Saskatchewan Health denied FSIN funding request to conduct own First Nations Patient Review

Commissioner Tony Dagnone’s Patient First Review report, released October 15, 2009, contains some discussion and two recommendations aimed at improving the health of First Nations and Métis people in Saskatchewan.

According to Dagnone the number of First Nations and Métis people living in Saskatchewan is growing faster than the number of non-Aboriginal people and they currently comprise about 15 per cent of the provincial population, projected to increase to 21 per cent by 2017.

“These two groups of people typically experience lower health status than other Saskatchewan people,” he said. “For example, First Nations and Métis people have significantly higher incidences of diabetes, tuberculosis, cardiovascular disease, obesity, arthritis and rheumatism. This disparity in health status is frequently attributed in large part to socio-economic disadvantages.”

Dagnone said he and his researchers “took steps to ensure that the First Nations and Métis voice was heard” during the review.

“In all of the general-population focus groups, at least one First Nations person and one Métis person were invited to attend. Four additional focus groups were held for First Nations and Métis people exclusively, in urban, rural and northern locations. Focus groups were also held on three reserves. Registered nurses working on reserve were invited to attend the provider focus groups and the Federation of Saskatchewan Indian Nations (FSIN), the Métis Nation - Saskatchewan (MN-S) and the Northern Inter-Tribal Health Authority were invited to attend the stakeholder forums,” Dagnone said.

“We decided that a minimum of 15 per cent of individuals we spoke to through our telephone survey should be self-identified as First Nations and Métis. I also attended meetings of the FSIN Health and Social Development Commission, the MN-S Health Roundtable and the Memorandum of Understanding on First Nations Health and Well Being Steering Committee. Through all of these mechanisms, we were able to distinguish the First Nations and Métis patient experience from the rest of the population.” [p. 19]

The Patient First Review was launched November 5, 2008. The review had two parts: a patient experience component and an administrative component.

Dagnone worked with consulting firm KPMG to assist with consultations, analyzing results and drafting recommendations for the patient experience review. He also worked with Deloitte Inc. on the administrative review. Each firm submitted their own report with recommendations.

In its report KPMG said the biggest area of concern from the Patient First Province-wide telephone survey is the finding that 45% of First Nations and Métis participants have experienced unacceptable behaviour compared with 30% among people with other backgrounds. To improve access to quality, safer health services the firm recommends a First Nations and Métis health care strategy should be developed within three years.

Unfortunately, one critical item has been omitted from the Dagnone and KPMG reports. Neither touches on the request made by the Federation of Saskatchewan Indian Nations (FSIN) for funding to conduct its own First Nations Patient Review.

Using briefing notes prepared by officials with the policy and planning branch of Saskatchewan Health between January 14 and May 25, 2009, and obtained under the province’s freedom of information legislation, it’s possible to construct a general time line of events leading up the provincial government’s decision to deny the request.

The FSIN senior technical advisory group (STAG) is comprised of health directors from Tribal Councils and Independent First Nations and provides advice to the FSIN Health and Social Development Commission (HSDC).

According to the earliest briefing note at the STAG meeting held January 13, 2009, “there was discussion about the Patient First Review research methodology and whether it would get the “right” First Nations input. A concern was expressed that this methodology may not lend itself well to First Nations people feeling comfortable expressing the racism and mistreatment they receive in the health system. In particular, there was discussion about how First Nations people would be recruited for the Patient First Review and about whether the Review would be using First Nations data sources such as the Regional Health Survey in the research.”

The group also noted “that the MOU on First Nations Health & Well-being was about working collectively and collaboratively together and yet the FSIN was never asked what First Nations would want in the Patient First Review.”

(The MOU on First Nations Health and Well-Being in Saskatchewan (signed August 19, 2008) is a formal tripartite partnership between the FSIN, Health Canada and Saskatchewan Health to improve the coordination of health programming, reduce administrative duplication, better adapt programs to the needs of First Nations and address the gaps in health services for First Nations people.

An inter-governmental steering committee has been established to oversee the implementation of the MOU.)

Vice Chief Glen Pratt said “there are too many critical incidents within the health system that involve First Nations and also said they would like a review and a public inquiry into how First Nations are treated in the health system.”

STAG passed the following resolution:

“WHEREAS, First Nations have a Treaty Right to Health under Treaties #2, 4, 5, 6, 8, and 10; and

“WHEREAS, the Province of Saskatchewan has initiated a process of Patient First Review within the Treaty Territories to gather experiences of interaction with the Health System within the province; and

“WHEREAS, First Nation individuals experience negative or inadequate interactions as the general population with the health system; and

“WHEREAS, First Nations have higher levels of Health concerns, i.e. Diabetes, Cancer, Suicide, Chronic Diseases, and Preventable Injuries; and

“WHEREAS, First Nation individuals and families experience unique negative or inadequate interactions with the health system that may not necessarily be included in the Province of Saskatchewan’s Patient First Review Process; and

“WHEREAS, First Nation have a Treaty Right to Health that includes access and use of traditional healing practices that may or may not be located only in Saskatchewan; and

“WHEREAS, First Nations require their own perspective to be included in this process, and that First Nations meet with the Commissioner to ensure input and an effective First Nations consultation Process; and

“THEREFORE, BE IT RESOLVED, that the Senior Technical Advisory Group recommend that Health and Social Development Commission direct FSIN to initiate a First Nation Patient Review process to capture the experiences First Nation have when interacting with the health system at all levels within the province of Saskatchewan.”

In the briefing note the provincial government states that it “recognizes the FSIN as a legitimate First Nations advocacy group in the province.” But then it immediately seems to try and diminish that legitimacy: “While the FSIN represents 74 First Nations in Saskatchewan, it was not a signatory to any of the Treaties in Saskatchewan. Since each First Nation sees itself as having a nation-to-nation relationship with the Federal Government, tensions between the individual First Nations and the FSIN sometimes arise.” What is the Wall government really trying to say?

Dagnone was “asked to attend” the FSIN Health and Social Development Commission meeting in Saskatoon on January 20, 2009. This seems to suggest that the FSIN were at least willing to hear what the Commissioner had to say.

The provincial government went to great lengths to emphasize that the review was “independent” yet the January 14, 2009, briefing note being quoted here contains 13 “key messages” written by health ministry officials for the Commissioner to use at the HSDC meeting.

These speaking points describe the various steps that researchers took to gather input from First Nations and Métis people and were clearly designed to put a positive spin on the review process. Dagnone seemed confident that his team had done a good job.

“Is it enough?” he said. “From a researcher’s perspective, I am told it is enough. From my perspective, I am open to hearing your views.”

Tucked away at the bottom of the Commissioner’s key messages is this subtle warning: “In respect of the [STAG] resolution, I urge the First Nations to be thoughtful in introducing a third process. We all want to improve First Nations health status and a third process may fragment this goal. I believe the Patient First Review can compliment the MOU process and we can make gains on behalf of First Nations people.” [Patient First Commissioner Speaking to the FSIN Health & Social Development Commission; Briefing Note, January 14, 2009]

In the end, Dagnone’s presence at the HSDC meeting failed to produce the desired outcome because the STAG resolution was passed. The folks at the FSIN have likely heard it all before. Perhaps to them the Commissioner was simply a new face putting a fresh spin on an old story.

A briefing note dated February 4, 2009, confirms that a resolution of the STAG and HSDC “has been developed and may make its way onto the agenda of the FSIN Legislative Assembly being held February 11-12, 2009 at Whitecap First Nation.”

The ministry apparently asked the FSIN if they would assist “in collecting contact information for RNs working on reserve so that these front-line health providers could be randomly selected to participate in the provider input phase of the Review.”

Ministry staff claims to have “received a voice mail indicating that the FSIN wouldn’t be able to assist in this manner since they plan to conduct their own process.”

Ministry staff said they were “uncertain whether this means that the FSIN and First Nations are planning to conduct a separate First Nations Patient First Review or if they will be collecting this type of information as part of the process to develop a 10-year health and well-being plan for First Nations through the MOU process.” [First Nations Concerns Regarding the Patient First Review; Briefing Note, February 4, 2009]

On February 18, 2009, health ministry officials prepared a briefing note updating the situation, presumably for the minister, which had only gotten worse.

At the FSIN Legislative Assembly held February 11, 2009, the members passed the following resolution:

“THEREFORE BE IT RESOLVED that the Chiefs-in-Assembly direct the Executive Member responsible for the health and social development portfolio to secure resources to initiate a First Nations Patient Review to document the experiences of First Nations citizens and will inform the Patient Review Commissioner of its findings.”

The executive member responsible was Vice Chief Glen Pratt.

Ministry officials weren’t sure where the resources would come from to support a First Nations Patient Review but speculated that the FSIN might approach the provincial government for the funding.

“If a proposal is submitted to the province, it will be assessed based on its merits and potential value to the Patient First Review process,” the briefing note said.

More importantly the document provides a clearer picture of what the problem was: The FSIN has “expressed concerns regarding their lack of involvement in developing the research methodology of the Review” and with the tripartite agreement in mind “believes they should have been involved in setting up the research for the Review.”

Health ministry officials go on to list five specific research methodology concerns that were expressed to them, presumably by the FSIN, and give rebuttals for three. These include: random digit dialing as a recruitment tool, surveys, focus group and patient triad settings.

The two concerns that government officials couldn’t answer for were: treaty right to health is not acknowledged; and, First Nations governments are not recognized in the process. These are pretty important. Dagnone’s report doesn’t mention treaty rights and First Nations governments aren’t acknowledged in the terms of reference for the review.

It seems like the government was determined to prove that the FSIN didn’t have a case.

The ministry still maintain that the “Commissioner and the researchers believe they have framed the research to capture the First Nations person’s voice during the patient input phase of the review.” [First Nations Concerns Regarding the Patient First Review; Briefing Note, February 18, 2009]

The FSIN’s belief that it should have been involved in setting up the review seems to point directly to the Scoping and Planning Project document that Dagnone prepared for the health ministry in early 2008.

Dagnone was initially retained by the government to prepare the terms of reference for the review and make recommendations on the study’s framework and methodology to Health Minister Don McMorris. The term of his contract was May 14, 2008, to June 30, 2008.

On November 7, 2008, an access to information request was submitted to Saskatchewan Health for a copy the framework report that Dagnone delivered to health officials.

The ministry denied the request on December 10, 2008, saying “the information contained in the Scoping and Planning Project document is exempt” because it “contains advice and recommendations to the Ministry of Health’s Executive Government; and… information pertaining to the deliberations of Executive Government and Senior Government employees within the Ministry of Health.”

What is the Wall government hiding?

On March 23, 2009, health ministry officials prepared another briefing note updating First Nations concerns with the review.

“The Minister of Health has received a letter from the FSIN requesting resources to support a First Nations Patient Review. A response is currently in development,” the report said.

The government response, however, was never sent.

According to an e-mail from a health ministry official on July 15, 2009, Minister Don McMorris received a letter from the FSIN requesting financial support for First Nations Patient First Review on March 9, 2009. Subsequent to receiving the letter, a meeting was arranged involving Minister McMorris (Minister Draude) and Vice-Chief Pratt. The meeting occurred on April 27, 2009, and “involved a discussion regarding the Patient First Review, among other matters.”

“While a letter of response was prepared, as indicated in the briefing note, it was not sent,” the e-mail said. Apparently the meeting sufficed.

The briefing note indicates that Commissioner Dagnone attended the March 17, 2009, meeting of the MOU on First Nations Health and Well-being Steering Committee and provided the group with an overview of the Patient First Review. He further highlighted for the group what had been done to capture the First Nations’ patient’s voice in this Review.

During the meeting “Vice Chief Pratt thanked the Commissioner for sharing his preliminary findings with the group and especially for visiting a northern Dene community as part of the patient input phase.”

The Commissioner and committee “agreed that they would share information with each other to better inform their respective initiatives. There was a general sense that the Patient First Review is capturing many of the same concerns that are being heard by the FSIN during its own internal sessions, as well as at the Steering Committee’s open dialogue sessions. Through these two processes, positive change to the health system to better meet the needs of First Nations people could be accomplished.” [First Nations Concerns Regarding the Patient First Review Updated; Briefing Note, March 23, 2009]

A May 25, 2009, briefing note by health ministry staff appears to bring the issue to a close stating: The FSIN “passed a resolution at their February assembly to conduct their own patient first review that would inform this review. The Ministry of Health declined the FSIN’s request for funding for this separate review since both organizations, along with Health Canada, are currently working together to develop a 10-year health plan for First Nations health and well being.” [Patient First Review; Briefing Note, May 25, 2009]

Given the Commissioner’s subtle warning in the January 14, 2009, briefing note the FSIN’s request likely had little chance of succeeding.

Government briefing notes can prove valuable but in many ways they are a one-sided conversation. It’s hard to know if the whole story is being told or whether some parts are being left out.

Take for example the FSIN’s claim that is should have been involved in setting up the research for the review, or Vice Chief Pratt saying they would like a review and a public inquiry into how First Nations are treated in the health system. The health ministry’s briefing notes leave these two very important issues unresolved.

The FSIN seem silent on the Patient First Review report – at least publicly. There are no media releases posted on the organization’s website commenting on the review or the process.

What seems clear is that the Wall government didn’t want any competition. It wanted the review all to itself and on its terms. Allowing a parallel process into the mix would have mucked up its well laid plans.

In his report Dagnone said the review process “embodied a spirit of openness and transparency.” He said as the review proceeded he “shared information with health care leaders, providers, stakeholders, and the public.” However, that sentiment never extended to his scoping and framework document. Until this record is released there will likely continue to be questions.