Legislative Assembly of Ontario

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Assemblée législative de l'Ontario

 

STANDING COMMITTEE ON
PUBLIC ACCOUNTS

HEALTH HUMAN RESOURCES
(Section 3.02, 2013 Annual Report of the Auditor General of Ontario)

1st Session, 41st Parliament
64 Elizabeth II

ISBN 978-1-4606-5755-3 (Print)
ISBN 978-1-4606-5757-7 [English] (PDF)
ISBN 978-1-4606-5759-1 [French] (PDF)
ISBN 978-1-4606-5756-0 [English] (HTML)
ISBN 978-1-4606-5758-4 [French] (HTML)


 

Legislative Assembly of Ontario

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Assemblée législative de l'Ontario

 

The Honourable Dave Levac, MPP

Speaker of the Legislative Assembly

Sir,

Your Standing Committee on Public Accounts has the honour to present its Report and commends it to the House.

Ernie Hardeman, MPP
Chair of the Committee

Queen's Park
May 2015

 


STANDING COMMITTEE ON PUBLIC ACCOUNTS

Comité permanent des comptes publics

Toronto, Ontario M7A 1A2


 

STANDING COMMITTEE ON PUBLIC ACCOUNTS

MEMBERSHIP LIST

 

1st Session, 41st Parliament

Ernie Hardeman

Chair

 

Lisa Macleod

Vice-Chair

Han Dong

John Fraser

Percy Hatfield

Harinder Malhi

Julia Munro

Arthur Potts

Lou Rinaldi

 

 

 

 

FRANCE GÉLINAS regularly served as a substitute member of the Committee.

 


 

William Short

Clerk of the Committee

Erica Simmons
Research Officer


Contents

Preamble   1

Acknowledgements   1

Background   1

Medical Education   1

HealthForceOntario Strategy  1

HealthForceOntario Marketing and Recruitment Agency  1

Audit Objectives and Scope   2

Summary of the Audit Report  2

Issues Raised in the Audit and Before the Committee   2

Physician and Nurse Employment and Service Gaps   3

Wait times  3

Emergency Departments  4

Northern, Remote and Rural Communities  4

Return-of-service obligation   5

Nursing Initiatives   5

Financial Oversight  6

Forecasting Supply and Projected Needs   7

Consolidated list of Committee Recommendations   8

 

 



Preamble

On Wednesday, December 3, 2014, the Standing Committee on Public Accounts held public hearings on the audit (Section 3.02 of the Auditor General’s 2013 Annual Report) of Health Human Resources administered by the Ministry of Health and Long-Term Care and the HealthForceOntario Marketing and Recruitment Agency. (For a transcript of the Committee proceedings, please see Committee Hansard, December 3, 2014.)

The Committee endorses the Auditor’s findings and recommendations, and presents its own findings, views, and recommendations in this report. Given the significant financial investment in HealthForceOntario of over $3.5 billion from 2006 to 2012, the Committee requests that the Ministry and the HealthForceOntario Agency establish timelines for providing the Clerk of the Committee with written responses to the recommendations following the tabling of this report with the Speaker of the Legislative Assembly.

Acknowledgements

The Committee extends its appreciation to officials from the Ministry of Health and Long-Term Care and the HealthForceOntario Marketing and Recruitment Agency. The Committee also acknowledges the assistance provided during the hearings and report writing deliberations by the Office of the Auditor General, the Clerk of the Committee, and staff in the Legislative Research Service.

Background

Medical Education

Medical education is funded jointly by the Min­istry of Training, Colleges and Universities (MTCU) and the Ministry of Health and Long-Term Care (MOHLTC or the Ministry). The MTCU funds universities for undergraduate positions, while the MOHLTC funds most aspects of postgraduate training.

HealthForceOntario Strategy

The MOHLTC and the MTCU jointly developed the HealthForceOntario Strategy (HFO Strategy) in 2005-06 to address concerns over shortages of physicians and nurses in Ontario and long wait times. Responsibility for implementing the strategy lies with the Health Human Resources Strategy Division of the MOHLTC but the responsible assistant deputy minister reports to the deputy ministers at both ministries. This establishes a link between the health care and education systems, and is designed to better manage the supply of health human resources.

HealthForceOntario Marketing and Recruitment Agency

As part of the Strategy, the Ministry established the HealthForceOntario Marketing and Recruitment Agency (HFO Agency) in 2007. The HFO Agency focuses on recruitment and retention of health professionals with the aim of ensuring that Ontario maintains the right number, mix, and distribution of qualified health-care providers.

Audit Objectives and Scope

The audit’s objective was to assess whether the Ministry, in conjunc­tion with the HFO Agency, had adequate systems and procedures in place to

·          identify and assess the appropriateness of the mix, supply and distribution of qualified health-care professionals to help meet the cur­rent and future needs of Ontarians across the province;

·          ensure that HFO Strategy initiatives were delivered in accordance with established regulatory requirements, applicable directives and poli­cies, and agreements; and

·          measure and report regularly on the progress of the HFO Strategy’s objectives.

Summary of the Audit Report[1]

·          In the six years preceding the Audit, the Ministry spent $3.5 billion on the HFO Strategy.

·          Total expenditures for the HFO Strategy in 2012-13 were $738.5 million, an increase of about 65% from the $448 million spent in 2006-07.

·          Ontario saw an 18% increase in physicians from 2005 to 2012 and a 10% increase in nurses from 2006 to 2012.[2]

·          While the HFO Strategy increased enrolment, created more postgraduate training positions, and attracted more doctors and nurses from other jurisdictions, the Auditor General found that Ontario had not met its goal of having the right number, mix, and distri­bution of physicians in place across the province to meet the population’s future health-care needs.

Issues Raised in the Audit and Before the Committee

Ministry staff noted that since the Auditor General’s report was released in December 2013, substantial progress has been made to address each of its four recommendations, which were both informative and useful to the Ministry.

Significant issues were raised in the audit and before the Committee. The Committee considers the issues below to be of particular importance.


 

Physician and Nurse Employment and Service Gaps

The Auditor had recommended that the MOHLTC in conjunction with the HFO

Agency take steps to reduce service gaps and assess the effectiveness of the HFO Strategy.

In their presentation of updated data on December 3, 2014, Ministry staff noted that HealthForceOntario’s role is evolving and the impact of the HFO Strategy from 2005 to 2013 includes

·          a 22% increase in physician supply and a 13% increase in nursing supply, with  just under 70% of nurses working full-time;

·          the development and implementation of different models of care, including 25 nurse-practitioner-led clinics providing care to 50,000 patients;

·          introducing innovative health care provider roles, including physician assistants, clinical specialist radiation therapists, advanced clinical practitioners in arthritis care, and five different new types of nursing roles;

·          creation of the health professionals database and other evidence-based tools for forecasting health care needs and planning for health care human resources; and

·          legislative and regulatory changes increasing the quality and safety of patient care, expanding scopes of practice for individual practitioners, and regulating new health professions.

The Committee notes that while the HFO Strategy has established a stable supply of health professionals, there are still shortages in some specialties and in some areas of the province.

Wait times

The Auditor found that about one-third of Ontario’s graduates in surgical specialities left the province each year between 2005 and 2011. The audit noted that graduates in some surgical specialities lack opportunities for full-time employment, despite long waiting lists for these types of surgeries.

The Ministry has worked with the Council of Ontario Faculties of Medicine on a strategic, evidence-based province-wide approach to medical education planning to ensure the appropriate intake of medical residents in specific specialities, as well as the overall number and mix of residency positions for 2015. Ministry staff explained that prioritization of resources means that Ontarians needing emergency procedures will receive treatment within 24 hours.


 

Committee Recommendation

The Standing Committee on Public Accounts recommends that:

1.    The Ministry of Health and Long-Term Care

a)    identify, by region, which non-emergency procedures have waitlists;

b)    evaluate whether wait times for these procedures in Ontario are reasonable compared to other provinces; and

c)    improve planning for, and implementation of, the optimal number, mix, and distribution of specialists.

Emergency Departments

The HFO Agency is working towards the objective of avoiding the closure of any emergency department as a result of the absence of a physician. A number of recruitment initiatives have been successful in this regard. MOHLTC representatives noted that the emergency department locum program is used primarily as an interim measure. When a physician leaves, the hospital initiates a recruitment process, and uses the locum program for a few months until the new physician is in place.

Northern, Remote and Rural Communities

The Auditor found that the MOHLTC had not evaluated the effectiveness of programs it manages that are intended to increase the number of physicians practicing in rural, remote, and northern areas of the province. The Auditor also reported that hospitals in northern, remote, and rural communities relied heavily on locum programs to deliver needed health-care services.

The Ministry indicated at the hearings that on average, about 92% of Ontarians have a primary care physician.

The MOHLTC described evaluations of several initiatives intended to improve the supply and distribution of physicians in northern, remote, and rural communities including medical education at the Northern Ontario School of Medicine, the Return of Service program, and the Northern and Rural Recruitment and Retention Initiative. The outcomes of these evaluations will be available in 2015.

Committee Recommendation

The Standing Committee on Public Accounts recommends that:

2.    The results of the evaluations of initiatives intended to improve the supply and distribution of physicians in northern, remote, and rural communities be shared with the Public Accounts Committee as soon as they become available.

Return-of-service obligation

The return-of-service obligation requires between two and five years of service in return for being admitted to Ontario medical education and training programs as an internationally trained medical graduate.

The MOHLTC is looking at applying the return-of-service obligations in a more targeted way to direct these physicians to communities where they are needed most.

The Committee notes that while both the return-of-service program and the locum programs bring health care professionals to northern, remote, and rural communities across the province on a short-term basis, it is vital for these communities to have health care professionals who will stay in the communities for the long term.

Committee Recommendations

The Standing Committee on Public Accounts recommends that:

3.    The Ministry of Health and Long-Term Care implement measures to encourage and support recruitment of health care professionals to underserved communities where they are needed, while reducing use of the more expensive locum program.

4.    The Ministry of Health and Long-Term Care

a)    evaluate the extent to which health care professionals continue to work in underserved communities after fulfilling their return-of-service obligation;

b)    seek to improve retention rates so that health care professionals stay in underserved communities for the long-term; and

c)    measure the success of return-of-service programs using long-term retention rates.

Nursing Initiatives

When the Nursing Strategy was launched in 2006, Ontario was experiencing a shortage of nurses. The Audit found that the Nursing Strategy was successful in increasing the number of nurses in Ontario but that Ministry needed to improve its oversight and assessment of the effectiveness of its nursing programs and initiatives. In particular, the Auditor recommended monitoring of nursing employment trends, assessing the outcomes of nursing employment initiatives, and assessing the effectiveness of nurse practitioner-led clinics.

Ministry representatives acknowledged declining participation rates in the Nursing Graduate Guarantee (NGG) program and indicated that the focus of the program will shift from the acute care hospital sector to the home and community care sector. The Ministry has met its objective of having more than 40,000 patients served by nurse practitioner-led clinics. The NGG has also been expanded to better support internationally educated nurses to move into practice.

At the time of the audit, the Ministry had not evaluated whether nurse practitioner-led clinics were meeting program requirements and achieving their patient targets and program objectives.

Committee Recommendation

The Standing Committee on Public Accounts recommends that:

5.    The Ministry of Health and Long-Term Care

a)    evaluate the effectiveness of planned nursing employment initiatives in meeting program goals such as increasing full-time employment of nurses and meeting health care needs;

b)    meet regularly with healthcare stakeholder organizations in the community and home-care sector to encourage their participation in the NGG program;

c)    ensure the implementation of accountability and oversight mechanisms for nursing programs; and

d)    monitor the nurse practitioner-led clinics more closely to ensure that they are meeting program requirements, targets, and objectives.

Financial Oversight

The Ministry provides funding for a range of health-care organizations including hospitals, Local Health Integration Networks (LHINs) and nurse practitioner-led clinics. The Auditor recommended that the MOHLTC perform timely reviews of relevant financial statements in order to improve financial oversight of funded organizations and recover unspent funds.

The MOHLTC has launched a system to improve financial oversight of organizations funded to support health human resources. This new system will generate regular summary reports to inform strategic financial management throughout the fiscal year. Over the past two years, the Ministry has taken aggressive steps to address the backlog of reconciliations and to recover any unspent funds.


 

Committee Recommendation

The Standing Committee on Public Accounts recommends that:

6.    The Ministry of Health and Long-Term Care commit to ensuring annual reviews of relevant financial statements and the recovery of unspent funds from Ministry-funded transfer payment organizations.

Forecasting Supply and Projected Needs

The Auditor recommended that the MOHLTC better ensure effective health human resources planning by providing reliable forecasts of the requirements for physicians and nurses.

The MOHLTC has created a health professionals database and other evidence-based tools to allow it to understand current healthcare needs and to inform health human resources planning in the future. Ministry staff noted that legislative and regulatory changes have increased the quality and safety of patient care, expanded scopes of practice for individual practitioners, and regulated new health professions. Ministry staff noted that having established a stable supply of physicians, their focus is now on more effectively managing the mix and distribution of physicians.

The MOHLTC has improved physician planning, including launching a strategic, evidence-informed approach to planning medical education. Updates have been made to information in existing supply-based models to improve health human resources planning. The MOHLTC also plans to explore what updates and improvements will enhance population-based funding with a population-based risk adjustment for health professional needs in the future.

The Ministry is meeting with a wide range of physician stakeholders to explore the development of a coordinated approach to addressing current and future physician planning challenges. Ministry staff meet regularly with the Council of Ontario Faculties of Medicine to discuss current and projected targets for the number of spaces in training programs for specialists. Reviews have been launched to ensure that selected physician initiatives continue to meet the needs of communities with recruitment challenges.

The Ministry told the Committee that it is continuing to update existing forecasting models with current data, and developing expanded models that address supply as well as demand or need.

Committee Recommendation

The Standing Committee on Public Accounts recommends that:

7.    The Ministry of Health and Long-Term Care improve both short-term and long-term forecasting to better plan to meet Ontario’s health human resources needs for physicians, nurses, and other health professionals, with a view to providing equitable access for all Ontarians.

Consolidated list of Committee Recommendations

The Standing Committee on Public Accounts recommends that:

1.    The Ministry of Health and Long-Term Care

a)    identify, by region, which non-emergency procedures have waitlists;

b)    evaluate whether wait times for these procedures in Ontario are reasonable compared to other provinces; and

c)    improve planning for, and implementation of, the optimal number, mix, and distribution of specialists.

2.    The results of the evaluations of initiatives intended to improve the supply and distribution of physicians in northern, remote, and rural communities be shared with the Public Accounts Committee as soon as they become available.

3.    The Ministry of Health and Long-Term Care implement measures to encourage and support recruitment of health care professionals to underserved communities where they are needed, while reducing use of the more expensive locum program.

4.    The Ministry of Health and Long-Term Care

a)    evaluate the extent to which health care professionals continue to work in underserved communities after fulfilling their return-of-service obligation;

b)    seek to improve retention rates so that health care professionals stay in underserved communities for the long-term; and

c)    measure the success of return-of-service programs using long-term retention rates.

5.    The Ministry of Health and Long-Term Care

a)    evaluate the effectiveness of planned nursing employment initiatives in meeting program goals such as increasing full-time employment of nurses and meeting health care needs;

b)    meet regularly with healthcare stakeholder organizations in the community and home-care sector to encourage their participation in the NGG program;

c)    ensure the implementation of accountability and oversight mechanisms for nursing programs; and

d)    monitor the nurse practitioner-led clinics more closely to ensure that they are meeting program requirements, targets, and objectives.

6.    The Ministry of Health and Long-Term Care commit to ensuring annual reviews of relevant financial statements and the recovery of unspent funds from Ministry-funded transfer payment organizations.

7.    The Ministry of Health and Long-Term Care improve both short-term and long-term forecasting to better plan to meet Ontario’s health human resources needs for physicians, nurses, and other health professionals, with a view to providing equitable access for all Ontarians.



[1] The Audit was conducted in 2013.

[2] See “Physician Employment and Service Gaps” (p. 3 of this memo) for more recent figures.