Health: Looking for a remedy

A healthy population is a thriving population. A vulnerable population is a population in need, affected by unfavourable circumstances. These circumstances become barriers, such as language, which prevent people from accessing available resources and services, among other things.

The French Language Services Act gives Francophones, particularly those in precarious situations, one less barrier to worry about. It’s an entrenched right. Is this right being honoured? Is it understood and recognized? On the basis of the too often lame responses that the government provides to the Commissioner’s Office in dealing with complaints, efforts need to be made to ensure a proactive approach to complaint resolution.

The absence of French-language services in the health care sector can go so far as to endanger citizens’ lives. Young or old, immigrants or migrants, sick people do not have the luxury of waiting for someone to hire a bilingual person to serve them. And then there is the case of Francophone seniors. At a certain age, health deteriorates. Fighting to get care in French may not be an option. Bravo to those who dare to do so anyway; congratulations on your tenacity.

When complaints come in to the Commissioner’s Office, time has already taken its toll. People are exasperated and frustrated and don’t know where to turn. Some of these complaints demonstrate a number of systemic problems to which the Commissioner’s Office has been striving to draw attention for the last eight years.

Kingston General Hospital

Francophones in the Kingston area have little choice when it comes to emergency care and health care in general. It is a designated area. Its two hospitals are not designated under the French Language Services Act; they are only identified. Consequently, they have no particular obligations under the Act.

A single complaint filed in this area in the summer of 2014 points to a whole series of systemic problems in the health sector. The case has multiple facets, including choice of language of service and wait times for Francophones. Another dimension is the almost superhuman effort it takes to file a complaint when the Francophone is already vulnerable because of his or her fragile health.

The complainant had a reaction to a medication and had to be rushed to Kingston General Hospital. Her ambulance ride was fine. Even though the paramedics were not subject to the French Language Services Act, they provided excellent service in French.

In the emergency room, the complainant, who was showing symptoms similar to those of a stroke, understood what the nurses were saying to her in English, but she was unable to speak English. All she could do was repeat herself in French. Yet, in her mind, she thought she was speaking English.

As it happens, the complainant is a retired nurse, and a nurse in the emergency room knew her. So this nurse insisted that she speak English. According to the complainant, one nurse ridiculed her by saying, “I know you can speak in English; we speak in English here.”

Then she was apparently transferred from the emergency room to the psychiatric ward, in a room watched by a security guard. The alleged reason for the transfer: aggressiveness, hysteria and non-compliance, all because she was speaking in French. Finally, they found a bilingual nurse to help her. The Commissioner’s Office wonders why this person wasn’t called in at the outset and why they didn’t at least contact an interpreter. Not surprisingly, the complainant absolutely refuses to go back to the Kingston General Hospital.

The hospital has apologized for this unacceptable experience for the patient. Worse yet, however, the hospital’s initial responses suggested that there was no broader understanding of a problem that was much larger than an employee’s lack of sensitivity. The problem is that there was no plan in place for French-language services and active offer.

Because of its identification as a health care institution, the hospital is required to provide some services in French. To do so, the hospital must have a plan and implement it to reduce the number of mistakes such as this one. That said, following inquiries from the Commissioner’s Office, the hospital has started to look at improvements. In conjunction with the South East Local Health Integration Network (LHIN) and the French Language Health Services Network of Eastern Ontario, Kingston’s hospitals are planning an information session on French-language service obligations for the area’s Francophone community. The hospital’s plan also includes other measures, such as the hiring of an assistant to support the implementation of the French-language services plan, the addition of signage on the availability of French-language services, and participation by a local planning entity officer in the French-language services committee. The Commissioner’s Office is delighted with this show of good faith by the parties involved. As for the complaint, it demonstrates that it is important to inform the Commissioner’s Office of such situations, as well as the positive results of good cooperation. Without complaints, there is little or no progress. Consequently, the Commissioner’s Office salutes the work of the Kingston General Hospital, which managed to transform a systemic problem into an opportunity to make improvements and provide equitable services to Francophones.

Action plan of the Ministry of Health and Long-Term Care

One of the elements in the 2012 action plan of the Ministry of Health and Long-Term Care, also included in the province’s Patients First plan published in February 2015, was access to the right care at the right time in the right place. This action plan not only fails to consider Francophones but also focuses exclusively on achieving a better return on each dollar invested. Let’s be clear: shortcomings in French-language services, particularly in the health sector, can only result in additional costs.

The government’s recent Patients First action plan provides for the appointment of a Patient Ombudsman. The Commissioner’s Office is pleased with this amendment to the Excellent Care for All Act, 2010. In fact, it intends to be proactive and work with this ombudsman to develop a memorandum of understanding on complaints resolution. Moreover, needless to say, the Commissioner’s Office hopes that this important post will have the capacity to interact with the province’s Francophones, by designating at least one of the investigator or complaint processing officer positions as bilingual.

Senior citizens: A minority population that has rights

By 2017, for the first time, Ontario will be home to more people over 65 than children under 15. Today, seniors account for nearly half of Ontario’s health care spending.⁹

Getting old can be difficult. Worse, losing the ability to communicate in one’s language when one is in a vulnerable situation and needs care makes life unbearable. The Commissioner’s Office receives poignant complaints about seniors who cannot ask for help by themselves. Family members contact the Commissioner’s Office on their behalf to get things moving. And in some cases, it works. While there is little that the Commissioner’s Office can do when the situation is outside its jurisdiction, it always does its best to help citizens in need.

With a plethora of examples at its disposal, the Commissioner’s Office is able to look a little more closely at what it suspects is just the tip of the iceberg. A lady in Ottawa-Carleton is caring for her 93-year-old mother on a full-time basis. Since this is very demanding, she would like to have access to a respite bed for her mother in a French-speaking setting so that she can get a bit of rest. As a result of her simple request, it was determined, with the assistance of the Commissioner’s Office, that there are only a few such respite beds in this designated area with a high concentration of Francophones, compared with 17 beds for the rest of the population.

In Northern Ontario, a woman is taking care of her 97-year-old mother-in-law on a daily basis. She is making arrangements to obtain basic home care and services (preparing meals, making the bed, helping her to sit in her chair, etc.). The complainant had to make multiple attempts and repeat over and over, most of the time in English, that she needed home support workers who were Francophone or truly bilingual for her mother-in-law, who speaks only French. Despite her follow-ups, she was sent workers who didn’t speak French on a number of occasions. According to the complainant, the director even told the staff member not to worry if the lady didn’t speak English; he could communicate with her by playing charades! Worse still, it turned out that no one showed up, because no French-speaking workers were available on those days. A long period of frustration followed. Exhausted, the family tried to find a place in a long-term care home. They were offered a place in a Francophone home, but outside the city. Meanwhile, the 97-year-old mother-in-law broke a hip. As a result, she found herself in a residence where only English is spoken because of the proximity.

[TRANSLATION] “What a frustrating experience! I called the Red Cross CarePartners and the Community Care Access Centre many times, mostly without any concrete results. We wouldn’t wish our experience with this health and community service system on anyone!”

A complainant

In view of the rapidity with which our population is aging, it is important to recognize that there is still a lot of work to do. That is the government’s responsibility. It must be treated as a priority issue, since the Francophone population is older than the total population of Ontario.¹⁰ What’s more, the situations reported here all took place in designated areas. Already in a disadvantaged situation, Francophone seniors cannot afford to pay more to get health services in French. Especially since they are less likely to request such services, for a number of reasons:¹¹

• fear of the specialized medical vocabulary used by their doctor;
• fear of not being capable enough and not understanding medical instructions;
• the feeling of being hurried because of the brevity of the consultation with the doctor; and
• difficulty expressing themselves in a second language and understanding English.

The Commissioner’s Office recognizes that efforts, though isolated, are being made, and he appreciates them. But on a broader scale, one wish remains: that Francophones be considered in the government’s action plan. The government’s most recent Action Plan for Health Care (Patients First, 2015)¹², Ontario’s Action Plan for Seniors (2013)¹³ and the recent report it commissioned on Ontario’s Seniors Strategy (Living Longer, Living Well, 2012)¹⁴ all fail to make reference to Francophone seniors, their specific needs and their rights under the French Language Services Act. These plans establish the priorities that the LHINs have to follow. If none of the priorities consider Francophones, the LHIN will see no need to prioritize a minority population that nevertheless has rights.

From this perspective, the government’s lack of response to the argument made by the Commissioner in his 2012-2013 annual report on the need to develop an action plan to ensure that disadvantaged populations have genuine access to French-language services seems rather curious. The most fragile populations in our society, such as the elderly, should have ready access to the French-language services they need so desperately.

Third parties: Still a bitter pill to swallow

In its 2013-2014 annual report, the Commissioner’s Office revealed the serious threat of the lack of regulatory clarity that the LHINs raised under the government’s nose. Irresponsibly, the LHINs argued that they are not required to ensure that services are provided in French in the health care sector. Therefore, according to the LHINs, they cannot “delegate” that responsibility to the health care service providers to which they contract out work paid for by public funds. In their view, Regulation 284/11 on the provision of French-language services on behalf of government agencies does not apply. The Commissioner’s Office is still of the opinion that this does not make sense.

In the Commissioner’s view, these discussions serve merely to muddy the waters. Remember, the new regulation was intended only to clarify existing obligations. It was not intended to add anything new. It was certainly not intended to absolve any governmental agency of existing responsibilities. The Ministry has confirmed to the Commissioner that the LHINs still have to fulfill their obligations. To argue otherwise is, in the Commissioner’s view, a red herring.

The Ministry fully recognizes that the LHINs are, of course, subject to the French Language Services Act (FLSA)and must ensure that Health Services in Designated Areas of the Province are provided in accordance with the Act. The LHINs had, and still have, obligations regarding the delivery of health services in French. Before the advent of the LHINs, it was the Ministry of Health and Long-Term Care that had direct responsibility for providing health services in French in designated areas. Consequently, the Ministry had direct responsibility for identifying health care service providers, so it could require them to develop the capacity to provide services in French. However, the LHINs’ arrival on the scene, replacing the Ministry in the direct relationship with health care service providers, is not a reason for Ontario’s Francophone population to get the short end of the stick. Such an interpretation would not only be legally unthinkable; most of all, it would be simply ridiculous and insulting to the province’s Francophones.

For the sake of clarity, we are not talking about organizations designated under the FLSA, which already have clearly defined obligations based on their status. The whole problem raised by the LHINs relates to the process of identifying providers of French-language health services in each of the 25 designated areas.

This identification process serves only to identify the Francophone community’s needs in relation to a health service provided by the government and to compel the identified providers to deliver French-language health care services accordingly.

However, if the LHINs’ legal interpretation prevails, it would mean that service providers can no longer be forced to build the capacity to deliver health care services in French. Such an interpretation would be completely inconsistent with the entire history of French-language services in the province in the health sector and certainly contrary to both the letter and the spirit of the Local Health System Integration Act, 2006 and the French Language Services Act.

The identification process itself is already nothing more than a legal crutch that is, to put it politely, not very sturdy – a crutch on which the government leans to ensure the delivery of high-quality French-language services in the health sector. It would therefore be unthinkable to retreat on such a shaky instrument.

Since the intervention by the Commissioner’s Office, no concrete measures have been undertaken to address this issue. A year has been lost. The Commissioner’s Office does not intend to leave matters there. Health is one of the sectors with the largest number of third parties. The issue is too important to be swept under the rug. Over the next year, the Commissioner will consider what should be its next steps.

On a more positive note, the Ministry informed the Commissioner that interesting discussions in regards to addressing French-language service gaps are in the works between LHINs and their French Language Health Planning Entities. While it looks promising, the Commissioner is tempted to add that it’s about time.

Since this matter relates to the Ministry of Health and Long-Term Care, the Commissioner’s Office has noted that it could do a better job of communicating with the public on its website. In fact, most of the complaints about the Ministry have to do with the lack of appropriate communications in French.

Although a directive and guidelines on communicating with the public in French are in place, disparities persist in the information provided to Francophones. The Commissioner’s Office is not referring to reports, news releases and announcements issued in French. The problem goes deeper. So deep and so far that one has to search for the French information about the health care services to which citizens are entitled. It takes patience and determination for Francophones to dig out this information from where it is buried on the Ministry’s website. The Commissioner will also study this matter with a view to suggesting concrete steps that this ministry could take to be more attentive to the needs of Ontario’s Francophones and encourage them more effectively to request health services in French.

Active offer

Since the beginning of his mandate, the Commissioner made the principle of active offer one of his most important targets. Without active offer, particularly in the health sector, there cannot be a real understanding of the needs of the Francophone community, nor of its existence.

As he wrote in his 2013-2014 annual report: “…the current situation does not create an environment conducive to reaching those who are still hesitant to use services in French on a daily basis, nor to helping avert the constant threat of assimilation. The Commissioner believes that many breaches of the Act could have been avoided with a decidedly active provision of services in French. And those breaches could sometimes have dramatic consequences, as in the fields of health care and access to justice. Having failed to obtain a satisfactory outcome, the Commissioner will once again have to revisit this critical issue.”

In March 2015, the Regroupement des Entités de planification des services de santé en français de l’Ontario and the Alliance des Réseaux ontariens de santé en français published a Joint Position Statement on the Active Offer of French Language Health Services in Ontario.¹⁵ This short document, which is only three pages long, summarizes finely the issue of active offer in the critical health care sector. In their own words: “This position statement establishes the relevance of active offer, provides a definition adapted to health services for Ontario’s Francophones and identifies the roles and responsibilities of several key actors in its implementation.”

The Commissioner is delighted by this position statement. As specified in this Joint Position Statement:

“Active offer of health services in French is the regular and permanent offer of services to the Francophone population. Active offer of services:

• respects the principle of equity;
• aims for service quality comparable to that provided in English;
• is linguistically and culturally appropriate to the needs and priorities of  Francophones; and
• is inherent in the quality of the services provided to people (patients, residents, clients) and an important contributing factor to their safety.

It is the result of a rigorous and innovative process for planning and delivering services in French across the entire health care continuum.

It depends on accountability at several levels and requires partners to exercise appropriate leadership with respect to health services in French.

In concrete terms, it takes the form of a range of health services available in French and offered proactively, that is, services are clearly announced, visible and easily accessible at all times.”

The Réseau and the Alliance’s Joint Position Statement also indicates in a section on the implementation of this statement on active offer that:

“Implementation of active offer of French language health services requires an appropriation of responsibility at several levels:

• The system (Ministry of Health and Long-Term Care, LHINs) that designs the policies and programs, sets the rules, allocates resources, retains providers’ services and holds them accountable;
• The organizations that provide the services;
• The professionals who work with patients, residents and clients; and
• The individuals who use health services.

Careful planning of active offer at each of these levels is necessary to ensure effective implementation and optimal conditions for Francophone patients.”¹⁶

The Commissioner intends to come back to this issue again, during the course of the next year. In the meantime, he can only congratulate the authors of this statement for its clarity and brevity and its desire to convince the relevant stakeholders of the validity of this statement. He offers them his collaboration to ensure its full implementation.

9. Ontario Seniors’ Secretariat, Independence, Activity and Good Health: Ontario’s Action Plan for Seniors, Toronto, 2013.

10. For more information: http://www.ofa.gov.on.ca/en/franco-stats-seniors-2009.html?p=highlights (page consulted in May 2015).

11. Louise Bouchard, Marie-Hélène Chomienne, Monique Benoit, Françoise Boudreau, Manon Lemonde, and Suzanne Dufour, “ Do chronically ill, elderly Francophone patients believe they are adequately served by Ontario’s health care system? Exploratory study of the effect of minority-language communities”, Canadian Family Physician, Vol. 58, 2012.

12. For more information: http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/ (page consulted in May 2015).

13. Ontario Seniors’ Secretariat, op. cit.

14. For more information: http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/docs/seniors_strategy_report.pdf (page consulted in May 2015).

15. For more information: http://www.reseaudumieuxetre.ca/wp-content/uploads/2014/10/EnoncE_OffreActive_10mars15_ANG.pdf (page consulted in May 2015).

16. Ibid, p.3.