Investigation Report: Peel-Halton French-language health services
In this report, the French Language Services Commissioner concludes that the region of Peel-Halton has lacked integrated French-language health services for over 20 years.
Final Investigation Report – Case 07-09-003
Centre de services de santé-Peel et Halton Inc.
1. On November 1, 2007, Centre de services de santé-Peel et Halton Inc. (the Center) filed a complaint with the Office of the French Language Services Commissioner (the Office), to the effect that the Ministry of Health and LongTerm Care (the Ministry) was failing to meet its obligations under the French Language Services Act (the FLSA) to offer primary health care in French in designated areas such as Mississauga and Brampton. These cities are located within the jurisdictions of two Local Health Integration Networks (LHINs), i.e., the Mississauga Halton LHIN and the Central West LHIN. In 2006, the total number of Francophones living in the areas served by these two LHINs was in excess of 32,000.1
In light of the new, more inclusive definition of Francophone that was recently adopted by the Government of Ontario, this number is now higher.
2. A petition signed by 217 individuals accompanied the Center’s complaint, reflecting a strong desire on the part of the Francophone community in PeelHalton to have a French health system that meets their needs in the region. It should also be noted that applications to the Ministry for such a system have been supported by most, if not all, of the region’s MPPs.
3. On April 21, 2008, a letter was sent to the Ministry to inform them of the Office intention to handle this complaint by means of a formal investigation. Since 1986, the complainants maintain that they have not received health services in French in their region, in spite of the fact that it became a designated area within the meaning of the FLSA when this Act came into force in 1989.
4. Under the FLSA, the Office of the French Language Services Commissioner is charged with conducting independent investigations, either following a complaint or on its own initiative. It is also responsible for preparing reports on its investigations and monitoring progress by government agencies in the delivery of French services in Ontario.2
5. As a new government agency, it was important for the Office to focus on the important issue of what constitutes service in French in the area of health, and to take a position on the role and functions of key government actors under the legislation, including the Local Health System Integration Act, 2006 (the Act).
6. In May 2009, the Office released a Special Report on French Language Health Services Planning in Ontario; Schedule 1 contains a summary of relevant excerpts of this report.
7. This special report enabled the Office to more fully grasp the complexity of the health system and the need to plan more effectively on the basis of the specific needs of Francophone communities in order to adequately serve these communities. Complaints received by the Office over alleged gaps in French health service offer and delivery are analyzed in light of the conclusions contained in this special report. The Center’s complaint is no exception. Indeed, the scope of its complaint is very broad; it reports on French health service delivery gaps across an entire region and spanning a period of many years, i.e., since the FLSA came into effect in 1989.
Background to the Complaint
8. According to the complainants, the offer of integrated health services in the PeelHalton region has been deficient for a very long time. Between 1988 and 1992, a group of Francophones in Peel-Halton struck a committee to make recommendations for French health services. Their decision to apply to the Ministry for funding for the creation of a French-language community health centre (CHC) was made in the wake of a report entitled Services de santé en français dans la région de Peel released in 1989 by the consulting firm of Rhéal Leroux et associés. Commissioned by the Conseil régional de santé de Peel, this report noted that approximately 13,000 Francophones in the region were without access to health services in French.
9. Officially submitted on January 14, 1992, the committee’s application for funding for the creation of a French-language community health centre was turned down by the Ministry. The committee then considered the possibility of opening a satellite centre of the Centre francophone de Toronto in Mississauga, only to be told at a meeting with Ministry officials with responsibility for French health services that no funding was available for this option.
10. In 1995, the group incorporated as Centre de santé communautaire de Mississauga Inc., with a mandate to raise the government’s awareness of the needs of Francophones in the region. The corporation submitted three new applications (in 1997, 1998, and 2001) for the funding needed to open a satellite centre of Centre francophone de Toronto in Mississauga. All three applications were turned down by the Ministry.
11. In 2005, the corporation decided to try a different approach. It submitted an application for funding for a Family Health Team (FHT); however, this application was turned down. It submitted as well another application for a satellite centre of Centre francophone de Toronto in Mississauga. It, too, was turned down.
12. In 2005, the government announced that $74.6 million had been earmarked for the construction of 22 new CHCs and 17 new satellite CHCs by the end of the 2007-2008 fiscal year. In response, Centre de santé communautaire de Mississauga Inc. submitted a new application for funding for a satellite CHC. Once again, its application was turned down.
13. In 2007, the corporation changed its name to Centre de services de santé-Peel et Halton Inc. and submitted a new application for funding for a CHC, this time in Peel. This application was also turned down.
14. In the summer of 2009, at the recommendation of the Ministry, the Center submitted a new application for funding for a community FHT. But when the approval of 19 new FHTs was announced on November 11, 2009, the Center’s application was not among them. Thus, of the 150 FHTs currently serving Ontarians across the province, not one serves the needs of the Francophone community in the region of Peel-Halton.
What is a CHC? What is an FHT?
15. CHCs are not-for-profit agencies with teams of physicians, nurse practitioners, nurses, counsellors, social workers, and dietitians. They provide care to individuals who have difficulty accessing primary health care due to barriers such as language, culture, physical disabilities, homelessness, poverty and geographical isolation. CHCs also provide care to individuals who are at greater risk of health problems than the general population. They offer programs and services that take into account such factors as education, employment, income, social support, and housing.
16. Family Health Teams (FHTs) include family physicians, nurse practitioners, registered nurses, social workers, and dietitians. These Teams provide comprehensive health care. They offer additional programs that are adapted to the needs of the communities they serve, including consultations for patients who do not have a family physician. Increasingly, FHTs are responsible for the management and prevention of chronic diseases and for the Ontario Diabetes Strategy.3
17. For the purposes of this investigation, the Office communicated with the complainants and with representatives of the Ministry on several occasions either in person, by phone or by e-mail. The Office sent to the Ministry a series of questions. Upon receipt of the responses from the Ministry, the Office requested several clarifications. An interim report was sent to the Ministry on January 8, 2010. The Ministry sent a detailed response on February 23, 2010.
Office’s Investigation Questions:
- What selection criteria are used to decide whether or not to allocate funding for a CHC?
- How are primary health services currently offered in French in the region?
- Is alternative funding available to fund this type of CHC?
- Are there other options that the Ministry is willing to entertain?
- What specific measures have been taken to ensure access to health services for the region’s 32,000 plus Francophones?
- If there are gaps in access to primary health services in French, these gaps must be taken into consideration. How has this been done?
- How will the needs of Francophones in the region be taken into account in the future?
- Now that alternatives to the CHC model exist (FHTs, NPLCs), will funding be made available to the complainants?
- What accountability mechanisms are in place to ensure that equivalent health services are available to the Francophone community?
Initial responses from the Ministry and Analysis:
18. The Ministry indicated that decisions over funding for new CHCs are based on geographical factors concerning the distribution of the population considered a priority for these services. Priority populations have traditionally consisted of individuals having difficulty accessing service (based on culture, language, education, age, socioeconomic status). In any event, the Ministry has stated that no funding is currently available for a CHC and that there are no plans to open a new CHC, since the government is now giving priority to FHTs.
19. The Ministry also indicated that, according to the Government of Ontario’s Corporate Provider Database, one physician in Mississauga has chosen French as his language of communication. The Ministry added that, according to a search of the College of Physicians and Surgeons of Ontario website, eight physicians practise in French in Mississauga and two physicians practise in French in Brampton.
The Office is of the opinion that the Ministry’s response clearly indicates that there are no locations where Francophones can obtain integrated French health services in the region of Peel-Halton, as the complainants have been requesting since 1989. French health services entail far more than the ability to consult a physician who speaks French. This fact was made abundantly clear in the Commissioner’s Special Report on French Language Health Services Planning in Ontario.
20. The Ministry indicated that Francophones living in Peel and Halton generally travel to Centre francophone de Toronto to obtain the services they need in French.
This statement reflects a very poor grasp of local health service needs. First, Centre francophone de Toronto has a very long waiting list and accepts few, if any, new patients. More importantly, this statement assumes that most of the people who live in Peel and Halton work in downtown Toronto. What about families? What about children? Even if Centre francophone de Toronto were able to accept them as patients, should they have to travel to downtown Toronto in order to obtain health services in French? The Ministry’s statement is an unwarranted assertion with no basis in fact; it reflects a disturbing lack of understanding of the local health system.
21. The Ministry is offering the complainants and the Office two options for improving
French health services in the region. The Ministry is suggesting alternative delivery models, including Family Health Teams (FHTs) and Nurse PractitionerLed Clinics (NPLCs), and is suggesting that the complainants submit new applications and that this would be the best option for the complainants to pursue.
Not only did the complainants agree; they prepared no fewer than two applications (not counting the applications submitted previously for funding for a CHC). The most recent application appears to have been turned down on December 11, when the government announced 19 new FHTs. Why was the most recent application turned down?
22. The Office cannot make assumptions about the reasons why the complainants’ application was, once again, rejected. Perhaps their application did not meet all of the criteria for obtaining an FHT. If this is so, these criteria should perhaps be examined to determine whether they in fact apply to a minority Francophone community.
23. For example if, in order to obtain an FHT, applicants must demonstrate that provision has been made for a specific number of health professionals, either in the application or in the Ministry’s review of the application, the Ministry must ensure that this number is based on a realistic approach to the offer of French health services.
24. The Ministry’s criteria for reviewing applications is based on the following five objectives:
Needs of the population – the scope of the service gaps; specific needs of the region;
Relevance of services – achievement of the FHT objectives, adapted to the needs of the population;
Health human resources – the proposed supplier mix suits the services being delivered; Integration of partners/services – the role of partnerships and community support; Availability – suppliers prepared to work, facilities, recruiting plans.
Are these criteria analyzed on the basis of the specific needs of minority Francophone communities? This question needs to be asked. For example, the first two criteria could be modified to ensure that priority is given to populations facing gaps in the delivery of French primary health care services.
The Commissioner recommends that the criteria used to review applications for a Family Health Team be modified to adequately reflect the specific situation of the Francophone community and that these criteria specify that priority will be given to populations coming up against gaps in French health service delivery.
25. In any event, the Office is of the opinion that the Ministry has not demonstrated that integrated health services in French exist in the region of Peel-Halton and that, since 1989, it has not taken steps to ensure that Francophones in this region are able to obtain equivalent French health services. To date, not a single health service provider has been designated under the FLSA to offer French health services in the region and only a handful of practitioners have been identified as being able to provide health services in French.
26. This situation exists in spite of the fact that the Ministry’s responsibilities in the area of French services are clear:
- To ensure that Ontario Francophones have access to health services in French;
- To ensure that an adequate number of health agencies offer French language services and that these services are provided according to government standards;
- To ensure that bilingual/French-speaking health professionals are adequately distributed across the province; and
- To ensure that adequate primary health care services are available in French.4
Ministry’s Response to the Recommendation:
Draft criteria for selecting the next wave of 30 FHTs is currently under review to determine the priority given to populations where there is an identified service gap in French language health service delivery. The review will consider if there are any built-in barriers to participation by the francophone community. The ministry’s application and selection process for new FHTs will consider how the proposed FHTs’ services will meet the need of the patient population including gaps in French language health service delivery. Applicants have an opportunity to demonstrate how their proposed FHT will meet local patient population needs including addressing service gaps in French language health service delivery.
The Ministry added that new measures will be included, such as:
Inclusion of French language health service delivery in designated areas included as a criterion in the Ministry’s application and selection process for new Family Health Teams.
In light of the Ministry of Health and Long-Term Care’s obligations under s. 5(1) of the French Language Services Act and in light of the fact that equivalent, integrated French health services are not currently being offered in the region of Peel-Halton, the Commissioner recommends that the Ministry unequivocally acknowledge that it is ultimately responsible for the provision of these services and that it take whatever steps are necessary to ensure that these services are indeed provided.
27. A bilingual FHT is one possible solution to the lack of French health services in Peel-Halton. However, the complainants have already submitted two applications and these applications were rejected. The Ministry has a duty to help Francophones in the region of Peel-Halton to find viable solutions that address the gaps in the delivery of equivalent French health services.
28. The Ministry has reminded the complainants of the importance of working with the LHINs, the agencies that are now responsible for the planning, integration, and funding of local health services. The French Language Health Services office has developed a French services accountability report and implementation plan that will be shared with the LHINs.
The Office is of the opinion that the plans and accountability reports proposed by French Language Health Services are woefully inadequate. This was amply demonstrated in the Commissioner’s Special Report on French Language Health Services Planning in Ontario.
Ministry’s Response to the Recommendation:
The Ministry recognizes there maybe gaps in the French Language Services in the Peel-Halton region and is committed to addressing these with new concrete measures.
Having said this, the Ministry is still referring to the changes made when the LHINs were created. The LHINs have to manage the local health care system. With the new Regulation regarding Francophone communities’ engagement, French Language Health Planning entities will have to be dealt with. For the Ministry, these entities will play a crucial role in working with the LHINs to improve services.
The Commissioner recommends that, in cooperation with the two LHINs, the Ministry develop and propose to the Francophone community of Peel and Halton, practical and concrete models for the delivery of French health services. He further recommends that it be possible to implement these models by the end of 2010.
Ministry’s Response to the Recommendation:
The Ministry supports the development of effective delivery models to ensure culturally and linguistically appropriate services. Over the past year, we have collaborated with the Centre de services de santé-Peel et Halton Inc., to draft a proposed project plan which will develop a culturally appropriate service delivery model for the region.
More importantly, the Ministry is committed to work closely with the Centre to find a concrete solution. The Ministry intends to work closely with the group to ensure this project is successful and will review the findings and model-development at its conclusion.
29. It goes without saying that the complaint by the Centre regarding the lack of integrated French language health services in the Peel-Halton region is founded. For years now, it has been very difficult for the Francophone community of this region to obtain health services in French. This must be taken into consideration when applications for funding are processed.
30. The Ministry is encouraging the complainants to work together with the two LHINs in whose jurisdictions the Francophone population of Peel and Halton live. However, it is up to the Ministry to ensure that the LHINs have the capacity and the resources to really understand and respond to the legitimate demands of the region’s Francophone population. Otherwise, the Francophone community will be forced, once again, to waste precious time and energy convincing not one, but two, LHINs of the importance of their legitimate requests.
Summary of the Special Report on French Language Health Services Planning in Ontario
In this special report, the Commissioner explains the importance of integrating French services into health care planning in Ontario. Throughout this report, the Commissioner identifies the obligations and responsibilities of the key players in the health care system with respect to the delivery of French health services. Supporting and illustrating his remarks are comments and anecdotes from the Francophone community. He then presents his conclusions and recommendations.
Chapter One contains an overview of Ontario’s Francophone population. In this overview, the Commissioner explains that the Francophone population has specific needs and characteristics that differ from those of the rest of the population, where health is concerned. The lack of human resources and the persistent myth that all Francophones are bilingual pose a number of challenges. For this reason, the Commissioner insists on the importance of taking into consideration structures that already exist in the health system and in the community and recognizing these structures as partners in the planning of services.
The Commissioner’s message in this regard is clear: make the Francophone community and its organizations true partners in the planning of French health care and use these organizations, which actively offer services that have been adapted to a community with distinctive needs, as models.
Chapter Two continues in this vein. By planning on the basis of the needs of Francophone individuals and communities, the government will be able to meet its obligations under the French Language Services Act (FLSA) and the Local Health System Integration Act, 2006 (LHSIA). In this chapter, the Commissioner sets out the roles and responsibilities of the ministries and the Local Health Integration Networks (LHINs ) with respect to planning French language health services.
Because the LHINs are government agencies within the meaning of the FLSA, they must engage the Francophone community in the development of their health service plans if they work within designated areas. For this reason, the Commissioner has recommended at the conclusion of Chapter Two, that the proposed regulation on the engagement of the Francophone community be amended to include true planning entities, as provided for in the LHSIA. In Chapter Three, the Commissioner begins with the responsibilities of the
LHINs vis-à-vis these planning entities. He recommends adding a French Language Services Coordinator to each LHIN. This would ensure that the activities of the French language health planning entities are followed up, and would make each LHIN accountable for its administrative decisions. The LHINs must justify the decisions they make and the actions they take – or fail to take – to the Francophone communities they serve. A process of accountability must be established to ensure that the health system meets it obligations to offer high-quality French health services.
In Chapter Four, the Commissioner recommends that clear guidelines be provided for a complaint procedure in the event of a lack of access to, or a lack of quality of, a French language health service. The public is entitled to highquality French services from care providers and agencies in the health system, whether these are hospitals, health centres or LHINs. If such services are not available, there must be an easy way to file a complaint. This process must be clearly indicated and explained and simple to follow.
Ontario’s health system is based on principles of quality of service and the Commissioner expects these principles to be also applied to the accessibility of its services. Access to high-quality health services in French is not a separate issue; it must be treated as a factor that has a direct impact on the health of Francophones. After all, members of the public benefit from receiving services in their own language and one such benefit is improved health. The Commissioner concludes his special report with the consequences of failing to take action, making the point that the health of the Francophone population is at stake. His eight recommendations are based on this premise.
List of Initialisms and Acronyms:
CHC: Community Health Centre
NPLC: Nurse Practitioner-Led Clinic
FHT: Family Health Team
LHIN: Local Health Integration Network
1. These numbers are based on data from the websites of the LHINs in question. Available on-line at:
http://www.mississaugahaltonlhin.on.ca/uploadedFiles/Home_Page/MH%20LHIN%20IHSP_%202010-2013_Final.pdf and http://www.centralwestlhin.on.ca/uploadedFiles/Home_Page/Integrated_Health_Service_Plan/Central%20West%20LHIN%20IHSP.pdff (pages consulted in December 2009).
2. Available on-line at http://www.flsc.gov.on.ca/en/node/3 (page consulted in December 2009).
3. Available on the Ministry of Health and Long-Term Care’s website at: http://news.ontario.ca/mohltc/en/2009/12/new-family-health-teams-on-the-way.html (page consulted in December 2009).
4. Available on-line at http://www.health.gov.on.ca/english/public/program/flhs/flhs_mn.html (page consulted in December 2009)