2008 Legislative Session: Fourth Session, 38th Parliament

SELECT STANDING COMMITTEE ON PUBLIC ACCOUNTS

MINUTES AND HANSARD

MINUTES SELECT STANDING COMMITTEE ON PUBLIC ACCOUNTS

Friday, October 24, 2008

10 a.m.

Douglas Fir Committee Room

Parliament Buildings, Victoria, B.C.

Present: Rob Fleming, MLA (Chair); Harry Bains, MLA; Randy Hawes, MLA; Claude Richmond, MLA; John Rustad, MLA; Bob Simpson, MLA; Ralph Sultan, MLA; Rick Thorpe, MLA; Claire Trevena, MLA; John Yap, MLA

Unavoidably Absent: Olga Ilich, MLA; Bruce Ralston, MLA

1. Resolved, that Mr. Rick Thorpe, MLA be elected Deputy Chair of the Committee.

2. The Committee received a report on the annual conference of the Canadian Council of Public Accounts Committees held in September 2008.

3. Resolved, that the Committee review the Auditor General Workplan at its earliest convenience.

4. The Committee considered the Auditor General’s report entitled Managing Access to the Corrections Case Management System (Report No. 8, 2007/08)

5. Resolved, that the Committee endorse the recommendations contained in the Auditor General’s report entitled Managing Access to the Corrections Case Management System; and recognizes the progress being made by the Ministry of Public Safety and Solicitor General, Ministry of Attorney General, and the Ministry of Children and Family Development and that no further action be taken at this time.

6.The Committee considered the Auditor General’s report entitled Follow-up of 2004/2005 Report 3: Preventing and Managing Diabetes in British Columbia (Report No. 4, 2007/08)

7. Resolved, that the Committee endorse the recommendations contained in the Auditor General’s report entitled Follow-up of 2004/2005 Report 3: Preventing and Managing Diabetes in British Columbia, and recognizes the progress being made by the Ministry of Health Services and the Ministry of Healthy Living and Sport, and that no further action be taken at this time.

8.The Committee considered the Auditor General’s report entitled Follow-up of 2003/2004 Report 4: Alternative Payments to Physicians: A Program in Need of Change (Report No. 7, 2006/2007)

9. Resolved, that the Committee endorse the recommendations contained in the Auditor General’s report entitled Follow-up of 2003/2004 Report 4: Alternative Payments to Physicians: A Program in Need of Change, and recognizes the progress being made by the Ministry of Health Services and that no further action be taken at this time.

10. The Committee adjourned at 1:39 pm to the call of the Chair.

The following electronic version is for informational purposes only.

The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

select standing committee on
Public Accounts

Friday, October 24, 2008

Issue No. 21

ISSN 1499-4259

[ Page 409 ]

FRIDAY, OCTOBER 24, 2008

The committee met at 10:05 a.m.

[R. Fleming in the chair.]

R. Fleming (Chair): Good morning, Members. Welcome back to the Public Accounts Committee. We're very glad to have several new members of our committee, including Mr. Rick Thorpe and Mr. Claude Richmond, joining the committee for the first time. Rejoining is probably the proper term.

We have a full agenda item, with three reports from the Auditor General and with witnesses from the ministries this morning. The first order of business is to elect our Deputy Chair.

I'll just actually ask if we could have a motion to adopt the agenda at this point in time. Any additions to the agenda?

R. Thorpe: I'd like to add an item to talk about the Auditor General's workplan.

R. Fleming (Chair): So to add discussion of the Auditor General's workplan, which our committee must do before the Finance Committee considers the budget for that office. Why don't we make that the new item 3, then, following the report from the CCPAC conference?

Any other amendments? Seeing none, then, I'll call for adoption of the agenda.

Meeting agenda as amended approved.

Election of Deputy Chair

R. Fleming (Chair): It's my pleasure to thank our outgoing Deputy Chair, Joan McIntyre, who is no longer a member of the committee, for the excellent work she has done over the past year or so in that position. She has been here for some of the tough stuff and some of the successes, including naming our new Auditor General. I know she's on to other business with this parliament, and we thank her for her work.

I will call for nominations from the floor for a Deputy Chair.

J. Yap: I'd like to nominate Rick Thorpe for the position of Deputy Chair.

R. Fleming (Chair): Rick Thorpe is nominated.

Are there any further nominations? Seeing none, I will ask Mr. Thorpe if he accepts the nomination.

R. Thorpe: With pleasure.

R. Fleming (Chair): With pleasure.

We will ask for a vote to make Mr. Thorpe the Deputy Chair of the committee. If someone would so move.

Motion approved.

R. Fleming (Chair): Welcome, Rick. I know we'll be more than happy to give you my position as Chair after the next election.

J. Yap: Chair, if I may. This morning, members of our caucus, along with all others, awoke to the news that our colleague the member for Malahat–Juan de Fuca has serious health issues. I just wanted to say that we all have him in our thoughts and, on behalf of our caucus, wish him a speedy recovery.

R. Fleming (Chair): Thank you for that. I expect your caucus will convey that, and I appreciate the sentiment. Our thoughts are definitely with John as he goes through this health issue. We know he'll come through on the other side stronger and louder than ever.

R. Hawes: Not louder.

R. Fleming (Chair): It's possible.

Thanks for that.

The new item 3, then, is the report from the CCPAC. Thank you.

Canadian Council of Public Accounts
Committees Conference

R. Fleming (Chair): Ralph Sultan might want to add to this, but the B.C. team attending this year's 29th conference was me and Josie Schofield, and John Doyle was there as the Office of the Auditor General, which meets simultaneously in a separate conference with some joint sessions with legislators.

It was a very interesting conference this year, hosted in Whitehorse. The office of the federal Auditor General, who audits the Territories' books, did a tremendous job of hosting people from across Canada. Every jurisdiction was represented but for the House of Commons. Due to a snap election call, members of that parliament were busy with other things.

[1010]

We had a number of international guests, as we did last year when Victoria hosted. It really added to the dynamic and the conversation that occurred at the conference. We again had Rick Stapenhurst, who some committee members will know from the World Bank Institute, attending, as well as representatives from Australia at the session.

We were very pleased to be addressed by the Premier of the Yukon, Dennis Fentie, who was able to present a lunch session with the organization. There were a number of interesting sessions. I will just highlight a couple.
[ Page 410 ]

One of them was from the Auditor from Newfound­land and Labrador, who presented the findings of his report, which also had court activities involved in it that were to do with accountability of members, relating to expenses and the conduct of their constituency offices. Some people may recall the news of this episode in Newfoundland and Labrador.

Really, while it was a shameful episode in Newfoundland's political history, it led to all kinds of discussions about accountability — how that loop is really closed by oversight committees like ours and the various independent offices of the Legislature. There were a number of interesting lessons from his presentation.

The other was…. John Doyle and I co-presented an interesting session — at least I hope it was — on trends in public performance reporting. Actually, it was interesting, and we did go on from the Yukon to participate in a two-day follow-up conference in Vancouver on performance reporting in the digital age and what that might mean in terms of performance indicators and public access to information in the real-time, immediate environment that we live in.

I think that probably covers most of it. We did have one final session on the last day on auditing health care. That sort of relates to the agenda we have and two of our reports today. I think we were very much missing the federal perspective because there were no MPs present, but it was an interesting session, and there will of course be the annual conference again next year. Hopefully, a number of members of Public Accounts can attend that as well.

I move my report.

Ralph, did you want to add anything?

R. Sultan: Thank you, Chair. I think you've given a commendable and comprehensive account of these very enjoyable three days in the Yukon, a magnificent territory of Canada. If you have never been to the Yukon, I urge you to do so. It is a startling piece of geography that you'll always remember.

The other thing about the Yukon which I took away was the fact that the total population of the Yukon is 34,000 people. It's smaller than my little community of West Vancouver, and yet it maintains the complete panoply of Premier, opposition members, committees, securities commission and on and on. I presume we replicate this in the other northern territories as well, so I suppose one might say it's certainly an example of democracy in action that we can sustain such an elaborate governance structure on such a small population base.

I came away struck by the fact that since we were a mixture of Auditors General and politicians, it felt like an old glove, talking to these people. They all had the same issues to deal with, including a judicial inquiry on expense accounts in Newfoundland that you've already referred to.

Curiously enough, it did end up with a judge and not with their Public Accounts Committee, which I thought was interesting. The judge who rendered the report came and proudly told us all of the transgressions, which struck me as being primarily a lack of recordkeeping rather than any blatant misdemeanour, but certainly things had become rather careless. I guess we all came away with a lesson on that score.

[1015]

I also came away with the impression — I don't know whether you would agree, Chair — that our public accounts institution here in British Columbia, I thought, looked rather good by comparison when we heard of the practices of some of the other comparable institutions where, for example, GAAP accounting is an unknown phrase.

Governments across the land, from time to time, seem quite at liberty to sort of make it up as they go along — create reserves; move money in and out; claim, by their own rather creative accounting, that they're in surplus when, in fact, I think a more objective assessment would say that isn't quite the way it is. So I felt quite proud of British Columbia in that context.

Performance audits. They certainly seem to look to British Columbia as a leader in this area. Some public accounts committees didn't really seem to do much of that at all.

You referred to the rather freewheeling discussion and brainstorming session on what to do about health care. One member from another province suggested that the health sector had grown so large and so intractable and raised so many complex issues that perhaps there should be a separate public accounts committee just for health care.

That's the end of my report.

R. Fleming (Chair): Thanks, Ralph.

I'll move the report.

Motion approved.

R. Fleming (Chair): We'll move on now to the main items of business. Sorry, we'll actually move on to the addition to the agenda, which is the Auditor General's financial audit plan. We'll have Rick put that on the floor and then maybe some comments from John Doyle.

Auditor General Workplan

R. Thorpe (Deputy Chair): Yes, it's my understanding, Chair — and you and I had the opportunity to discuss this a little earlier this morning — that the Auditor General develops a workplan and brings it to the committee for review, perhaps discussion, of the committee before it goes forward to the Finance Committee, with respect to the budget requests, etc.
[ Page 411 ]

It's my understanding that the Finance Committee is trying to complete its work between November 20 and November 30. Therefore, I believe the committee would be well served if we could get a commitment from the Auditor General and his team that this committee receive the workplan no later than the end of the first week of November.

R. Fleming (Chair): Okay. I'll ask Mr. Doyle just to talk about the progress on that and maybe some scheduling in light of the Finance Committee's upcoming agendas.

J. Doyle: We're planning to send out the workplan at the end of next week.

R. Fleming (Chair): Great.

We're going to look at scheduling meetings shortly now that the House is going to be recalled on November 20. It may be just before or during the early part of when that House is back.

We'll move on to the first item, first hearing — Managing Access to the Corrections Case Management System. I will ask John to introduce the topic and maybe introduce his audit team. I see Bill Gilhooly is with us again and Pam Hamilton. Then we will hear the ministry's response.

I would ask, John…. You've got a PowerPoint that you wanted to direct our attention to, to introduce this report.

Auditor General Report:
Managing Access to the Corrections
Case Management System

J. Doyle: Thank you, Chair. Good morning, everyone. I'm pleased to report our March 2008 report on Managing Access to the Corrections Case Management System, which is also known as CORNET.

With me today is Bill Gilhooly, who is the assistant Auditor General, in our finance group. I also have with me Pam Hamilton, who is an IT specialist and was involved in the conduct of the audit. Behind me there is Ada Chiang, who is also an IT specialist, and also Faye Fletcher, who was involved with the project in the form of quality control.

[1020]

I just want to emphasize that all of this team have been with the office for 18 years-plus, and Faye recently received her 25-year pin for service within the public sector. They've all trained up as IT audit specialists within the office.

This is an audit about how well government manages access to sensitive information. In the past my office has focused on financial systems rather than these kinds of systems, and we're changing that so that we look at both. So this is the first of our focus on non-financial systems — but as you will see, still very important systems. And it's still very important for government to be able to demonstrate that these systems operate as intended, that the information contained within them is not subject to change and that it's of good quality.

Currently at the moment, as part of this shift in focus, we've also got work going on in regard to one of the health authorities, and we're also looking at wireless computing within the Victoria area.

I think it's probably fair to say that the public expects government to properly manage access to confidential information and in this particular case, when we're referring to information around the justice system, even more so.

Managing this access can be difficult. It's a bit like having a building. You need people to come into the building. They need to be able to get in easily. They need to be able to do what they have to do, but you don't necessarily want anyone just wandering into the building and having a look around and doing things. So you need to build appropriate measures of access and accountability to ensure that whilst the access that's required to do a job properly is available, it's not so open that you can basically go in and wander the corridors and do whatever it is that you like.

We carried out this audit, therefore, to assist government in improving its controls and security in one of the key areas of the justice system, and we do expect — and we have found — that the response to our work has been that the issues that we have found are being looked at not only in respect to this system but across other applications that are there, and we expect there to be lessons learned from this review that flow right across the broader public sector in regard to access to information, privacy concerns, data security, etc.

I'm going to turn over to Pam now to provide you a brief overview of the work that was actually undertaken and identify all the key points.

P. Hamilton: Good morning, committee members and the Chair.

As introduced, I will be giving a brief presentation on managing access to the corrections case management system referred to as CORNET. I'll begin with the background, and then I'll explain what we looked at, what we found and what our findings mean.

CORNET is the case management system that's used to track offenders that are serving their time in custody or on probation in the community according to the terms set out by the courts. It calculates their sentences and contains information on offenders' histories, their sentences, the types of offences they've committed, their risk levels and information about their victims.
[ Page 412 ]

The database contains information dating back about 30 years for approximately 400,000 current and past offenders. There are currently about 2,900 offenders in custody and 27,000 offenders in the community. This includes both youth and adult offenders.

There are close to 4,000 system users within CORNET with various access levels. Most of the users work for the government in either the Ministry of Public Safety and the Solicitor General or Children and Families or in the Attorney General. They hold positions such as correctional officers and probation officers. The remaining users are federal and municipal government workers or contract staff, and they hold positions such as Crown counsel and health care workers.

[1025]

What we looked at. We specifically looked at who has been granted access and how well the access was managed. Access should be granted to users based on their position and what they need to have access to. For example, an adult corrections officer does not need to have access to youth offender records, and the records officers should be the only ones that are able to change the sentences.

What we did not look at was the quality of data in the system. This means that we do not look at such things as whether the data was entered properly or whether the sentences were being calculated accurately. Nor did we look at physical access. That refers to such things as the physical accesses around the data centre. And we did not look at the security controls in other copies of the CORNET database.

This diagram shows what we looked at. It's on page 19 of the report. It shows a simplified view of the CORNET environment and shows the six areas where we focused our audit. I'll take a few minutes to go through the components of the environment.

On the left are the user groups and the network access methods. This shows that the users enter either through the government network or from specific external networks or through secured remote connections. The firewall, marked on the diagram as No. 1, is the device that all connections arrive at. The firewall rules should be set up to only allow certain types of connections — certain networks should go to the application and certain ones to the database — and then to stop all other unknown connections.

The application, which is related to No. 2 on the diagram, is what the users use to enter and view data. The application can be set to allow users to only see and change certain data according to their position.

The database, marked as No. 3, is where all 400,000 offender records are stored. The data is retrieved by the application for the users to work with. There should be controls that do not allow the users to access the database directly, as users should only go through the application to get to the data.

What is important here to know about the operating system, which is marked as No. 5, is that if not properly restricted and secured, it could provide a point of entry to allow someone to gain full control of the data.

The last components, labelled No. 6 on the diagram, are the links to external databases. The links allow data to come in or out of the CORNET database, so it is important that these links are secured and authorized. We looked at the links, but we did not look at the access to those external databases. It was in this area that we focused our audit. In each area we were looking for controls that would provide an adequate level of security.

What we found. At the application level, which is No. 2 on the diagram, we found that the access granted through the application was for the most part appropriately assigned, meaning that positions such as the corrections officers were in fact given the appropriate access for them to conduct their job. But in saying that, we did find that there were some incorrect accesses, meaning that some users could view or change data that they should not have access to.

We also found that maintaining access was an issue. Access was not removed promptly when users resigned, retired or went on extended leave. This was because the process that was supposed to be set up to alert key people to change their access assignments when they went on leave or resigned was not being followed properly.

At the database level, which is marked as No. 3 on the diagram, we found that several controls broke down. This meant that a large number of users could bypass the application and go directly to the database. If a user did enter this way, they would be able to change, view or download any data from the database. This was due to a few incorrect settings in the database and in the firewall to prevent entry, and then insufficient monitoring to detect such entry.

[1030]

At the operating system level, which is No. 5 on the diagram, we found that a particularly powerful user ID was being shared by a few IT support staff. The risk here is that if the user ID were to be compromised, it would be hard to detect because of the fact that it was being shared. If compromised, it would allow full control of the database.

Another issue we found, which relates to both the database and the operating system, was that the vendor-supplied updates, called patches, were not being applied. This could potentially result in a break-in or a disruption of service.

Our last key finding was the role of the security group. They set the security policy, and in many situations the IT support staff apply the security settings. But we found that the security group has not taken on the next step, which is the role of enforcing the policy and advising the IT support staff in the production areas.

What do these findings mean? Overall, our conclusions are that at the application level the assignment of access
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was good, but at the user maintenance level access was not removed promptly when users should no longer have it. At the database level several controls needed strengthening to adequately protect the database. These issues were brought up to the ministry during our audit, and controls to fix the gaps were implemented quickly.

In total, there were 92 recommendations in the detailed management report, which were fully supported by the ministries. And 34 of these recommendations were brought forward to the public report and were in turn summarized into nine key recommendations, which are on page 8 of the public report.

This concludes our presentation on the audit of the CORNET system.

R. Fleming (Chair): I thank you for that. I think the best way to proceed might be to ask the comptroller general to call witnesses from, probably, the Ministry of Public Safety and Solicitor General to make their presentation. They have a PowerPoint as well, and then we can have questions from members on any of the presentations following that.

C. Wenezenki-Yolland: We call the witnesses from Public Safety and Solicitor General.

We have Robert McDonald, executive director and chief information officer, Ministry of Public Safety and Solicitor General; Rob Watts, provincial director, Ministry of Public Safety and Solicitor General; Bill Young, director of strategic technology, corporate projects, Ministry of Public Safety and Solicitor General; Mark Scherling, director of privacy, risk management, information security management, Ministry of Public Safety and Solicitor General, and Ministry of Attorney General; and Barry Lynden, director of youth custody services, Ministry of Children and Family Development.

Welcome.

R. Fleming (Chair): Thank you. Welcome, Robert and the rest of the ministry that's here with us this morning. I will ask you to take it away and give your response to the report.

R. McDonald: Thank you for the opportunity to respond to the Office of the Auditor General's report on managing access to CORNET. I'll skip over the introductions, since they've already been done.

As part of our response, we thought we would just complement the background that was already given by the Office of the Auditor General, talk a little bit more about the ministries involved in using CORNET, CORNET itself, our response to the audit, our conclusions, and then answer any questions that you may have of us.

[1035]

The Ministry of Attorney General, which I report to, has a division called the information technology division. If you will, we are basically the custodians of the CORNET systems, including the database, applications and some of the security technology that is in place for CORNET.

The two primary users of the corrections system are the Ministry of Public Safety and Solicitor General, specifically the corrections branch…. They are the co-owner of the application and responsible for all of the adult offender data. The other co-owner is the Ministry of Children and Family Development, who are the youth justice services and co-owner of the application and responsible for young offender data.

To complement the discussion that Pam had, CORNET is a mission-critical adult and young offender case management system designed to support court-ordered supervision of approximately 27,000 offenders in the community and 3,000 offenders in custody.

To put access control into the context of the youth and adult corrections environment, there is a strong requirement, including seven-by-24 access, for timely and comprehensive access to sensitive information to obviously manage the risk posed by these offenders and to protect the community, victim and staff from these offenders, whether they're in the community or in custody. Although there is a strong requirement for systems security, we need to balance that against effective access controls.

In terms of a response to the thorough examination of CORNET by the Office of the Auditor General, our ministries did appreciate the professionalism of the audits team examination, including the steps they took to protect the information that could cause future harm to the integrity of the CORNET system. Although there were some significant findings, we were encouraged that our security was appropriate in most circumstances. The audit provided great insight into where we could improve access controls moving forward.

Our staff worked cooperatively with the audit team throughout the review, and we were able to remediate most of the problems when they were identified, almost immediately. In a few minutes I will identify other issues that will require medium- and longer-term solutions and strategies.

The outcome of the audit is improved security for both database and application, and we do remain committed to addressing all of the findings and recommendations contained in the report by the Auditor General.

I should say that security is of utmost importance in the justice sector. All of our staff that has privileged access, whether they're correctional officers or IT staff supporting these, have extensive background checks and security checks done before they're allowed to access the system.

As for the bulk of the recommendations, we have made some adjustments in user access levels to meet the recommendations of the audit. As chief information officer
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I immediately issued a directive to all business areas to ensure that staff transactions such as leave, retirement or extended leave were immediately addressed in terms of access control. Periodic reviews are now in place to monitor that compliance.

Database accounts and access have now been revised, as have application and user accounts. The CORNET database has been moved to a new high-security zone. The database has been upgraded to Oracle's recommended version, and the appropriate security patches, as identified by the Auditor General's report, have been applied. Again, periodic reviews and audits are in place to monitor compliance.

We're now in the process of improving audit logs and the monitoring capability of the application and database. Formal security policies have been reinforced, and once again, periodic reviews and audits are in place to monitor that compliance.

Of the 92 recommendations, 65 were addressed within the first 90 days of having received the draft report from the Office of the Auditor General. Ten recommendations will be addressed by the end of this month, and 13 recommendations will be addressed by the end of March 31, 2009.

The four remaining recommendations will require longer-term action plans, including funding. They would include such things as comprehensive risk management strategy, provisioning and access strategy, vulnerability management strategy and a patch management strategy.

[1040]

As I said earlier, the justice sector does take security very seriously, so I thought I would demonstrate that by having a few other activities that are ongoing within the justice sector itself. We are constantly deploying new tools to automatically scan and report on vulnerabilities. External access to the security zones require two-factor authentication by the end of March 2009.

All access to security zones will require two-factor authentication by 2011, so that is both internal and external access. We are in constant development of new automatic logging, auditing and monitoring capabilities into our system.

In conclusion, we found that the Office of the Auditor General's audit was valuable and that it gave us insight into some of the weaknesses of CORNET's access, most of which we were able to address immediately. We have improved the security of the information under the control of the ministries, and we have increased awareness of the program and IT areas. Above all, this continues to improve the overall information security of the justice sector.

Thank you for your time. We'd be happy to answer any questions.

R. Fleming (Chair): Thank you, Mr. McDonald.

Questions from members.

J. Yap: Thank you to both for the presentations. This is obviously a critical area. It sounds like the Office of the Auditor General did excellent work in reviewing this complex area.

I want to get to the core question, which is whether the system worked in preventing unauthorized access. So my question, I guess, to the audit team is: during the course of your review, did you find any instance of unauthorized access?

J. Doyle: There was some…. It's a hard question, member, because the records that were maintained lasted, I think, for 30 days. So we had a window of 30 days where we could go back and have a look. Bearing in mind that it was a fairly strong system anyway, it is not beyond possibility that access did take place, and we wouldn't be able to say exactly what occurred in there. So the issue is that it's a possibility. That door has now been closed.

J. Yap: So within the 30-day window of your sample, if I could put it that way, did you find any instance of unauthorized access?

J. Doyle: There were some suspicious footsteps and records, but we can't find out enough about what happened in those particular instances to know what occurred.

Would that be a correct…?

Perhaps the ministry could tell you more.

J. Yap: Yeah, to the ministry to respond to that.

R. McDonald: I would have to say no. We have no evidence that has been brought to our attention of any unauthorized access either through the logs or through our employees or through the management.

J. Yap: And I assume — if I may, Chair — the instances of suspicious, perhaps, attempts…. You're satisfied in your own review that they're explainable?

R. McDonald: Yes, and as John Doyle has indicated, we have now closed those gaps.

J. Yap: So the conclusion, then, is that this review showed that there were no breaches of the CORNET system by unauthorized users.

R. McDonald: Correct.

J. Doyle: I wouldn't go as far as to say that, because I rely upon a level of evidence which means that I can put my opinion to that, and I don't have that evidence. As I said, we found some footprints, but we couldn't say what had actually occurred or if anything was changed or if anything was downloaded.
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It was a sensitive area. One of the concerns I've got is that the log only lasted for 30 days, so there was no history.

[1045]

I think I'll reiterate. The doors have been closed, and there is a higher expectation and sensitivity to these kinds of issues. If it wasn't already high, it's even higher now. And as the door is closed, then going forward we would suspect that such issues, if they were attempted, would be picked up immediately.

B. Simpson: To the Auditor General: in your introductory comments you talked about the fact that this has public sector–wide implications. So there are other databases out there that have similar security issues and rights-of-access issues. Is there any sense of the government, to your knowledge, taking this example and doing some of the work on a broader basis?

J. Doyle: It would be fair to say that my teams, as they go out and conduct audits, frequently comment on some of the issues that are quite basic, like access controls, password management, people being on leave or retiring or leaving not being removed from lists of access.

A higher degree of sensitivity is being demonstrated within government in regard to getting on top of these things and making sure that there's a faster response time — similar to the way that the ministries in this particular case responded.

Just because we do an audit in one area doesn't mean that everyone else can lean back and go to sleep, basically. I think that in this particular case, it was quite clear that there is another major system within justice that needs to be looked at. The lessons and the issues that have been uncovered under CORNET are being applied to that system or have been applied to that system, although I'll let the ministries respond to that precisely.

So that one audit could actually have a ripple effect right across the system. I would argue that that is the same outside these three particular ministries as well. We should be looking at what lessons can be learned from this particular report, and CIA should be saying: "How does that apply to where I'm working and the space that I occupy, and what sensitivity is there in regard to actually making sure that the general level of security is improved right across the whole of government?"

I'm sending that message, and I will be following up as I go forward to ensure that, in fact, that message has been listened to and acted upon.

B. Simpson: Just a point of clarification. When we talk about victim data all being in the system as well, is that part of what the report refers to as a sealed data? There was the youth offenders data, and then there was sealed data. Is the victim information in that sealed data? Do you know?

R. Watts: The victim data is, in a sense, in two components. Much of it is inputted by our staff. Again, they don't have to seal it from themselves. There is another component where the victim services access CORNET data, and that is a one-way flow, in a sense. Our staff have no opportunity to use that aspect of the system to access any victim data that may be visible. So the victim data that our staff have access to is indeed victim data that is inputted by corrections or MCFD staff.

B. Simpson: On a specific point from the Auditor's report, with respect to the youth data, has that been rectified so that that is not openly accessible to the adult offenders corrections officers?

B. Young: This issue of the youth sealed data and access…. Currently the data is sealed according to the rules of the YCJA. CORNET in fact is the only application in Canada that is fully compliant with the YCJA. So the rules within the application manage when data should be sealed.

[1050]

The concern that was raised by the Auditor was that some access levels of some staff members — so these are fully cleared correctional officers and youth justice officers — allowed them access to youth data that was not sealed. There has been, to my knowledge, no access to youth sealed data other than where it's appropriate through the application. There are potential risks with that — access to the database and so on and so forth — but I think it's fair to say that the steps we've taken on the recommendations of the Auditor have addressed those things.

B. Simpson: Thank you. And my final question. In my previous life before politics, I did change management for large corporations, and IT was a real issue for us, because there are three parts to the system. One, of course, is the system construction, the actual guts of the system, and it has to match the organization's needs, the rights of access, how you layer it — all of those things.

The second part of the system is the administration of not just the system but the personnel. Some of the recommendations the Auditor General is pointing to have to do with the breakdown in that system. For example, as employees rotate through or go on leave, etc., you need to administer their access and so on. That's part of that system.

Then the third is the personnel. Do you have the right people with the right skills? If you've got high employee turnover, are you doing the right training, etc.?

I didn't get a sense from this audit that the system was fully looked at, that what you were doing was drilling down on the IT component. The response from government is mostly focused on the IT component. There are other parts of the system where there are evident breakdown and vulnerabilities.
[ Page 416 ]

In my experience, if you do an intervention like this, you bring the focus — and that word has already been used — but it may last six months, because the other parts of the system haven't been addressed.

Do we have the right number of personnel? Do we have an issue with being able to retain personnel that have the knowledge? Are we managing the system appropriately from an administration level?

So can you give me a sense…? Are you looking at it? Is anybody kind of stepping back and looking at it from that perspective? As you look at the retirees — for example, the turnover — all of those things are part of this system, and simply fixing security or putting the database into a more secure place will not address what I see as the other system failures that are occurring here. So is somebody looking at it from a more macro level?

R. Watts: I think the quick answer — and not to be superficial — is yes. We have a very structured process in place, specifically around training. We do have a series of checks and balances, if you would, in place. Clearly, they were not as enforced as they should have been, and there is no question about that. I think that has been rectified both through the work of ITSD and our own work.

I think it is an ongoing issue totally unrelated to the audit. I just use this as an example. Our assistant deputy minister recently sent a memo, as it were, to all staff in our branch, reminding them of the sensitivity of all electronic information and around the need to ensure that it is protected at all times. Again, it was not related to the audit; it was just what I would call a fairly sort of standard process. It needs to be done on an ongoing basis, because people can become complacent on these issues.

From the corrections branch point of view, we certainly do take it seriously. We do have an internal audit process around quality control, which we maintain and which we've always maintained. I think vigilance is something that has to be an ongoing process. There's no question about that.

C. Trevena: I just wanted to pick up on a couple of questions that preceding members have mentioned. I was very interested in the response to the questions by the member for Richmond-Steveston, Mr. Yap. I was wondering…. The logs were only kept for 30 days. Is there any move to keep the logs for longer now so you can track back if there is any issue there?

[1055]

M. Scherling: Yes, we are actually looking at what is called a security event and information management system to allow us to track that longer. The problem you get is: how much information do you want to keep over what period of time?

Those are things that we're looking at. We're trying to plan for the future. We're looking at somewhere around 2011 to try and implement that as part of the bigger program, which we are doing for the security across all of the systems.

I'm hoping that answers your question.

C. Trevena: It does. But you're talking 2011, which is another — at least — two-plus years. Are you going to be keeping the logs any length of time before that?

B. Young: Maybe just a point of clarification. The application — the front end that the staff use and the authorized users use — is basically fully logged. So there's a footprint of all access — where they go, what they do, what they see, what they add or, for that matter, change.

The question of the audit logs on the 30 days or on the database side, which has very restricted access…. Fortunately, the Auditor pointed out some holes there which we were able to plug. We are working on increasing the capacity of the logs there. The issues that I think Mark is referring to are that it takes some time to build that kind of capacity. That's partly where the funding issues come in.

We're comfortable on the application side that we have the right controls in place, but we're working on improving the ones on the database end, which is behind the firewalls and has been made more secure, thanks to the audit.

C. Trevena: I have one other quick question. We're talking about three different ministries involved and outside users as well — to wit, the RCMP, victim services and others. What sort of coordination is there? Everybody is going to have their own chief information officer or their own IT group, and they're all going to have their own unit working on this. How are you all actually working together?

B. Young: It's an effective collaboration, in short. Going back…. CORNET has been around 30 years. It's one of the earlier systems in government, with a database and a lot of personal information in it. It's evolved over time.

At one time, as you probably all know, Attorney General was one ministry, and youth was part of corrections. One of the divisions or the separation that you see up here in the presentations, or perhaps in the fact that there are many of us around the table, is a result of the fact that youth is now with MCFD. AG is now AG and SG.

We've kept a central office for IT, which has been very effective. Rob's shop and Mark's shop have the…. We collaborate with them, both from the Ministry of Children and Families and ourselves, over CORNET. The relationship between us is an effective working relationship.
[ Page 417 ]

So a central agency for the ministry…. We build some of the better justice technologies in North America. As you may know, CORNET and JUSTIN and the other justice suites have been purchased by Quebec, and there are other provinces looking at it. This is a result of, if you will, an effective collaboration.

The relationship — relatively new, I suppose — with WTS and the chief government information officer is funnelled mainly through our ministry's CIL. So that, again, is about collaboration and partnerships.

Yes, it's complex. Is it effective? Yes. Will it continue to help us improve the application? Yes.

R. Fleming (Chair): Thank you.

Other members?

I just wanted to ask a couple of questions myself. There was a significant amount of recommendations. The comment was made in the audit report that more weaknesses were found than perhaps anticipated. There are always vulnerabilities in any database and any user-access system like this.

Some of those recommendations you've been able to act upon quickly. Others are in process. One of the weaknesses around the database was that…. While it's extremely unlikely, because of the knowledge one would have to have to get at the database, nevertheless, if somebody was able to corrupt or use an Oracle user ID, they would be able to access not just the CORNET database but all databases of the Attorney General Ministry.

[1100]

I'm wondering if that was one of the recommendations that the ministry was able to act on immediately to correct. We've heard today that there are logs on the user interface, and they're maintained for 30 days. But it's more difficult to track activity within the database.

I'm just wondering. The Auditor doesn't know, but he can't assure us that, for example, someone hasn't downloaded significant portions of a database like this with a huge amount of records on British Columbians. I want to maybe hear from ministry officials to give this committee some assurance that they're convinced that nothing of that type of activity occurred or has been occurring in CORNET.

R. McDonald: I just want to clarify that the authorized access is only limited to internal staff. So the diagram that the Office of the Auditor General had up there with the firewalls — that all protects…. Anybody else that is not identified on there basically has no access through all of the other controls such as firewalls and intrusion detection devices.

So the scope of your question really is folks that work within the justice sector specifically that have access to CORNET. Because you have access and you have an Oracle ID that would connect you to CORNET, that does not give you access to any of the other applications within the justice sector, of which there are numerous applications.

There are some privileged IDs, as was identified in the Office of the Auditor General report. Those are specifically restricted to those trusted individuals that have background security checks and have limited access to the databases, purely for support purposes and ensuring that the reliability of the application is maintained so that we have that seven-by-24 access.

R. Fleming (Chair): Okay. Well, I'll accept that answer for the time being. What I will ask is…. I’ll just focus on another finding in the audit, and that was around IT support staff. Obviously, there's a tremendous dependence on them to maintain and make the system function. Several of the findings or recommendations dealt with who monitors the IT staff, and the findings were that IT staff are often accessing, updating and maintaining the database using the same user ID, therefore making it indistinct which actual employee is accessing the system and altering the system.

I'm wondering if that's something that has been corrected, if it's one of the things that were seized upon as a result of the audit findings. Also, I suppose the issue really is that — maybe this is for comment…. Is there some way to have IT staff, I suppose, supervised? The electronic trail, it was suggested, can be erased or not noticed by others. Basically, the question is: who is overseeing the IT staff and then reporting back to ministry officials?

R. McDonald: Yes, that was identified as part of the office of the Auditor General report and audit, and we have immediately…. That was part of the 65 recommendations that were immediately fixed.

As far as the question around who is watching the people with the golden keys, that's a very good question. There really isn't a good answer for that. There are technologies that you then again put in place, but eventually somebody has to have the golden key to manage the rest of the golden keys. So you have to absolutely put your trust in somebody eventually to do that due diligence.

How we try to manage that risk again is with regular background and security checks of our staff. We do look for anomalies when there are breaches. When I say a breach…. Somebody makes a mistake or there's questionable activity that is raised and escalated to folks like myself, where we will interview the staff and find out exactly what has gone on and ensure that there hasn't been a breach to information or to any of the public policies of government.

[1105]

I know that also extends into the line of business on both the adult corrections and youth justice corrections as well.
[ Page 418 ]

R. Fleming (Chair): I can see the dilemma. Other areas of the audit findings show that there was just too much access, and people who no longer required access weren't being denied the ability to do that, so obviously you have focused on paring down the thousands of people who have access and found some that shouldn't.

There were also some comments in the report about some people having too much ability to alter records. I'm wondering if one of your reforms coming from this audit has been to have different levels of clearance and page views and abilities based on the need of that employee and the system, and if you could maybe just describe what changes have come as a result of the audit in that regard.

B. Young: Yes. To some extent you're damned if you do, and you're damned if you don't. CORNET, in fact, has multiple layers of access for staff. So a correctional officer needs to see ten pages of information, but a records officer, who admits an offender and enters their sentence details and their victim information and those kinds of things, needs access to 30 or 40 screens.

So we have about 25 of those levels. A Crown counsel out in Prince George needs to have access to this information in our database on a relatively restricted view of the activity with the corrections branch of this offender that's before the court — you know, what's he been doing for the last ten years? So they have even less, but they have a profile just for them. Each of these job functions, if you will, has profiles.

What the problem that you've pointed out was that…. Certainly — I'll use correctional centres as an example or perhaps probation offices — we transfer staff between offices. Or in a correctional centre — 24-hour operation, seven days a week — a records officer goes on holidays, so we have backfill staff for them — specially trained, authorized, approved staff who can come from the line and work in that records department to do that job function on a Saturday afternoon. They pop in and out. Staff rotate. There's a lot of change in a large institution like that.

A lot of the instances where the staff had too much access were where they were either previously trained to be in that records area or a function had changed where they no longer required that level of access. They belonged to a group that had too much access. So we made those changes, and that's what the review did.

The other issue, I think, for us is that as staff transfer and retire and so on and so forth, the ability for us to get that information…. Whether it's the ministry shop or our shop in terms of administering access rights, we need that information from the field. So it could be from a Crown office; it could be from our own office. But when a transfer or a retirement happens, we need that fairly quickly.

Now, the access controls do expire if you don't use it for 90 days, so it's not like they stay active forever. However, we want to be able to shut that down quite quickly, and that's why our CIO put out the message saying, "Give us the information to the central agency immediately," so we can adjust those — both the access, the ability to access and the levels of access you should have.

So if you've transferred from Prince George to Vancouver, we want to know that. The way CORNET also works is that you only get access to the information about a group of offenders that are unique to your office in Vancouver or unique to your office in Prince George. Those are the controls that we do have in the application, but if we fail to make the changes quickly, then we're defeating ourselves.

R. Watts: Just one further point is that, again from the program perspective, because most of our staff have an obligation to enter data, there is a control in the sense that within 24 hours, that data cannot be changed. It has to go back to our central quality management unit, and if any data that is being, as I say, entered for longer than 24 hours…. So that holds true for all of our staff.

[1110]

R. Thorpe (Deputy Chair): I would just like to say…. This is obviously my first meeting back on Public Accounts, which I did serve on some time ago.

This, to me, is an example, a very good example, of the Auditor General's staff…. I note that the Auditor concluded his report, which was only dated March 2008…. That says: "I would like to thank the staff in the Ministries of Attorney General, Public Safety and Solicitor General, Children and Family Development, Labour and Citizens' Services for the cooperation and assistance they provided my staff during our work on this audit."

I noted that Mr. McDonald, when he made his presentation, thanked the Auditor General for the work that they've done. I also note that as of March 31, 2009, which will be one year after the report was issued, 96 percent — 96 percent — of the recommendations will be implemented.

Again, it's been some time since I've served on Public Accounts, but to me, I think that demonstrates the seriousness with which the recommendations from the Auditor General's department have been taken by the individuals in the ministries I represented earlier — the protection and the security of this information — in discharging their responsibilities.

So I wanted to recognize that 96 percent of the work will be done in a year. Thank you very much for doing that, guys — and from both of you.

R. Fleming (Chair): Seeing no further questions from members, I will just suggest a motion, which maybe Mr. Hawes has already beat me to, based on what we heard, that this committee endorse the report's recom-
[ Page 419 ]
mendations and note the progress by government in implementing them to date.

Is there discussion on that from the members? Seeing none, then I'll call the committee to vote.

Motion approved.

R. Fleming (Chair): With that, I will thank our number of witnesses for being here this morning, for presenting and for answering our questions. And thank you for your work with the Auditor General's office in implementing the recommendations and the work. It sounds like it's been a very valuable exercise for everyone involved.

Switching gears a little bit, next we have a report on preventing and managing diabetes in British Columbia.

It may just take a couple of minutes to set that up, so members might want to stretch their legs but not go too far.

The committee recessed from 11:13 a.m. to 11:18 a.m.

[R. Fleming in the chair.]

R. Fleming (Chair): We will ask the Auditor General to begin the presentation on Preventing and Managing Diabetes in B.C., and I'm especially pleased that the presentation appears to be a mere eight slides long.

Well done, and carry on.

Auditor General Report:
Preventing and Managing Diabetes
in British Columbia

J. Doyle: I would point out, Chair, that two of the slides are just header pages, so it's really only six slides.

Thank you for the opportunity to present this report. It's a follow-up. I won't be saying many words in advance because Morris Sydor, who is with me and is one of the assistant Auditors General who is responsible for the original work and also for the follow-up, will go through a brief presentation. So I'll hand it straight over to Morris to get started.

M. Sydor: Good morning, Chair and committee members. Yes, as you've seen, this is going to be a very, very brief presentation. What I'm going to do is just take you through the events leading to the follow-up report.

If you look at our original report…. It was issued in October of 2004, and it contained three recommendations. That report was reviewed by the Public Accounts Committee in January of 2005. The committee at the same time issued its annual report of the Review of Auditor General Reports, in which it endorsed the three recommendations, and it didn't add any of its own.

If we go back to the original report. Our audit purpose was to assess whether British Columbians were receiving value for money from B.C.'s efforts to manage and prevent diabetes. Our overall conclusion was that significant change is needed, that B.C.'s efforts to prevent and manage diabetes are praiseworthy but inadequate to address the extent of the problem.

[1120]

We structured our report along these lines, looking at primary prevention of diabetes, secondary prevention, management of those who have diabetes and then how well the government reports on the results of its programs. The report contains the three recommendations that I've mentioned.

The recommendations were unusual in that, rather than being addressed to the ministry, they were being addressed to the provincial government. One of the main reasons for that was that many of the prevention tools were actually held by agencies other than the Ministry of Health. As well, if the ministry was going to achieve the sort of results it expected, significant investments would have to be made in programs for preventing diabetes.

Our three recommendations focused on presenting an organized approach for the ministry and government to search out the best mix of program efforts to be used in this endeavour.

Those three recommendations were, firstly, to search out effective research-supported methods of preventing diabetes and pilot-test these in B.C. to determine which ones should be used in our jurisdiction; secondly, to provide to cabinet a well-supported set of strategies, including the costs and benefits of applying them and the costs of not applying them; lastly, of course, to implement the chosen strategies in a way that achieves effectiveness and is sustainable.

We issued a follow-up report in October 2007. That identified the status of the recommendations as of June 2007. At that time the three recommendations in the report were all identified by the ministry as being partially implemented.

I would just advise the committee that we have completed a second follow-up recently, and we will be issuing a series of follow-up reports in the near future.

That concludes my presentation on our eight slides.

R. Fleming (Chair): Well done, Morris. Thank you.

Committee, I would recommend again that we hear from the Ministry of Health Services' witnesses. Stephen Brown is here to present the ministry response, and then we will have questions from members.

S. Brown: Thank you. This is my first time in front of a standing committee, and I think we failed straightaway because I think it is a 41-slide deck. So apologies for a 41-slide deck — only 39 if you take off the front and the back.
[ Page 420 ]

R. Fleming (Chair): We're going to have to pace it well, then. I think that's our challenge here.

S. Brown: We will pace it well between us. Also, the responsibility, as Morris said…. There's a broad responsibility. But just specifically in terms of this presentation….

The presentation is from the two ministries now, the Ministry of Health Services, for which I will present the second half of the presentation, and then the Ministry of Healthy Living and Sport. Andy Hazlewood is the assistant deputy minister. Also assisting is Sylvia Robinson, who knows a lot about the data and some of the analysis behind some of the slides that we'll be providing and so is here to provide assistance.

Just in terms of some background very quickly, diabetes is a chronic condition that results from the body's inability to sufficiently produce and use insulin. There are three types. The most common type is type 2, which accounts for 90 percent of the diagnosed cases.

Using a probabilistic tool, we believe that there are approximately 265,000 individuals here from '06-07 with confirmed cases of diabetes. The risk factors are quite well known in terms of being overweight or obese and lack of physical activity.

What that translates to is that we have approximately 6.2 percent of British Columbians who have diabetes. It is spread broadly, obviously, across the population, not concentrated in any one particular physical area, so it is dispersed across the population. Importantly, it often occurs in combination with other chronic diseases as an individual ages.

[1125]

The actual complications that result from diabetes, which then have quality-of-life implications as well as cost implications, include cardiovascular disease, kidney disease, damage to sight and limb amputation. Some of those indicators we'll come to right at the end of the presentation, showing some of the trend lines and where we think there's some indication of the impact that we're beginning to have in terms of addressing some of the issues associated with the disease.

In gross terms, approximately $880 million is spent, so it's a significant amount of money that is spent. Various analyses talk about what might be done, because this is very much, in terms of the type 2, a preventable disease. Various calculations are done, but what we have put in the deck wouldn't be unusual in terms of estimates that up to 25 percent could be reduced, in terms of diabetes, if there were effective systems in place.

That could lead to savings — rather than savings, it's probably more correct to say cost avoidance — into the future of $200 million by implementation of lifestyles modification programs as well as effective management of the disease when it occurs. As was mentioned by Morris at the beginning, this isn't a simple one-ministry strategy. This is a complex issue across society and therefore, at a government level, for multiple ministries.

Morris talked to what the recommendations and the assessments were, so I won't talk to that. Simply, on this slide we've kind of framed how we will do our presentation, which you see the individual there at the bottom of the slide, and there are really two major directions that you can go in. There's a prevention approach, which Andy will talk to and, in particular, talk about the initiative the province has taken with ActNow B.C.

Then when the disease occurs, there's an opportunity, through effective chronic disease management or proactive management, to impact on the course of that disease over a person's lifetime, both in terms of the quality of the person's life and the longevity of the life and in the complications that can occur. Without that occurring, then you end up with reactive, episodic care, which is one of the most expensive options.

So the focus that we've had across the two ministries is on the prevention side and then also beginning to frame out more effective ways for the clinical management of the disease once it occurs.

With that, I'll hand over to Andy, who will actually talk through the prevention piece of this.

A. Hazlewood: My name is Andrew Hazlewood, Assistant Deputy Minister with the Ministry of Healthy Living and Sport. We thought we would do this as a bit of a tag team, to both reinforce the importance of the two ministries working together. It wasn't long ago that I was part of the Ministry of Health Services. With the new ministry creating a focus on healthy living, it certainly gives us an opportunity to do even more and better around prevention and ActNow.

I thought I'd just frame what I'd like to say. I'd like to talk a little bit about ActNow — not as a program, because it really isn't a program. It's a platform, and it's really quite unique, certainly in this country, and quite a unique platform that the world has really taken a close look at.

I'd like to talk a little bit about a project we've had underway for the last two or three years of describing public health core functions, relate that to this particular issue and then wrap up my presentation with a bit of a discussion around the first nations health plan and how that ties into diabetes and diabetes prevention.

Lifestyle modification has been mentioned a couple of times. It sounds so easy, and yet it is probably the most difficult task we have in government — to try to influence a societal norm. Most individuals know that you can be healthier if you have more physical activity. You can be healthier if you have good nutrition and a good diet. You can be healthier if you don't smoke. Certainly you can be healthier, especially during pregnancy, if you avoid alcohol consumption.

For society to change the behaviour, it requires, I believe, a whole-government approach, and that has
[ Page 421 ]
also been mentioned earlier. Ministries of Health or of Healthy Living and Sport cannot change a societal behaviour without the engagement of society itself. That's really the unique piece of ActNow.

[1130]

What we're trying to do is actually use a platform that will create a societal change within British Columbia by using all of government — not just one ministry or two but all ministries of government — and at the same time engage civil society in ways that we have never really engaged those non-governmental sectors and those other organizations that we have in the past.

The key to ActNow, as I would describe it, would be…. You have to set an overarching goal — some aspiration — that government would like to meet. Historically those goals associated with healthy living have been established and set by Ministries of Health, and yet the Ministries of Health never have the mechanisms or the policy levers to actually accomplish those kind of goals or targets.

So we have, for the first time, an overarching goal: to be the healthiest jurisdiction to host the Olympics. That has driven a set of goals and standards that we are trying to achieve, and they have to be achieved through a whole government approach, not one ministry at a time.

The progress that we've made with regard to ActNow. I think we can find that within tobacco and within our obesity rates. Obesity is really a combination of healthy eating and increased physical activity. In 2007 we actually accomplished the target that we’re set, as a whole government, of 14 percent of the adult population as smokers.

That particular accomplishment is probably as good as any jurisdiction in the world. We're really quite proud of that, and if that chart went back several more years, the progress that we've made within British Columbia of reducing tobacco prevalence here in British Columbia is really quite remarkable and probably as good as any other jurisdiction in the world.

This is rather a busy slide, but it's relatively new. It's self-reported obesity rates from 2005 to 2007 across Canada. You'll note that British Columbia, while generally the best in the country, was the only jurisdiction to actually see a statistically significant decline in obesity rates. Every other jurisdiction either went up….

British Columbia is on the far left. Alberta had a significant increase. If you take a look at those lines at the top, those are within the range. So if you look at Saskatchewan, which is the next one over, while it appears that it went down slightly, it probably stayed the same.

So British Columbia, for the first time, is the only jurisdiction in the country where the obesity rate is actually going in the right direction. These are our obesity rate trends from 1996 to 2007, and you can see that from 1998 to 2005, there was a general increase in our obesity rates in this province. We have for the first time seen a decline in 2007.

A brief discussion around public health core functions. We're attempting to sit back and do a systematic literature review of a best-practice model for a variety of public health core programs. There are 21 of them, and if you're interested, I can provide the committee with a listing of all of them. But some of them are very applicable to our work around healthy eating, food security and physical activity.

You'll note on the bottom that our core functions, which is an evidence-based program, are being developed for food security, healthy living, healthy communities and chronic disease prevention.

As we develop these plans and we develop them with our health authorities, with academic institutions and with partners across the country, we are asking that the health authorities take a look at the model core programs and develop a performance improvement plan that's specific to their area and really specific to the population base that they serve.

We're not trying to provide a cookie-cutter approach in the core programs to all health authorities but are asking them to take a look at the best evidence that we have collected along with them and customize their program and implement them and really do an overall improvement process over a number of years.

[1135]

I'd like to finish my part of the presentation with a discussion around the first nations health plan. That is a tripartite agreement between the province, the first nations within British Columbia and the federal government. Certainly, there are a number of key activities that have been identified. Many of them are associated with what I've just been talking about.

The first nations community within British Columbia has a much higher prevalence rate of diabetes, and one of the key indicators in the plan is to reduce the gap in prevalence of diabetes by 33 percent. That would be the gap between the rest of the population and first nations — again, a very aggressive target.

The first nations plan requires us to work in a tripartite way. That takes additional effort and energy, working with first nations within the community. Having them work with us to develop key initiatives is absolutely critical if those initiatives are going to be relevant to that population.

I've mentioned one. The provincial Honour Your Health challenge is a significant piece of our aboriginal ActNow strategy. It is really doing wonderful work in bringing the first nations communities together as a train-the-trainer model, which goes back to first nations community to do that training in the key aspects of ActNow.

The other piece I'd like to bring is the different relationship we have with our non-governmental organizations. Again, the non-governmental groups within British Columbia have coalesced together and have created the B.C. Healthy Living Alliance. It's a group of nine large
[ Page 422 ]
provincial organizations that have an interest in healthy living. The B.C. Cancer Agency, the heart and stroke society, the B.C. Recreation and Parks Association — to name but a few — have come together. They have produced four specific chronic disease prevention strategies, of which diabetes is a major player, that are consistent and complementary to the strategies that the province and other ministries and other government agencies have developed.

So for the first time in this province, we've actually got the non-governmental sector working closely and collaboratively with government agencies and not just the Ministry of Health or Healthy Living but the Ministry of Agriculture and the Ministry of Environment and other government agencies that, by their policies and actions, can actually drive a healthier agenda.

We have, as the Auditor General mentioned, tried very hard to ensure that as we move forward and develop pilot projects, all of the activities we are doing…. We and our other colleagues within our other ministries are doing an extensive evaluation framework.

You might be interested to know that the World Health Organization is actively looking at and reviewing ActNow itself. I was in Ottawa just yesterday, where the WHO provided the first review of their key findings of ActNow. And again, particularly interested in: how do you get a whole government approach to move forward consistently in chronic disease prevention, and how do you develop that different relationship with the non-governmental sector?

This is just quickly…. It's in the deck, but we are trying to do an evaluation framework at the provincial level, the program level, the community level and the infrastructure level. All of those are in process. The first special report, or monograph, we hope to be released by the WHO probably in January or February of this year.

So with that, I'm going to turn it back to Stephen.

S. Brown: In terms of the actual clinical care of people who have already got the disease, we just wanted to start off by highlighting, in particular, the MOHS-BCMA 2006 agreement. The reason we wanted to do that is because…. For the treatment piece of this…. An absolutely critical and significant piece of the treatment element is the family doctor.

One of the challenges that we had going in, to begin to try to implement and move on the agenda that is set out, is the way that we were structured in terms of family physicians, which was predominantly fee-for-service. Literally, we have 800 or 900 individual practices that are composites of one, two, three, four, five doctors all operating independently from each other. So we needed a framework in which we could begin to work with the family physicians that would actually be able to impact on chronic diseases.

The BCMA–Ministry of Health agreement in 2006 was significant in a number of ways. Number 1, we actually agreed at the table to set aside a significant chunk of money to focus on primary care physicians.

[1140]

The other piece that we did — which has been critical to the process moving forward in terms of evaluating and beginning to be flexible, to see if we are using the money effectively to bring about change — was take that parcel of money and removed it from the traditional stream which it goes through, which is into the fee-for-service, and put it into a separate stream which has been co-managed by ourselves and the BCMA through representatives of family physicians, through the GP Services Committee. That committee has actually used that money.

Actually, as we've implemented incentives and focused on…. We've been able to do that by looking at the evidence, looking at where the change is happening and making modifications to the compensation as we have gone along, which has been a significant change from the traditional way that we work in terms of compensating physicians.

It would be to emphasize that we've actually got a very strong collaborative working relationship with family physicians, not just with the BCMA but through the BCMA to the broader family physician community across the province, which will hopefully come…. You'll see that as we move through.

The other piece that we also did as a key piece of managing the disease is going to be access to information. So another piece that we did at the table as a building block was setting aside some moneys for the implementation of the e-health initiative at the point-of-care level in physicians' offices through electronic medical records, which is a piece I'll talk to shortly. I wanted to put that up front, because that was a key enabler that we think we've been able to build on successfully over the last couple or three years.

In terms of moving into this area in terms of secondary prevention strategies, preventing the consequences — that's that stream 2 — a key piece we've done is tried to get consensus and build around a common understanding of what would be the key elements that we would be working towards. The point, building on what Morris was saying, is that the role of the ministry in this is a piece. We've got the health authorities. We've got physicians. We've got multiple other partners that we needed to coalesce around an approach.

So what we used was what we called an expanded chronic care model, of which Sylvia was a key developer. That expanded chronic care model…. We talked about the community piece, and Andy has talked about that. In terms of the health system piece, they're in the middle. We identified four blocks which, if we build those elements successfully and to the recommendations of the Auditor….

We effectively used some pilots to see whether we can make some headway. We believe those are key building
[ Page 423 ]
blocks that can move the agenda at a provincial systemic level. Those were information systems, decision support, best information at point of care for improved care, and the actual delivery system and design.

The delivery system is: how do we actually engage with 800 or 900 different family practices across the province in a coordinated way to move an agenda? Then you've not only got the family practitioners, but you've got the whole interface between the family practitioners and the specialist services, and then between them and the hospital care.

We tried to think about what would be a good design that we could begin to work collaboratively to build, which would actually enable and accelerate access to best care for patients.

Then the fourth piece, which we're very positive about, is that we believe the patient is the most knowledgable person about their disease, and the knowledge of that in terms of the science and art of medicine is that the science tells you a lot about what you can do with individual diseases.

The complexity comes in with diabetes in that it's often present with other chronic diseases, and they interact and interface with each other and get more complex as the person gets…. So the patient's knowledge of what's happening to them and how they're handling the disease is critical.

Those are the building blocks which we've been trying to move forward on, the result being that we have an informed and activated patient working with a team, not just the physician — we see the physician as critical — but the team of health care providers in the community.

Moving through relatively quickly, in terms of decision support, we have got a longstanding collaboration that came about in the middle of the '90s with the BCMA around guidelines and protocols, which over the last several years we've moved ahead with in a very solid way to have guidelines and protocols across a range of areas and, in this case, with diabetic care. With that, we're looking at electronic as well as manual ways of getting that information to physicians at the point of care. So the decision support is one piece.

[1145]

With the information technology piece, we have got and developed a probabilistic —which if you have questions on, Sylvia can talk to later — diabetes patient register, which is where that number of the 265…. That was important to develop for us in terms of understanding the scope and scale of how many individuals we're reaching across the province in terms of the initiatives that we're taking.

Then we developed what we call the chronic disease management toolkit, which is an information technology tool that's being used now. It's somewhat kind of clunky. If there were primary health care physicians in this room, they would tell you that it's kind of a clunky tool, which was an interim in advance of us actually moving with the EMR initiative, which is the third initiative.

What that toolkit has done…. In some absolutely brilliant examples across the province, groups of physicians use the tool very effectively to understand what's happening in their practice and what's happening to individual patients in terms of the implementation of best practice, where they're getting results back.

What will happen with the CDM toolkit is that it will become part of the new electronic medical record systems that we're developing in collaboration with the BCMA through what we call the Physician Information Technology Office, where over the next three years…. We're just in the prototype stage now where we're beginning to roll out. We've got about a thousand physicians engaged in this early stage of development.

Over the next three to five years we will see a rollout of enhanced electronic records at point of care that we think will significantly help in terms of using IT effectively to improve care and track what's happening to patients.

In terms of the patients' self-management, we've continued with pilot projects. We've got 221 individuals across the province who are trained to run self-management courses. To date we've had 1,533 patients. That's a very small amount, I know, in the context of the total amount of patients that we're talking about.

But in terms of that pilot, what we're seeing is that with patient self-management — and we reference just below there the Bounce Back program, which is a new program we're just launching, which is self-help through electronic means in terms of dealing with depression — the management of chronic disease often is associated with depression in terms of the coping with the disease on a day-to-day basis.

By actually enabling patients to work together to talk about how they're managing, it makes them activated. It enhances self-control — perceived control — in terms of what they're doing to manage their disease and makes them an active partner.

We believe this has got great potential. I'll talk to you shortly about how we're hoping now to kind of expand this and move it out on a bigger basis over the coming period of time.

In terms of the delivery system design and reorientation, we've gone with two different approaches which complement each other. The easiest approach, once we'd done the agreement in 2006, was through the GP Services Committee to introduce in a segmented way a series of incentives that began to focus attention back on to the care of chronic disease by individual physicians.

The issue here was about linking. It's not some magic area in the 125. It's actually linking the compensation structures to the most needed areas, in this case chronic disease management, beyond just simply the office visit.

By introducing this incentive program, we believe we've brought attention, focus and engagement of physicians
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in terms of applying best practice to the care of diabetic patients.

The learning we got from that is that when I walk through the door, I don't have one disease. Often individuals will have two, three, four or five diseases. So what we needed to do was engage physicians in actually thinking through the complex interaction between different diseases. So we introduce a complex care fee which allows physicians the time to spend with patients and to look at the multifaceted interactions that are occurring, to enhance care.

We've also understood, by working on this, that individual physicians running busy offices also look for assistance and help in thinking through how they design their offices to run most effectively. We've picked out four areas that we've been working on with physicians and their office assistants across the province, which is advanced access. A key issue when you've got a disease is to be able to get access quickly, so you're not waiting long times to get access to your doctor. The advanced access system is doing that.

The chronic disease management is actually educating physicians in best practice, bringing them up to speed and showing them the resources that are available to them.

[1150]

We see group medical visits as a great potential for a subset of the population where that will link with patients' self-management. Where physicians are engaged working with groups, nurses and other health care practitioners can be brought in. And the group can also be doing self-management and support as well as getting access to advice in terms of their….

Across the province we've done a whole range of what we call practice support programs, and to date we've had approximately 1,700 family physicians. This is from a pool of about 4,300, but in terms of the subset that work with families, that's probably about 3,500. So we're about 50 percent there. Of those, we've had engagement with 1,300 medical office assistants, who are a key player in the office practices of the family physicians.

The next piece that we're trying to build, and we're running it right now — I think it's about 26 projects across the province — is what we're calling integrated health networks. This is the family physicians isolated by themselves but not networked with their community and with other health care providers in their community, who have limited capacity to actually engage in this issue.

What we've done is create some funding to develop integrated health networks which actually link together physicians. It can be with nurses; it can be with counsellors; it can be with community development — a range of health professionals who then work together on targeted areas.

The area we've targeted first is working together with patients who have complex care needs by having multiple chronic conditions. We're developing that right now. We've got 29, and we're expanding as we go along and evaluating how well that works, but this is about trying to create the interdependence of teams working together around patients in terms of improved care.

Linked to that, I should say also, is that we're now beginning to go beyond the integrated health network teams and actually look at how we can link together physicians at a community level, where they can begin to engage and influence and take ownership about what is happening at a community level with their population. That network then can work effectively with the health authorities in strategizing and working out population level in terms of care. So that's a new enhancement that we're building on right now.

The next piece, and it kind of builds on Morris's first point, was that we had no overall agenda that was a shared agenda across the province. As Andy was talking about, with that now — a shared agenda for what we're trying to do with primary care….

We have developed a primary health care charter, which is available. We would be happy to share if no one has seen a copy of it. We're proud of the work that was done in developing that. That was a collaboration across, I think, 27 or 28 community agencies who were engaged in one way or another in the care of the patients at a primary care level.

We built a consensus across 28 parties across the province, and we came out with a primary care charter. It has been in place for a couple of years and is now in the process of being evaluated about what progress we've made and actually refreshed in terms of new agendas. That charter is a key building block we see in terms of mapping out an agenda for us.

What I've outlined there in the deck for you are the elements of that charter, which I won't go into — the elements of it — and then the summary there about some of the key areas that we're focusing in on, which are chronic disease management, of which diabetes is part; the patient conferencing; complex care; and cardiovascular risk assessment. There's a range of things that we're trying to do as a suite to move the agenda in terms of improved care, of which diabetes is a critical part.

In terms of what evidence we have of what's happening, the last few slides just summarize. In terms of the incentive payments, the dark blue represents the payment for diabetes. You can see there that from 2003-04, where we had 1,500 physicians engaged…. This payment relates to the use of the guideline and best practice in terms of treating patients. You can see now that we've actually got 3,000 physicians engaged in that program.

In terms of the number of patients who are getting benefit through that, you see the number there — '03-04 — at 50,000, and then incrementally we're now at approximately 150,000 patients. That emphasizes the comment that the Auditor General made in terms of praiseworthy but inadequate.
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We've still got a large chunk of people to reach, and those are areas that we're focusing in on now in terms of how we begin to close that gap further. As you get further into this, closing the gap becomes more challenging in terms of some of the subsets of the population. But you can see that we've made…. We believe we've made significant progress.

[1155]

I mentioned at the beginning, then: what is the evidence in terms of the value for money for this? What you see here in this slide is…. In the top line there you see the percentage of diabetic patients who are receiving the A1c tests being a critical kind of canary or indicator as a test. You see that in terms of best practice we were up to 70 percent of patients receiving that, where their doctor is actually using the CDM bonus — compared to, you see, the low result where the doctor has not yet been engaged in terms of using the bonus. We do believe that the bonus has had a significant impact in terms of engagement of physicians in focusing on best practice.

Then, in terms of some indicators, we used a few indicators there. We used end-stage kidney failure, and you can see there the '97 through '04-05 in terms of changes that are occurring there in the rate, compared against the broader population.

Then we used the retinal — again, one of the key indicators or outcomes of unmanaged…. You see there in terms of the first retinal procedure among people with and without diabetes. You see the direction that's occurring there incrementally.

Those are the two that we picked. So we'll open up to questions.

R. Fleming (Chair): Thank you for that very detailed response, Stephen, and for getting through it with us. I'll ask members if they have questions.

H. Bains: Thank you. I was watching the presentation very carefully and looking through the report and the responses. Given the diverse population makeup of our province, I noticed that there are data available about first nations, which is a good thing, and there is a specific program designed to help that part of the population.

Has anyone done any work on different ethnic minorities in the province to see where they fit in compared to the general population? I say this because meeting with Fraser Health Authority, I'm advised that South Asians have diabetes about three or four times higher than the general population and that it is even higher — up to 29 percent — for women from that background who are pregnant.

There are a significant number of those people that live in the Lower Mainland, at least, and also they are out in the other cities. If this disease is at such a high rate in that population, why weren't they considered and then special programs put in place to deal with that issue?

I don't know who could answer that, either the Auditor General or the ministry.

S. Brown: I'll ask, first, Sylvia to actually answer the data question: "Do we have knowledge of it?" And then I'll tell you about some of the dialogue that we're currently engaged in with Fraser, in particular through the Surrey area there, in terms of what we were looking at exploring to do.

S. Robinson: My understanding is that we know about increased risk among South Asian populations and among Chinese populations from the literature but that, due to our privacy regulations, we haven't been able to collect information that would allow us to give population-based data by ethnic group or racial group.

Because of the difference in funding for health care for first nations people, there are insurance requirements that have flags in the data for that because of the different jurisdictions involved, which we don't have for all of our higher-risk groups.

What we found is that most of the health authorities have local responses — where, as they see more people coming in…. For example, at the Jubilee, there was a request from the Punjabi-speaking community for special programming, and that was done in conjunction with local community groups in Duncan and Victoria. In Vancouver, with the Chinese population, there has been real leadership from UBC in getting engaged with that community, but there's been a much more local response rather than a data-driven response.

[1200]

S. Brown: And then, just in terms of the dialogue that we're having currently with Fraser, we're in the early stages. By that, I mean in terms of dialogue, but we're looking for some action before the end of this fiscal year.

When I talked about the integrated health networks and the divisions of family practice, which is grouping together physicians, we're looking at targeting Surrey as being one that has a high need in terms of some of the challenges for family physicians in that area but also in terms of the diversity of the population in that area and some of the subsets of the population about how best might we outreach. There are areas that we're having discussion with, and we've had a range of ideas brought to us right now.

Number one. With the Chinese immigrant population, a landed immigrant population, we've actually been doing a number of sessions sponsored through UBC. To show the interest — and it perhaps underscores what you're saying; I think it was on a Saturday afternoon — we've had two sessions now, which have had, I think, in excess of 300 people attending to discuss primary care needs and how best we might meet those needs.
[ Page 426 ]

With the Sikh population, we've had a few doctors who are very interested and are actually encouraging us that we need to think outside of the office in terms of how we outreach and work with the population in terms of chronic disease, so we've had some initial discussions.

You'll see this developing in the next couple or three months in terms of how we might move it forward, in terms of how we actually work with the temples or some of the community groups in terms of outreaching services in group settings in various ways in meeting the needs and understanding how to tailor these initiatives through this health plan. We use the same principles but tailor them to meet the needs of the population.

J. Rustad: Thank you for the presentation. In the north, when you're talking about the primary care in the north, there has been quite an initiative taken on by doctors of the Care North, which is specifically dealing with the chronic health issues such as diabetes. It's actually quite exciting. The doctors that are working there are actually very excited about working in that type of a model as opposed to the standard practice.

Actually, the question I have for you is because in the north, in my area, the first nations, of course, have a very high incidence of diabetes. I know that there have been some initiatives at UNBC working with first nations, both on research as well as trying to implement some policies. I'm just wondering if you can elaborate on those initiatives that are happening at UNBC.

A. Hazlewood: Well, I can talk about the prevention side. UNBC is a host to a National Collaborating Centre for Aboriginal Health. We've been working with them for the last two and a half or three years to assist us in developing those prevention strategies that are both relevant and culturally appropriate to our first nations population.

I mentioned one in my presentation. The Honour Your Health challenge, again, is a result of that collaboration with UNBC and with the National Collaborating Centre. The collaborating centre doesn't do formal first-line research. Their mandate and goal is to do and support pilots, support the best evidence that's of use to practitioners and then disseminate that into the population right across the country. We're working very closely with them.

Just back on the other comment on the prevention side, it's an equal challenge to make sure that the programs we introduce are appropriate and relevant to the mosaic that B.C. has. We're trying very hard to not just translate information but translate and make sure that it's culturally appropriate.

Our latest effort in that regard was the nutrition guide for seniors. We didn't just translate that into different languages. We actually sat down and worked with the local community so that when it was translated, the discussion, the choices and the type of food that we were suggesting for a healthy diet were actually appropriate to that culture.

C. Trevena: I've got a question partly about first nations. You mention in your presentation that the incidence of diabetes can be reduced approximately 25 percent with a cost avoidance of up to $200 million in health care dollars through implementation of a lifestyles modification program. I'm assuming that by "lifestyles modification" you're meaning ActNow B.C.

I'm wondering if you've put any examination into the social-determinants costs of health care. As we all know, diabetes has a higher incidence among people who are living in poverty. We're seeing an increase in the number of people living in poverty in B.C. who can't actually afford to live by the principles of ActNow.

[1205]

A. Hazlewood: Yeah, you're right on. If you take a look at the risk factors that we've targeted…. Historically, within this province and other jurisdictions, we had a diabetes prevention strategy. We had a heart and stroke prevention strategy and a lung disease prevention strategy. If you take a step backwards, most of those chronic conditions are a result of those risk factors that we've talked about.

That discussion automatically leads to a discussion and a debate about what causes the risk factors, and that gets you very quickly into the social determinants of health. I think ActNow has certainly recognized that. You're not going to change smoking habits, you're not going to change the societal norm around healthy eating and physical activity or physical inactivity without taking a look at those social determinants of health as well.

We're getting very good cooperation by our non-governmental sector in what they are attempting to do to assist us. It's a very difficult problem because there's no one solution. I think if you take a look at what this province looked like 40 years ago on tobacco, we have actually changed the societal norm from what was normal then to what is viewed as normal now.

How we do that for physical activity and healthy eating is a bit of a challenge. How do you sit back and have some assurance that a 14-year-old will walk to the 7-Eleven rather than being driven and, while he or she is there without mother or father standing over their shoulder, will choose a healthy-choice food? We've got a long way to go, and it takes an awful lot more than just telling people what to do. You have to allow them to have the choices to make those healthy decisions.

If there's no bike path in order to walk to 7-Eleven, they won't walk. If we don't start looking at how we build our communities and develop healthy communities that are walkable, that have people living where they work,
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that change won't happen. So the social determinants of health are really the foundation and the fundamental principles behind ActNow, if you take it the next step back.

C. Trevena: I just have a subsequent question.

I understand what you're saying, but I'm taking it one step lower because there are many people who can't afford to go and shop at 7-Eleven, or if they do, it's a huge expense.

Are you working, therefore — if I can frame it a little differently — with other ministries? We now have the two ministries of health in the new lineup. Are you working with the other ministries — the Ministry of Housing and Social Development and the Ministry of Children and Family Development — on ensuring that we are dealing with poverty issues? We do have the highest child poverty in the country here.

We have very high levels of poverty across B.C. These are the people who aren't questioning whether they're going to walk to the 7-Eleven or not. They just simply can't afford to eat and are going to be more at risk of having diabetes at a later age.

A. Hazlewood: Yeah. ActNow, again, as I've mentioned, is attempting to become a whole government approach to deal with the burden of chronic illness. We have established a cross-government ADM committee where we meet on a regular basis and have these discussions.

We've also provided to each ministry some expertise to sit down and look at their core business and, without changing their core business, go through a logic model development process where ministry X, Y or Z…. Again, every ministry is an employer, and every ministry has policies and programs that can either be neutral, positive or negative to healthy living in general. With the huge burden of chronic disease, that should be a focus of all of government.

So we've actually worked with each ministry in government and have sat down with them and their executive and developed, with their assistance and input, a logic model to really take a look at what things they could do, without changing their core business, to push a healthy-living agenda rather than being neutral or negative. So that is work in progress.

Certainly, the Ministry of Healthy Living and the Ministry of Health don't pretend to be the "ministry of everything." Other ministries need to stand up to the plate. But if you can capture their attention and sit down and walk through their business plan with a healthy-living lens on what they do, they can actually change some of their policies that will drive it in the right direction.

[1210]

R. Hawes: I have a question and then maybe just a comment.

I'm really aware that there's…. I'm appreciative of the efforts that you are making in terms of prevention — obesity, exercise, diet — but I know also that there are a huge number of people walking around that have early symptoms of type 2 that have not been diagnosed and will become diagnosed when they really begin to exhibit symptoms, which is further along in the disease than really necessary if they are diagnosed earlier.

I also know that a lot of people don't have ready access to the family doctor, and they don't often go to the family doctor until they don't feel well. I'm wondering about, and I did not see in here, the role of the pharmacist, which I happen to think is probably the most underutilized professional in the health care spectrum.

I'm wondering what the role of pharmacists could be here, and what your thoughts are on…. The example I'll give is that in the drugstore I can put my arm in a blood pressure cuff. It's not entirely definitive, but it can be an indicator, and the pharmacist could actually give me some advice to go see my family doctor, or whatever.

I'm wondering about glucose testing in the drugstore, which they're prohibited at the present time from doing. I know, having talked to pharmacists, that they would be happy to do that if there were legislation that allowed them to do glucose testing, which of course could be an indicator and would then act as a referral to the doctor at maybe a more appropriate time, early in the disease.

What are your thoughts for pushing for that kind of authority for pharmacists, and would that be helpful?

S. Brown: I don't think it would be a matter of pushing, to be honest, because the dialogue which the Pharmacare division has been engaged in now over the last year or so is very much actively exploring what can be the potential role for pharmacists. We're beginning today…. We are looking at the pharmacist right now in terms of a key player in terms of looking for cross-indicators, obviously, across the various medications around the complex care. The association is very much engaged with us in looking at trying to explore ways in which pharmacists can actually expand and move value-added.

In terms of the specifics about the insulin tests here, I couldn't comment on that because I haven't got the knowledge, but I could certainly get you a response on that from the Pharmacare division.

S. Robinson: Well, one of the things that might be useful as a piece of context here is that about 85 percent of people who are eligible for being screened for diabetes get screened in B.C. We've got, actually, a very high rate of screening. You're never going to have an idea in your mind that you'd get 100 percent of everybody every year that they're eligible, because it just doesn't work that way on a whole population basis. But 85 percent is considered a very high rate of screening.
[ Page 428 ]

Where we hear the providers and patients talking about the pharmacy role, and where I think interest in the care gap is most obvious and immediate, actually has to do with managing the medication, managing when I have diabetes and asthma or diabetes and kidney disease and the interactions.

Coping with those kinds of questions that come up I think has been the first point of interest. We've had tremendous interest from clinical pharmacists, community pharmacists, to be engaged, and I think vice versa from the teams that are working to try to help people who have sort of more complex situations.

R. Hawes: I think you're speaking about people there who have already been diagnosed. I'm talking about people who are walking around. Now, you say that 80 percent of the people who are eligible to be screened are being screened? Or 85 percent? I don't know what that means. Who is eligible to be screened? Is it 100 percent of the population that is eligible to be screened or is it certain parts of the population that might have genetic or other predispositions to diabetes? I'm not sure who you are talking about here.

S. Robinson: Right. The most recent guidelines have just been issued this fall. I haven't reviewed them, but in the past they have been…. Basically, type 2 diabetes is what we're looking for in a screening, which is a blood test the first thing in the morning to see how your blood sugars are.

The incidence of that climbs about age 45, so it's that group over 45. But there are other groups of people who are at higher risk — for instance, moms who have very large babies or who have had gestational diabetes, and they might be getting screened earlier because we know that there are risks. So it generally is an older population, with some subgroups where you might choose to screen more often.

[1215]

R. Hawes: I guess the genesis of my question — I guess I'll put it as a suggestion — is that having had discussions with pharmacists and actually with some of the manufacturers of glucose strips, I think there would be a willingness to provide those at no cost, or very low cost, to pharmacies if pharmacists were allowed to do the simple glucose test, which isn't definitive without a full blood test but is certainly indicative.

You may find…. There are a lot of people who go to pharmacies. You'll get an awful lot more people having an elemental type of screening that may get referred that otherwise will show up later with symptoms and much more cost to government. So that's my soapbox on that.

Then I just wanted to make a comment. When I read the recommendations: "Search out effective, research-supported methods of preventing diabetes and test these…Provide to cabinet a well-supported set of strategies, including cost and benefits…." Blah blah blah. "Implement the chosen strategies."

The recommendations from the Auditor sound on the surface to be extremely simple, but I just want to comment and congratulate you on what is obviously not simple. When I read through your pretty long presentation here, you've got a long way to go still, but you've come an awful long way.

I just want to congratulate you and make sure that everybody understands that might read the Auditor's report that this is so complex and so difficult, there isn't a simple solution. So while sometimes recommendations appear simple, solutions are far less simple. That's my other little comment.

B. Simpson: Part of the role of this committee is monitoring the Auditor General's work and the government's response to it. A couple of my questions are to that end. The Auditor General's recommendations — and it's a question to the Auditor General — specifically indicate…. As Member Hawes has pointed out, they seem very simple on the surface. Go research out some approaches to diabetes prevention. Make a presentation to cabinet about your findings and get on with the job — right?

The presentation that we got from government was predominantly around chronic care management, chronic disease management and preventative care on a broader scale. But I also note that the Auditor General made a specific reference to a presentation to cabinet and strategies chosen by cabinet and the response generalizes that to government.

Is that just semantics? You'll never get the middle one off the checklist if a presentation isn't done to cabinet. If the Ministry of Health is seeing it as just a general "we're going to go out and advise government on this," it seems to me that we'll always get these reports every year, because it will never get done.

To the Auditor General: was the Auditor General's office looking specifically for a diabetes response to avoid what, according to the ministry's documentation, could be as much as $400 million in costs to the system if you can get prevention? So specifically to diabetes and specifically to cabinet, not to government. You're looking for cabinet to respond to this. Is that the reason that you used the word "cabinet" in your recommendations?

J. Doyle: Thank you for your question. You'll appreciate this was a little before my time.

B. Simpson: Yup.

J. Doyle: Maybe I should make a comment and then also, hopefully, I don't mess it up for Morris when he supplements my comments.

I don't think you can separate diabetes out from complex care. I'm actually very pleased that in fact it has all been
[ Page 429 ]
rolled in together, and we're not just talking about diabetes today — although that is where the searchlight is — but are looking at a raft of different health issues and the way that the medical community as well as the Ministry of Health and other ministries are dealing with it. That's to the credit of government that it's this broad approach.

When the report was originally written, it was about making sure that leadership decisions were made at the highest possible level based on good clinical evidence that those kinds of strategies and processes would work, but testing that they would work in this mosaic — I think was the phrase that was used — called British Columbia. They do look simple — the recommendations — because they were hitting a very high-level, strategic position.

[1220]

They were different because they were looking not at a particular ministry; they were looking at a societal issue that needs to be addressed and was lifting itself in importance. If it ever was unimportant, I don't know. But it was certainly lifting itself in importance. So that was why the recommendations were phrased that way.

I think that the response that we've heard says: "Let's not just focus on exactly what the recommendations say, but let's say, 'What is the solution to this broad fabric of the problem that the population actually has?'" I think that's a welcomed way of looking at those recommendations and then finding practical solutions to try and make a difference into the future.

Morris, is there anything you wanted to add to that?

M. Sydor: I guess the only other thing I would add is that, as was indicated in the presentation and as we indicated, it's not just the ministry that has the tools that are necessary but a number of different agencies and communities involved.

I think that's why our recommendation was pitched at that higher level, because it would require clear direction from government as to the involvement of others and the understanding that there are tools available — in the Ministry of Finance, in Transportation, in Education — that can be used, but they have to be coordinated with the other initiatives that are underway.

We didn't want to address them solely to the minister, but we wanted that broader perspective taken on the problem.

R. Fleming (Chair): I think Mr. Hazlewood had a comment.

A. Hazlewood: Just a quick one. Certainly, the creation of the Ministry of Healthy Living and Sport has a very strong emphasis on ActNow, which is our platform for chronic disease prevention.

The precursor to that was a Minister of State for ActNow. Minister Hogg did sit at the executive table. ActNow has been to cabinet many, many times and has had many, many discussions. Trying to get a whole government approach really does require that political leadership, and it requires cabinet's endorsement and activity.

I think the creation of the minister of state and, subsequently to that, a ministry itself focused in on healthy living and sport is kind of an endorsement that a whole government approach is absolutely critical for chronic disease prevention.

B. Simpson: Fair enough. Again, it's more a procedural issue for us. We get these reports back and sometimes…. I guess what I'm pointing out is that if the Auditor General feels comfortable that a government response is maybe more than what the specific recommendations were and has gone beyond that — because these reports can continue to come back, and you've got this "partially completed," "partially completed…." Yet as we've seen, there's a response that may be actually above and beyond what is in there.

It's more of a logistical or procedural thing for us. I think it would be helpful, as opposed to just this little report card we get that shows three things partially completed, if we get a presentation that shows that the government is actually responding above and beyond — that a note is made that the Auditor General is actually adjusting the original recommendations or coming off of that in some fashion.

Do you understand what I mean? It's more just how we operate as a Public Accounts Committee and the due diligence that we do.

R. Fleming (Chair): It's about the follow-up process really — isn't it?

B. Simpson: Yeah. So that point having been made — and I think it's something that the Auditor General can take a look at, along with the Chair, in how we do that — to the government folks…. It does go back, however — and I think one of the reasons for taking it to cabinet — to MLA Trevena's comment that if you don't get to those social determinants….

If your other government policies and programs are not coming into play, then all of the good work that you're doing and that you've presented to us today amounts to a hill of beans, because you're not getting to the root causes. So if there's a lesson from this, I think it really is that at that cabinet level, the filter of chronic disease prevention — not management but the prevention — looking at the potential cost savings associated with dealing with these social determinants becomes absolutely critical.

R. Fleming (Chair): Who'd like to answer that as briefly as possible?
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S. Brown: We'll be taking that back in terms of the point that was being made to….. Yes, exactly.

R. Fleming (Chair): As a comment? Okay, fair enough.

A. Hazlewood: Very quickly, I think that if you take a look at the service plans of most ministries of this government, you will find things in most, if not all, of those service plans that deal with this particular issue. I've been in government for many, many years, and that's a first that I've seen.

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So to have a government where all of the ministries, including the Ministries of Agriculture, Transportation and on and on, actually recognize that what they do…. You may have some disagreement on what they're doing and how far they're going, but to have all of the ministries recognize that they contribute, to some extent within their policy framework, to the burden of chronic illness is really quite remarkable, in my perspective.

R. Fleming (Chair): Thank you.

J. Doyle: Chair, I would be grateful if I could have a few minutes right at the end of the next presentation, just to talk about follow-up, talk about some of those issues and, perhaps, clarify a few things.

R. Fleming (Chair): Okay. After the next hearing. Certainly.

R. Sultan: I think I'll leave, because I was going to raise it, and it has been discussed.

I would only comment that I think British Columbia has shown an astonishing improvement in all the indicators. I mean, the briefing notes that I looked through…. Whether we're talking obesity, smoking rates, the incidence of diabetes-related chronic disease, diet and exercise, I think there's much to be proud of.

When I read that the Auditor General says the efforts are "praiseworthy but inadequate to address the problem," I have to assume he's really just trying, in a backhanded sort of way, to point out the seriousness of the problem. I guess on that we would certainly all agree.

R. Fleming (Chair): I just had one brief comment. Just after hearing all of the efforts and the array of programs available across government and the work that government has been trying to do, the statistics…. I'm just wondering what frustration there is at the top levels of the two ministries represented here. The statistics seem to be winking at all of the efforts.

This is a value-for-money audit about whether the prevention programs and the diabetes management programs are working. There is some very good information in government's response, looking at the promise of doing a better job, hoping that costs of a billion a year today don't rise to, perhaps, $2 billion by 2015 for this disease alone. Yet the incidence of diabetes and the prevalence rates continue to climb, even as smoking rates fall and self-reported obesity rates are dropping.

All that said, and with the audit results here where the findings are that partially, the recommendations that PAC looked at four years ago have been implemented across government, where is the point in the curve where we really start to see a potential reward for the efforts that government is making? I appreciate that many of these things do have a long time scale and that you have presented that we're really dealing with social norms here that take some time to change.

I wonder if you could maybe comment, because this is an update. This is about what progress we're making on that question.

A. Hazlewood: You're right. It is, as I've mentioned, a societal norm change. I think we've certainly accomplished that in tobacco. Whether or not the trend on obesity rates will continue to go down…. As I've mentioned, this is the first time in many, many years that our trajectory is actually going in the right direction. It's actually decreasing, not increasing. Again, we're the only jurisdiction in Canada where that's the case.

I think ActNow has had a lot to do with that. I do think the whole government approach and our relationship with the non-governmental sector in the communities and with local government is helping to drive that.

It isn't a quick fix. Certainly once you have diabetes, you have it for life. There are probably, as one of the members said, individuals out there that have not been diagnosed. When they are diagnosed, the prevalence goes up. Trying to reduce chronic conditions through lifestyle modification and behaviour does require time and effort.

The payback on that, in some cases, is relatively short. There are some short-term gains from quitting smoking, from eating healthier and getting more physically active, but the real population base return will be a bit longer. It will be five years and ten years and beyond.

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I do believe if we don't start now and continue to do what we're doing in this province for the long term, the cost of chronic disease and the burden that places on society will be huge. I think we're in the right direction. I think tobacco is an example of where, if you have a coordinated approach, you can actually change a societal norm.

R. Fleming (Chair): Thank you. Seeing no members with further comments, I'll ask Mr. Hawes for a motion.

R. Hawes: I'll move that we accept the Auditor's follow-up report and the response of the ministries.
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R. Fleming (Chair): Discussion, members?

Motion approved.

R. Fleming (Chair): Thank you very much to our witnesses, again, for presenting on this report and for a very thorough briefing on this issue.

I am going to suggest, committee, that we recess for ten minutes here. There is lunch provided, and then we will begin the last item of business on our agenda.

The committee recessed from 12:31 p.m. to 12:47 p.m.

[R. Fleming in the chair.]

R. Fleming (Chair): We'll proceed with our final item of business, which is Alternative Payments to Physicians: A Program in Need of Change. I will ask John Doyle again to introduce this item before we hear from Mr. Brown again.

Auditor General Report:
Alternative Payments to Physicians:
A Program in Need of Change

J. Doyle: Thank you, Chair. What we wanted to talk about next is the follow-up of a 2003-2004 report entitled Alternative Payments to Physicians: A Program in Need of Change. Again, I have my colleague Morris Sydor, assistant Auditor General, to make a presentation that gives some background to the report, just to remind members of the committee of what the report was about. I'll hand over to Morris straightaway.

M. Sydor: Thank you. Again, if we go back to the original report timetable, the report was issued in November 2003, and it contained 24 recommendations. The Public Accounts Committee reviewed it in February of 2004. In its report of January 2005 all 24 recommendations were identified as being endorsed, and no specific recommendations from the committee were there.

The purpose and conclusion of our report. The overall purpose was to assess whether the alternative payments program management and accountability practices were adequate. As was just indicated, overall we concluded that the program was in need of change. It was poorly managed and needed to become much more accountable.

Our report followed the performance reporting framework that was in place, so it had three sections. First, we looked at the program's strategic alignment with ministry direction, and in that section we concluded with six recommendations. We also looked at whether there were sound and efficient program operations, and we had 11 recommendations for that area. The last area we looked at was results-focused program performance — are you measuring results and reporting on them? — and we had seven recommendations.

When we did our follow-up report, we obtained the status as of May 2005, and the report was issued in February 2006. Of the 24 recommendations, approximately half were fully or substantially implemented. There were 13 recommendations that were only partially implemented at that time.

If we look at those recommendations in relation to the components of the performance management framework, most of the ones that were fully and substantially implemented were in the sound and efficient programs operation area. For strategic alignment and results-focused performance, those recommendations were generally only partially implemented at the time.

That concludes my brief presentation.

R. Fleming (Chair): Members may wish to applaud now. Thank you, Morris.

We'll ask Stephen Brown to come back, and we'll….

R. Thorpe (Deputy Chair): That's the practice that has been established here.

R. Fleming (Chair): A little thicker presentation here.

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S. Brown: It is my ongoing learning. This is an improvement over my last deck — it's half the size — but also I will emphasize three strategic things.

I'll theme this and then allow you to get into more detailed questions. We found it a little bit tricky, because we wanted to be able to respond to the multiple recommendations, and we have, in the deck. What I'll do is that I'll theme it and then open it up immediately so that you can ask me more detailed questions.

Just as a background piece. I think the first piece — going to Morris's report, which is why we asked for this in 2003 — is: what exactly should be the focus of the APP program?

Coming from that early on, we identified a number of principles. These are still in evolution and development. The alignment with patient-system need, flexibility and certainty in service provision outside of a fee-for-service arrangement can allow focus on difficult-to-serve populations, and it can provide opportunities for physician leadership, clinical leadership, outside of the direct patient encounter, which is important. Also, alternative payment arrangements for physicians are important in terms of supporting various aspects of our medical schools and the physicians.

We began to hone in, in terms of one of the key issues, about what the focus is of APP. Then, as Morris has said, in terms of the poor management — that is, operational management…. That was our first and primary focus, which was to tighten up. As Morris said, in terms of the follow-up report, that showed that we had substantially improved and made headway against the recommendations for sound
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program operations. I'll just highlight one of those today when I come to it.

The two key areas that we then needed to focus in on were strategic alignment and results-focused performance. What I hope to show you today is that on the strategic alignment, we believe we have made substantive headway against the recommendations.

Also, on the results focus, we believe we've made substantive headway, but with a caveat, which I'll highlight, that I think points to the work that is ongoing. I'll tell you what work we're doing to address that. The focus is going to be on the 13 that Morris highlighted, which were partially completed.

In terms of the strategic alignment…. I'll move through these, then, relatively quickly and let you dig down on them. The strategic alignment was a fundamental question we have to ask ourselves. What is the role of alternative payments, and how does it relate and get direction from some kind of a strategic context — which the Auditor, having invited him in to do the report, found was lacking? The key things that we've done there, I would say, are around two streams.

First of all, internally, there has been quite significant change in the ministry over the last four years in terms of clarity around what the ministry's vision and strategic objectives aligned to government are, our articulation of those to the various divisions of the ministry and the obligation of the divisions to then translate those into service plans and, within their divisional service plans, identify the various programs.

Going back now two years, we did the three-year service plan for the division that I'm accountable for in this area. The service plan clearly went to what the key strategic objectives were, what the role of the division is in terms of meeting the ministry objectives and then, linking again, what the various branches are.

In terms of the alternative payments branch, we also embedded the alternative payments branch into an overall new branch which we have worked on, which is on the physician human resource management branch. It then integrates together not just consideration of alternative payments but also rural, the negotiations, fee-for-service payments that we make so that we actually take an integrated approach to looking at how we consider physician compensation.

We have moved, in terms of the program objectives. Trying to clarify, I will elaborate on that towards of the end of this now. In terms of…. We have gone to a second, deeper level, I think, in terms of consideration of this.

The first few slides take you through that in terms of the strategic alignment of what we've done. I've given some examples of action taken to date. I need to also say that we have tried to do a sample here. Behind each of these are often several different specific actions that we're taking that we would, obviously, be reviewing with the Auditor on the follow-up.

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The policy we've also made…. You can see that we put that onto websites, so as you move through those, through the slides, through recommendation 5 there in terms of implemented, you can see that we've tried to actually, then, embed and build on the recommendation that the Auditor gave in terms of the alignment of this program.

On the program operations a key issue that was still outstanding, only partially there, was the recommendation to establish an IT strategic plan to actually enable and use information technology to improve the overall management of the program. Where we're at with that goal right now is…. We've developed an overarching IT strategic plan for the branch, the alternative payments program.

We've also implemented what we call the HAPR system, the health authority physician remuneration system, which actually now gives us an integrated understanding of all of the various streams of income and compensation that go into physician compensation. That's there in a database that we can use when we're actually looking at requests for funding and looking at assessing different financial arrangements in terms of compensation.

A key piece of this was the ministry's interface out into the health authorities and how we best manage that interface with the health authorities in terms of the use of alternative payment programs. We initiated a senior-level committee, which is called the physicians services strategic advisory committee, which I co-chair with one of the senior VPs from the HAs. We meet monthly, and we not only look at a range of physician issues but also provide oversight to what is happening on the alternative payment area in terms of contract issues, initiatives….

We've also used that for strategic purposes in terms of understanding what are some of the key areas that HAs want to focus in on and prioritize and where alternative payment arrangements may benefit or enable them to move forward. I can give examples of that if you like.

Then, we're also proceeding over the coming year or so now with a renewal on the claims payment system, which was going back to when Morris came in first. It was heavily a manual system, so we will be moving that agenda to bring this to a close. So we have got the broad…. And we're moving ahead with a number of systems there in terms of making headway with that particular piece of the operations.

Then the results focused…. You know, it's actually a…. Probably Morris wouldn't believe me on this, but this report has been used significantly over the last four years. One of my senior staff who is with me today, actually — John…. One of the comments I get continually when I'm out and about is that people are fed up with John referencing the Auditor General's report. John has been absolutely focused in a very, very specific way in terms of these recommendations, in terms of pushing it.
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What this has opened up is: how do you establish a linkage between compensation and an outcome for patient? So on the results-focused side, I would say that where we're at now is we've become much more explicit — and you this in our contracts — in terms of outputs. There's significantly more clarity from the inputs to the outputs. So they evaluated: is APP the right mechanism to use versus fee for service? Should other mechanisms be considered? What we now need to focus in on — and we're beginning to, but it's a tricky area — is outcomes.

It's tricky in this sense. If we're asked to be monitored on outputs, most of us have a comfort level. When we're actually asked to be monitored on outcomes, we get much more anxious about what the implications could be for us. That issue manifests strongly in the area of health care where the outcomes are multifaceted in terms of what might cause or impact on an outcome. So getting those explicit in agreements or contracts is a slow process where it gets nuanced through all of the various factors that can be considered.

Nevertheless, we are beginning to open up in terms of outcomes and look up population levels or groups of outcomes that we should be considering. But that's a gap. So in the recommendation, it was that we needed a full complement of measures, right the way through to patient outcomes, and that's an area that we need to focus in on.

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What we've done with this results focus is taken a step back. I'll move you through the recommendations, where you can see the pieces that we put in place to the end point here…. We've taken a step back from this process and actually expanded it out.

When we were at the table with the physicians, we said that in terms of the payment schedule for physicians, not only have we got a complex alternative payment, but with the alternative payment arrangements, that equally has not been a panacea for either physicians or for patients in terms of what outcomes. There have been some very value-added elements that come from alternative payments, which I will talk about.

We're also looking at…. Should we be looking at blended models and other different ways of mixing? Should we be looking at performance incentives built in? So we've taken a step back over the past year, and we're actually developing a whole range of materials — think papers in terms of a broader policy framework for physicians which link not only the compensation piece but also: how do we support and incent physicians; how do we collaboratively work; how do we get physicians aligned and linked to health authorities, working effectively in terms of patient needs?

We're going to be working it through over the several months. We're doing this very much in collaboration with the physician community, with the BCMA and obviously with the HAs as we move forward.

So we are looking, and I've just highlighted some there for you. It's not just the compensation. As the report identified originally, it's not what the compensation is, but how does the compensation incent or work with the physician within the context of where they're working, the models of care, how they're working, who they're working with, and how does that relate out to clinical practice and quality improvement.

You saw in the previous presentation that we did some of the experimentation that we've done with the primary care in terms of different and creative ways of looking at compensation.

So on the results performance, we see ourselves as still partially…. We believe we've made significant headway in terms of outputs and discipline. We also believe we've made significant headway at the HA-level in terms of contracts, but we're now looking at the population patient–level outcomes.

So I'll finish there and open it up to questions.

R. Fleming (Chair): Thanks very much, Stephen.

Members, questions on the report and the response?

R. Sultan: Clearly, from your own description, this is a terribly important topic within the ministry, one would judge. I perhaps didn't do all my homework, but if one were to measure the trend in terms of alternative payment mechanisms as opposed to traditional fee-for-service, what would one observe over time? Is the ministry and is the industry — if I can use that term — tending more to alternative payment mechanisms?

S. Brown: There's a growing interest in alternative payment mechanisms. Then it becomes: what exactly is an alternative payment mechanism, which is traditionally defined as it's not fee-for-service? An alternative payment mechanism, which has been the dominant mechanism, has been to do a contract arrangement, and that achieves many of the objectives that were set out as principles for the APP, which I put in the first slide there.

However, is that the right way to go? Across various jurisdictions, not only here but across internationally…. We just had a cross-jurisdictional meeting a week or so ago, and then we just had some discussions with colleagues across various other countries. The contract in and of itself does not necessarily give you the full range of incentives that you might want to use for incenting performance or productivity or quality.

I would say that where we are now, first of all, is still only a small percentage. It's a significant amount of money. We're talking $350 million in the context of a $3 billion budget, so it's not an insignificant amount of money. It is very significant. In terms of the percentage of physicians, in terms of growth, we've had about 11 percent. I think it still only accounts for 11 percent of the payments that we're actually making to physicians.
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We're anticipating that as the younger physicians graduate…. They are certainly expressing more interest in this. The caution that I bring to it now is that we're looking at that and saying that we need to be more sophisticated in thinking through just the contract or blended approaches or blended approaches with performance incentives built in.

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So my belief would be that in the next two to three years, you will see growing experimentation with that. One of the members referenced the northern care group, and they are very keen to experiment in ways that would have been unthinkable four or five years ago, linked very much to patient care and patient outcomes. So I would say you'll see more experimentation, but not necessarily just a traditional contract approach.

R. Sultan: Well, I commend you for your experimentation. It seems to me that this is an essential ingredient of good management of the health system. Thank you.

C. Trevena: Mr. Sultan asked very much the question I was wanting to ask. I was wondering about how it is working when you see students leaving their training and wanting to specialize rather than going into GP practice, whether we're looking at alternative payments, and particularly salaries, as a way of attracting new graduates in as GPs and particularly devolving further down into areas where it's hard to fill GPs in rural areas — if this is something that's being examined.

S. Brown: The answer is that it's being examined. The salaried is probably the…. Actually, this may be incredible. I think salaried is one of the top areas that came out of the Conversation on Health. People thought: "If only we had physicians on salary."

I was talking just a couple of days ago to somebody from the U.K. who works in one of the large hospitals in the north of England and who was telling me that their dream would be to get off the salaried physician, because they're having all kinds of issues around how you manage the outputs of salaried physicians.

They were actually looking at us on the fee-for-service and saying, "That looks really interesting — having more fee-for-service," which gets to the fact that there's no panacea in the payment mechanism — right? But the point you're making about the mix is very much yes, there is a mix that's going on.

Many of the younger physicians coming out are interested in joining, in terms of alternative arrangements. I wouldn't say on the primary care side right now that there's a drive by the majority of the physicians to say: "Please let us get onto some kind of contracts." I would say that what we're seeing on the primary care side right now for family physicians is that mix of incentives to really focus and target attention on specific populations and make sure those patients get the attention they need.

Some blended and some contract arrangements, like the integrated health networks, enable physicians to spend time on activities that are away from the office, from the examining room, where you're cranking people through. You could actually think in terms of different ways. So there are a number of experiments there, and I think they will continue both there and also in the hospital.

The other challenge on the rural side, as it is in the hospital, is that you've often got a mixture. We haven't solved this yet — how you actually get the mixture. So you could be bringing the physician in that says: "I would like to be on a contract." But in fact his colleagues, who are of a different age and a different generation, say: "No, no. Actually, fee-for-service is the way to go." They're looking for equity — not equity just in conversation, but equity in terms of mechanisms.

So there are some challenges about how you introduce, how many people you need to actually introduce mechanisms. That's why I think some of the blended approaches will appeal to many physicians and give them a safety net. If they want to work significantly harder, they want the opportunity that they can get rewarded for that, which they don't see necessarily in the contract frameworks that we have now.

J. Yap: Clearly, this is a work in progress, and I commend you on the efforts to date.

One of the areas, I understand, where this alternative payment system would be suitable and applicable is in emergency departments. In my community, in Richmond, we have a very busy and great hospital — Richmond Hospital. I understand that this is in place in Richmond, among other communities.

I wonder if you can comment on the program in emergency departments, and Richmond in particular.

S. Brown: I won't be able to speak immediately to Richmond in particular, but what in terms of the emergency departments? That did become a major theme in terms of stabilizing some of the large hospitals, with some using the alternative payment arrangements.

I wouldn't have the numbers at hand, but I think we're running at about 15 hospitals right now. Emergency departments have moved on to contract arrangements, and there's a range of others.

What we did was prioritize some of the large hospitals first, to give a level of stability on that front. We're also working with the physicians in terms of workload models. An interesting thing in evolution with the contracting is doing a contract and then signing off a contract and saying, "There's a contract for you," when in fact volumes and demand shift and change.

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It isn't as successful in terms of use of resources or successful in terms of planning. So we are building in, and EM is one of those where we are building in now.
[ Page 435 ]
By actually identifying workload models, it allows projections of what is required and allows preplanning in terms of recruitment than actually coming up against negotiations.

In the end we've had significant expansion, plus we're actually building a workload model that allows projections of where we will need EM positions because of the lead time in recruitment. That's been an innovation there. We've also done the same, actually, with the B.C. Cancer Agency. I think we'll see that innovation and multi-year contracts, with some escalators built on workload, to be able to respond to demand to build in. But you are right. The EMs are being a major focus in terms of the last couple of three years.

J. Rustad: Back in 2000, I think it was, there were some real challenges in around rural B.C., and particularly in Prince George. There was a rally of about…. I think it was around 4,000 people that came out with concerns particularly around health care. Out of that, of course, we've seen a northern medical program that has been very, very successful in terms of attracting people to the north — in the training. Through that process this summer we saw the first batch of those doctors.

What I'm wondering about is the effectiveness of the APP program with regards to that issue we had in Prince George as well in rural B.C. in terms of being able to fill that need, which was clearly identified at that time.

S. Brown: The need at that time…. Could you just articulate for me just a bit more what you would see the need as?

J. Rustad: What it was at that time…. We had a real problem of attracting doctors and getting doctors into the community in Prince George. A number of the rural communities also were well underserved. They didn't have the physicians that they needed. So I am just wondering what role APP had played. Things have improved a fair bit in terms of that recruitment effort, so I am just wondering what role the APP program has done?

S. Brown: I think the alternative payments have played just a partial role, to be honest with you, in terms of the transformation that has occurred there. I think there are a number of factors. I think that, actually, not least among the factors is the significant leadership — just using the Prince George example — and engagement of the physician community in working with both the health authority and the ministry in moving agenda.

I have had several really productive meetings with the physicians' leadership up in Prince George. Just to compliment them, I think that they're just doing an exceptional job, so they need to own a lot of the success of how they recruit.

Now, I do believe that what has helped them is the program that has been a long-term program going back ten, 15 years — the rural incentive program. We've got some tinkering to do with that program, which isn't in alternative payments but how we actually incent and work with…. That's been an evolving and improving program that we're just in the middle of.

We're just completing a review of that program to see how we can incent. That has been a major piece, I think, in terms of acknowledging and working with the issues around recruitment, as well as using such programs as Health Match B.C. and being more targeted, collaborative — working collaboratively with the physicians in terms of recruitment issues. I think those have been the more dominant. Now note, having said that, APP has played a part, but I would say it would be a partial in terms of that particular area.

H. Bains: My question is around the payment system that was brought in, in the good old 1990s, I believe it was, where the family physician would be paid full fee for the first so many patients and then on a sliding scale thereafter. Then I guess there was…. If they wanted to see them, it would be free after that.

My couple of questions come out of how well that system is working, because I understand that was kept in the last few years, and I think it's still in existence today. How well is that working as far as, I guess, controlling costs, and whether that plays any role in attracting and/or having the family physician's availability in different parts of our province?

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S. Brown: So it is still in place. It's the fee-for-service controller in terms of visits, and it was because of the quality issues in terms of if you are seeing too many patients.

I think the evolution — and it links into the previous discussion we were having on chronic disease — is that…. My observation…. I've spent a lot of time with family physicians. The gruellingness of being in an office — we all go to our GP — and of bouncing between two offices and seeing patients…. Even at the 50-a-day level…. You think about 50 patients coming through a day and how fast you're bouncing between the two.

It's worked as a cap in terms of that, but the sense I get, working with physicians, is that they believe that the way the funding structure was then left, which is just the fee-for-service, as it was, is just reinforcing it then, even up to the 50 a day.

Yet if I'm a patient and I walk in and I've got three or four chronic diseases…. You've seen this issue, probably, in your own offices, where we debate, duke them with one issue. Well, we don't often go, particularly when we get older, with one issue. We've got a range of issues, which are interfacing with each other.

I believe that the modification that's come to that fee-for-service has been the chronic disease piece, which
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we've done in collaboration with the BCMA and the physicians, around how we incent so that physicians are rewarded in terms of meeting their overhead and getting a reasonable compensation for spending the time that's required with the more complex patients. So my answer would be that yeah, it would still be in place.

My sense in terms of no push — that should be removed. It would be there; that's there as a cap. But that is also now nuancing going on within the day about how we actually support and enable physicians to be able to provide the kind of care that's required as the population ages and has more ranges of complex conditions that have to be dealt with.

R. Thorpe (Deputy Chair): Steve, thanks very much for the presentation. It's my understanding that this year — and I don't know whether it's in place yet or not — the APP program was actually going to be introduced or that parts of it were going to be introduced in some form or another at the B.C.'s Children's Hospital to address needs there to provide services for our children in British Columbia. Can you tell the committee what has happened there?

S. Brown: Yes. That's a very good example, which actually shows the complexity of introducing an alternative payment arrangement. B.C.'s Children's, under some really solid leadership, wanted to actually, on the pediatric side, get a level playing field that supports some of the rewarding but very complex work that Children's Hospital does.

The task at hand there is — and I may get the numbers slightly wrong — that there are 17, I think it is, subgroups, subspecialties, of physicians to do with pediatric care. Trying to move 17 subspecialties across a full practice, which then has got both clinical and hospital — and you're actually doing that in an academic research environment — has been, on a given day, challenging for the physicians and for staff involved in Children's.

That, I think, is an example of where a value-add comes into play. I would say that the reference point, a comparator to that that we could use for the Children's, is that the B.C. Cancer Agency shows where you can take an alternative payment program.

That's where I think we'll see what is already excellent work in Children's Hospital. We'll see them leverage off an alternative payment, because it does then allow you…. It gets you off the fee-for-service trap, where you can begin to look at clinical leadership, guidelines, protocols, standardization, efficiencies and how you can actually increase flow-through.

You see all of that very much evident in what B.C. Cancer Agency, which I would say is probably the most advanced in the…. I don't know about in the country, but certainly it's an advanced example in this province of what can be done with an alternative payment. I think you will see that. That's very much the goal of the group that's involved there and the leadership. They want to leverage off that — to make that apply there and use it well.

[1320]

R. Thorpe (Deputy Chair): So this 40-year-old program that's been in place now in British Columbia, obviously evolving in an ever-complex medical world, is actually providing the opportunity for better care, more comprehensive bringing together for care for our children. Is that a fair…?

S. Brown: I absolutely think that's the case. I also think that then becomes a major building block for recruitment, and it also becomes a building block for the academic work that needs to be done in terms of supporting the medical school. So that's an example where the APP hit some very important deliverables that are important to the system.

R. Thorpe (Deputy Chair): Thank you.

R. Fleming (Chair): I just had a comment, maybe for the Auditor General. We're going to talk about follow-ups in a moment. Maybe this is a better time. Our committee members have been handed a report that is from the previous parliament that was then followed up on.

The original findings on APP were quite harsh. The strategic alignment was described as lacking "clear objectives and effective strategies." The program operations were defined as having "weak management support systems" improper to manage a $300 million program, and the results-focused performance was described as lacking "reliable or relevant performance information."

So that was several years ago. The follow-up report suggested that perhaps a little over half of the recommendations had been acted on, to one degree or another. Here we are, the Public Accounts Committee in the fall of 2008, dealing with a quite dated follow-up report.

I guess the question for the Auditor General is: do you plan to review this again with a fresh pair of eyes? This hearing is…. I think it has hampered our members' ability to find out what's going on by how long it's taken us, in part, to be able to have this report before us. We're not really able to evaluate, with information this old, what effectively is being done.

We've had a good idea from Mr. Brown that many things have happened since your office looked at this five years ago, but in terms of being able to say whether the APP program is addressing all the original concerns and what kind of follow-up is required at this point in time…. I don't have a great idea, and I say that as the Chair of this committee.
[ Page 437 ]

J. Doyle: Thank you, Chair. I wasn't proposing to do another formal follow-up. I am proposing — and I've already started discussions with the ministry — to have a fresh look at where would be a good place to shine a searchlight on this area of physician payments.

We're going through that at the moment, and it will probably take us a few months to come to a conclusion. We'll either be reporting or be well on our way to completing the fieldwork by the end of next calendar year on another piece that will basically become a new focus for the committee to have a look at this important area.

R. Fleming (Chair): Will it be called a follow-up report?

J. Doyle: New work.

R. Fleming (Chair): Okay. It'll have a different scope. It'll be a different….

J. Doyle: One of the dangers that I see about getting reports and looking at them is that recommendations can get dated. If you like, the report could be narrowly focused, and therefore it could just form part of a strategic review of activity by ministry and so on. And I think it's beholden on me to make sure that the focus of reports is kept fresh.

From time to time, I think that means going back and having another look at a different aspect of the situation. I hesitate to say "elephant" and look at an elephant from different directions, but basically, looking at an issue from different directions at different points of time is a very useful exercise.

[1325]

Could I say that the response from the ministry has been up to date. They're talking about what the situation is now, about a situation that was raised many years ago. I think it's fantastic that a large structure and organization that in some jurisdictions — not here, of course, but in some jurisdictions — has a very healthy corporate immune system to resist anything, has in fact moved forward very well and has got this enthusiasm around what they're doing to bring about change to the benefit of citizens. Actually, I find it quite rewarding, and I have found that the relationship we have with this particular ministry as we move forward is very open and very positive.

Yes, there are problems. I don't know if you used the word "harsh" in your opening comments, but certainly, it was a tough audit when it was first done. We'll continue to be moving forward in a constructive way, and we'll report as we find.

I'm rather pleased at the positive response that we've got, but we need to go back and then have a look at different aspects of different issues that we'd previously reported on, rather than vacate the space for another ten or 15 years.

R. Hawes: I recognize that the Auditor's report is dated, but I do think it is refreshing that the ministry is able to report progress as it has and continues with some zeal, I think, to make progress.

With that, I'd move that we accept the dated follow-up report and the current report from the ministry and that we accept both.

R. Fleming (Chair): Do we have a motion?

R. Hawes: That's the motion. I move that we accept both.

R. Fleming (Chair): It's moved and seconded. Any discussion on that?

Motion approved.

R. Fleming (Chair): I want to thank Stephen Brown very much for making two very good presentations this afternoon.

For the Auditor General and his staff: do you still wish to make some brief comments about follow-up reports at this time, at the close of the meeting?

Auditor General Follow-up Reports

J. Doyle: What we've seen today is two follow-ups where my office went into some detail in regard to a report that had been published some time before. In both situations we saw ministries come forward with detailed responses about what had happened and what the current situation is.

Now, these follow-up reports do take up a lot of resources to actually do — almost as much, if not more, than the original report itself. With an effort to make sure that follow-up is timely and that ministries who have accepted recommendations from previous reports are actually dealing with them appropriately, I've put into place a process whereby every six months the committee will be apprised of where each agency thinks it is in regard to recommendations that have previously been presented to it or tabled in parliament, if you haven't yet discussed the report.

The first of those is being published next week, and it contains the management assertions, which is the phraseology that I use, as to the progress that has gone on in the range of, I think, about seven or eight different reports that have been previously published by my office.

What we have done is print what the agencies have said they've achieved. Before we printed it, we had a good look at it to make sure that it seemed reasonable, based on our knowledge of the business and our knowledge of the situation. Where necessary, we handed back the documentation and suggested that they might like to revise it. That did happen, but not right across the board.
[ Page 438 ]

What we've got in this document is the management assertions about their progress in regard to recommendations they've received in the past. Once that's been tabled and presented, I would invite the committee to ask me to look at any that they would like greater analysis in. But I will also select some myself to go back and test those assertions for reasonableness and whether or not they're as accurate as they could be. There are situations where we think we've done something, where in reality it would take a very charitable view to actually agree with that.

[1330]

If there is deeper analysis required, we would conduct that work and then publish it in the subsequent six-month report as a separate section in that subsequent report. By doing that, I think what we will be able to do is provide a lot of information around the response to the Auditor General reports, over time, to the committee and also provide the committee the opportunity to appraise just how progress is going against literally hundreds of recommendations.

I think the Deputy Chair mentioned earlier on today that 96 percent of the recommendations in regard to CORNET had actually been dealt with within 12 months. Frankly, that's unusual, but it's good. I'm not complaining, but it's unusual. One of the indicators that we've put in my annual report for a number of years is just how many recommendations are outstanding. This is part of a process to try and get the number of recommendations that are actually actioned by agencies lower so that they are completed and moved through and dealt with appropriately.

In going through that process, we might well detect issues that were raised today, whereby recommendations perhaps don't seem to be as important now, or the focus of recommendations, if they were written today, might very well be different. I think that's a natural evolution, where a situation that was detected at some point in time can evolve and change as different activity is undertaken by ministries, governments, individuals and so on over a period of time.

We could very well find situations where there is agreement now with a recommendation, but at some time in the future it could be that we actually don't need to do this because we've either accepted the risks that were involved or we've found alternative methods to actually deal with this particular situation, not necessarily the ones you recommended.

Again, there is a little bit of an evolution there about…. It may be that ministries in the future may not do exactly what the Auditor General has recommended. They might find another way of actually achieving the same outcome. And that's entirely acceptable, because again, the object is to look at the situation, outcomes from that situation and how they can be addressed. Again, it would be an issue that's in the open, as opposed to a silent "no, we're not going to do it" type of process, which is basically private correspondence between myself and a particular agency.

The other side of this is that I think timeliness is important. Each one of these recommendations has either been accepted or rejected by an agency, and we would be seeking to gain from them, at some time near the point that we write the recommendation, just how long it will take for them to actually address these issues, who is responsible, and so on.

In return, we'll also be providing some information around how important we think these recommendations are and our view of timeliness as well and, in that way, perhaps come to some agreements around speed and the need to address some issues quicker than others. I think you saw an example of that with the CORNET situation, when they were saying: "We dealt with these things very, very quickly." I'm glad they did, because they were very important.

That approach, by the way, is one that we have adopted in other audits as well, which we'll bring to your attention next year — again, in the IT area, where we've got issues — but we're working closely with the ministries concerned to deal with those issues before we actually bring them forward in the way of a formal report.

The background work that's being done means that we will come to you with recommendations, but action on those recommendations might well have been completed when we do bring them forward. It's just a "report what we find" type of process, but we give people the opportunity, particularly in tentative areas, to deal with issues before they become public knowledge.

[1335]

I'm hoping that I can have a dialogue with the committee at some time in regard to the follow-up process to see whether or not they fully endorse this approach. It is not that I don't want go into detail in regard to responses from particular agencies, but what I'm finding is a very strong commitment from most, if not all, agencies to actually deal with recommendations well and to deal with them in a timely fashion. That behooves me to write the right recommendations and behooves them to only accept what they're going to do something about.

Thank you for the opportunity to make a few comments.

R. Fleming (Chair): Thank you, John.

R. Thorpe (Deputy Chair): Thanks, John. As someone who was on Public Accounts back in the late '90s and someone who actually pushed for follow-up reports, I think what you've said is a very good beginning.

I would look forward to a dialogue on how we can make them more timely, more effective, more results-orientated. I think that's important, no matter which side of the House you sit on, and I think it's also important to move government along.
[ Page 439 ]

I think that one of the things, in establishing whatever the recommendations may be, is…. Everyone is going to have to understand that when those recommendations are made and whenever they're made…. Are they part of a legislative change that's required, and if so, where does that fit in a legislative cycle?

If they are capital, and major capital, where does that fit in a capital thing? Because there's no sense, in my opinion, in either side of the House creating an expectation that something is really, really simple. As we actually saw with three presentations today, they're not always simple fixes.

I think we have to look again — and I'll support streamlining and simplifying the follow-up process — in bringing forward whatever the recommendations may be, so that the expectations of those implementations are actually realistic, given the stream in which they have to fall, whatever it may be — legislative, capital, whatever.

I strongly believe…. What I've seen here in 12½ years is that the public service, no matter what ministry it is, no matter what the issues, wants to do the right thing. Sometimes, due to the constraints that I've mentioned — legislative, capital, etc. — there are some challenges.

We've got to set reasonable expectations. Some are going to be much more urgent than others. I would look forward — and the Chair and I have actually had the discussion on follow-ups — to them becoming much more timely so they can be acted upon and we can move things forward. I look forward to that discussion.

R. Fleming (Chair): I recommend, maybe when we go over the workplan at our next meeting, that we revisit this topic.

I think members can go away and have some thoughts about what the Public Accounts Committee's role is in this too. Where do we add value to taking some ownership and, in some cases, adding recommendations but certainly, in this case, to taking a more active role in the follow-up at this committee by having more timely, more meaningful, reporting back?

R. Hawes: Are you suggesting, then, that we go away and think about it now by virtue of a motion to adjourn?

R. Fleming (Chair): That's exactly what I'm thinking. You read my mind, Randy, and I heard a motion to adjourn.

I will thank John, Morris and others for being here today, and members, as well, for their participation.

We'll see you at the next meeting.

The committee adjourned at 1:39 p.m.

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