objectives, and it's not that we clearly don't state the budget. Those two things are clear, but we do not audit 100% of our agreements.

Mr. Maurice Vellacott: But if you did, there would be adequate information on the table to get at—

Mr. Paul Cochrane: In most cases there would be. There's no doubt that we conduct certain audits where there is an absence of information or there is an absence of supporting evidence. So that does happen when we do audit—

Mr. Maurice Vellacott: I have two supplementaries, then.

With the transfer agreements, then, and also the note that they need to be improved so we or Health Canada can evaluate adequately those programs, what accountability is there to Health Canada in a transfer agreement situation, or is it fairly hands-off at that point?

Mr. Paul Cochrane: No, there is an accountability. Each first nation has to provide an annual reporting against their health objectives, which they now set instead of Health Canada. They have to provide that, and as well, they have to produce a financial report each year. The arrangements normally cover a five-year period, and each year they report against their objectives and against their financial allocations.

• 1215

But what they don't have to report against is a set of standard program delivery criteria, which is the normal way that Health Canada would deliver the program, so it allows them flexibility. Also, they are supposed to provide accountability to their band membership each year in a transfer arrangement.

Mr. Maurice Vellacott: This is my last question, Madam Chair.

They're supposed to, but they don't have to?

Mr. Paul Cochrane: Again, as I said, we don't audit every agreement.

In most communities we deal with in transfer, accountability to the community in fact increases in a transfer arrangement, rather than decreases.

Mr. Maurice Vellacott: They ought not to account to their people or give them reports, or they are not required to, by way of a transfer agreement.

Mr. Paul Cochrane: Yes, they have to report—

Mr. Maurice Vellacott: To their own people?

Mr. Paul Cochrane: —but as to whether or not each of those bands that is in a transfer arrangement actually reports, I wouldn't be in a position to provide that information unless we audited 100% of the agreements to see if they did in fact report to the community.

Mr. Maurice Vellacott: Okay.

The Chair: Thank you.

Monsieur Drouin.

[Translation]

Mr. Claude Drouin: You were telling us earlier that, between 1991 and 1995, there was annual growth of 20 percent and, fortunately, last year, growth was -3 percent. However, there is still considerable room for improvement and everything must be tightened.

As for transportation, does this involve contracts and, if yes, can we impose penalties or cancel a contract when abuse occurs? Can we impose conditions to ensure people are making the right applications and invoicing correctly?

[English]

Mr. Paul Cochrane: In every arrangement that we have there is a penalty clause or a cancellation clause, so a mechanism exists to terminate an arrangement if we find abuse or misuse.

The difficulty does arise from time to time, though, that certain providers of services do have a preferred status in terms of certain communities in delivery of the services.

So where we find issues of misuse and abuse, there is a mechanism in the agreements to terminate them. What we generally try to do, though, is resolve any disagreement between the provider and ourselves or the provider and client, because, on the one hand, we certainly do not tolerate abuse and we don't want to see any waste in the agreement, but if it prejudices the client from accessing the service, we also have to take that into consideration.

We won't just rush in and terminate an agreement. We will go in, deal with the provider and try to straighten out the situation.

But let me assure you that should it be clear that there's evidence of fraud or misuse, we will refer that file to the RCMP. Then the RCMP will follow up in the local jurisdiction. We definitely take those actions.

The Chair: Thank you.

Mrs. Bennett.

Ms. Carolyn Bennett (St. Paul's, Lib.): Nobody wants to hear the stories of the $200 cab ride for a bottle of aspirin.

I was heartened to hear that the new first nations health has a mail-in component—is that right?—for some of the maintenance drugs. If we're dealing with remote communities, for some maintenance drugs, to actually have to go the pharmacy— I think we've actually seen pharmacies fill a prescription for only a month when somebody needs to be on it for a year and when it hasn't changed in the five last years. They should be able to get a three-month supply at a time. I think there are innovative new ways of delivering the goods. That's the first part of my question.

Second, is not the real problem the fact that there's not a real on-site health practitioner in some of these communities who would be the on-site auditor or permission-giver for ordering the cab or the ambulance or whatever? Shouldn't we be actually working to have more aboriginal people trained as nurse practitioners to make sure there are people in these communities who actually co-ordinate the care and coach these decisions?

• 1220

Mr. Paul Cochrane: Certainly we would want, we would wish— and indeed we work with first nations to try to increase the number of aboriginal physicians, aboriginal nurses, aboriginal nurse practitioners. In fact, we have a program called the health careers program, where we provide bursaries and scholarships to aboriginal people to pursue careers in the health professions. The numbers are increasing, but the numbers are nowhere near meeting the needs.

Jay, what is the number of aboriginal physicians in Canada?

Dr. Jay Wortman: It approaches 40 at the moment.

Mr. Paul Cochrane: The number of aboriginal nurses is probably now in the range of 500 to 600, whereas probably five years ago it was more like 300. But the number of practitioners doesn't approach the need, so we encourage first nations and in fact we try to stimulate that process through the use of bursaries and scholarships.

About the $200 taxi ride for a bottle of aspirin, I'm glad we're not talking about it, because the number of cases where it actually happens is very, very, very small. But in any system where you have a client using a system—and God forbid that this client might be a Canadian taxpayer who is interfacing with the tax system—from time to time situations arise which aren't 100% kosher. We're never going to have a perfect system of access.

Our greatest demand on transportation is out of isolated communities in the north. For those of you who are aware of environments such as Sandy Lake or Round Lake in northern Ontario, or Fox Lake in Alberta, these communities are geographically disadvantaged. A large percentage of our transportation budget is spent ensuring that first nations can have the same access to the Health Sciences Centre in Winnipeg as can somebody living in the north end of Winnipeg. The majority of our transportation costs go to ensuring that first nations are not geographically disadvantaged in terms of being able to access tertiary health care services.

Even in those situations we are now more closely monitoring patient movement to see if there are more efficient ways serve to more patients. One of the great dilemmas we face in delivering this program is the issue of language and the issue of children and legal issues around consent. If you move a young child out of Shamattawa and you put that young child in a plane to go the Health Sciences Centre in Winnipeg, the return air fare may cost $2,500 or $2,600. If that child can't speak English, the child will need an escort. If that child is under the age of majority, he or she will need an escort in case when he or she gets to Winnipeg consent forms have to be signed.

So when we move these people—geographic disadvantage, linguistic and cultural disadvantage—this program allows for those people to be treated the same way as other people can be treated in a tertiary environment. Hence the costs of transportation are high. But I'm not sure that as the senior manager in this program I have alternatives to overcome that.

Sure, we try to get more physicians in the communities. There are nurse practitioners in every isolated community. But they still need access to physician services. We bring in physicians. Physicians provide clinics. But physicians going in and providing clinics also make referrals to specialists.

We have to ensure that first nations have as equitable an access to the mainstream system as everybody else in the country.

The Chairman: We have a last question from Mr. Hubbard.

Mr. Charles Hubbard (Miramichi, Lib.): I have a very brief one. I came in late, when we were talking mainly about costs in terms of money. Having some knowledge of the reserve system and first nations, I have as my main concern the human cost involved in the abuse of drugs.

• 1650

I think I heard you say that in many cases the RCMP would be contacted to audit. In terms of trying to curb the major problem, which is the fact that certain native people go to more than one doctor—it could be three or four or five—they also go to more than one drugstore. They have a tremendous amount of prescription drugs on hand, which they distribute to younger members of the reserves and to other people in the community. Has the department considered, for example, the idea of a single source for monitoring the use of drugs?

For example, with those who belong to a Blue Cross group, all the prescriptions are funnelled through a source that is knowledgeable of the amount of drugs taken by particular individuals. I really don't think your department is doing that. I know at least three reserves in New Brunswick that have tremendous problems of drug abuse. I have never really heard of your department yet going to the RCMP, and I've talked to the RCMP on that. Have you given consideration to trying to funnel the acquisition of drugs through a single desk, which will alleviate the problem of the over-subscriptions?

Mr. Paul Cochrane: Indeed, you came in partway through the discussion. Our current contract has what is called point-of-sale technology, and that will be enhanced in our new contract. For the first time, pharmacists in Newcastle or pharmacists anywhere in New Brunswick—Fredericton or Saint John—will be able, once that client comes in and presents their band number, to see what the prescription pattern was for this individual.

Currently we do not have that technology at the front end of the system. What we had was a post-utilization review. Now we will have a pre-utilization review. There is only one carrier for the Health Canada system, and in Atlantic Canada it currently is Atlantic Blue Cross as part of the national contract. I'm not actually sure who the subcontract carrier will be in Atlantic Canada, but under the new contract, with point of sale, we think we will go a long way towards addressing the suggestion you make.

You may not be aware of it, sir, but I can assure you that in Atlantic Canada we have brought the issue of abuse and misuse to the attention of the authorities in both New Brunswick and in Nova Scotia. In some cases it has resulted in dramatic changes in the prescribing practices of some physicians.

As for the issue of street abuse of medication, we have also initiated with a number of the communities in New Brunswick—with chief and council—education programs about the debilitating effects of the misuse of drugs. However, some of it continues. We don't accept that, and don't think it's in any way an appropriate thing to be going on. We continue to intensify our efforts, but we also need the support of the leadership.

The Chair: Mr. Cochrane, may I ask you, since you are talking about this contract right now—and I don't know if this is legal—could you get us a copy the new contract and the old contract?

Mr. Paul Cochrane: I can get you a copy of the old contract, Madam Chairperson, but I can't get you a copy of the new contract, because while the contract has been awarded to a successful bidder, the actual document and the negotiation haven't been completed.

The Chair: Mr. Cochrane, when it's possible, if you can't give us the actual contract, could you maybe write out and deliver to the clerk the major differences in the two contracts? I think everybody in the committee would be interested in that. Could you do that, at a a point when it's possible?

Mr. Paul Cochrane: Yes, we certainly could.

The Chair: Thank you, and I'd like to thank you very much for coming. Also, Dr. Wortman and Ms. Conway, thank you very much for coming.

Could the rest of you just stay? It will only be a two-minute meeting, I hope. I'll get right into it so that we won't hold anybody up here.

I did have a meeting with the minister, and he's very anxious to come and talk about the estimates. He has given us a date of December 8.

I also mentioned that since most of us are new on the health committee, we would like to talk to the departmental people and really have an in-depth study of the department, and he thinks it's a good idea and is quite willing that the department come, either the meeting before or the meeting after. We don't have to decide that right now, but I'm just letting you know that he's quite willing that we do that.

• 1230

In order to discuss that and something else I'm going to bring up, I'm going to suggest that we have a working meeting on Thursday.

The other matter that came up is that I now have the letter from the minister with the parameters or the terms of reference of studying the herbal remedies. I would like to read that to you now, and then we'll give you a copy of it. You'd all be able to have it for our next meeting. I'm going to read it to you for a specific reason. It says:

Dear Ms. Phinney:

As you know, on October 4, 1997, I announced my intention to request the House of Commons Standing Committee on Health to hold hearings on the legislation and regulation of natural health products. I would like to take this opportunity to formalize my request.

—notice that it's a request—

Having consulted with several stakeholders during the past month on the proposed issues to be reviewed by the Committee, I would suggest the following terms of reference.

I don't think I'll read those particular terms of reference, because we can study them on Thursday. He continues:

Thank you for considering this request. I look forward to the Committee's advice on these matters—

I'd like to go right ahead with our discussions on what our boundaries will be, how much of what we want to follow is in the letter. I suggest that Thursday's meeting be a working meeting, and possibly the following Tuesday, because the researchers have suggested that if we air all the feelings we have about this on Thursday, they will write up some kind of guideline and on Tuesday we will be able to take a good look at that, at where we will go in the next four or five months. I'm just putting that before you now, if you think we could have a working meeting on Thursday at the regular time, 11 a.m. to 12.30 p.m.

Mr. Reed Elley: Being a rookie on this committee and in this House, I have a question. When is the last day that we have before the tabling of estimates in the House for this committee?

The Clerk of the Committee: The last day of this estimates period is December 10.

Mr. Reed Elley: My information is actually—

The Clerk: [Editor's Note—Inaudible]— the report.

Mr. Reed Elley: Yes. When is the last day?

The Clerk: It seems to be floating at the moment. It could be as early as the 25th.

Mr. Reed Elley: We've heard the 25th, which doesn't give us a lot of time even to think about estimates.

It concerns me that in a previous meeting we had a motion, made by the honourable member from Winnipeg North Centre, that we deal with the estimates first and that we ask the minister to appear. That was moved and passed by everybody—

The Chair: Could we have verification of that? I'm not sure that it said it would be studied first.

Ms. Judy Wasylycia-Leis: I can clarify it. My motion was that the estimates be considered at either the first or second meeting of this committee, depending on the minister's schedule. So yes, I would concur that we are already behind schedule with respect to that committee consensus.

Mr. Reed Elley: In light of that previous motion that we passed, I move that we ask the minister to appear next Tuesday, if possible.

The Chair: The minister has indicated that the first time he can appear is on December 8. Now, we could have the department people and split it, have the department people here sooner if they can come and then have him later if you want. He doesn't mind the department people coming before him or after him. He doesn't mind which one he does. But if he can't come, he can't come. That's all.

Mr. Reed Elley: I'm getting advice that perhaps even Thursday is the last day we can do this, if indeed the 25th is the day on which it has to be presented in the House.

The Chair: It's not the last day we can do it. It's the last day on which we can put a report into the House saying—

Mr. Reed Elley: Yes, before we could put it in the House. That's what I'm saying.

The Chair: —we have heard the minister's comments.

Mr. Reed Elley: So I move that we ask either the minister or department officials to appear at our Thursday meeting to discuss the estimates.

• 1235

The Clerk: Thursday—

Mr. Reed Elley: This Thursday, November 19. Is it November 20?

The Clerk: Yes, it's November 20.

Mr. Reed Elley: All right.

The Chair: We can certainly ask.

Mr. Dan McTeague (Pickering—Ajax—Uxbridge, Lib.): Madam Chair, Mr. Elley must have read my mind. I was going to ask when we would eventually deal with the estimates and have the minister. I think it would be very appropriate if you were to ask the minister to perhaps expedite his attendance before this committee, maybe even before December 8, if that's at all possible.

Failing that, I leave it in your hands as to how we eventually deal with that. It's very much a normal process of what the committee goes through. The minister, I'm sure, would like to— there are questions from both sides that ought to be treated.

Mr. Reed Elley: Do I have to have a motion?

Mr. Dan McTeague: Yes.

The Chair: Would you repeat your motion, Mr. Elley?

Mr. Reed Elley: I move that we ask the minister, or officials in his department, to appear on November 20 to discuss the estimates.

The Chair: There certainly isn't any harm in asking him. He can only say yes or no. If he can come, then we'll ask him to come on Thursday.

Any other comments?

Mr. Dan McTeague: I think the motion is quite reasonable. It's simply asking that the minister provide an opportunity, for him or his department. I see nothing wrong with that.

The Chair: Is everybody in agreement?

Mr. Grant Hill: Madam Chair, I might make one comment. We did have a motion from the health committee quite a time ago, and it's unusual to have this request denied.

The Chair: Well, I'm not sure that it is—

Mr. Grant Hill: Could you express that?

The Chair: I have been here for nine years, and I have never had a minister come in, within that short period of time at the beginning of a session, to give the estimates. They always do it sometime— in all the committees I've been at. But I've not been on a lot of other committees, so it doesn't mean that's the majority, by far.

Mr. Grant Hill: What this does is to disallow the ability of this committee to make suggestions. We will be past the time where we can make changes, where we can put something to the House of Commons. That's what the problem is here. We have a tight time; we requested, and that request has been denied.

Mr. Reed Elley: I would concur. It's slightly unsettling—

The Chair: The clerk says we can still table comments under Standing Order 108(2).

Mr. Grant Hill: Table comments after the minister is here, if he's not here on time?

The Clerk: Well, the last date for this estimates period is December 10. It is the last day of the supply period. Now, the last day for reporting may be as early as November 25 and as late as December 5, but I'm advised by my senior officers in the committees directorate that we can still table a report, under Standing Order 108(2), past that date.

Mr. Grant Hill: Let's have that in writing.

The Clerk: Certainly, Mr. Hill. I'd be happy to supply that.

Mr. Reed Elley: Yes, it would be nice to have that in writing.

The Chair: That's a good point. It would be good if we could do that.

Can I ask for a motion to—

Mr. Dan McTeague: Madam Chair, I want to ask the clerk if indeed the motion that was proffered earlier is recorded, the motion by member Wasylycia-Leis.

The Clerk: Yes. I used her exact wording when I wrote out the motion.

Mr. Dan McTeague: Because I think this motion would be redundant if in fact we are to deal with this. It specifically says “November 20”. I think it was either the first or the second— We've already dealt with the aboriginal issue here. Therefore, it would necessarily follow that the next order of business would deal with the estimates.

The Chair: I'll read what it says in the minutes:

That study of the Main Estimates be the first priority of the Committee pending the Minister's availability and that, in the event that he is not available for a meeting on Thursday, November 6, 1997, that the Auditor General be invited to appear on that date.

This is what happened. So we have followed that motion.

Mr. Dan McTeague: All right. In that case, have we made a request to the Auditor General? Is that what the motion says?

The Chair: We've already had that.

Mr. Dan McTeague: I'm sorry; I thought you meant the Auditor General in its entirety. So we've done that.

The Chair: Yes, we've done that already. You weren't here for that.

Mr. Dan McTeague: All right. So there's no point in continuing with this motion; it's simple.

• 1240

The Chair: I think we could accept the motion if we could just have— we can ask again. There's nothing wrong in asking.

The Clerk: It's just a case of asking him to move his date up. That's not a problem.

The Chair: Does anybody object to the motion?

Mr. Maurice Vellacott: Could we have a recorded vote?

Some hon. members: Oh, oh!

The Chair: We don't need a recorded vote. We're in agreement.

Mr. Dan McTeague: I don't think there's a need for a recorded vote.

The Chair: We're in agreement.

Mr. Dan McTeague: Excuse me, I think there's a consensus here—

The Chair: I agree with that.

Mr. Dan McTeague: —that you request the minister or his delegates to appear. You don't need a motion for that.

The Chair: If the minister's staff or the minister cannot appear on Thursday, will we have a working meeting—

Mr. Reed Elley: I guess we'll have to, or we should, anyway.

The Chair: —to discuss the letter that the minister has sent us?

My next question is, then—

Ms. Judy Wasylycia-Leis: I would think, then, on interpreting the motion we agreed to, that if by some chance we can't get the minister or departmental officials this Thursday, we will then try for the next earliest opportunity, which is November 24, and if not that, November 26, to get it on the agenda as quickly as possible. I think that's the will of the committee.

The Chair: Can I assure you that I will go to the minister personally and ask him if he can move the date up? I'll do my best to get it moved up. Is that okay?

We'll have a working meeting on Thursday. We will pass out copies of the letter from the minister now so you have time to look at them beforehand.

Could I have an indication from you as to whether you want the meeting to be open or closed? Are there any comments?

Some hon. members: Open.

The Chair: Fine.

An hon. member: In this room?

The Chair: You'll get a notice.

Please pick up your letter here from the minister.

The Clerk: Excuse me. The meeting will be in room 362, East Block.

The Chair: But you will get a notice.

The Clerk: Yes.

The Chair: Thank you very much.

I declare the meeting adjourned.