Pat Hoy, MPP
Chair of the Standing Committee on Finance and Economic Affairs
Room 1405, Whitney Block
Toronto, Ontario, Canada
November 23, 2009
Dear Mr. Hoy,
It is ironic and disturbing that as public health nurses across the province are working around the clock leading efforts against the H1N1 pandemic, the legislature is considering an amendment to the Health Protection and Promotion Act (HPPA) that could have the effect of reducing the capacity of public health at precisely the moment when the opposite is called for.
The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve. Nurses know the pivotal importance of a strong public health system in health protection and promotion, disease and injury prevention, reducing health inequities, and reducing the costs of a system too often focused on illness rather than well-being.
Section 12(6) of Schedule 18 of Bill 212, An Act to Promote Good Government, is deceptively brief: “Subsection 71(3) of the [Health Protection and Promotion Act] is repealed.”
Subsection 71(3) of the HPPA currently requires a public health nurse in this province to be a registered nurse who is a member of the regulatory body, the College of Nurses of Ontario. It reads:
(1) Every board of health shall engage the services of such persons, including public health nurses, as are considered necessary to carry out the functions of the board of health, including the duties of the board of health in respect of mandatory health programs and services. R.S.O. 1990, c. H.7, s. 71 (1).
(2) No board of health shall engage the services of any person in a professional, administrative or technical classification unless the person meets the qualifications and requirements prescribed by the regulations for the classification. R.S.O. 1990, c. H.7, s. 71 (2).
(3) No board of health shall engage any person as a public health nurse unless the person is a member of the College of Nurses of Ontario who is a registered nurse and,
(a) has the public health nursing education prescribed by the regulations from a degree granting institution in Canada or at a degree granting institution outside Canada that is accepted as equivalent by such an institution in Canada; and
(b) meets such additional qualifications and requirements as are prescribed by the regulations. R.S.O. 1990, c. H.7, s. 71 (3); 1998, c.
18, Sched. G, s. 55 (10).
It is not clear whether the government’s purpose in proposing this amendment is to open the door to non-baccalaureate-educated public health nurses in Ontario or to replace the statutory language with existing or newly-worded regulation. In RNAO’s view, both are problematic.
First, repealing s.71(3) of the HPPA does not, on the surface fit the usual definition of a ‘housekeeping’ amendment in an omnibus bill such as Bill 212. Quite the contrary, the repeal of this section threatens to have a significant and detrimental effect on population health and the practice of public health in the province. When Severe Acute Respiratory Syndrome (SARS) spread across the globe in 2002-2003, killing 44 Canadians and causing illness in hundreds more, and taking a particularly high toll among health care workers, public health nurses worked collaboratively with other public health professionals to lead the emergency and disaster response. Much was learned from the SARS outbreak that has been applied to the current response to the H1N1 pandemic, but, as the National Advisory Committee on SARS and Public Health found, it was the power of public health that, despite being under-resourced, prevented the crisis from being catastrophic.
While the value of public health in confronting infectious outbreaks such as SARS and H1N1 is unquestioned, the National Advisory Committee noted an unfortunate pattern whereby “public health is taken for granted until disease outbreaks occur, whereupon a brief flurry of lip service leads to minimal investments and little real change in public health infrastructure or priorities”. For this cycle to end and to ensure the continued effectiveness of public health, the Committee puts the onus squarely on the need to increase capacity at the local and provincial level and, specifically, on a “well-trained, adequate and fully prepared workforce.” While public health involves the collaboration of a number of regulated and unregulated health workers, including nurse practitioners, physicians, dentists, dietitian/nutritionists, epidemiologists, health promoters, public health inspectors and others, the single largest group of public health professionals are public health nurses. In its recommendations, the National Advisory Committee emphasizes the importance of investment in the education of additional public health professionals and the need for high national standards for public health nursing practice, including the establishment of a set of competencies.
This highlighting of the importance of highly-skilled public health nurses with the knowledge and competencies to meet 21st century needs was echoed in the 2005 report Building the Public Health Workforce for the 21st Century. Our most valuable public health resources, according to the report, are human resources, and a strong public health system depends directly on public health professionals with the “right knowledge, skills and supports to do their jobs”. The Community Health Nurses Association of Canada released a document in May 2009 articulating the required skills and knowledge for public health nurses. This document builds on the Public Health Core Competencies released by the Public Health Agency of Canada in 2006. It is clear from the competencies listed that a baccalaureate preparation is necessary to fulfill this role.
Enshrining in section 71(3) of the HPPA that a public health nurse must be a registered nurse with a baccalaureate education and a member of the College of Nurses of Ontario ensures the high level of competencies and knowledge that is increasingly expected of public health nurses as we confront the challenges of the 21st century. Inexplicably removing the statutory minimum qualification sends precisely the wrong message to all public health professionals and, most important, to the public.
It is possible that the government intends to replace the statutory language with a future amendment to Regulation 566 under the Act on the basis of consistency with other public health professionals. However, there is no regulatory language currently before the committee or public and there is no commitment to introduce any. The RNAO strongly urges keeping the high standard for public health nurses in the Act. Statutory recognition of public health nurses’ qualifications is consistent with the growing evidence of the crucial role of public health.
Repealing s.71(3) of the Health Protection and Promotion Act is not a ‘housekeeping’ amendment. It does not belong in Bill 212, an omnibus “Good Government” bill. It should not proceed absent of full consultation and without consideration of the overall role of public health human resources in the province today. The RNAO strongly urges the Committee to amend Bill 212 to remove the repeal of s.71(3).
We appreciate the opportunity to comment on Bill 212, a bill that in important respects can have a profound effect on public health nurses and the health and well-being of the public that we serve.
Doris Grinspun RN, MSN, PhD (cand.) O.ONT.
Registered Nurses’ Association of Ontario
Wendy Fucile, RN, BScN, MPA, CHE
Registered Nurses’ Association of Ontario