Board of Health Meeting Woodstock Location: 410 Buller Street, Woodstock, Ontario Basement Boardroom Wednesday, April 10, 2019 4:30 p.m.
AGENDA Item Agenda Item Lead Expected Outcome 1.0 COVENING THE MEETING 1.1 Call to Order, Recognition of Quorum Larry Martin • Introduction of Guests, Board of Health Members and Staff 1.2 Approval of Agenda Larry Martin Decision 1.3 Reminder to disclose Pecuniary Interest and the General Nature Larry Martin Thereof when Item Arises 1.4 Reminder that Meetings are Recorded for minute taking Larry Martin purposes 2.0 AGENDA ITEMS FOR INFORMATION.DISCUSSION.ACCEPTANCE.DECISION 2.1 Finance and Facilities Standing Committee Report for April 2019 Joe Preston Decision 3.0 APPROVAL OF MINUTES 3.1 Approval of Minutes from February 13, 2019 Larry Martin Decision 4.0 APPROVAL OF CONSENT AGENDA ITEMS 4.1 Support of Provincial Oral Health Program for Seniors David Smith Information February 6, 2019 – Simcoe Muskoka District Health Unit Summary: This letter expresses the support for a provincial oral health program for low-income seniors. The support would include an increase to clinical capacity, including in Public Health Units, in order to address the severe need among low income seniors. 4.2 Letter of Support for SWPH Request for Increased Action to the Peter Heywood Information Opioid Crisis January 7, 2019 – Peterborough Public Health Summary: This letter expresses support for the increased actions in response to the current opioid crisis from both provincial and federal governments. 4.3 Receipt of Correspondence – Health Canada Peter Heywood Information January 17, 2019 – Health Canada, Minister of Health Summary: The Honourable Ginette Petitpas Taylor acknowledges the letter and Jennifer Novak, Executive Director for the Opioid Response Branch, Health Canada responded. The letter provides assurance that the opioid crisis is a “top priority” and the Canadian Drug and Substances Strategy is being reviewed, so that it is “more responsive to the needs and concerns of Canadians”. 4.4 Support for Bill 60 – Food Insecurity David Smith Information February 27, 2019 – North Bay Parry Sound DHU Summary: This letter expresses the continued support for Bill 60. The letter shares the resolutions passed at the BOH meeting along with a copy of a poster created to highlight and emphasize the magnitude of the issue in their area. 4.5 Mandatory Food Literacy Curricula in Ontario Schools David Smith Information February 11, 2019 – Windsor-Essex County Health Unit Summary: This letter expresses the strong urgency to include food literacy and food skills training as a part of the education system in Ontario. This comes at a time when the Ministry of Education is examining the current school curricula concerning food literacy. 4.6 Funding for Healthy Babies Healthy Children (HBHC) Program Susan MacIssac Information February 11, 2019 – Windsor-Essex County Health Unit Summary: This letter expresses the concern for action on the HBHC program funding. It states that the program has seen an increase in the complex needs of the clients across the province and urges the review for funding the program. It noted “that the Ministry has indicated that there is no funding available for the implementation of these changes to the HBHC program in the 2019 fiscal year.” 4.7 Ontario Basic Income Pilot Cathie Walker Information February 11, 2019 - Windsor-Essex County Health Unit Summary: This letter expresses concern and a call to action to reconsider the termination of the Ontario Basic Income Pilot. It is in support of the Thunder Bay District Health Unit’s correspondence expressing concern for the cancellation of the Pilot. 4.8 Smoke-Free Ontario Act, 2017 and Cannabis Legislation Peter Heywood Information February 11, 2019 – Windsor-Essex County Health Unit Summary: This letter expresses “support of Peterborough Public Health’s call to action and shared concern regarding funding associated with the cannabis legislation and the introduction of the Smoke-Free Ontario Act 2017.” 4.9 Universal School Food Program David Smith Information February 11, 2019 - Windsor-Essex County Health Unit Summary: This letter expresses support for “Toronto’s Board of Health and Senator Art Eggleton’s call for a federal universal health school program”. They “urge the federal government to support an adequately-funded national cost-shared universal healthy school food program.” 4.10 Managed Opioid Programs Peter Heywood Information February 12, 2019 – City of Toronto Summary: This report informs the Board of Health for the City of Toronto of the strategy developed by the Medical Officer of Health, to respond to the overdose crisis in British Columbia and Albert. This indicates an urgent need in Toronto and elsewhere in Ontario. 4.11 Letter of Acknowledgement – Re: Legalization of Cannabis Peter Heywood Information February 14, 2019 – Ministry of the Attorney General Summary: This letter confirms receipt of the SWPH letter about the concern raised for the Ontario Legalization of Cannabis Secretariat. 4.12 Implication of Bill 66 Peter Heywood Information February 20, 2019 – Simcoe Muskoka District Health Unit Summary: This letter expresses concern about the Government of Ontario’s decision to enact Bill 66, Restoring Ontario’s Competitiveness Act, 2018. The letter indicates that the implementation of this Bill will negatively affect several acts and regulations that are intended to protect and promote public and environmental health. 4.13 Oral Health Programs for Low Income Adults and Seniors David Smith Information February 27, 2019 – Peterborough Public Health Summary: This letter expresses “full support of the provincial government’s plan to invest in an oral health program for low- income seniors and urge that access be expanded to include low- income adults.” 4.14 Cannabis Use in Public Places Peter Heywood Information January 31, 2019 – Durham Region Summary: This letter informs the Premier of Ontario that the committee adopted a number of recommendations in relation to Cannabis Use in Public Places. 4.15 Support for Oral Health Program for Low Income Adults and David Smith Information Seniors March 4, 2019 – Renfrew County and District HU Summary: This letter expresses support for the Oral Health Program for Low Income Seniors and encourages the government to expand access to include low income adults. 4.16 Smoke Free Ontario Act, 2017 Peter Heywood Information March 4, 2019 – Renfrew County and District HU Summary: This letter expresses the urge for the “Ontario government to strengthen the Smoke-Free Ontario Act, 2017 to prohibit through regulation, the promotion of vaping products.” 4.17 Health Canada’s Consultation on Cannabis Regulations (New Peter Heywood Information Classes of Cannabis) and the Proposed Order amending Schedule 3 and 4 to the Cannabis Act February 20, 2019 – Southwestern Public Health Summary: Southwestern Public Health’s response to Health Canada’s request for input on the new regulations of additional cannabis products, including edible cannabis, cannabis extracts and cannabis topicals.
4.18 Potential measures to reduce the impact of vaping products Peter Heywood Information advertising on youth and non-users of tobacco products February 27, 2019 – Southwestern Public Health Summary: Southwestern Public Health’s response to Health Canada’s plan to introduce regulatory measures under the Tobacco and Vaping Products Act that will reduce the impact of vaping product advertisement on youth and non-users of tobacco products. 5.0 CORRESPONDENCE RECEIVED REQUIRING ACTION None.
6.0 AGENDA ITEMS FOR INFORMATION.DISCUSSION.ACCEPTANCE.DECISION 6.1 Smoking Cessation Presentation Ashlyn Brown Information 6.2 E-Cigarette Position Statement Peter Heywood Approval 6.3 Outdoor Space Position Statement Peter Heywood Approval 6.4 Smoke Free Housing Position Statement Peter Heywood Approval 6.5 Correspondence between County of Elgin and SWPH Board Chair Larry Martin Information 6.6 Chief Executive Officer’s Report for April 2019 Cynthia St. John Acceptance 7.0 CLOSED SESSION 8.0 RISING AND REPORTING OF THE CLOSED SESSION 9.0 FUTURE MEETINGS & EVENTS 9.1 Board of Health Regular Meeting – May 8, 2019 Chair Information 10.0 ADJOURNMENT
Finance & Facilities Standing Committee REPORT Open Session
MEETING DATE: April 10, 2019
SUBMITTED BY: Joe Preston, Chair, Finance and Facilities Standing Committee
SUBMITTED TO: Board of Health Finance & Facilities Standing Committee Governance Standing Committee Transition Governance Committee
PURPOSE: Decision Discussion Receive and File
AGENDA ITEM # 2.1
RESOLUTION # 2019-BOH-0410-2.1
The Finance and Facilities Standing Committee (FFSC) met on April 3, 2019 to consider a number of items. A brief synopsis and various recommendations are below.
1) Audited Financial Statements (Decision):
The Committee reviewed draft audited financial statements for the period ending December 31, 2018 which were prepared by the auditing firm of Graham Scott Enns. The auditors presented the financials to the Committee and addressed Committee questions. There were no issues with the audit and no material errors were noted. The audited statements are attached for your review. Auditors from Graham Scott Enns will be attending the Board of Health meeting to address any additional questions.
MOTION: (2019-BOH-0410-2.1A) That the Board of Health for Southwestern Public Health accept the Finance & Facilities Standing Committee’s recommendation to approve the audited financial statements for the period ending December 31, 2018.
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2) Appointment of Auditors (Decision):
The Committee is recommending that Graham Scott Enns be appointed as the auditing firm for 2019. The Committee is confident that this firm has the required experience to complete a thorough financial audit for SWPH.
MOTION: (2019-BOH-0410-2.1B) That the Board of Health for Southwestern Public Health accept the Finance & Facilities Standing Committee’s recommendation to appoint Graham Scott Enns as the auditing firm for the year ending December 31, 2019.
3) Internal Controls & Processes (Receive and File):
The Committee reviewed the process of internal financial controls as per the Ministry of Health and Long Term Care Standards and determined that all monthly procedures were followed accurately and timely.
MOTION: (2019-BOH-0410-2.1C) That the Board of Health for Southwestern Public Health accept the Finance & Facilities Standing Committee’s recommendation to receive and file the internal controls process checklist.
4) Annual Service Plan (Receive and File):
The Committee reviewed the Ministry of Health and Long Term Care’s Annual Service Plan for SWPH. This is in essence the approved budget and program plans put on Ministry forms. The Plan was signed by the Board Chair and CEO. Ratification of the Board Chair signature is required.
MOTION: (2019-BOH-0410-2.1D) That the Board of Health for Southwestern Public Health ratify the signing of the Annual Service Plan for 2019.
5) Amending Agreements (Decision): The Finance and Facilities Standing Committee received the approved 2018 Amending Agreement for Southwestern Public Health. The agreement has been signed by Larry Martin and myself. Ratification of the Board Chair’s signature is required. The agreement is attached as an FYI.
MOTION: (2019-BOH-0410-2.1E) That the Board of Health for Southwestern Public Health ratify the Board Chair’s signing of the current Amending Agreement between the Ministry of Health and Long-Term Care and Southwestern Public Health.
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6) Facilities Report (Receive and File):
The Committee received updates about building repairs completed, a review of space needs, and building security matters.
MOTION: (2019-BOH-0410-2.1) That the Board of Health for Southwestern Public Health accept the Finance & Facilities Standing Committee report for April 2019.
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OXFORD ELGIN ST. THOMAS HEALTH UNIT
Operating as
SOUTHWESTERN PUBLIC HEALTH
Financial Statements
December 31, 2018
D ra ft SOUTHWESTERN PUBLIC HEALTH
Financial Statements
For the Eight Month Period Ended December 31, 2018
Table of Contents D PAGE r Independent Auditors' Report a 1 - 2 f Statement of Financial Position t 3
Statement of Operations and Surplus 4
Statement of Change in Net Financial Debt 5
Statement of Cash Flows 6
Notes to the Financial Statements 7 - 17
Schedule of Expenditures 18 - 20
Twelve Months Statement of Operations and Surplus 21 INDEPENDENT AUDITORS' REPORT
To the Board of Health, Members of Council, Inhabitants and Ratepayers of the participating municipalities of the County of Oxford, County of Elgin and City of St. Thomas:
Opinion We have audited the financial statements of Southwestern Public Health, which comprise the statement of financial position as at December 31, 2018, and the statement of operations and surplus, statement of changes in net debt and statement of cash flows for the period then ended, and notes to the financial statements, including a summary of significant accounting policies.
In our opinion, the organization's financial statements present fairly, in all material respects, the financial position of the organization as at December 31, 2018, and the results of its operations and its cash flows for the period then ended in accordance with Canadian accounting standards for public sector entities.
Basis for Opinion We conducted our audit in accordance with CanadianD generally accepted auditing standards. Our responsibilities under those standards are further described in ther Auditors' Responsibilities for the Audit of the Financial Statements section of our report. We are independenta of the organization in accordance with the ethical requirements that are relevant to our audit of the financialf statements in Canada, and we have fulfilled our other ethical responsibilities in accordance with these requirements.t We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.
Other Information Note 18 in these financial statements provides details on the merger between the Elgin St. Thomas Health Unit and the Oxford County Health Unit. Our opinion is not modified with respect to this matter.
Responsibilities of Management and Those Charged with Governance for the Financial Statements Management is responsible for the preparation and fair presentation of the financial statements in accordance with Canadian accounting standards for public sector entities, and for such internal control as management determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error.
In preparing the financial statements, management is responsible for assessing the organization's ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless management either intends to liquidate the organization or to cease operations, or has no realistic alternative but to do so.
Those charged with governance are responsible for overseeing the organization's financial reporting process.
Auditors' Responsibilities for the Audit of the Financial Statements Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor's report that includes our opinion.
-1- INDEPENDENT AUDITORS' REPORT (CONTINUED)
Auditors' Responsibilities for the Audit of the Financial Statements (Continued) Reasonable assurance is a high level of assurance, but is not a guarantee that an audit conducted in accordance with Canadian generally accepted auditing standards will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements.
As part of an audit in accordance with Canadian generally accepted auditing standards, we exercise professional judgment and maintain professional skepticism throughout the audit. We also: • Identify and assess the risks of material misstatement of the financial statements, whether due to fraud or error, design and perform audit procedures responsive to those risks, and obtain audit evidence that is sufficient and appropriate to provide a basis for our opinion. The risk of not detecting a material misstatement resulting from fraud is higher than for one resulting from error, as fraud may involve collusion, forgery, intentional omissions, misrepresentations,D or the override of internal control. • Obtain an understanding of internal control relevantra to the audit in order to design audit procedures that are appropriate in the circumstances, but not for the purposef of expressing an opinion on the effectiveness of the organization's internal control. t • Evaluate the appropriateness of accounting policies used and the reasonableness of accounting estimates and related disclosures made by management. • Conclude on the appropriateness of management's use of the going concern basis of accounting and, based on the audit evidence obtained, whether a material uncertainty exists related to events or conditions that may cast significant doubt on the organization's ability to continue as a going concern. If we conclude that a material uncertainty exists, we are required to draw attention in our auditor's report to the related disclosures in the financial statements or, if such disclosures are inadequate, to modify our opinion. Our conclusions are based on the audit evidence obtained up to the date of our auditor's report. However, future events or conditions may cause the organization to cease to continue as a going concern. • Evaluate the overall presentation, structure and content of the financial statements, including the disclosures, and whether the financial statements represent the underlying transactions and events in a manner that achieves fair presentation.
We communicate with those charged with governance regarding, among other matters, the planned scope and timing of the audit and significant audit findings, including any significant deficiencies in internal control that we identify during our audit.
St. Thomas, Ontario Graham Scott Enns LLP REPORT DATE CHARTERED PROFESSIONAL ACCOUNTANTS Licensed Public Accountants
-2- SOUTHWESTERN PUBLIC HEALTH
Statement of Financial Position December 31, 2018
(Note 18) 2018 $ FINANCIAL ASSETS Cash 4,192,533 Accounts receivable 207,038 Government remittance receivable 201,473
4,601,044
FINANCIAL LIABILITIES Accounts payable and accrued liabilities 1,361,056 Deferred revenue (Note 3) 1,133,950 Due to Province of Ontario 110,070 Long-term debt (Note 5) 8,057,000
10,662,076 NET FINANCIAL DEBT (PAGE 5) D (6,061,032) NON-FINANCIAL ASSETS ra Prepaid expenses f 44,573 Tangible capital assets (Note 4) t 9,008,370 9,052,943
ACCUMULATED SURPLUS (PAGE 4) 2,991,911
Approved by the Board:
______Director
______Director
The accompanying notes are an integral part of these financial statements. -3- SOUTHWESTERN PUBLIC HEALTH
Statement of Operations and Surplus For the Eight Month Period Ended December 31, 2018
(Note 14) (Note 18) Budget Actual 2018 2018 $ $ REVENUES Operating grants Municipal: County of Elgin 577,455 585,088 City of St. Thomas 448,745 454,709 County of Oxford 1,434,985 1,457,565 Province of Ontario (Note 6) 11,167,275 10,183,870 Healthy Kids Community Challenge (Note 7) 43,750 84,486 Public Health Agency of Canada (Note 8) 83,250 83,642 Canada Health Infoways (Note 9) - 26,159 Student Nutrition (Note 10) - 54,591 Total operating grants 13,755,460 12,930,110 Other Other fees and recoveries 64,483 158,536 Clinics D 16,667 19,491 Interest - 43,485 ra Total other revenue ft 81,150 221,512 TOTAL REVENUES 13,836,610 13,151,622 EXPENDITURES - SCHEDULE (PAGE 19) 13,675,667 12,285,628 EXCESS OF REVENUES OVER EXPENDITURES 160,943 865,994 SURPLUS, BEGINNING OF PERIOD (NOTE 18) - - CONTRIBUTED SURPLUS AT MAY 1, 2018: Elgin St. Thomas Health Unit - 1,525,489 Oxford County Public Health - 600,428 - 2,125,917
ACCUMULATED SURPLUS, END OF PERIOD (NOTE 2) 160,943 2,991,911
The accompanying notes are an integral part of these financial statements. -4- SOUTHWESTERN PUBLIC HEALTH
Statement of Change in Net Financial Debt For the Eight Month Period Ended December 31, 2018
(Note 14) (Note 18) Budget Actual 2018 2018 $ $
EXCESS OF REVENUES OVER EXPENDITURES 160,943 865,994
Amortization of tangible capital assets - 250,485 Net acquisition of tangible capital assets - (629,366) Change in prepaid expenses - (14,293) County of Oxford reserve contribution - 531,523
DECREASE IN NET DEBT 160,943 1,004,343
NET FINANCIAL DEBT, BEGINNING OF PERIOD 7,065,375 7,065,375
NET FINANCIAL DEBT, END OF PERIOD 7,226,318 6,061,032 D ra ft
The accompanying notes are an integral part of these financial statements. -5- SOUTHWESTERN PUBLIC HEALTH
Statement of Cash Flows For the Eight Month Period Ended December 31, 2018
(Note 18) 2018 $ OPERATING ACTIVITIES
Excess of revenues over expenditures 865,994 Items not involving cash: Amortization of tangible capital assets 250,485 Change in non-cash assets and liabilities: Accounts receivable 178,863 Government remittances receivable (100,545) Prepaid expenses (14,293) Accounts payable and accrued liabilities 268,394 Deferred revenue 986,111 Due to Province of Ontario 634,771
Cash provided by operating activities 3,069,780
CAPITAL ACTIVITIES D Net acquisition of tangible capital assets ra (629,366) f Cash applied to capital activities t (629,366)
FINANCING ACTIVITIES
Reserve contribution from the County of Oxford 531,523 Repayment to long-term debt (137,000)
Cash applied to financing activities 394,523
NET CHANGE IN CASH DURING THE YEAR 2,834,937
CASH, BEGINNING OF PERIOD 1,357,596
CASH, END OF PERIOD 4,192,533
The accompanying notes are an integral part of these financial statements. -6- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
Southwestern Public Health (the "organization") provides health services to the residents of the City of St. Thomas, County of Elgin and the County of Oxford and is accountable to the Province of Ontario as outlined in the Health Protection and Promotion Act. 1. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES The financial statements of the organization are prepared by management in accordance with Canadian accounting standards for public sector entities. Significant aspects of the accounting policies adopted by the organization are as follows: Basis of Accounting The financial statements are prepared using the accrual basis of accounting. The accrual basis of accounting records revenue as it is earned and measurable. Expenses are recognized as they are incurred and measurable based upon receipt of goods or services and/or the creation of a legal obligation to pay. Accounting Estimates The preparation of these financial statements is in conformity with Canadian accounting standards for public sector entities which requires managementD to make estimates and assumptions that affect the reported amount of assets and liabilities, the disclosure of contingent assets and liabilities at the date of the financial statements, and the reportedr amountsa of revenues and expenditures during the current period. These estimates are reviewed periodicallyf and adjustments are made to income as appropriate in the year they become known. t
In particular, the organization uses estimates when accounting for certain items, including: Useful lives of tangible capital assets Employee benefit plans Financial Instruments The organization's financial instruments consist of cash and cash equivalents, accounts receivable, accounts payable and accrued liabilities and long-term debt. Unless otherwise noted, it is management's opinion that the organization is not exposed to significant interest, currency, or credit risk arising from these financial instruments.
Government Transfers Government transfers are recognized in the financial statements as revenues in the financial period in which events giving rise to the transfer occur, providing the transfers are authorized, any eligibility criteria have been met including performance and return requirements, and reasonable estimates of the amounts can be determined. Any amount received but restricted is recorded as deferred revenue in accordance with Section 3100 of the Public Sector Accounting Handbook and recognized as revenue in the period in which the resources are used for the purpose specified.
-7- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
1. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES (CONTINUED) Tangible Capital Assets Tangible capital assets are recorded at cost, which includes all amounts that are directly attributable to acquisition, construction, development or betterment of the asset. The cost, less residual value, of the tangible capital assets, excluding land are amortized on a straight-line basis over their estimated useful lives as follows: Land improvements 20 years Building 40 years Roof 20 years Component equipment 24 years Computer equipment 4 years Amortization begins the first month of the year following the year the asset is placed in service and to the year of disposal. Assets under construction are not amortized until the asset is available for productive use. Deferred Revenue The organization administers other non-mandatoryD public health programs funded by the Province of Ontario and reported on a Provincial fiscal year end of March 31st. Any unexpended funding for these programs at December 31st is reportedra as deferred revenue on the statement of financial position. Additionally the organization receivesf certain grants and other funding from external sources for administering public health programst and may defer funds not spent at December 31st if the respective funding agreement has a term beyond the year end. Employee Benefit Plans The organization accounts for its participation in the Ontario Municipal Employees Retirement System (OMERS), a multi-employer public sector pension fund, as a defined contribution plan. The OMERS plan specifies the retirement benefits to be received by the employees based on the length of service and pay rates. Employee benefits include post employment benefits. Post employment benefits are subject to actuarial valuations and are accrued in accordance with the projected benefit method, prorated on service and management's best estimate of salary escalation and retirement ages of employees. Any actuarial gains and losses related to past service of employees are amortized over the expected average remaining service period. Recent Accounting Pronouncements PSAB released a standard related to Financial Instruments (PS 3450). The standard applies to all local governments for fiscal years beginning on or after April 1, 2019. The standard applies to all types of financial instruments. The new standard requires that equity and derivative instruments be measured at fair value, with changes in value being recorded in the statement of remeasurement gains/losses. The standard gives the option of cost/amortized cost vs. fair value of remaining instruments, which is elected upon by the government organization. The organization has not yet determined what, if any, financial reporting implications may arise from this standard.
-8- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
2. ACCUMULATED SURPLUS
The accumulated surplus consists of the following individual fund surplus/(deficit) and reserves as follows: 2018 $
SURPLUS General reserve 1,060,713 Contingency reserve, set aside by the Board 979,828 Invested in tangible capital assets 9,008,370
11,048,911 AMOUNTS TO BE RECOVERD Net long-term debt (8,057,000)
ACCUMULATED SURPLUS 2,991,911
The organization approved the creation ofD a reserve for contingencies to meet unforeseen program or corporate expenditures. The balance of the reservera is not to exceed 5% of the total annual budget. f 3. DEFERRED REVENUE t 2018 $
Merger - One time funding 670,960 St. Thomas - Low German Needs Assessment 69,576 Healthy Smiles Ontario: Dental Equipment - One time funding 66,187 Student Nutrition 52,467 School Health Screening - One time funding 44,818 Sewage Inspection Program 17,439 Other 212,503
Total Deferred Revenue 1,133,950
-9- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
4. TANGIBLE CAPITAL ASSETS December 31, 2018 Cost Opening Additions Disposals Ending $ $ $ $
Land 572,909 - - 572,909 Land improvements 161,330 - - 161,330 Building 7,373,729 77,710 - 7,451,439 Roof 157,000 - - 157,000 Building component equipment 769,346 63,824 - 833,170 Information technology equipment 804,974 487,832 - 1,292,806
9,839,288 629,366 - 10,468,654
Accumulated Amortization Opening Amortization Disposals Ending $ $ $ $
Land improvements D 26,890 5,378 - 32,268 Building r616,453a 122,895 - 739,348 Roof 26,167f 5,233 - 31,400 Building component equipment 323,721t 25,850 - 349,571 Information technology equipment 216,568 91,129 - 307,697
1,209,799 250,485 - 1,460,284
Net Book Value Opening Ending $ $
Land 572,909 572,909 Land improvements 134,440 129,062 Building 6,757,276 6,712,091 Roof 130,833 125,600 Building component equipment 445,625 483,599 Information technology equipment 588,406 985,109
8,629,489 9,008,370
The opening figures have been restated to include the tangible capital assets from both the Oxford County Public Health and the Elgin St. Thomas Health Unit at May 1, 2018.
-10- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
5. LONG-TERM DEBT
a) The balance of long-term debt reported on the Statement of Financial Position is made up of the following: 2018 $ RBC bankers' acceptance to finance construction of new office building 8,057,000
Principal payments relating to the long-term debt outstanding are due as follows:
2019 2020 2021 2022 2023 Thereafter Total $ $ $ $ $ $ $
211,000 218,000 226,000 232,000 241,000 6,929,000 8,057,000
On January 2, 2014 the former Elgin St. Thomas Health Unit converted the short term construction loan into long-term financing. The formerD organization was advanced $9,000,000 in a 32 day banker acceptance notes at the CDOR rate of 1.22%r plus a stamping fee of 0.40%. The former organization at the same time entered into an interest rate aswap contract to fix the interest rate on their long-term financing at 2.85% for a 30 year time frame. Asf a result of these transactions, the former organization had fixed their rate on this debt obligation at 2.85%t plus the stamping fee (3.25% for 2018). The stamping fee is reviewed every fifteen years to determine if the risk assessment of the organization has changed from the last review at which point the rate could increase if additional risk is determined. As a result of the interest swap agreement, if the organization were to repay the long- term debt at December 31, 2018 an additional cost of $276,201 would be incurred. An additional $250,000 can be borrowed at any time and added to this swap agreement.
-11- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
6. PROVINCE OF ONTARIO 2018 $ Cost shared programs General Public Health Programs 6,011,598 Vector Borne Diseases 96,127 Small Drinking Water Systems 20,469
Total cost shared programs 6,128,194
Other programs and one-time funding Healthy Babies Healthy Children 1,115,930 Healthy Smiles Ontario operating 672,623 Merger Costs - One Time Funding 453,104 Smoke-Free Ontario 450,006 Infectious Disease Control Initiative 260,510 Public Health Nurse Initiative 232,134 Harm Reduction Program Enhancement 222,693 Chief Nursing Officer D 163,434 Infection Prevention and Control Nurses rInitiative 126,864 Prenatal and Postnatal Nurse Practitioner Servicesa 92,656 Medical Officer of Health Compensation Initiativef 72,423 Enhanced Food Safety - Haines Initiative t 41,666 Healthy Smiles Ontario - One Time Funding 37,163 Needle Exchange Program 28,486 Enhanced Safe Water Initiative 21,640 Electronic Cigarettes Act Protection and Enforcement - One Time Funding 21,432 Public Health Inspector Practicum Placement - One Time Funding 20,000 School Health Screening - One Time Funding 15,932 Needle Exchange Program - One Time Funding 6,980
Total other programs and one-time funding 4,055,676
Total Province of Ontario grants 10,183,870
-12- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
7. HEALTHY KIDS COMMUNITY CHALLENGE
The organization is an administrator for funding from the Minister of Health and Long-Term Care for funds to carry out the Ontario's Healthy Kids Community Challenge. The program requires the implementation of local activities based on one specific theme related to healthy eating or physical activity every nine months. The organization reports on a fiscal year end of March 31st to the Minister of Health and Long-Term Care. Any unexpended funding for this program at December 31st is reported as deferred revenue on the statement of financial position.
2018 $
Revenue 84,486
Expenditure Program Supplies 67,264 Salaries 13,778 Benefits D 3,444 r 84,486 Program excess of revenue over expendituresa - ft 8. PUBLIC HEALTH AGENCY OF CANADA
The organization receives funding from the Public Health Agency of Canada for funds to carry out the Creating Connections project. The organization and local developers will partner to improve walkability in the City of St. Thomas. Any unexpended funding for this program at December 31st is reported as deferred revenue on the statement of financial position.
2018 $
Revenue 83,642
Expenditure Purchased services 83,642
Program excess of revenue over expenditures -
-13- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
9. CANADA HEALTH INFOWAYS The organization receives funding from Canada Health Infoway (CHI) - a not-for-profit corporation funded by the Government of Canada to foster and accelerate amongst other matters the development and adoption of electronic health information systems, common standards, health surveillance, and telehealth technologies, which are compatible and interoperable on a pan-Canadian basis. Any unexpended funding for this program at December 31st is reported as deferred revenue on the statement of financial position. 2018 $ Revenue 26,159 Expenditure Program supplies 26,159 Program excess of revenue over expenditures -
10. STUDENT NUTRITION The organization receives funding from Da number of external agencies including the United Way and VON to provide healthy foods to participatingr schools in Oxford County. Any unexpended funding for this program at December 31st is reporteda as deferred revenue on the statement of financial position. f t 2018 $ Revenue 54,591 Expenditure Program supplies 54,591 Program excess of revenue over expenditures -
11. OPERATING LEASES The organization leases two buildings from the County of Oxford at $44,167 per month plus HST on an ongoing monthly basis. The lease term ends April 30, 2020. On an annual basis the landlord increases the annual rent by the percentage increase of the Consumer Price Index.
The minimum annual lease payments required in each of the next two years in respect of operating leases are as follows: $ 2019 530,000 2020 176,667
-14- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
12. CASH FLOW FROM THE PROVINCE OF ONTARIO MINISTRIES OF HEALTH AND LONG-TERM CARE AND CHILDREN AND YOUTH SERVICES The organization receives funding from the Province of Ontario Ministry of Health and Long-Term Care, Public Health Division and Health Promotion Division, and the Ministry of Children and Youth Services to carry out mandatory and related health programs and services. Funding provided from the Ministry for the year ended December 31, 2018 (12 month) is as follows: Public Children Health and Youth Division Services $ $ Mandatory 9,017,400 - Merger Costs 1,779,500 - Healthy Smiles Ontario operating 1,008,100 - Smoke-Free Ontario Strategy 655,900 - Infectious Disease Control Initiative 389,000 - Social Determinants of Health Nurses Initiative 361,000 - Harm Reduction Program EnhancementD 300,000 - Chief Nursing Officer r 243,000 - Medical Officer of Health Compensation Initiativea 176,275 - Infection Prevention and Control Nurses Initiativef 180,200 - Healthy Smiles Ontario capital t 103,350 - Vector-Borne Diseases 119,600 - Needle Exchange Program 85,300 - Healthy Growth/School Health Screening 60,750 - Enhanced Food Safety - Haines Initiative 50,000 - Enhanced Safe Water Initiative 31,000 - Small Drinking Water Systems 30,700 - Electronic Cigarettes Act Protection and Enforcement 28,100 - Public Health Inspector Practicum Placement 15,000 - Healthy Babies Healthy Children - 1,653,539 Prenatal and Postnatal Nurse Practitioner Services - 141,174 Records Information Management 70,000 - 14,704,175 1,794,713
-15- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
13. PENSION AGREEMENTS
The organization makes contributions to the Ontario Municipal Employees Retirement Fund (OMERS), which is a multi-employer plan, on behalf of members of its staff. The plan is a defined benefit plan which specifies the amount of the retirement benefit to be received by the employees based on the length of service and rates of pay. Each year, an independent actuary determines the funding status of OMERS Primary Pension Plan (the Plan) by comparing the actuarial value of invested assets to the estimated present value of all pension benefits the members have earned to date. The most recent actuarial valuation of the Plan was conducted December 31, 2018, and the results of this valuation disclosed actuarial liabilities of $100.1 billion in respect of benefits accrued for service with actuarial assets at that date of $95.9 billion leaving an actuarial deficit of $4.2 billion.
Since any surpluses or deficits are a joint responsibility of all Ontario municipalities and their employees, the organization does not recognize any share of the OMERS Pension surplus or deficit in these financial statements.
The amount contributed to OMERS for the eight months ended December 31, 2018 was $693,979. OMERS contribution rates for 2017 and 2016 depending on income level and retirement dates ranged from 9.0% to 15.8%. D 14. BUDGET FIGURES ra The operating budgets approved by the organizationf and the Province of Ontario for 2018 are reflected on the statement of operations and aret presented for comparative purposes. The budget figures have been presented based on the proportion of the May 1, 2018 to December 31, 2018 year to the total yearly budget for the organization subsequent to the merger.
15. PUBLIC SECTOR SALARY DISCLOSURE ACT 1996
The Public Sector Salary Disclosure Act, 1996 ( the "Act") requires the disclosure of the salaries and benefits of employees in the public sector who are paid a salary of $100,000 or more in a year. The organization complies with the Act by providing the information to the Ontario Ministry of Health and Long-Term Care for disclosure on the public website at www.fin.gov.on.ca.
16. CONTINGENT LIABILITIES As at December 31, 2018 a legal action was pending against the organization. Subsequent to year end, the known litigation was settled and will be reflected in the 2019 year end.
Estimated costs to settle claims are based on available information and projections of estimated future expenses developed based on the organization's historical experience. Claims are reported as an operating expense in the year of the loss, where the costs are deemed to be likely and can be reasonable determined. Claim provisions are reported as a liability in the statement of financial position.
-16- SOUTHWESTERN PUBLIC HEALTH Notes to the Financial Statements For the Eight Month Period Ended December 31, 2018
17. FINANCIAL INSTRUMENTS
Risks and Concentrations The organization is exposed to various risks through its financial instruments. The following analysis provides a measure of the organization’s risk exposure and concentrations at the balance sheet date.
Liquidity Risk Liquidity risk is the risk that the organization will encounter difficulty in meeting obligations associated with financial liabilities. The organization is exposed to this risk mainly in respect of its accounts payable and accrued liabilities.
Credit Risk Credit risk is the risk that one party to a financial instrument will cause a financial loss for the other party by failing to discharge an obligation. The organization’s main credit risk relate to its accounts receivable.
Interest Rate Risk Interest rate risk is the risk that the fair value or future cash flows of a financial instrument will fluctuate because of changes in market interestD rates. The organization is exposed to interest rate risk on its fixed and floating interest rate financialr instruments. Given the current composition of long- term debt (proportion of debt at a fixed interesta rate compared to a floating interest rate), fixed-rate instruments subject the organization to a fair valuef risk while the floating-rate instruments subject it to a cash flow risk. t
It is management's opinion that the entity is not exposed to any significant market, foreign currency or price risk.
No financial liabilities of the organization were in default during the period.
The organization was not subject to any covenants during the period.
18. MERGER A merger between the Elgin St. Thomas Health Unit and the Oxford County Health Unit was effective May 1, 2018, and was given formal approval on March 29, 2018 under the Health Protection and Promotion Act R.R.O. 1990, Regulation 553, Areas Comprising Health Units, Schedule 7.
As such the current period presented represents the period from May 1, 2018 to December 31, 2018 and these represent the first financial statements of the merged organization.
-17- SOUTHWESTERN PUBLIC HEALTH
Schedule of Expenditures For the Eight Month Period Ended December 31, 2018
(Note 14) (Note 18) Budget Actual 2018 2018 $ $ SALARIES AND WAGES Nursing - 1,441,106 Management - 1,138,847 Clerical and support - 662,073 Inspection and environment - 477,455 Nutrition and health promotion - 348,326 Maintenance and security - 63,029
5,155,558 4,130,836 FRINGE BENEFITS Group pension - 693,979 Medical insurance - 236,137 Canada pension plan - 189,982 Long term disability - 169,205 Employer health tax D - 137,086 Dental plan r - 98,372 Employment insurance a - 86,342 Workplace safety insurance ft - 66,802 Supplementary unemployment benefits - 39,690 Group life insurance - 29,473 Part-time benefits - 8,230 Employee assistance programs - 5,814 Vision and other - 4,548 Benefits to other programs - (573,490)
1,127,660 1,192,170 FEES AND HONORARIA Audit and legal 66,150 99,652 Labour relations 23,333 11,194 Board 9,000 9,818 Clinical services 12,400 7,781 Meeting expense 8,867 3,256
119,750 131,701
TRAVEL 92,569 124,251
-18- SOUTHWESTERN PUBLIC HEALTH
Schedule of Expenditures For the Eight Month Period Ended December 31, 2018
(Note 14) (Note 18) Budget Actual 2018 2018 $ $
EQUIPMENT 96,237 575,964
PROGRAM SUPPLIES 534,713 283,552
AMORTIZATION - 250,485
RENT AND UTILITY SERVICES Building and facilities rental 273,239 356,969 Interest on long-term debt 314,000 180,783 Maintenance and supplies 113,927 145,796 Utilities 65,667 55,173 Property taxes and insurance - 1,582
D 766,833 740,303 r ADMINISTRATIVE a Telephone f 58,987 51,657 Professional development t 63,499 64,192 Insurance 47,420 37,662 Engagement strategies 20,000 37,591 Public awareness and promotion 194,635 38,340 Printing and supplies 21,667 33,119 Fees and subscriptions 22,661 14,163 Equipment maintenance and rental 21,135 10,311 Postage 10,000 8,693 Staff recruitment 4,333 3,604 Courier - 356
464,337 299,688
VECTOR-BORNE DISEASES PROGRAM 79,733 132,925
SMALL DRINKING WATER SYSTEMS PROGRAM 20,467 27,293
TOTAL COST SHARED PROGRAM EXPENDITURES 8,457,857 7,889,168
-19- SOUTHWESTERN PUBLIC HEALTH
Schedule of Expenditures For the Eight Month Period Ended December 31, 2018
(Note 14) (Note 18) Budget Actual 2018 2018 $ $
OTHER PROGRAMS AND ONE-TIME EXPENDITURES
Healthy Babies Healthy Children 1,102,359 1,115,930 Healthy Smiles Ontario Operating 672,067 691,563 Merger Costs 1,266,667 413,665 Smoke-Free Ontario 437,267 463,114 Infectious Diseases Control 259,333 261,226 Social Determinants of Health Nurses Initiative 240,667 235,195 Harm Reduction 200,000 232,945 Chief Nursing Officer 162,000 163,435 Infection Prevention and Control Nurses Initiative 120,133 126,864 Prenatal and Postnatal Nurse Practitioner Services 92,667 93,040 Healthy Kids Community Challenge 43,750 84,486 Public Health Agency Canada D 83,250 83,642 Medical Officer of Health Compensation Initiativer 126,000 72,324 Sewage Inspection Program a - 54,591 Student Nutrition f 69,517 52,941 Enhanced Food Safety - Haines Initiative t 33,333 41,667 Needle Exchange Program 40,600 35,120 Healthy Smiles Ontario: Dental Equipment & Software 91,867 34,992 Low German Partnership 53,333 26,684 Canada Health Infoways - 26,159 Electronic Cigarettes Act Protection and Enforcement 18,733 22,353 Enhanced Safe Water Initiative 20,667 21,611 Public Health Inspector Practicum Placement 13,333 20,000 School Health Screening 54,000 15,932 Needle Exchange Program 16,267 6,981
Total other programs and one-time expenditures 5,217,810 4,396,460
TOTAL EXPENDITURES 13,675,667 12,285,628
-20- SOUTHWESTERN PUBLIC HEALTH
Statement of Operations and Surplus For the Twelve Month Period Ended December 31, 2018
Oxford Elgin County St. Thomas Southwestern Public Health Public Health Public Health Total Jan - Apr Jan - Apr May - Dec 2018 $ $ $ $ REVENUES Operating grants Municipal: County of Elgin - 292,518 585,088 877,606 City of St. Thomas - 227,285 454,709 681,994 County of Oxford 724,673 - 1,457,565 2,182,238 Province of Ontario 2,594,728 3,002,502 10,183,870 15,781,100 Healthy Kids Community Challenge - 87,447 84,486 171,933 Public Health Agency of Canada D- 124,950 83,642 208,592 Canada Health Infoways -ra - 26,159 26,159 Student Nutrition - ft - 54,591 54,591 Total operating grants 3,319,401 3,734,702 12,930,110 19,984,213
Other Other fees and recoveries 78,120 15,004 158,536 251,660 Clinics 89,895 8,753 19,491 118,139 Interest - 11,422 43,485 54,907
Total other revenue 168,015 35,179 221,512 424,706 TOTAL REVENUES 3,487,416 3,769,881 13,151,622 20,408,919
EXPENDITURES 3,490,527 3,215,129 12,285,628 18,991,284 EXCESS OF REVENUES OVER EXPENDITURES (3,111) 554,752 865,994 1,417,635
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MONTH 2019 Control Description Completed at Month End (Y/N/NA) CASH Deposit of cheques/cash • Mail is opened by the Executive Assistant (to Director of Finance). Any cash payments are processed in the cash register by frontline staff. Daily closing of the cash register is processed by the Payroll & Benefits Administered (St. Thomas) and the Administrative Assistant (Woodstock). the Accounting Supervisor prepares the deposits and Journal Entry summary which is approved by the Director of Finance. Bank Reconciliations • Bank reconciliations are prepared monthly by the Accounting Supervisor for all accounts. The Director of Finance reviews the reconciliations to identify any unusual reconciling items. Director of Finance reviews and initials the bank deposits. Cheques • the Accounting Supervisor ensures all outstanding cheques less than six months old. the Director of Finance reviews all outstanding cheques along with the bank reconciliations. Petty Cash • the Accounting Supervisor reconciles petty cash monthly if used (Petty cash on hand + reimbursement vouchers = Balance per G/L) and the Director of Finance initials the reconciliation. ACCOUNTS RECEIVABLE Receivables • Receivables are tracked in excel monthly by the Accounting Supervisor and are supported by detailed schedules that reflect all transactions that have occurred in the month (includes taxes, employees etc.) The Director of Finance agrees to financials monthly. Sub ledger • No subledger exists; therefore no reconciliation performed INVENTORY Inventory • Inventory is currently maintained in central supply. Access is restricted by use of a FOB and access is granted only to managers and Program Assistants. • A perpetual inventory control system is in place. PREPAIDS Prepaids • All prepaids are tracked monthly by the Accounting Supervisor and are amortized over their remaining useful life. All prepaids are agreed to supporting invoices. The Director of Finance agrees to financials monthly.
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MONTH 2019 Control Description Completed at Month End (Y/N/NA) FIXED ASSETS Fixed assets subledger • The Office Manager maintains the fixed asset listing. • the Director of Finance reviews the fixed asset subledger quarterly for accuracy and completeness. All transactions are tracked in an excel spreadsheet and agreed to invoices and compared to the budgeted amounts. Write-offs • All assets that have been sold, damaged or are no longer in use are written off by the Director of Finance when informed by the manager after having received approval from CEO. Repairs & maintenance • the Director of Finance reviews the repair and maintenance accounts monthly to ensure all expenditures have been accounted for in accordance with SWPH's capital policy. ACCOUNTS PAYABLE Processing Accounts • POs are generated for all purchases in accordance with SWPH's procurement policy (see "Procurement Policy") for authorization Payable levels. • Goods that are received must have an initial on the purchase order/ paper requisition (if applicable). All invoices whether attached to a packing slip or not are sent to the appropriate personnel and signed to verify the goods were received and the pricing terms are correct. Invoices are then sent to the Accounting Supervisor who codes the invoices and sends them to the Director of Finance for review. The Director of Finance reviews the allocation to the G/L, pricing, terms, ensures authorized approval and initials them. Payment of Accounts • Cheque runs are printed twice a month – on the 5th and 20th of the month and additional runs, as required. The Accounting Payable Supervisor processes the cheques/EFTs to be signed and attaches a copy of each cheque/EFT to the appropriate invoice and sends it to be signed. • The Director of Finance reviews and signs the cheques/EFTs and ensures again that the invoices have been approved for payment. She also reviews the cheque register provided with the cheque run. • Once the Director of Finance has reviewed, the cheques and invoices are sent to CEO for review and signature. The CEO sets aside any unusual items if she feels they need a further explanation. • All cheques require dual signatures (one of which must be CEO). • Cheques are kept in a locked cabinet accessible only by the Accounting Supervisor or the Director of Finance. The computer processes the numbers on the cheques and does not allow for duplication. Sub ledger • The Accounts Payable subledger is reviewed monthly by the Director of Finance and agreed to the Accounts Payable balance.
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MONTH 2019 Control Description Completed at Month End (Y/N/NA) Vendor Purchase Summary • Each month the Director of Finance will summarize total purchases by vendor and ensure the value of the purchases fall in line with the procurement policy. ACCRUED LIABILITIES Accrued liabilities • the Accounting Supervisor tracks all accrued liabilities monthly in an excel spreadsheet and agrees to the GL. The Director of Finance verifies to monthly financial statements. PAYROLL Processing Payroll • All employees must record their time daily in Dayforce. Authorized Directors and Managers have access to the Dayforce system and can view time reports at any time. Directors/Managers must approve each of their assigned staffs timesheets. If the timesheets are not approved, the Payroll & Benefits Administrator will follow-up with the director/manager to ensure hours are correctly recorded. At the end of the pay period the Payroll & Benefits Administrator reviews all the time entries to ensure all are approved and identify any issues. The Payroll & Benefits Administrator then makes any necessary adjustments to payroll such as mileage claims, expenses, etc. Payroll Approval • Once all payroll information is entered, the Payroll & Benefits Administrator provides the Director of Finance with a copy of the preview for review. Once approved, the Payroll & Benefits Administrator processes the payroll and completes the required journal entries monthly. The Director of Finance reviews the manual information and signs off on the final submitted payroll register. Source Deductions • All Source deductions are remitted after each payroll by "Ceridian Dayforce", the company used to process our payroll. The Director of Finance receives and reviews the monthly statement provided by the Government confirming remittance (online). Pension Filings • The Payroll & Benefits Administrator prepares and submits the pension filings monthly. The amounts are reconciled by employee to the payroll register and submitted via cheque. Benefits Reconciliations • The Payroll & Benefits Administrator reconciles the benefits invoice from Sunlife monthly to ensure only active employees are included and each employee is correctly categorized. MISCELLANEOUS HST • The HST return is completed quarterly by the Accounting Supervisor and reviewed and initialed by the Director of Finance after the Accounting Supervisor files. The Accounting Supervisor then books the necessary journal entries when the funds are received. Expenses • There are three corporate credit cards. The Accounting Supervisor reconciles them monthly and processes them the same as accounts payable (see AP above for detailed procedures). All staff expenses are processed through payroll. Staff must complete an
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MONTH 2019 Control Description Completed at Month End (Y/N/NA) expense form which is signed and approved by their supervisor. The form is then submitted to the Payroll & Benefits Administrator for processing with payroll. The Director of Finance reviews along with the payroll register. Settlement Forms • Settlement forms are completed annually by the auditors. Upon completion the forms are reviewed by the Director of Finance, approved by CEO before providing to the Board for final approval. FINANCIAL STATEMENTS Monthly Internals • Financial statements are generated monthly and are compared to budget. The financials are provided to the appropriate Directors/Managers to review their financials and note any reasons for variances to budget. The internals along with summary notes are provided to the CEO monthly to review as well and discuss with direct reports. Board Statements • Financial statements are generated Quarterly and provided to Finance and Facilities Standing Committee and the Board of Health. Cynthia reviews them at the FFSC meeting and highlights any discrepancies. The FFSC make the recommendation for the Board to approve the statements. During the Board meeting any additional questions are asked and the statements are approved. Mandatory Quarterly • Quarterly financial reports are completed by the Director of Finance in the template provided by the Ministry. Once complete, the Reporting to the Ministry CEO reviews and approves before the forms are electronically submitted to the Ministry. HBHC, PPNP, and HKCC • Quarterly financial reports are completed by the Director of Finance and then reviewed by the Program Manager. Once complete, Quarterly Reporting the CEO reviews and approves before the forms are electronically submitted to the Ministry.
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THIS PUBLIC HEALTH FUNDING AND ACCOUNTABILITY AGREEMENT effective as of the first day of May, 2018.
B E T W E E N:
HER MAJESTY THE QUEEN IN RIGHT OF ONTARIO as represented by the Minister of Health and Long-Term Care
(the “Province”)
- and -
Board of Health for the Oxford Elgin St. Thomas Health Unit
(the “Board of Health”)
BACKGROUND:
The Province provides grants to the Board of Health under the Health Protection and Promotion Act (Act) pursuant to section 76 of that Act.
By receiving the grant under section 76 of the Act, the Board of Health is expected to deliver mandatory and related public health programs and services that meet the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability and other requirements of the Act.
It is acknowledged that the Board of Health may provide additional programs and services in response to local needs as indicated in the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability published under section 7 of the Act and in section 9 of the Act. Provincial funding, however, is intended to support those programs that the Board of Health is required to provide under the Act (and other programs only if specifically authorized by the Ontario Government) and is not intended to cover the potential total scope of public health programming.
The Ontario Public Health Standards: Requirements for Programs, Services, and Accountability, which came into effect on January 1, 2018, includes a revised Public Health Accountability Framework which articulates the scope of the accountability relationship between the Board of Health and the Province and establishes expectations for the Board of Health in the domains of the delivery of programs and services, fiduciary requirements, good governance and management practices, and public health practice. Accountability is demonstrated in part through the submission of planning and reporting tools by the Board of Health to the Province. These tools enable the Board of Health to demonstrate that they are meeting defined expectations and provide appropriate oversight for public funding and resources.
Provincial funding for mandatory and related programs is subject to the provisions of this Agreement, which has no fixed term and may only be terminated or amended in accordance with this Agreement.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 1 of 21 CONSIDERATION:
In consideration of the mutual covenants and agreements contained herein and for other good and valuable consideration, the receipt and sufficiency of which are expressly acknowledged, the Parties agree as follows:
ARTICLE 1 INTERPRETATION AND DEFINITIONS
1.1 Interpretation. For the purposes of interpretation:
(a) words in the singular include the plural and vice-versa;
(b) words in one gender include all genders;
(c) the background and the headings do not form part of this Agreement; they are for reference only and shall not affect the interpretation of this Agreement;
(d) any reference to dollars or currency shall be to Canadian dollars and currency; and,
(e) “include”, “includes”, and “including” shall not denote an exhaustive list.
1.2 Definitions. In this Agreement, the following terms shall have the following meanings:
“Act” means the Health Protection and Promotion Act.
“Admissible Expenditures” are those considered by the Province to be reasonable and necessary for the Board of Health to achieve and/or maintain compliance with the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability, the Organizational Requirements, this Agreement, and other requirements of the Act and regulations and, as such, are eligible for reimbursement by the Province. These expenditures must be authorized in accordance with the policies of the Board of Health, consistent with government policies, and related to the delivery of mandatory and programs.
“Agreement” means this Agreement entered into between the Province and the Board of Health and includes all of the schedules to this Agreement listed in section 27.1 and any Amending Agreement entered into pursuant to section 3.3.
“Budget” means the budget attached to this Agreement in Schedule “A”.
“Effective Date” means the date set out at the top of this Agreement.
“Event of Default” has the meaning ascribed to it in section 14.1.
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“Board of Health Funding Year” means the period commencing on January 1st and ending on the following December 31st.
“Grant” means the grant provided to the Board of Health by the Province pursuant to section 76 of the Act and this Agreement.
“Indemnified Parties” means Her Majesty the Queen in Right of Ontario, Her ministers, agents, appointees and employees.
“Maximum Base Funds” means the maximum base funds set out in Schedule “A”.
“Maximum One-Time Funds” means the maximum one-time funds set out in Schedule “A”.
“Minister” means Her Majesty the Queen in Right of Ontario as represented by the Minister of Health and Long-Term Care, and “Ministry” shall refer to the Ministry of Health and Long-Term Care.
“Ministry Funding Year” means the period commencing on April 1st and ending on the following March 31st.
“Non-Admissible Expenditures” are those considered by the Province to be unrelated to the provision of mandatory and related programs, the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability, Organizational Requirements, the requirements of this Agreement, and other requirements of the Act or that are not compatible with applicable government directives. Examples of non-admissible expenditures include, but are not limited to: sick time and vacation accruals, donations to individuals or organizations, capital fund reserves, depreciation on capital assets/amortization, gym membership fees, alcoholic beverages, and providing administrative services on behalf of third parties.
“Notice” means any communication given or required to be given pursuant to this Agreement.
“Notice Period” means the period of time within which the Board of Health is required to remedy an Event of Default, and includes any such period or periods of time by which the Province considers it reasonable to extend that time.
“Ontario Public Health Standards: Requirements for Programs, Services, and Accountability” means the Ontario Public Health Standards published by the Minister of Health and Long-Term Care pursuant to section 7 of the Act.
“Organizational Requirements” means those requirements articulated in the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability.
“Parties” means the Province and the Board of Health.
“Party” means either the Province or the Board of Health.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 3 of 21
“Performance Variance” means any of: a) non-compliance with any aspect of the Health Protection and Promotion Act, its regulations, the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability published by the Minister under s. 7 of the Act; or, b) any other matter that could significantly affect the Board of Health’s ability to perform its obligations under this Agreement.
“Program(s)” means:
(a) Mandatory Program(s): the health programs and services the Board of Health must provide to its local communities in accordance with section 5 of the Act and the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability; or,
(b) Related Program(s): the programs described in Schedule “B”.
“Reports” means the reports described in Schedule “C”.
“Wind-Down Amount” means the amount the Province sets if this Agreement is terminated under sections 12.3(c) or 13.2(c).
ARTICLE 2 REPRESENTATIONS, WARRANTIES AND COVENANTS
2.1 General. The Board of Health represents, warrants and covenants that:
(a) it is, and shall continue to be for the term of this Agreement, a validly existing legal entity with full power to fulfill its obligations under this Agreement; and,
(b) unless otherwise provided for in this Agreement, any information the Board of Health provided to the Province in support of its requests for a Grant (including information relating to any eligibility requirements) was true and complete at the time the Board of Health provided it and shall continue to be true and complete for the term of this Agreement, unless otherwise reported in writing by the Board of Health to the Province.
2.2 Execution of Agreement. The Board of Health represents and warrants that it:
(a) has the full power and authority to enter into this Agreement;
(b) will fulfill the obligations set out in the schedules to this Agreement in accordance with their terms;
(c) will deliver programs and services that meet the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability published under section 7 of the Act, and will comply with the Organizational Requirements therein; and,
(d) has taken all necessary actions to authorize the execution of this Agreement including, where required, passing a Board resolution or
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 4 of 21
municipal by-law authorizing the Board of Health to enter into this Agreement with the Province.
2.3 Governance. The Board of Health represents, warrants and covenants that it has, and shall maintain, in writing, for the period during which this Agreement is in effect:
(a) strategies, policies, and/or procedures to ensure compliance with the Organizational Requirements included in the Ontario Public Health Standards: Requirements for Programs, Services and Accountability;
(b) a code of conduct and ethical responsibilities for the Board of Health as an organization;
(c) strategies, policies, and/or procedures to ensure the ongoing effective functioning of the Board of Health;
(d) decision-making policies, procedures and/or mechanisms;
(e) strategies, policies, and/or procedures to provide for the prudent and effective management of the Grant;
(f) strategies, policies, and/or procedures to enable the successful completion of the obligations set out in this Agreement and in the schedules to this Agreement;
(g) strategies, policies, and/or procedures to enable the timely identification of risks to the Board of Health’s ability to perform its obligations under this Agreement and mechanisms/strategies to address the identified risks;
(h) strategies, policies, and/or procedures to enable the preparation and delivery of all Reports required pursuant to Article 8; and,
(i) strategies, policies and/or procedures to deal with such other matters as the Board of Health considers necessary to ensure that the Board of Health meets its obligations under this Agreement.
2.4 Supporting Documentation. Upon request, the Board of Health shall provide the Province with proof of the matters referred to in this Article 2.
ARTICLE 3 TERM OF THIS AGREEMENT
3.1 Term. The term of this Agreement shall commence on the Effective Date and shall continue unless terminated pursuant to Article 12, Article 13 or Article 14.
3.2 Application of Schedules during Term. A schedule, or parts of a schedule, may apply for only part of the Term of this Agreement. Where a schedule, or part of a schedule, applies for only part of the Term of this Agreement, it shall be so indicated in the schedule.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 5 of 21
3.3 Amendments to this Agreement during Term. The Parties agree that amendments to the Agreement and schedules may be made during the Term of this Agreement. Without limiting the generality of the foregoing, the Province may, at any time, upon consultation with the Board of Health, amend the Agreement by adding:
(a) a new Schedule “A” (Grants and Budget);
(b) a new Schedule “B” (Related Program Policies and Guidelines);
(c) a new Schedule “C” (Reporting Requirements); and/or,
(d) a new Schedule “D” (Financial Controls).
3.4 Deemed to be replaced. If the Province provides a new schedule in accordance with section 3.3, the new schedule shall be deemed to be Schedule “A” (Grants and Budget), Schedule “B” (Related Program Policies and Guidelines), Schedule “C” (Reporting Requirements), or Schedule “D” (Financial Controls), as the case may be, (collectively referred to as “New Schedules”), for the period of time to which it relates, provided that if the Board of Health does not agree with all or any of the New Schedules, the Board of Health may terminate the Agreement pursuant to section 12.1.
3.5 Additional Schedules during Term. The Parties agree that additional schedules may be added to this Agreement by the Province, upon consultation with the Board of Health, during the Term of this Agreement.
3.6 Review of Agreement. The Parties agree to review this Agreement every five (5) years to determine if amendments are necessary and/or appropriate.
ARTICLE 4 GRANT
4.1 Grant Provided. The Province shall:
(a) provide the Board of Health a Grant for the purpose of carrying out the obligations set out in the Act, the regulations under the Act, the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability, the Organizational Requirements, and this Agreement including the schedules to this Agreement; and,
(b) deposit the Grant into an account designated by the Board of Health provided that the account resides at a Canadian financial institution and is in the name of the Board of Health.
4.2 Limitation on Payment of the Grant. Despite section 4.1, the Province:
(a) is not obligated to provide any Grant to the Board of Health until the Board of Health provides the insurance certificate or other proof as the Province may request pursuant to section 11.2;
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 6 of 21
(b) is not obligated to provide instalments of the Grant until it is satisfied with the progress of the obligations set out in this Agreement and the schedules;
(c) may adjust the amount of the Grant it provides to the Board of Health in any Funding Year based upon the Province’s assessment of the information provided by the Board of Health pursuant to section 8.1;
(d) if, pursuant to the provisions of the Financial Administration Act (Ontario), the Province does not receive the necessary appropriation from the Ontario Legislature for payment under this Agreement, the Province is not obligated to make any such payment, and, as a consequence, the Province may:
(i) reduce the amount of the Grant; or
(ii) terminate this Agreement pursuant to section 13.1 and cease providing Grant funding for a period or periods specified by the Province.
4.3 Use of Grant Funding. The Board of Health shall:
(a) use the Grant only for the purposes of the Act and to provide or to ensure the provision of the health programs and services in accordance with sections 4, 5, 6, and 7 of the Act and for the purposes of carrying out the obligations in the schedules;
(b) use the Grant only for the provision of the Programs described in this Agreement and the schedules;
(c) carry out the obligations in the schedules:
(i) in accordance with the terms and conditions of this Agreement; and,
(ii) in compliance with all federal and provincial laws and regulations, all municipal by-laws, and any other orders, rules and by-laws related to any aspect of the Programs; and,
(d) spend the Grant only on Admissible Expenditures.
4.4 No Changes. The Board of Health shall not make any changes to schedules, the timelines and/or the use of the Grant without the prior written consent of the Province.
4.5 Interest Bearing Account. If the Province provides the Grant to the Board of Health prior to the Board of Health’s immediate need for the Grant, the Board of Health shall place the Grant in an interest bearing account in the name of the Board of Health at a Canadian financial institution.
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4.6 No Interest Payable by Province. The Board of Health agrees that the Province shall not pay interest on any amount to which the Board of Health may otherwise be entitled under this Agreement.
4.7 Rebates, Credits and the Grant. The Board of Health shall not use the Grant for any costs, including taxes, for which it has received, will receive, or is eligible to receive, a rebate, credit or refund.
ARTICLE 5 PERFORMANCE IMPROVEMENT
5.1 Performance Improvement. The Parties agree to adopt a proactive and responsive approach to performance improvement (“Performance Improvement Process”), based on the following principles:
(a) a commitment to continuous quality improvement;
(b) a culture of information sharing and understanding; and,
(c) a focus on risk-management.
5.2 Elements of Performance Improvement Process. The Board of Health’s Performance Improvement Process shall include, but is not limited to:
(a) measuring the Board of Health’s performance as articulated in Schedules “A”, “B”, and “C”; and,
(b) the use of tools including, but not limited to those specified in sections 5.4, 5.5, and 5.6.
5.3 Reports. If, through its Performance Improvement Process, a Board of Health identifies a variance in its performance, the Board of Health shall submit in writing a report to the Province, within the timeframe provided by the Province. In addition, the Province may request in its sole discretion such a report from the Board of Health, and the Board of Health shall provide a report to the Province, within the timeframe provided by the Province. The report to the Province shall include:
a) the cause of the variance;
b) an assessment of the impact of the variance on program and service delivery;
c) a description of how the Board of Health plans to resolve the variance and the timeline within which the Board of Health expects to resolve it; and,
d) a description of how the Board of Health plans to resolve any impacts on program and service delivery and the timeline within which the Board of Health expects to resolve them.
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5.4 Action Plan. The Province may request in writing, either before or after a report(s) specified in section 5.3 has been requested or provided, that the Board of Health submit an Action Plan to address variance(s) described in the report(s). The Action Plan shall describe:
(a) the remedial actions undertaken (or planned to be undertaken) by the Board of Health; and,
(b) the timeframe when the remedial action is expected to be completed.
5.5 Approval of Action Plan. The Action Plan must be approved by both the Province and the Board of Health prior to its implementation. Any revisions to the Action Plan also require the approval of both the Province and the Board of Health.
ARTICLE 6 ACQUISITION OF GOODS AND SERVICES, AND DISPOSAL OF ASSETS
6.1 Acquisition. If the Board of Health acquires supplies, equipment or services with the Grant, it shall do so through a process that promotes the best value for money. All procurement of goods and services should be consistent with the Ontario Public Health Standards: Requirements for Programs, Services, and Accountability, Organizational Requirements, good procurement practices, and applicable government directives.
ARTICLE 7 CONFLICT OF INTEREST
7.1 No Conflict of Interest with Use of the Grant. The Board of Health shall carry out the obligations set out in this Agreement and use the Grant without an actual, potential or perceived conflict of interest. Note that nothing in this Agreement applies to any other local or municipal conflict of interest not dealing with the use of the Grant.
7.2 Conflict of Interest Includes. For the purposes of this Article, a conflict of interest includes any circumstances where:
(a) the Board of Health; or,
(b) any person who has the capacity to influence the Board of Health’s decisions,
has outside commitments, relationships or financial interests that could, or could be seen to, interfere with the Board of Health’s objective, unbiased and impartial judgment relating to its obligations under this Agreement and the use of the Grant.
7.3 Disclosure to Province. The Board of Health shall:
(a) disclose to the Province, without delay, any situation that a reasonable person would interpret as either an actual, potential or perceived conflict of
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interest; and,
(b) comply with any terms and conditions that the Province may prescribe as a result of the disclosure. Note that the Province may determine that no further action is required if it determines that the conflict has been adequately addressed in accordance with the Board of Health conflict of interest policies.
ARTICLE 8 REPORTING, ACCOUNTING AND REVIEW
8.1 Preparation and Submission. The Board of Health shall:
(a) submit to the Province at the address provided in section 16.1 or at any other address specified by the Province, all Reports in accordance with the timelines and content requirements set out in Schedule “C”, or in a form as specified by the Province from time to time;
(b) submit to the Province at the address provided in section 16.1, or at any other address specified by the Province, any other reports as may be requested by the Province in accordance with the timelines and content requirements specified by the Province;
(c) ensure that all Reports and other reports are completed to the satisfaction of the Province; and,
(d) ensure that all Reports and other reports are signed on behalf of the Board of Health by an authorized signing officer.
8.2 Record Maintenance. The Board of Health shall keep and maintain:
(a) all financial records (including invoices) relating to the Grant in a manner consistent with generally accepted accounting principles; and,
(b) all non-financial documents and records relating to the Grant or otherwise in connection with Article 5 (Performance Improvement) and the schedules in accordance with applicable law and Board of Health policies.
8.3 Inspection, Audit or Investigation. The Province, its authorized representatives and/or an independent auditor identified by the Province may, at its own expense, upon 24 hours’ Notice to the Board of Health and during normal business hours, enter upon the Board of Health’s premises to review the Board of Health’s expenditure of the Grant and/or assess compliance with this Agreement, and for these purposes, the Province, its authorized representatives or an independent auditor identified by the Province may:
(a) inspect and copy the records and documents referred to in section 8.2;
(b) remove any copies made pursuant to section 8.3(a) from the Board of Health’s premises; and/or,
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(c) conduct an audit or investigation of the Board of Health in respect of the expenditure of the Grant, and/or compliance with this Agreement.
8.4 Assessment. The Province may carry out an assessment of the Board of Health under section 82 of the Act if the legal requirements for an assessment under that section have been met. An assessment may be conducted under the terms of that section irrespective of whether or not an inspection is conducted under section 8.3 of this Agreement.
8.5 Disclosure. To assist in respect of the rights set out in section 8.3, the Board of Health shall disclose any information requested by the Province, its authorized representatives or an independent auditor identified by the Province, and shall do so in a form requested by the Province, its authorized representatives or an independent auditor identified by the Province, as the case may be, subject to applicable law.
8.6 Province Right to Request Information. The Province may request additional information, or may request meetings with the Board of Health to support compliance with any aspect of this Agreement, subject to applicable law.
8.7 No Control of Records. No provision of this Agreement shall be construed so as to give the Province any control whatsoever over the Board of Health’s records.
8.8 Auditor General. For greater certainty, the Province’s rights under this Article are in addition to any rights provided to the Auditor General pursuant to section 9.1 of the Auditor General Act (Ontario).
ARTICLE 9 FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY
9.1 FIPPA. The Board of Health acknowledges that the Province is bound by the Freedom of Information and Protection of Privacy Act (Ontario) (FIPPA) and that any information provided to the Province in connection with this Agreement may be subject to disclosure in accordance with FIPPA.
9.2 MFIPPA. The Province acknowledges that the Board of Health is bound by the Municipal Freedom of Information and Protection of Privacy Act (Ontario) (MFIPPA) and that any information provided to the Board of Health in connection with this Agreement may be subject to disclosure in accordance with MFIPPA.
9.3 Confidentiality of records. The Board of Health shall ensure that all personal information or personal health information in its custody or under its control is managed in accordance with the provisions of the Act and its regulations, the MFIPPA and its regulations, the Personal Health Information Protection Act (PHIPA) and any other applicable legislation.
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ARTICLE 10 INDEMNITY
10.1 Indemnification. The Board of Health hereby agrees to indemnify and hold harmless the Indemnified Parties from and against any and all liability, loss, costs, damages and expenses (including legal, expert and consultant fees), causes of action, actions, claims, demands, lawsuits or other proceedings, by whomever made, sustained, incurred, brought or prosecuted, in any way arising out of or in connection with the Programs or otherwise in connection with this Agreement, unless solely caused by the negligence or wilful misconduct of the Province.
ARTICLE 11 INSURANCE
11.1 Board of Health’s Insurance. The Board of Health represents and warrants that it has, and shall maintain for the term of this Agreement, at its own cost and expense, with insurers having a secure A.M. Best rating of B+ or greater, or the equivalent, all the necessary and appropriate insurance that a prudent person carrying out programs and services similar to the programs and services covered by this Agreement would maintain, including commercial general liability insurance on an occurrence basis for third party bodily injury, personal injury and property damage, to an inclusive limit of not less than two million dollars ($2,000,000) per occurrence. The policy shall include the following:
(a) the Indemnified Parties as additional insureds with respect to liability arising in the course of performance of the Board of Health’s obligations under, or otherwise in connection with, this Agreement;
(b) a cross-liability clause;
(c) contractual liability coverage; and,
(d) a 30-day written notice of cancellation, termination or material change.
11.2 Proof of Insurance. The Board of Health shall provide the Province with certificates of insurance, or other proof as may be requested by the Province, that confirms the insurance coverage as provided for in section 11.1. Upon the request of the Province, the Board of Health shall make available to the Province a copy of each insurance policy.
ARTICLE 12 TERMINATION ON NOTICE
12.1 Termination on Notice. The Province or the Board of Health may terminate this Agreement at any time upon giving at least 120 days’ Notice to the other Party.
12.2 Termination of Specific Program. Despite section 12.1, the Province may terminate any Program that is funded by the Grant under this Agreement with 120 days’ Notice. If a Program funded by the Grant under this Agreement terminates for any reason, the Parties agree to amend this Agreement and schedules to
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incorporate any necessary changes to this Agreement.
12.3 Consequences of Termination on Notice by the Province. If either the Province or the Board of Health terminates this Agreement or a specific Program pursuant to sections 12.1 or 12.2, the Province may:
(a) cancel all further instalments of the Grant;
(b) demand the repayment of any Grant remaining in the possession or under the control of the Board of Health; and/or,
(c) assist the Board of Health to wind-down the Program, project, or other initiative purchased with the Grant; set the Wind-Down Amount; and,
(i) permit the Board of Health to offset the Wind-Down Amount against any Grant amount remaining in the possession or under the control of the Board of Health; and/or,
(ii) provide a Grant to the Board of Health to cover the Wind-Down Amount.
ARTICLE 13 TERMINATION WHERE NO APPROPRIATION
13.1 Termination Where No Appropriation. If, as provided for in section 4.2(d), the Province does not receive the necessary appropriation from the Ontario Legislature for any payment the Province is to make under this Agreement, the Province may terminate this Agreement immediately by giving Notice to the Board of Health.
13.2 Consequences of Termination Where No Appropriation. If the Province terminates this Agreement pursuant to section 13.1, the Province may:
(a) cancel all further instalments of the Grant;
(b) demand the repayment of any Grant funds remaining in the possession or under the control of the Board of Health; and/or,
(c) assist the Board of Health to wind-down a Program, project or other initiative purchased with the Grant; set the Wind-Down Amount; and, permit the Board of Health to offset such Wind-Down Amount against the amount owing pursuant to section 13.2(b).
13.3 No Additional Grant Funding. For purposes of clarity, if the Wind-Down Amount exceeds the Grant remaining in the possession or under the control of the Board of Health, the Province shall not be required to provide additional Grant funding to the Board of Health.
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ARTICLE 14 EVENT OF DEFAULT, CORRECTIVE ACTION AND TERMINATION FOR DEFAULT
14.1 Events of Default. Each of the following events may constitute at the sole option of the Province an Event of Default:
(a) the Board of Health breaches any representation, warranty, covenant or other material term of this Agreement, including failing to do any of the following in accordance with the terms and conditions of this Agreement:
(i) carry out its obligations in the schedules;
(ii) use or spend the Grant; and/or,
(iii) provide, in accordance with section 8.1, Reports or such other reports as may have been requested pursuant to section 8.1(b);
(b) the Board of Health’s operations, or its organizational structure, changes so that it no longer meets one or more of the applicable eligibility requirements of the Program under which the Province provides the Grant; and/or,
(c) the Board of Health ceases to operate, is merged or otherwise dissolved.
14.2 Consequences of Events of Default and Corrective Action. If an Event of Default occurs, the Province may, at any time, take one or more of the following actions:
(a) initiate any action the Province considers necessary in order to facilitate the successful continuation or completion of the Board of Health’s obligations under this Agreement;
(b) provide the Board of Health with an opportunity to remedy the Event of Default;
(c) suspend the payment of the Grant for such period as the Province determines appropriate;
(d) reduce the amount of the Grant;
(e) cancel all further installments of the Grant;
(f) demand the repayment of any amounts of the Grant remaining in the possession or under the control of the Board of Health that is not already promised by legal agreement that the Board of Health has with another person;
(g) demand the repayment of an amount equal to any Grant the Board of Health used for purposes not agreed upon by the Province;
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(h) demand the repayment of an amount equal to any Grant the Province provided to the Board of Health; and/or,
(i) terminate this Agreement at any time, including immediately, upon giving Notice to the Board of Health.
14.3 Opportunity to Remedy. If, in accordance with section 14.2(b), the Province provides the Board of Health an opportunity to remedy the Event of Default, it shall provide Notice to the Board of Health of:
(a) the particulars of the Event of Default; and,
(b) the Notice Period.
14.4 Board of Health not Remedying. If the Province has provided the Board of Health with an opportunity to remedy the Event of Default pursuant to section 14.2(b), and:
(a) the Board of Health does not remedy the Event of Default within the Notice Period;
(b) it becomes apparent to the Province that the Board of Health cannot completely remedy the Event of Default within the Notice Period; and/or
(c) the Board of Health is not proceeding to remedy the Event of Default in a way that is satisfactory to the Province;
the Province may extend the Notice Period, or initiate any one or more of the actions provided for in sections 14.2 (a), (c), (d), (e), (f), (g), (h) and (i).
14.5 When Termination Effective. Termination under this Article shall take effect as set out in the Notice.
14.6 Ministry’s Rights under the Act maintained. Nothing in this Agreement shall limit the Province’s or the Chief Medical Officer of Health’s rights under section 82 of the Act to conduct an assessment of the Board of Health if the conditions under that section are met.
ARTICLE 15 RETURN OF THE GRANT
15.1 Return of The Grant. If the Province requests in writing the repayment of the whole or any part of the Grant; due, for example, to an Event of Default or at the end of the Board of Health Funding Year or the Ministry Funding Year; the amount requested shall be deemed to be a debt due and owing to the Province and the Board of Health shall pay the amount immediately, unless the Province directs otherwise.
15.2 Method of Return. The Province may recover the Grant requested in section 15.1 through a cash-flow adjustment. If a cash-flow adjustment is not possible, the Board of Health shall repay the amount payable by cheque payable to the
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“Ontario Minister of Finance” and mailed to the Province at the address set out in the Province’s request for repayment.
15.3 Interest on the Grant Payable. The Province reserves the right to demand interest on any amount owing by the Board of Health at the then current rate charged by the Province on accounts receivable. Interest shall accrue 30 days after Notice has been provided under section 15.1 for repayment of the Grant.
15.4 Unused Grant. The Board of Health agrees that it shall report to the Province in writing any part of the Grant that has not been used or accounted for by the Board of Health, either 30 days prior to the end of the Board of Health Funding Year, in the quarterly financial reports, or in a report provided as soon thereafter as possible, and when the amount of the unused Grant is known.
15.5 Carry Over of Grant Not Permitted. The Board of Health is not permitted to carry over the Grant from one Board of Health Funding Year to the next, unless pre-authorized in writing by the Province. In no case shall the Board of Health be permitted to carry over the Grant beyond the end of the Ministry Funding Year.
15.6 Return of Unused Grant. Without limiting any rights of the Province under Article 13, or sections 15.1 or 15.2, if the Board of Health has not spent all of the Grant allocated for the Board of Health Funding Year or the Ministry Funding Year as provided for in the schedules, the Province may:
(a) demand the return of the unspent Grant; and,
(b) adjust the amount of any further instalments of the Grant accordingly.
ARTICLE 16 NOTICE
16.1 Notice in Writing and Addressed. Notice shall be in writing and shall be delivered by e-mail, postage-prepaid mail, personal delivery or facsimile, and shall be addressed to the Province and the Board of Health respectively as set out below or as either Party later designates to the other by Notice:
To the Province: To the Board of Health:
Office of Chief Medical Officer of Health, Board of Health for the Oxford Elgin Public Health St. Thomas Health Unit Ministry of Health and Long-Term Care
393 University Ave., 21st Floor 1230 Talbot Street Toronto ON M7A 2S1 St. Thomas ON N5P 1G9
Attention: Attention: Brent Feeney Cynthia St. John Manager, Funding and Oversight Chief Executive Officer
E-mail: [email protected] E-mail: [email protected]
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16.2 Notice Given. Notice shall be deemed to have been received:
(a) in the case of postage-prepaid mail, seven (7) days after a Party mails the Notice; or,
(b) in the case of e-mail, personal delivery or facsimile, at the time the other Party receives the Notice.
16.3 Postal Disruption. Despite section 16.2(a), in the event of a postal disruption:
(a) Notice by postage-prepaid mail shall not be deemed to be received; and,
(b) the Party giving Notice shall provide Notice by personal delivery, by facsimile, or by e-mail.
ARTICLE 17 CONSENT BY PROVINCE
17.1 Consent. The Province may impose any terms and conditions on any consent the Province may grant pursuant to this Agreement.
ARTICLE 18 SEVERABILITY OF PROVISIONS
18.1 Invalidity or Unenforceability of Any Provision. The invalidity or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision of this Agreement. Any invalid or unenforceable provision shall be deemed to be severed.
ARTICLE 19 WAIVER
19.1 Waivers in Writing. If a Party fails to comply with any term of this Agreement, that Party may only rely on a waiver of the other Party if the other Party has provided a written waiver in accordance with the Notice provisions in Article 16. Any waiver must refer to a specific failure to comply and shall not have the effect of waiving any subsequent failures to comply.
ARTICLE 20 INDEPENDENT PARTIES
20.1 Parties Independent. The Board of Health acknowledges that it is not an agent, joint venturer, partner or employee of the Province, and the Board of Health shall not take any actions that could establish or imply such a relationship.
ARTICLE 21 ASSIGNMENT OF AGREEMENT OR THE GRANT
21.1 No Assignment. The Board of Health shall not assign any part of this Agreement or the Grant without the prior written consent of the Province.
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21.2 Agreement Binding. All rights and obligations contained in this Agreement shall extend to and be binding on the Parties’ respective heirs, executors, administrators, successors and permitted assigns.
ARTICLE 22 GOVERNING LAW
22.1 Governing Law. This Agreement and the rights, obligations and relations of the Parties shall be governed by and construed in accordance with the laws of the Province of Ontario and the applicable federal laws of Canada. Any actions or proceedings arising in connection with this Agreement shall be conducted in the courts of Ontario, which shall have exclusive jurisdiction over such proceedings.
22.2 Conflicts – Ontario. In the event of a conflict between this Agreement and the Ontario Public Health Standards, the Organizational Standards or the Act or its regulations, the Ontario Public Health Standards, Organizational Standards or the Act or its regulations prevail.
22.3 Conflicts – Municipal. In the event of a conflict between any requirement of this Agreement and any municipal or local requirement at law to which the Board of Health is subject, the Board of Health shall comply with the stricter requirement.
ARTICLE 23 FURTHER ASSURANCES
23.1 Agreement into Effect. The Board of Health shall provide such further assurances as the Province may request from time to time with respect to any matter to which this Agreement pertains, and shall otherwise do or cause to be done all acts or things necessary to implement and carry into effect the terms and conditions of this Agreement to its full extent.
ARTICLE 24 JOINT AND SEVERAL LIABILITY
24.1 Joint and Several Liability. Where the Board of Health is comprised of more than one entity, all such entities shall be jointly and severally liable to the Province for the fulfillment of the obligations of the Board of Health under this Agreement.
ARTICLE 25 RIGHTS AND REMEDIES CUMULATIVE
25.1 Rights and Remedies Cumulative. The rights and remedies of the Province under this Agreement are cumulative and are in addition to, and not in substitution for, any of its rights and remedies provided by law or in equity.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 18 of 21 ARTICLE 26 FAILURE TO COMPLY WITH OTHER AGREEMENTS
26.1 Other Agreements. If the Board of Health:
(a) has failed to comply (a “Failure”) with any term, condition or obligation under any other agreement with Her Majesty the Queen in the right of Ontario or a Crown agency;
(b) has been provided with notice of such Failure in accordance with the requirements of such other agreement;
(c) has, if applicable, failed to rectify such Failure in accordance with the requirements of such other agreement; and,
(d) such Failure is continuing,
the Province may suspend the payment of the Grant for such period as the Province determines appropriate.
ARTICLE 27 SCHEDULES
27.1 Schedules. This Agreement includes the following schedules:
(a) Schedule “A” – Grants and Budget;
(b) Schedule “B” – Related Program Policies and Guidelines;
(c) Schedule “C” – Reporting Requirements; and,
(d) Schedule “D” – Board of Health Financial Controls.
27.2 Purpose of Schedules. The purpose of the schedules under this Agreement is to:
(a) specify the Grant to be allocated from the Province to the Board of Health to deliver public health programs and services that meet the Ontario Public Health Standards, the Organizational Requirements, and other requirements of the Act;
(b) provide the Board of Health with further information on expectations related to the Grant;
(c) improve and strengthen the Province’s ability to effectively analyze the Board of Health’s expenditures and ensure accountability for the use of the Grant; and,
(d) contribute to a public health sector with a greater focus on performance improvement, accountability and sustainability.
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ARTICLE 28 SURVIVAL
28.1 Survival. The provisions in Article 1, Article 4, Article 5, sections 8.1 (to the extent that the Board of Health has not provided the Reports or other reports to the satisfaction of the Province), 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, Articles 9, 10 and 11, sections 13.2, 14.2, 14.3 and 14.4, Articles 15, 18, 19, 21, 22, 24, 25, 26, 27, 28, 29 and 30, and all applicable Definitions, cross-referenced provisions and schedules shall continue in full force and effect for a period of seven years from the date of expiry or termination of the Agreement.
ARTICLE 29 COUNTERPARTS
29.1 Counterparts. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument.
ARTICLE 30 ENTIRE AGREEMENT
30.1 Entire Agreement. This Agreement constitutes the entire agreement between the Parties with respect to the subject matter contained in this Agreement and supersedes all prior oral or written representations and agreements.
30.2 Modification of Agreement. This Agreement may only be amended by a written agreement duly executed by the Parties.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 20 of 21 The Parties have executed this Agreement on the dates set out below.
HER MAJESTY THE QUEEN IN RIGHT OF ONTARIO as represented by the Minister of Health and Long-Term Care
______Name: Dr. David Williams Date Title: Chief Medical Officer of Health Office of Chief Medical Officer of Health, Public Health
Board of Health for the Oxford Elgin St. Thomas Health Unit
I/We have authority to bind the Board of Health.
______March 26, 2019 Name: Larry Martin Date Title: Board Chair
______March 26, 2019 Name: Cynthia St. John Date Title: Chief Executive Officer
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 21 of 21 SCHEDULE "A" GRANTS AND BUDGET
Board of Health for the Oxford Elgin St. Thomas Health Unit
GRANTS
Amount Funding Type Funding Period ($) For each Board of Health Funding Year from the Effective Date until the (1) 9,017,400 Maximum Base Funds - Mandatory Programs (Cost-Shared) Maximum Base Funds change, or the Agreement is terminated. For each Board of Health Funding Year from the Effective Date until the (1) 3,496,200 Maximum Base Funds - Related Programs (100%) Maximum Base Funds change, or the Agreement is terminated. For each Board of Health Funding Year from the Effective Date until the (1) 150,300 Maximum Base Funds - Related Programs (Cost-Shared) Maximum Base Funds change, or the Agreement is terminated. For the Ministry Funding Year from April 1, 2018 to Maximum One-Time Funds (100%) 2,163,200 March 31, 2019, unless otherwise noted.
Maximum Total Funds for the Board of Health and Ministry 14,827,100 Funding Years(2)
NOTES: (1) The Board of Health may be permitted to carry over maximum base funds from the end of the Board of Health funding year to the end of the Ministry funding year, upon written request from the Board of Health and subsequent written consent from the Province.
(2) Maximum base and one-time funding is flowed on a mid and end of month basis. Cash flow will be adjusted when the Province provides a new Schedule "A".
DETAILED BUDGET - MAXIMUM BASE FUNDS (FOR THE PERIOD OF JANUARY 1, 2018 TO DECEMBER 31, 2018, UNLESS OTHERWISE NOTED) 2018 Approved Programs/Sources of Funding(1) Allocation ($) Mandatory Programs (Cost-Shared) 9,017,400
Chief Nursing Officer Initiative (100%) # of FTEs 2.00 243,000
Electronic Cigarettes Act : Protection and Enforcement (100%) 28,100
Enhanced Food Safety - Haines Initiative (100%) 50,000
Enhanced Safe Water Initiative (100%) 31,000
Harm Reduction Program Enhancement (100%) 300,000
Healthy Smiles Ontario Program (100%) 1,008,100
Infection Prevention and Control Nurses Initiative (100%) # of FTEs 2.00 180,200
Infectious Diseases Control Initiative (100%) # of FTEs 3.50 389,000
MOH / AMOH Compensation Initiative (100%)(2) 189,000
Needle Exchange Program Initiative (100%) 60,900
Small Drinking Water Systems Program (Cost-Shared) 30,700
Smoke-Free Ontario Strategy: Prosecution (100%) 17,400
Smoke-Free Ontario Strategy: Protection and Enforcement (100%) 278,500
Smoke-Free Ontario Strategy: Tobacco Control Coordination (100%) 200,000
Smoke-Free Ontario Strategy: Youth Tobacco Use Prevention (100%) 160,000
Social Determinants of Health Nurses Initiative (100%) # of FTEs 4.00 361,000
Vector-Borne Diseases Program (Cost-Shared) 119,600
Total Maximum Base Funds 12,663,900
Page 1 of 2 SCHEDULE "A" GRANTS AND BUDGET
Board of Health for the Oxford Elgin St. Thomas Health Unit
DETAILED BUDGET - MAXIMUM ONE-TIME FUNDS (FOR THE PERIOD OF APRIL 1, 2018 TO MARCH 31, 2019, UNLESS OTHERWISE NOTED)
2018-19 Approved Projects / Initiatives Allocation ($)
Mandatory Programs: Merger Costs (100%) 1,900,000
Healthy Growth/School Health: School Health Screening Coordination (100%) 81,000
Healthy Smiles Ontario Program: Dental Equipment and Software (100%) 137,800
Needle Exchange Program Initiative (100%) 24,400
Public Health Inspector Practicum Program (100%) 20,000
Total Maximum One-Time Funds 2,163,200
(1) The Board of Health may be permitted to move approved funding from one funding source to another, upon written consent from the Province. (2) Cash flow will be adjusted to reflect the actual status of current MOH and AMOH positions.
Page 2 of 2 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
Chief Nursing Officer Initiative (100%) Under the Organizational Requirements of the Ontario Public Health Standards, the Board of Health is required to designate a Chief Nursing Officer. The Chief Nursing Officer role must be implemented at a management level within the Board of Health reporting directly to the Medical Officer of Health (MOH) or Chief Executive Officer, preferably at a senior management level, and in that context will contribute to organizational effectiveness. Should the role not be implemented at the senior management level as per the recommendations of the ‘Public Health Chief Nursing Officer Report (2011)’, the Chief Nursing Officer should nonetheless participate in senior management meetings in the Chief Nursing Officer role as per the intent of the recommendation.
The presence of a Chief Nursing Officer in the Board of Health will enhance the health outcomes of the community at individual, group, and population levels:
• Through contributions to organizational strategic planning and decision making; • By facilitating recruitment and retention of qualified, competent public health nursing staff; and, • By enabling quality public health nursing practice.
Furthermore, the Chief Nursing Officer articulates, models, and promotes a vision of excellence in public health nursing practice, which facilitates evidence-based services and quality health outcomes in the public health context.
The following qualifications are required for designation as a Chief Nursing Officer:
• Registered Nurse in good standing with the College of Nurses of Ontario; • Baccalaureate degree in nursing; • Graduate degree in nursing, community health, public health, health promotion, health administration or other relevant equivalent OR be committed to obtaining such qualification within three (3) years of designation; • Minimum of 10 years nursing experience with progressive leadership responsibilities, including a significant level of experience in public health; and, • Member of appropriate professional organizations (e.g., Registered Nurses’ Association of Ontario, Association of Nursing Directors and Supervisors in Official Health Agencies in Ontario-Public Health Nursing Management, etc.).
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 1 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
Base funding for this initiative must be used for Chief Nursing Officer related activities (described above) of up to or greater than 1.0 Full-Time Equivalent (FTE). These activities may be undertaken by the designated Chief Nursing Officer and/or a nursing practice lead. Base funding is for nursing salaries and benefits only and cannot be used to support operating or education costs.
Electronic Cigarettes Act – Protection and Enforcement (100%) The government has a plan, Patients First: Ontario’s Action Plan for Health Care (February 2015), for Ontario that supports people and patients – providing the education, information and transparency they need to make the right decisions about their health. The plan encourages the people of Ontario to take charge and improve their health by making healthier choices, and living a healthy lifestyle by preventing chronic diseases and reducing tobacco use. Part of this plan includes taking a precautionary approach to protect children and youth by regulating electronic cigarettes (e-cigarettes) through the Electronic Cigarettes Act, 2015.
Base funding for this initiative must be used for implementation of the Electronic Cigarettes Act, 2015 and enforcement activities, including prosecution. Any prosecution costs must be identified through the reporting templates provided by the ministry.
The Board of Health must comply and adhere to the Electronic Cigarettes Act: Public Health Unit Guidelines and Directives: Enforcement of the Electronic Cigarettes Act.
Communications and Issues Management Protocol
1. The Board of Health shall: a. Act as the media focus for the Project; b. Respond to public inquiries, complaints and concerns with respect to the Project; c. Report any potential or foreseeable issues to the CMD of the Ministry of Health and Long-Term Care; d. Prior to issuing any news release or other planned communications, notify the CMD as follows: i. News Releases – identify five (5) business days prior to release and provide materials 2 business days prior to release; ii. Web Designs – 10 business days prior to launch; iii. New Marketing Communications Materials (including, but not limited to, print materials such as pamphlets and posters) – 10 business days prior to production and 20 business days prior to release; iv. Public Relations Plan for Project – 15 business days prior to launch;
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 2 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
v. Digital Marketing Strategy – 10 business days prior to launch; vi. Final advertising creative – 10 business days to final production; and, vii. Recommended media buying plan – 15 business days prior to launch and any media expenditures have been undertaken. e. Advise the CMD prior to embarking on planned public communication strategies, major provider outreach activities and the release of any publications related to the Project; f. Ensure that any new products, and where possible, existing products related to the Project use the Ontario Logo or other Ontario identifier in compliance with the Visual Identity Directive, September 2006; and, g. Despite the time frames set out above for specific types of communications, all public announcements and media communications related to urgent and/or emerging Project issues shall require the Board of Health to provide the CMD with notice of such announcement or communication as soon as possible prior to release.
2. Despite the Notice provision in Article 16 of the Agreement, the Board of Health shall provide any Notice required to be given under this Schedule to the following address:
Ministry of Health & Long-Term Care Communications & Marketing Division Strategic Planning and Integrated Marketing Branch 10th Floor, Hepburn Block, Toronto, ON M7A 1R3 Email: [email protected]
Enhanced Food Safety – Haines Initiative (100%) The Enhanced Food Safety – Haines Initiative was established to augment the Board of Health’s capacity to deliver the Food Safety Program as a result of the provincial government’s response to Justice Haines’ recommendations in his report “Farm to Fork: A Strategy for Meat Safety in Ontario”.
Base funding for this initiative must be used for the sole purpose of implementing the Food Safety Program Standard under the Ontario Public Health Standards. Eligible expenses include such activities as: hiring staff, delivering additional food-handler training courses, providing public education materials, and program evaluation.
Funded projects/activities must be over and above the level of activities underway or planned based on existing mandatory programs base funding.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 3 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
Enhanced Safe Water Initiative (100%) Base funding for this initiative must be used for the sole purpose of increasing the Board of Health’s capacity to meet the requirements of the Safe Water Program Standard under the Ontario Public Health Standards.
Funded projects/activities must be over and above the level of activities underway or planned based on existing mandatory programs base funding.
Harm Reduction Program Enhancement (100%) The scope of work for the Harm Reduction Program Enhancement is divided into three components:
1. Local Opioid Response; 2. Naloxone Distribution and Training; and, 3. Opioid Overdose Early Warning and Surveillance.
Local Opioid Response:
Base funding for this program is intended to support the Board of Health in building sustainable community outreach and response capacity to address drug and opioid-related challenges in their communities. This includes working with a broad base of partners to ensure any local opioid response is coordinated, integrated, and that systems and structures are in place to adapt/enhance service models to meet evolving needs.
Local response plans, which can include harm reduction and education/prevention, initiatives, should contribute to increased access to programs and services, and improved health outcomes (i.e. decrease overdose and overdose deaths, emergency room visits, hospitalizations). With these goals in mind, the Board of Health is expected to:
• Conduct a population health/situational assessment o Identification of opioid-related community challenges and issues, which are informed by local data, community engagement, early warning systems, etc. • Lead/support the development, implementation, and evaluation of a local overdose response plan (or drug strategy) o Any plan or initiative should be based on the needs identified (and/or gaps) in your local assessment. o This may include building community outreach and response capacity, enhanced harm reduction services and/or education/prevention programs and services.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 4 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
• Engage stakeholders o Identify and leverage community partners to support the population health/situational assessment and implementation of local overdose response plans or initiatives. This should include First Nations, Métis and Inuit communities where appropriate. • Adopt and ensure timely data entry into the Ontario Harm Reduction Database o Transition to the Ontario Harm Reduction Database and ensure timely collection and entry of minimum data set as per ministry direction (to be provided).
Naloxone Kit Distribution and Training:
Base funding for this program will establish the Board of Health (or their Designate) as a naloxone distribution lead/hub for eligible community organizations, as specified by the ministry, which will increase dissemination of kits to those most at risk of opioid overdose. To achieve this, the Board of Health is expected to: • Order naloxone o Ordering of naloxone kits as outlined by the ministry; this includes naloxone required by eligible community organizations distributing naloxone. • Coordinate and supervise naloxone inventory o Includes managing supply, storage, maintaining inventory records, and distribution of naloxone to eligible community organizations. o Ensure community organizations distribute naloxone in accordance with eligibility criteria established by the ministry. • With the exception of entities (organizations, individuals, etc.) as specified by the ministry: o Train community organization staff on naloxone administration . Includes the provision of training on how to administer naloxone in cases of opioid overdose, recognizing the signs of overdose and ways to reduce the risk of overdose. Board of Health staff would also instruct agency staff on how to provide training to end-users (people who use drugs, their friends and family). o Train community organization staff on naloxone eligibility criteria . Includes providing advice to agency staff on who is eligible to receive naloxone and the recommended quantity to dispense. o Support policy development at community organizations . Provide consultation on naloxone-related policy and procedures that are being developed or amended within the eligible community organizations. o Promote naloxone availability and engage in community organization outreach . Encourage eligible community organizations to acquire naloxone kits for distribution to their clients.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 5 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
Use of NARCAN® Nasalspray
The Board of Health will be required to submit orders for Narcan to the ministry in order to implement the Harm Reduction Program Enhancement. By receiving Narcan, the Board of Health acknowledges and agrees that:
• Its use of the Narcan is entirely at its own risk. There is no representation, warranty, condition or other promise of any kind, express, implied, statutory or otherwise, given by her Majesty the Queen in Right of Ontario as represented by the Ministry of Health and Long-Term Care, including Ontario Government Pharmaceutical and Medical Supply Service (OGPMSS) in connection with the Narcan. • The ministry takes no responsibility for any unauthorized use of the Narcan by the Board of Health or by its clients. • The Board of Health also agrees: o To not assign or subcontract the distribution, supply or obligation to comply with any of these terms and conditions to any other person or organization without the prior written consent of the ministry. o To comply with the terms and conditions as it relates to the use and administration of Narcan as specified in all applicable federal and provincial laws. o To provide training to persons who will be administering Narcan. The training shall consist of the following: . Opioid overdose prevention; . Signs and symptoms of an opioid overdose; and . The necessary steps to respond to an opioid overdose, including the proper and effective administration of Narcan. o To follow all ministry written instructions relating to the proper use, administration, training and/or distribution of Narcan. o To immediately return any Narcan in its custody or control at the written request of the ministry at the Board of Health’s own cost or expense. o That the ministry does not guarantee supply of Narcan, nor that Narcan will be provided to the Board of Health in a timely manner.
Opioid Overdose Early Warning and Surveillance:
Base funding for this program will support Boards of Health to take a leadership role in establishing systems to identify and track the risks posed by illicit synthetic opioids in their jurisdictions, including the sudden availability of illicit synthetic opioids and resulting opioid
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 6 of 17 SCHEDULE “B”
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Type of Funding Base Source Public Health overdoses. Risk based information about illicit synthetic opioids should be shared in an ongoing manner with community partners to inform their situational awareness and service planning. This includes: • Surveillance systems should include a set of “real-time” qualitative and quantitative indicators and complementary information on local illicit synthetic opioid risk. Partners should include, but are not limited to: emergency departments, first responders (police, fire and ambulance) and harm reduction services. • Early warning systems should include the communication mechanisms and structures required to share information in a timely manner among health system and community partners, including people who use drugs, about changes in the acute, local risk level, to inform action. They should also include reporting to the province through a mechanism currently under development.
Healthy Smiles Ontario Program (100%) The Healthy Smiles Ontario (HSO) Program provides preventive, routine, and emergency and essential dental treatment for children and youth, from low-income families, who are 17 years of age or under.
HSO builds upon and links with existing public health dental infrastructure to provide access to dental services for eligible children and youth.
The HSO Program has the following three (3) streams (age of ≤ 17 years of age and Ontario residency are common eligibility requirements for all streams):
1. Preventive Services Only Stream (HSO-PSO): • Eligibility comprised of clinical need and attestation of financial hardship. • Eligibility assessment and enrolment undertaken by boards of health. • Clinical preventive service delivery in publicly-funded dental clinics and through fee-for- service providers in areas where publicly-funded dental clinics do not exist.
2. Core Stream (HSO-Core): • Eligibility correlates to the level at which a family/youth’s Adjusted Net Family Income (AFNI) is at, or below, the level at which they are/would be eligible for 90% of the Ontario Child Benefit (OCB), OR family/youth is in receipt of benefits through Ontario Works, Ontario Disability Support Program, or Assistance for Children with Severe Disabilities Program.
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RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
• Eligibility assessment undertaken by the Ministry of Finance and Ministry of Community and Social Services; enrolment undertaken by the program administrator, with client support provided by boards of health as needed. • Clinical service delivery takes place in publicly-funded dental clinics and through fee-for- service providers.
3. Emergency and Essential Services Stream (HSO-EESS): • Eligibility comprised of clinical need and attestation of financial hardship. • Eligibility assessment undertaken by boards of health and fee-for-service providers, with enrolment undertaken by the program administrator. • Clinical service delivery takes place in publicly-funded dental clinics and through fee-for- service providers.
Base funding for this program must be used for the ongoing, day-to-day requirements associated with delivering services under the HSO Program to eligible children and youth in low-income families. It is within the purview of the Board of Health to allocate funding from the overall base funding amount across the program expense categories.
HSO Program expense categories include:
• Clinical service delivery costs, which are comprised of: o Salaries, wages, and benefits of full-time, part-time, or contracted staff that provide clinical dental services for HSO; o Salaries, wages, and benefits of full-time, part-time, or contracted staff that undertake the following ancillary/support activities for HSO: management of the clinic(s); financial and programmatic reporting for the clinic(s); and, general administration (i.e., receptionist) at the clinic(s); and, o Overhead costs associated with HSO clinical service delivery services such as: clinical materials and supplies; building occupancy costs; maintenance of clinic infrastructure; staff travel associated with portable and mobile clinics; staff training and professional development associated with clinical staff and ancillary/support staff, if applicable; office equipment, communication, and I & IT. • Oral health navigation costs, which are comprised of: o Salaries, wages, and benefits of full-time, part-time, or contracted staff that are engaged in: . Client enrolment for all streams of the program;
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 8 of 17 SCHEDULE “B”
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Type of Funding Base Source Public Health
. Promotion of the HSO Program (i.e., local level efforts at promoting and advertising the HSO Program to the target population); . Referral to services (i.e., referring HSO clients to fee-for-service providers for service delivery where needed); . Case management of HSO clients; and, . Oral health promotion and education for HSO clients. o Salaries, wages, and benefits of full-time, part-time, or contracted staff that undertake the following ancillary/support activities related to oral health navigation: management, financial and programmatic reporting, and general administration (if applicable). o Overhead costs associated with oral health navigation such as: materials and supplies; building occupancy costs incurred for components of oral health navigation; staff travel associated with oral health navigation, where applicable; staff training and professional development associated with oral health navigation staff and ancillary/support staff, if applicable; office equipment, communication, and I & IT costs associated with oral health navigation.
The Board of Health is responsible for ensuring promotional/marketing activities have a direct and positive impact on meeting the objectives of the HSO Program.
The Board of Health is reminded that HSO promotional/marketing materials approved by the Province and developed provincially are available for use by the Board of Health in promoting the HSO Program.
The overarching HSO brand and provincial marketing materials were developed by the Province to promote consistency of messaging, and “look and feel” across the province. When promoting the HSO Program locally, the Board of Health is requested to align local promotional products with the provincial HSO brand. When the Board of Health uses the HSO brand, it is required to liaise with the ministry’s Communications and Marketing Division (CMD) to ensure use of the brand aligns with provincial standards.
Operational expenses not covered within this program include: staff recruitment incentives, billing incentives, and client transportation. Other expenses not included within this program include other oral health activities required under the Ontario Public Health Standards, including the Oral Health Protocol, 2018.
Other requirements of the HSO Program include:
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 9 of 17 SCHEDULE “B”
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Type of Funding Base Source Public Health
• The Board of Health is required to bill back relevant programs for services provided to non- HSO clients using HSO resources. All revenues collected under the HSO Program, including revenues collected for the provision of services to non-HSO clients such as Ontario Works adults, Ontario Disability Support Program adults, municipal clients, etc., with HSO resources must be reported as income in the Standards Activity Reports, Annual Reports, and Annual Service Plan and Budget Submission. Revenues must be used to offset expenditures of the HSO Program. • For the purposes of reporting and monitoring for the HSO Program, the Board of Health must use the following provincial approved systems or mechanisms, or other as specified by the Province. o Aggregate screening, enrolment, and utilization data for any given month must be submitted by the 15th of the following month to the ministry in the ministry-issued template titled Dental Clinic Services Monthly Reporting Template. o Client-specific clinical data must be recorded in either dental management software (e.g., ClearDent, AbelDent, etc.) or in the template titled HSO Clinic Treatment Workbook that has been issued by the ministry for the purposes of recording such data. • The Board of Health must enter into Service Level Agreements with any partner organization (e.g., Community Health Centre, Aboriginal Health Access Centre, etc.) delivering services as part of the HSO Program. The Service Level Agreement must set out clear performance expectations, clearly state funding and reporting requirements between the Board of Health and local partner, and ensure accountability for public funds. • Any significant change to previously approved HSO business models, including changes to plans, partnerships, or processes, must be approved by the Province before being implemented. • Any contract or subcontract entered into by the Board of Health for the purposes of implementing the HSO Program must be conducted according to relevant municipal procurement guidelines. • The Board of Health is responsible for ensuring value-for-money and accountability for public funds. • The Board of Health must ensure that funds are used to meet the objectives of the HSO Program with a priority to deliver clinical dental services to HSO clients.
Infection Prevention and Control Nurses Initiative (100%) The Infection Prevention and Control Nurses Initiative was established to support additional FTE infection prevention and control nursing services for every board of health in the province.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 10 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
Base funding for this initiative must be used for nursing activities of up to or greater than one (1) FTE related to infection prevention and control activities. Base funding is for nursing salaries and benefits only and cannot be used to support operating or education costs.
Qualifications required for these positions are:
1. A nursing designation (Registered Nurse, Registered Practical Nurse, or Registered Nurse in the Extended Class); and, 2. Certification in Infection Control (CIC), or a commitment to obtaining CIC within three (3) years of beginning of employment.
Infectious Diseases Control Initiative (180 FTEs) (100%) Base funding for this initiative must be used solely for the purpose of hiring infectious diseases control positions and supporting these staff (e.g., recruitment, salaries/benefits, accommodations, program management, supplies and equipment, other directly related costs) to monitor and control infectious diseases, and enhance the Board of Health’s ability to handle and coordinate increased activities related to outbreak management, including providing support to other boards of health during infectious disease outbreaks. Positions eligible for base funding under this initiative include physicians, inspectors, nurses, epidemiologists, and support staff.
The Board of Health is required to remain within both the funding levels and the number of FTE positions approved by the Province.
Staff funded through this initiative are required to be available for redeployment when requested by the Province, to assist other boards of health with managing outbreaks and to increase the system’s surge capacity.
MOH / AMOH Compensation Initiative (100%) The Province committed to provide boards of health with 100% of the additional base funding required to fund eligible MOH and Associate Medical Officer of Health (AMOH) positions within salary ranges initially established as part of the 2008 Physician Services Agreement and continued under subsequent agreements.
Base funding must be used for costs associated with top-up for salaries and benefits, and for applicable stipends to eligible MOH and AMOH positions at the Board of Health and cannot be used to support other physicians or staffing costs. Base funding for this initiative continues to be separate from cost-shared base salaries and benefits.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 11 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
The maximum base allocation approved for the Board of Health includes criteria for potential MOH and AMOH positions such as: additional salary and benefits for 1.0 FTE MOH position and 1.0 FTE or more AMOH positions where applicable, potential placement at the top of the MOH/AMOH Salary Grid, and inclusion of stipends. Some exceptions will apply to these criteria.
The maximum base allocation in Schedule A of the Agreement does not necessarily reflect the cash flow that the Board of Health will receive. Cash flow will continue to be adjusted regularly by the Province based on up-to-date application data and information provided by the Board of Health during a funding year. The Board of Health is required to notify the Province if there is any change in the eligible MOH and/or AMOH(s) base salary, benefits, FTE and/or position status as this may impact the eligibility amount for top-up.
There have been no changes to the MOH/AMOH Salary Grid under this initiative since June 1, 2015. Any future changes to the Salary Grid will be communicated to boards of health pending the status of negotiations related to a new Physician Services Agreement.
Needle Exchange Program Initiative (100%) Base funding for this initiative must be used for the purchase of needles and syringes, and their associated disposal costs, for the Board of Health’s Needle Exchange Program.
Small Drinking Water Systems Program (Cost-Shared) Base funding for this program must be used for salaries, wages and benefits, accommodation costs, transportation and communication costs, and supplies and equipment to support the ongoing assessments and monitoring of small drinking water systems.
Under this program, public health inspectors are required to conduct new and ongoing site- specific risk assessments of all small drinking water systems within the oversight of the Board of Health; ensure system compliance with the regulation governing the small drinking water systems; and, ensure the provision of education and outreach to the owners/operators of the small drinking water systems.
Smoke-Free Ontario Strategy (100%) The government released a plan for Ontario in February 2015 that supports people and patients – providing the education, information and transparency they need to make the right decisions about their health. The plan encourages people of Ontario to take charge and improve their health by making healthier choices, and living a healthy lifestyle by preventing chronic diseases and reducing tobacco use.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 12 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
The plan identifies the Smoke-Free Ontario Strategy as a priority for keeping Ontario healthy. It articulates Ontario’s goal to have the lowest smoking rates in Canada.
The Smoke-Free Ontario Strategy is a multi-level comprehensive tobacco control strategy aiming to eliminate tobacco-related illness and death by: preventing experimentation and escalation of tobacco use among children, youth and young adults; increasing and supporting cessation by motivating and assisting people to quit tobacco use; and, protecting the health of Ontarians by eliminating involuntary exposure to second-hand smoke. These objectives are supported by crosscutting health promotion approaches, capacity building, collaboration, systemic monitoring and evaluation.
The Province provides funding to the Board of Health to implement tobacco control activities that are based in evidence and best practices, contributing to reductions in tobacco use rates.
Base funding for the Smoke-Free Ontario Strategy must be used in the planning and implementation of comprehensive tobacco control activities across prevention, cessation, prosecution, and protection and enforcement at the local and regional levels.
The Board of Health must comply and adhere to the Smoke-Free Ontario Strategy: Public Health Unit Tobacco Control Program Guidelines and the Directives: Enforcement of the Smoke-Free Ontario Act. Operational expenses not covered within this program include information and information technology equipment.
Communications and Issues Management Protocol
1. The Board of Health shall: a. Act as the media focus for the Project; b. Respond to public inquiries, complaints and concerns with respect to the Project; c. Report any potential or foreseeable issues to CMD of the Ministry of Health and Long- Term Care; d. Prior to issuing any news release or other planned communications, notify the CMD as follows: i. News Releases – identify five (5) business days prior to release and provide materials 2 business days prior to release; ii. Web Designs – 10 business days prior to launch; iii. New Marketing Communications Materials (including, but not limited to, print materials such as pamphlets and posters) – 10 business days prior to production and 20 business days prior to release;
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 13 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
iv. Public Relations Plan for Project – 15 business days prior to launch; v. Digital Marketing Strategy – 10 business days prior to launch; vi. Final advertising creative – 10 business days to final production; and, vii. Recommended media buying plan – 15 business days prior to launch and any media expenditures have been undertaken. e. Advise the CMD prior to embarking on planned public communication strategies, major provider outreach activities and the release of any publications related to the Project; f. Ensure that any new products, and where possible, existing products related to the Project use the Ontario Logo or other Ontario identifier in compliance with the Visual Identity Directive, September 2006; and, g. Despite the time frames set out above for specific types of communications, all public announcements and media communications related to urgent and/or emerging Project issues shall require the Board of Health to provide the CMD with notice of such announcement or communication as soon as possible prior to release.
2. Despite the Notice provision in Article 16 of the Agreement, the Board of Health shall provide any Notice required to be given under this Schedule to the following address:
Ministry of Health & Long-Term Care Communications & Marketing Division Strategic Planning and Integrated Marketing Branch 10th Floor, Hepburn Block, Toronto, ON M7A 1R3 Email: [email protected]
Social Determinants of Health Nurses Initiative (100%) Base funding for this initiative must be used solely for the purpose of nursing activities of up to or greater than two (2) FTE public health nurses with specific knowledge and expertise in social determinants of health and health inequities issues, and to provide enhanced supports internally and externally to the Board of Health to address the needs of priority populations impacted most negatively by the social determinants of health.
Base funding for this initiative is for public health nursing salaries and benefits only and cannot be used to support operating or education costs.
As these are public health nursing positions, required qualifications for these positions are:
1. To be a registered nurse; and,
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 14 of 17 SCHEDULE “B”
RELATED PROGRAM POLICIES AND GUIDELINES
Type of Funding Base Source Public Health
2. To have or be committed to obtaining the qualifications of a public health nurse as specified in section 71(3) of the Health Protection and Promotion Act (HPPA) and section 6 of Ontario Regulation 566 under the HPPA.
Vector-Borne Diseases Program (Cost-Shared) Base funding for this program must be used for the ongoing surveillance, public education, prevention and control of all reportable and communicable vector-borne diseases and outbreaks of vector-borne diseases, which include, but are not limited to, West Nile virus and Lyme Disease.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 15 of 17 SCHEDULE “B”
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Type of Funding One-Time Source Public Health
Mandatory Programs: Merger Costs (100%) One-time funding must be used to support the planning and implementation costs associated with the merger of the Boards of Health for the Elgin-St. Thomas and Oxford County Health Units. Eligible costs include communications, legal, accounting, information technology, project management and change management support, human resources, and staff engagement.
Healthy Growth/School Health: School Health Screening Coordination (100%) One-time funding must be used to assist in the integration of school screening programs. Eligible expenses include staffing, travel, and promotional costs.
Healthy Smiles Ontario Program: Dental Equipment and Software (100%) One-time funding must be used to purchase dental equipment, including a new sterilization centre, dental instruments, mobile equipment, oral hygiene aids and instruments, and for an upgrade to the Dentrix software license for the Board of Health’s community dental clinic.
Needle Exchange Program Initiative (100%) One-time funding for extraordinary costs associated with delivering the Needle Exchange Program. Eligible costs include purchase of needles/syringes and associated disposal costs.
Public Health Inspector Practicum Program (100%) One-time funding must be used to hire the approved Public Health Inspector Practicum position(s). Eligible costs include student salaries, wages and benefits, transportation expenses associated with the practicum position, equipment, and educational expenses.
The Board of Health must comply with the requirements of the Canadian Institute of Public Health Inspectors (CIPHI) Board of Certification (BOC) for field training for a 12 week period; and, ensure the availability of a qualified supervisor/mentor to oversee the practicum student’s term.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 16 of 17 SCHEDULE “B”
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Type of Funding Other Source Public Health
Vaccine Programs Funding on a per dose basis will be provided to the Board of Health for the administration of influenza, meningococcal, and human papillomavirus (HPV) vaccines.
In order to claim the vaccine administration fees, the Board of Health is required to submit, as part of the Standards Activity Reports or other reports as requested by the Province, the number of doses administered. Reimbursement by the Province will be made on a quarterly basis based on the information. The Board of Health is required to ensure that the vaccine information submitted on the Standards Activity Reports, or other reports requested by the Province, accurately reflects the vaccines administered and reported on the Vaccine Utilization database.
Influenza The Province will continue to pay $5.00/dose for the administration of the influenza vaccine.
Meningococcal The Province will continue to pay $8.50/dose for the administration of the meningococcal vaccine.
Human Papillomavirus (HPV) The Province will continue to pay $8.50/dose for the administration of the HPV vaccine.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 17 of 17 SCHEDULE “C” REPORTING REQUIREMENTS
The reports mentioned in this Schedule are provided for every Board of Health Funding Year unless specified otherwise by the Province.
The Board of Health is required to provide the following reports/information in accordance with direction provided in writing by the Province (and according to templates provided by the Province):
Name of Report Reporting Period Due Date
March 1 of the current 1. Annual Service Plan and For the entire Board of Board of Health Budget Submission Health Funding Year Funding Year
2. Quarterly Standards Activity Reports
April 30 of the current Board Q1 Standards Activity Report For Q1 of Health Funding Year
July 31 of the current Board Q2 Standards Activity Report For Q2 of Health Funding Year
October 31 of the current Q3 Standards Activity Report For Q3 Board of Health Funding Year
January 31 of the following Q4 Standards Activity Report For Q4 Board of Health Funding Year
April 30 of the following For the entire Board of 3. Annual Report and Attestation Board of Health Funding Health Funding Year Year April 30 of the following For the entire Board of 4. Annual Reconciliation Report Board of Health Funding Health Funding Year Year June 30 of the current 5. MOH/AMOH Compensation For the entire Board of Board of Health Funding Initiative Application Health Funding Year Year
As directed by the 6. Other Reports and Submissions As directed by the Province Province
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 1 of 3 Definitions
For the purposes of this Schedule, the following words shall have the following meanings:
“Q1” means the period commencing on January 1st and ending on the following March 31st.
“Q2” means the period commencing on April 1st and ending on the following June 30th.
“Q3” means the period commencing on July 1st and ending on the following September 30th.
“Q4” means the period commencing on October1st and ending on the following December 31st.
Report Details
Annual Service Plan and Budget Submission • The Board of Health shall provide its Annual Service Plan and Budget Submission by March 1st of the current Board of Health Funding Year. • The Annual Service Plan and Budget Submission Template sets the context for reporting required of the Board of Health to demonstrate its accountability to the Province. • When completed by the Board of Health, it will: describe the complete picture of programs and services the Boards of Health will be delivering within the context of the Ontario Public Health Standards; demonstrate that Board of Health programs and services align with the priorities of its communities, as identified in its population health assessment; demonstrate accountability for planning – ensure the Board of Health is planning to meet all program requirements in accordance with the Ontario Public Health Standards, and ensure there is a link between demonstrated needs and local priorities for program delivery; demonstrate the use of funding per program and service.
Quarterly Standards Activity Reports • The Quarterly Standards Activity Reports will provide financial forecasts and interim information on program achievements for all programs governed under the Accountability Agreement. Through these Standards Activity Reports, the Board of Health will have the opportunity to identify risks, emerging issues, changes in local context, and programmatic and financial adjustments in program plans.
Annual Report and Attestation • The Annual Report and Attestation will provide a year-end summary report on achievements on all programs governed under the Accountability Agreement, in all accountability domains under the Organizational Requirements, and identification of any major changes in planned activities due to local events. The Annual Report will
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 2 of 3 include a narrative report on the delivery of programs and services, fiduciary requirements, good governance and management, public health practice, and other issues, year-end report on indicators, and a board of health attestation on required items.
Annual Reconciliation Report • The Board of Health shall provide to the Province an Annual Reconciliation Report for funding provided for public health programs governed under the Accountability Agreement. • The Annual Reconciliation Report must contain: Audited Financial Statements; Auditor’s Attestation Report in the Province’s prescribed format; and, Annual Reconciliation (Certificate of Settlement) Report Forms.
MOH/AMOH Compensation Initiative • The Board of Health shall complete, sign, and submit an annual application in order to participate in this Initiative and be considered for funding. • Any participating MOH or AMOH shall also complete, sign, and submit a Physician Authorization and Consent Form. • Application form templates and eligibility criteria/guidelines shall be provided by the Province.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 3 of 3 SCHEDULE D
BOARD OF HEALTH FINANCIAL CONTROLS
Financial controls support the integrity of the Board of Health’s financial statements, support the safeguarding of assets, and assist with the prevention and/or detection of significant errors including fraud. Effective financial controls provide reasonable assurance that financial transactions will include the following attributes:
• Completeness – all financial records are captured and included in the Board of Health’s financial reports; • Accuracy – the correct amounts are posted in the correct accounts; • Authorization – the correct levels of authority (i.e., delegation of authority) are in place to approve payments and corrections including data entry and computer access; • Validity – invoices received and paid are for work performed or products received and the transactions properly recorded; • Existence – assets and liabilities and adequate documentation exists to support the item; • Error Handling – errors are identified and corrected by appropriate individuals; • Segregation of Duties – certain functions are kept separate to support the integrity of transactions and the financial statements; and, • Presentation and Disclosure – timely preparation of financial reports in line with the approved accounting method (e.g., Generally Accepted Accounting Principles (GAAP)).
The Board of Health is required to adhere to the principles of financial controls, as detailed above. The Board of Health is required to have financial controls in place to meet the following objectives:
1. Controls are in place to ensure that financial information is accurately and completely collected, recorded, and reported.
Examples of potential controls to support this objective include, but are not limited to: • Documented policies and procedures to provide a sense of the organization’s direction and address its objectives. • Define approval limits to authorize appropriate individuals to perform appropriate activities. • Segregation of duties (e.g., ensure the same person is not responsible for ordering, recording, and paying for purchases). • An authorized chart of accounts. • All accounts reconciled on a regular and timely basis. • Access to accounts is appropriately restricted. • Regular comparison of budgeted versus actual dollar spending and variance analysis. • Exception reports and the timeliness to clear transactions. • Electronic system controls, such as access authorization, valid date range test, dollar value limits, and batch totals, are in place to ensure data integrity.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 1 of 3 • Use of a capital asset ledger. • Delegate appropriate staff with authority to approve journal entries and credits. • Trial balances including all asset accounts that are prepared and reviewed by supervisors on a monthly basis.
2. Controls are in place to ensure that revenue receipts are collected and recorded on a timely basis.
Examples of potential controls to support this objective include, but are not limited to: • Independent review of an aging accounts receivable report to ensure timely clearance of accounts receivable balances. • Separate accounts receivable function from the cash receipts function. • Accounts receivable sub-ledger is reconciled to the general ledger control account on a regular and timely basis. • Original source documents are maintained and secured to support all receipts and expenditures.
3. Controls are in place to ensure that goods and services procurement, payroll and employee expenses are processed correctly and in accordance with applicable policies and directives.
Examples of potential controls to support this objective include, but are not limited to: • Policies are implemented to govern procurement of goods and services and expense reimbursement for employees and board members. • Use appropriate procurement method to acquire goods and services in accordance with applicable policies and directives. • Segregation of duties is used to apply the three (3) way matching process (i.e., matching 1) purchase orders, with 2) packing slips, and with 3) invoices). • Separate roles for setting up a vendor, approving payment, and receiving goods. • Separate roles for approving purchases and approving payment for purchases. • Processes in place to take advantage of offered discounts. • Monitoring of breaking down large dollar purchases into smaller invoices in an attempt to bypass approval limits. • Accounts payable sub-ledger is reconciled to the general ledger control account on a regular and timely basis. • Employee and Board member expenses are approved by appropriate individuals for reimbursement and are supported by itemized receipts. • Original source documents are maintained and secured to support all receipts and expenditures. • Regular monitoring to ensure compliance with applicable directives. • Establish controls to prevent and detect duplicate payments. • Policies are in place to govern the issue and use of credit cards, such as corporate, purchasing or travel cards, to employees and board members. • All credit card expenses are supported by original receipts, reviewed and approved by appropriate individuals in a timely manner. • Separate payroll preparation, disbursement and distribution functions.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 2 of 3 4. Controls are in place in the fund disbursement process to prevent and detect errors, omissions or fraud.
Examples of potential controls include, but are not limited to: • Policy in place to define dollar limit for paying cash versus cheque. • Cheques are sequentially numbered and access is restricted to those with authorization to issue payments. • All cancelled or void cheques are accounted for along with explanation for cancellation. • Process is in place for accruing liabilities. • Stale-dated cheques are followed up on and cleared on a timely basis. • Bank statements and cancelled cheques are reviewed on a regular and timely basis by a person other than the person processing the cheques / payments. • Bank reconciliations occur monthly for all accounts and are independently reviewed by someone other than the person authorized to sign cheques.
Board of Health for the Oxford Elgin St. Thomas Health Unit Page 3 of 3 February 13, 2019 Board of Health Meeting Minutes
A meeting of the Board of Health for Oxford Elgin St. Thomas Health Unit was held on Wednesday, February 13, 2019 at the Woodstock Site location commencing at 4:30 p.m.
PRESENT: Mr. G. Jones Board Member Mr. L. Martin Board Member (Chair) Mr. D. Mayberry Board Member Mr. S. Molnar Board Member Mr. J. Preston Board Member (Vice-Chair) Mr. L. Rowden Board Member Ms. S. Talbot Board Member Ms. C. St. John Chief Executive Officer Dr. J. Lock Medical Officer of Health Ms. T. Terpstra Executive Assistant
GUESTS: Mr. P Heywood Program Director Ms. M. Laprise Director, Finance Ms. S. MacIsaac Program Director Mr. D. McDonald Director, Corporate Services & Human Resources Mr. D. Smith Program Director Ms. C. Walker Program Director Ms. A. Pavletic Program Manager Ms. M. Cornwell Manager, Communications Mr. R. McLay Filion Wakely Thorup Angeletti LLP
REGRETS: Mr. T. Marks Board Member Ms. L. Baldwin-Sands Board Member
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1.1 AGENDA:
Resolution # (2019-BOH-0213-1.2) Moved by S. Talbot Seconded by D.Mayberry
That the agenda for the Southwestern Public Health Board of Health meeting for February 13, 2019 be approved. Carried.
1.3 Reminder to disclose Pecuniary Interest and the General Nature Thereof when Item Arises.
1.4 Reminder that Meetings are Recorded for minute taking purposes.
2.0 APPROVAL OF MINUTES:
Resolution # (2019-BOH-0213-2.1) Moved by S. Talbot Seconded by D. Mayberry
That the minutes from the Southwestern Public Health Board of Health meeting held January 9, 2019 be approved. Carried.
3.0 CONSENT AGENDA:
Resolution # (2019-BOH-0213-3.1) Moved by S. Talbot Seconded by D. Mayberry
That the Board of Health for Southwestern Public Health receive and file consent agenda items 3.1 – 3.7. Carried.
S. Molnar noted that in relation to consent agenda item 3.4 Ontario Basic Income Pilot, it would be appreciated if the Board could review the letters sent on behalf of SWPH. L. Martin noted that the original letter was shared with the previous board.
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4.0 CORRESPONDENCE RECEIVED REQUIRING ACTION:
Resolution # (2019-BOH-0213-4.1) Moved by J. Preston Seconded by D. Mayberry
That the Board of Health for Southwestern Public Health endorse an organizational response to the changes in alcohol policy and request the province to support the development of a provincial alcohol strategy that includes the engagement of local public health units. Carried.
5.0 AGENDA ITEMS FOR INFORMATION.DISCUSSION.DECISION:
Resolution # (2019-BOH-0213-5.1) Moved by D. Mayberry Seconded by J. Preston
That the Board of Health for Southwestern Public Health receive and file the Healthinspect Southwestern Presentation as presented on February 13, 2019.
Carried.
A. Pavletic provided a presentation related to the Healthinspect initiative to the Board of Health. Questions were received and answers were provided.
Resolution # (2019-BOH-0213-5.2) Moved by S. Molnar Seconded by L. Rowden
That the Board of Health for Southwestern Public Health receive and file the Improving the Planning Process report as presented. Carried.
C. Walker noted that she believes Southwestern Public Health has the leading program planning process in the province and noted it was able to be rolled out during the Merger process which is a major accomplishment. Each year the database and process will be reviewed for enhancement including expanding variables and reporting requirements related to the annual service plan. The database was created to minimize duplicate processing to make it more efficient for all information to be located in a central area and to place structure on the work that the health unit does.
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Resolution # (2019-BOH-0213-5.3) Moved by L. Rowden Seconded by S. Molnar
That the Board of Health for Southwestern Public Health accept the Chief Executive Officer’s Report for February 2019. Carried.
Resolution # (2019-BOH-0213-5.4) Moved by J. Preston Seconded by D. Mayberry
That the Board of Health for Southwestern Public Health accept the Finance and Facilities Standing Committee report for February 2019. Carried.
Resolution # (2019-BOH-0213-5.4C) Moved by J. Preston Seconded by L. Rowden
That the Board of Health for Southwestern Public Health accept the Finance & Facilities Standing Committee’s recommendation and approve the 2019 Southwestern Public Health General Programs, Related Services, and 100% Provincially funded budget.
Carried.
J. Preston, Chair of the Committee, thanked the Finance and Facilities Standing Committee and health unit staff for their dedication in bringing this budget together.
J. Preston noted while it is helpful during the budget review process to have a budget from a previous year to compare to, the committee understands that due to Southwestern Public Health becoming a new entity as of May 1, 2018 it is difficult to provide comparable numbers as both agencies budgeted differently.
J. Preston noted that C. St. John provided all the information possible and answered any questions the Finance and Facilities Standing Committee had in relation to the various programs and budgets.
J. Preston noted that the increase in levy was an area of contention and was unexpected. J. Preston noted however, that the Finance and Facilities Standing Committee is recommending approval of the budget as presented. Carried
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Resolution # (2019-BOH-0213-5.4B) Moved by J. Preston Seconded by D. Mayberry
That the Board of Health for Southwestern Public Health approve that the Board Chair sign the Engagement letter and Audit Planning Letter received from Graham Scott Enns as presented, in preparation for the upcoming 2018 financial audit.
Carried. J. Preston noted that the Finance and Facilities Standing Committee received the 2018 engagement letter and audit planning letter from Graham Scott Enns. The committee has reviewed the letters which are standard requirements for an annual audit. The Committee recommended that the Chair sign the letters on behalf of the Board.
6.0 TO CLOSED SESSION:
Resolution # (2019-BOH-0213-C6.0) Moved by S. Molnar Seconded by L. Rowden
That the Board of Health moves to closed session in order to consider one or more the following as outlined in the Ontario Municipal Act: (a) the security of the property of the municipality or local board; (b) personal matters about an identifiable individual, including municipal or local board employees; (c) a proposed or pending acquisition or disposition of land by the municipality or local board; (d) labour relations or employee negotiations; (e) litigation or potential litigation, including matters before administrative tribunals, affecting the municipality or local board; (f) advice that is subject to solicitor-client privilege, including communications necessary for that purpose; (g) a matter in respect of which a council, board, committee or other body may hold a closed meeting under another Act; (h) information explicitly supplied in confidence to the municipality or local board by Canada, a province or territory or a Crown agency of any of them; (i) a trade secret or scientific, technical, commercial, financial or labour relations information, supplied in confidence to the municipality or local board, which, if disclosed, could reasonably be expected to prejudice significantly the competitive position or interfere significantly with the contractual or other negotiations of a person, group of persons, or organization; (j) a trade secret or scientific, technical, commercial or financial information that belongs to the municipality or local board and has monetary value or potential monetary value; or (k) a position, plan, procedure, criteria or instruction to be applied to any negotiations carried on or to be carried on by or on behalf of the municipality or local board. 2001, c. 25, s. 239 (2); 2017, c. 10, Sched. 1, s. 26.
Other Criteria: (a) a request under the Municipal Freedom of Information and Protection of Privacy Act, if the council, board, commission or other body is the head of an institution for the purposes of that Act; or (b) an ongoing investigation respecting the municipality, a local board or a municipally-controlled corporation by the Ombudsman appointed under the Ombudsman Act, an Ombudsman referred to in
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subsection 223.13 (1) of this Act, or the investigator referred to in subsection 239.2 (1). 2014, c. 13, Sched. 9, s. 22. Carried.
7.0 RISING AND REPORTING OF CLOSED SESSION:
Resolution # (2019-BOH-0213-C7) Moved by L. Rowden Seconded by S. Molnar
That the Board of Health rise with a report. Carried.
Resolution # (2019-BOH-0213-C1.2) Moved by G. Jones Seconded by S. Molnar
That the Board of Health for Southwestern Public Health accept the Chief Executive Officer’s report for February 13, 2019 as presented. Carried.
Resolution # (2019-BOH-0213-C1.3) Moved by S. Molnar Seconded by G. Jones
That the Board of Health for Southwestern Public Health accept the Labour Relations Update report for February 13, 2019 as presented. Carried.
8.0 FUTURE MEETINGS & EVENTS
9.0 ADJOURNMENT:
Resolution # (2019-BOH-0213-9) Moved by G. Jones Seconded by S. Molnar
That the meeting adjourns at 6:07 p.m. Carried.
Confirmed:
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4.1
February 6, 2019
The Honourable Doug Ford Premier of Ontario Legislative Building Queens’s Park Toronto, ON M7A 1A1
Dear Premier Ford:
Re: Support of a Provincial Oral Health Program for Seniors
The Board of Health for the Simcoe Muskoka District Health Unit (Board) is encouraged by the new provincial government’s support for a provincial oral health program for low-income seniors. The financial, health and social impacts of poor oral health in seniors has been a long standing area of concern for our Board.
In 2016, our Board sent a letter to the Minister of Health calling on the Provincial Government to expand access to publically funded dental care for all low income adults, including low income seniors and all institutionalized seniors. The letter cited how access to prevention and dental treatment would reduce oral health inequities in Ontario that profoundly impact some of the most vulnerable people in our local jurisdiction and the Province as a whole.
As an indication of this need, in 2017 there were 4,069 visits to emergency departments within hospitals in Simcoe and Muskoka for oral health reasons. This figure remains highly troubling. It shows that a large number of our residents lack access to preventive and restorative oral health care, and therefore, need to resort to emergency departments for their dental needs. Unfortunately, these visits further burden an already overwhelmed hospital system and ultimately fail to address the underlying oral health problems causing pain and infection.
The Ontario Progressive Conservative Party has pledged to implement a publically funded dental care program for low income seniors. As well, they have committed to increase dental services through Public Health Units, Community Health Centres, and Aboriginal Health Access Centres and to increase funding to provide investment for service delivery in underserviced areas. Our Board sees firsthand the positive impact that our Healthy Smiles Dental Clinics have on the clients and communities we serve. In 2018, we completed approximately 4,300 appointments for eligible clients in our clinics and over 900 preventive appointments for Healthy Smiles Ontario children in schools. We support increasing clinical capacity, including in Public Health Units, in order to address the severe need among low income seniors. We await further news concerning public health’s role in reducing barriers to oral health, increasing service delivery for low income seniors and improving health system efficiency.
Sincerely,
ORIGINAL Signed By:
Anita Dubeau Chair, Board of Health
AD:HM:cm
Cc. Honorable Christine Elliot, Minister of Health and Long-Term Care Dr. David Williams, Chief Medical Officer of Health Members of Provincial Parliament for Simcoe and Muskoka Ontario Boards of Health Ms. Loretta Ryan, Association of Local Public Health Agencies Ms. Jacquie Maund and Ms. Anna Rusak, Ontario Oral Health Alliance Mayors and Councils in Simcoe Muskoka Central Local Health Integration Network North Simcoe Muskoka Local Health Integration Network
4.2 Jackson Square, 185 King Street, Peterborough, ON K9J 2R8 P: 705-743-1000 or 1-877-743-0101 F: 705-743-2897 peterboroughpublichealth.ca
Serving the residents of Curve Lake and Hiawatha First Nations, and the County and City of Peterborough Serving the residents of Curve Lake and Hiawatha First Nations, and the County and City of Peterborough
St. Thomas Site Woodstock Site Administrative Office 410 Buller Street 1230 Talbot Street Woodstock, ON St. Thomas, ON N4S 4N2 N5P 1G9
October 24, 2018
The Honourable Doug Ford Premier of Ontario Legislative Building, Queen’s Park Toronto, ON M7A 1A1
Dear Honourable Doug Ford,
On behalf of the Southwestern Public Health Board, I am writing to both our provincial and federal government leaders to reinforce the urgency of the opioid poisoning emergency in our country and urge both the provincial and federal governments to increase actions in response to this emergency based on the evidenced-informed four pillar approach of harm reduction, prevention, treatment and enforcement.
There is an expanding opioid crisis in Canada that is resulting in epidemic-like numbers of overdose deaths. These deaths are the result of an interaction between prescribed, diverted and illegal opioids (such as fentanyl) and the recent entry into the illegal drug market of newer, more powerful synthetic opioids. The current approaches to managing this situation – focused on changing prescribing practices and interrupting the flow of drugs – have failed to reduce the death toll and should be supplemented with an enhanced and comprehensive public health approach. Such an approach would include the meaningful involvement of people with lived experience. 1
We call on both levels of government to support initiatives that address the causes and determinants of problematic substance use, to make all tools and resources available to support efforts to address the opioid crisis at a community level, to expand and strengthen the integration of surveillance information between provincial and federal partners, to expedite approvals for newer therapeutic modalities for medication assisted and opioid substitution treatment, to provide funding to municipalities and regional health services to establish safe consumption facilities, and to support harm reduction and health promotion services needed to mitigate the opioid crisis at a regional level.
Injection drug use is associated with many serious drug-related harms, such as the transmission of blood borne infections (HIV, Hepatitis C, Hepatitis B), and with fatal and non-fatal overdoses and injection site bacterial infections. In some parts of the world, these harms are widespread among people who inject drugs. Access to interventions such as needle and syringe exchange, opioid substitution therapies, naloxone distribution, sharps management strategies, overdose prevention sites, and supervised consumption sites are essential to reducing these harms and improving the health of the people who use drugs.2
www.swpublichealth.ca October 24, 2018 Page 2
We are urging both our federal and provincial Ministers of Health to continue their efforts to address this crisis in our country with a coordinated pan-Canadian action plan spanning all four pillars of the national drug strategy.
Sincerely,
______Bernie Wiehle Chair, Board of Health Southwestern Public Health
copy:
Honourable Justin Trudeau, Prime Minister of Canada Honourable Ginette Petitpas Taylor, Federal Minister of Health Honourable Christine Elliott, Minister of Health and Long-Term Care, Deputy Premier Honourable Jeff Yurek, Member of Provincial Parliament, Elgin – Middlesex – London Honourable Ernie Hardeman, Member of Provincial Parliament, Oxford Association of Local Public Health Agencies Ontario Boards of Health
1 https://www.cpha.ca/opioid-crisis-canada 2 Harm reduction international www.hri.global/public-health-approaches-to-drug-related-harms
2 / 2 4.3
4.4
4.5
February 11, 2019
Hon. Christine Elliott, Deputy Premier Minister, Ministry of Health and Long-Term Care 80 Grosvenor St., Hepburn Block, 10th Floor Toronto, ON M7A 1E9 [email protected]
Hon. Lisa Thompson, Minister Ministry of Education 900 Bay St., Mowat Block, 22nd Floor Toronto, ON M7A 1L2 [email protected]
Dear Ministers Elliott and Thompson:
Mandatory Food Literacy Curricula in Ontario Schools
On behalf of the Windsor-Essex County Health Unit, we would like to express our support for the Kingston, Frontenac, Lennox & Addington Board of Health’s call to examine the current school curricula concerning food literacy, and the introduction of food literacy and food skills as a mandatory component of school curricula.
Food literacy and food skills are the foundation for healthy eating, encompassing factors including food and nutrition knowledge, and the skills necessary to prepare healthy and affordable meals. In Canada, food literacy has been in decline over the past few decades affecting all segments of society. The lack of essential food literacy skills coupled with changes in the food environment and increased practices in marketing of unhealthy food and beverages have made it a challenge for Ontarians to practice healthy eating habits. It has led to an increase of pre- prepared, packaged and convenience foods higher in fat, salt and sugar; and foods linked to a greater risk of diet- related chronic diseases.
The school setting is an opportunity to support students with knowledge and food skills that will equip them to make healthy decisions in a complex food environment. While, the current system makes food literacy curriculum available to students in high school, it is estimated that only one-third of Ontario students who entered Grade 9 from the 2005/06 to 2009/10 school years earned one or more credits in a course that included a food literacy component during their secondary school education. Food literacy needs to be part of the mainstream school curriculum, incorporated in a cross-curricular approach starting at the elementary school level. This approach would ensure that healthy eating concepts are consistently taught, reinforced, and reflected as students move through the school years.
As the Ministry of Education engages in a consultation regarding the education system in Ontario, our Board of Health strongly urges that mandatory food literacy and food skills training be included in the school curricula.
The Windsor-Essex County Health Unit thanks you for your consideration.
Sincerely,
Gary McNamara Theresa Marentette, RN, MSc Chair, WECHU Board of Health Chief Executive Officer, Chief Nursing Officer https://www.wechu.org/board-meetings/september-2018-board-meeting
Encl. KFL&A Public Health – Letter to Hon. Indira Naidoo-Harris – April 2018 c: Ontario Boards of Health Windsor-Essex Board of Health Lisa Gretzky, MPP Windsor-West Percy Hatfield, MPP Windsor-Tecumseh Taras Natyshak, MPP Essex Rick Nicholls, MPP Chatham-Kent-Essex WEC local school boards Dr. David Williams, Chief Medical Officer of Health Association of Local Public Health Agencies (alPHa) Association of Municipalities of Ontario (AMO) Ophea and ODPH
4.6
February 11, 2019
The Honorable Lisa MacLeod, Minister Ministry of Children, Community and Social Services 56 Wellesley Street West, 14th Floor Toronto, ON M7A 1E9
Dear Minister MacLeod:
Funding for the Healthy Babies, Healthy Children (HBHC) program
On behalf of our Board of Health, I am writing to you in support of Thunder Bay District Health Unit’s call to action and shared concern regarding the Healthy Babies, Healthy Children (HBHC) program funding.
As noted in Thunder Bay District Health Unit’s call to action, the HBHC program is a prevention/early intervention initiative designed to ensure that all Ontario families with children (prenatal to age six) who are at risk of physical, cognitive, communicative, and/or psychosocial problems have access to effective, consistent, early intervention services and is a mandatory program for Boards of Health.
The Windsor Essex County Health Unit has seen an increase in the complexity of the clients in the HBHC program. As evidenced by the 2018 Response to Screening and Working With Families With Complex Needs survey that was completed by all 35 public health units, the HBHC program is seeing an increase in the complex needs of the clients across the province. This survey highlights the need for the potential changes to the model. However, the Ministry has indicated that there is no funding available for the implementation of these changes to the HBHC program in the 2019 fiscal year. Over the last several years, our local School Boards have expressed concerns over the number of children who are experiencing challenges at school entry. The inability to change the current model will continue to affect the percentage of children who achieve optimal growth and development and readiness for school.
The province did indeed commit to funding the HBHC program at 100%. However, since 2008, the HBHC program has not seen any increases in the budget except for the one-time funding in 2012 to support the implementation of the 2012 protocol, and an increase in our FTE to support the Liaison role.
Furthermore, as noted in Thunder Bay District Health Unit’s call to action, the review of the HBHC program in 2016 by MNP found a funding gap of approximately $7.808m (Ministry of Children and Youth Services - Healthy Babies Healthy Children Program Review Executive Summary p.7). Notably, this gap continues to grow every year with the increases in salaries, benefits, and operational costs.
On behalf of the Windsor-Essex County Health Unit, we thank you for your consideration.
Sincerely,
Gary McNamara Theresa Marentette, RN, MSc Chair, Board of Health Chief Executive Officer, Chief Nursing Officer https://www.wechu.org/board-meetings/january-2019-board-meeting c: Association of Local Public Health Agencies (alPHa) Association of Municipalities of Ontario (AMO) Ontario Boards of Health Windsor-Essex MPPs Windsor-Essex Board of Health
November 21, 2018
SENT VIA EMAIL
The Honourable Lisa MacLeod Minister of Children, Community and Social Services 14th Flr, 56 Wellesley St W, Toronto, ON M7A 1E9
Dear Minister MacLeod, On behalf the Thunder Bay District Health Unit (TBDHU) Board of Health, it is with significant concern that I am writing to you regarding funding for the Healthy Babies, Healthy Children (HBHC) Program.
The Healthy Babies Healthy Children (HBHC) program is a prevention/early intervention initiative designed to ensure that all Ontario families with children (prenatal to age six) who are at risk of physical, cognitive, communicative, and/or psychosocial problems have access to effective, consistent, early intervention services and is a mandatory program for Boards of Health.
In 1997 the province committed to funding the Healthy Babies Healthy Children program at 100%. Province wide funding allocations have been essentially “flat- lined” from an original allocation that was completed in 2008, with the exception of the one-time funding increases for implementation of the 2012 Protocol. In the interim, collective agreement settlements, travel costs, pay increments and accommodation costs have increased the costs of implementing the HBHC program. Management and administration costs related to the program are already offset by the cost-shared budget for provincially mandated programs.
Simultaneously the complexity of clients accessing the program has increased requiring that more of the services be delivered by professional versus non- professional staff. The TBDHU has made every effort to mitigate the outcome of this ongoing funding shortfall however it has become increasingly more challenging to meet the targets set out in HBHC service agreements. At the current funding level services for these high-risk families will be reduced.
In 2016 the firm MNP performed a review of the HBHC program provincially and found that “based on the activities of the current service delivery model, and using the targets outlined in the service agreements … there is a gap in the current funding of the program of approximately $7.808M.” (Ministry of Children and Youth Services - Healthy Babies Healthy Children Program Review Executive Summary p.7) The Thunder Bay District Board of Health continues to advocate that the Ministry of Children, Community and Social Services fully funds the Healthy Babies Healthy Children program, including all staffing, operating and administrative costs.
…/2 Minister McLeod Page 2 November 21, 2018
Thank you for your attention to this important public health issue.
Sincerely,
Original Signed by
Joe Virdiramo, Chair Board of Health Thunder Bay District Health Unit cc. Michael Gravelle, MPP (Thunder Bay-Superior North) Judith Monteith-Farrell, MPP (Thunder Bay-Atitkokan) All Ontario Boards of Health
4.7
February 11, 2019
The Honorable Doug Ford Premier of Ontario [email protected]
The Honorable Lisa MacLeod Minister of Children, Community and Social Services [email protected]
Dear Premier Ford and Minster Macleod:
Ontario’s Basic Income Pilot
On behalf of our Board of Health, I am writing to you in support of Thunder Bay District Health Unit’s concern and call to action to reconsider the termination of the Ontario’s Basic Income Pilot and reduction of scheduled increases to the Ontario Works and Ontario Disability Support Programs (3% to 1.5%).
The Windsor-Essex County Board of Health has previously written the government expressing its support for the Basic Income Pilot as an evidence-based program to improve quality of life for the most vulnerable Ontarians.
The Windsor-Essex County Health Unit agrees that addressing issues of poverty is a public health priority, and a health equity and human rights issue. Individuals, or households, with lower incomes experience higher levels of food insecurity and suffer from higher mortality from chronic diseases, including mental illness. In Windsor approximately 33% of children under 18, or 1 in 3, live in poverty. Providing a basic income assists in ensuring their basic needs are met, including proper nutrition, and allowing children to grow healthy and reach their full potential.
The Windsor-Essex County Health Unit thanks you for your consideration.
Sincerely,
Gary McNamara Theresa Marentette, RN, MCs Chair, Board of Health Chief Executive Officer, Chief Nursing Officer https://www.wechu.org/board-meetings/january-2019-board-meeting
Encl. c: Association of Local Public Health Agencies (alPHa) Association of Municipalities of Ontario (AMO) Ontario Boards of Health Windsor-Essex MPPs Windsor-Essex Board of Health November 21, 2018
Hon. Doug Ford Premier of Ontario [email protected]
Hon. Lisa Macleod Minister of Children, Community and Social Services [email protected]
Dear Premier Ford and Minister Macleod,
As chair of the board of health for the Thunder Bay District Health Unit, I am writing to convey my concern at the termination of Ontario’s Basic Income Pilot and reduction of the scheduled increase to Ontario Works and Ontario Disability Support Program from 3% to 1.5%, and urge you to reconsider your decision.
The government’s current decision is a retraction of the pre-election indications to continue the project, and will place more than 4000 pilot participants in very challenging socio-economical circumstances. The pilot was provincially and nationally recognized as a pivotal opportunity to study the impact of basic income on societal, economical and health outcomes in Ontario. Significant resources have already been invested in the planning and implementation of the project; to terminate the project at this inopportune time would be wasteful especially without gathering insight from its outcomes.
The Thunder Bay District Health Unit believes that addressing issues of poverty is a public health priority, and a healthy equity and human rights issue. There is considerable research to show that individuals or households with lower income experience higher levels of food insecurity, which is linked to higher levels of adverse health and societal outcomes, compared to those with higher incomes1. This includes morbidity and/or Premier Ford and Minister MacLeod Page 2 of 5 November 21, 2018 mortality from chronic diseases (i.e. obesity, diabetes), mental illness (i.e. depression, anxiety, and reduced learning and productivity), infant mortality, infectious diseases, amongst others1. In 2014, 11.9% or 594,900 Ontario households experienced food insecurity2, which is defined as the inadequate or insecure access to food due to financial constraints1. This statistic is acknowledged as an underestimate as it does not reflect households in First Nations reserves and those that are homeless2. Furthermore, 64% of Ontario households reliant on social assistance were food insecure2. In some cases, employment does not guarantee that a households’ basic needs are met, as almost 60% of food insecure Ontario households were relying on income from wages and salaries2. As a result, the estimated burden on healthcare costs from socio-economic health inequalities amounts to a staggering $6.2 billion annually, with Canadians in the lowest income bracket accounting for approximately 60% of these costs3. The fact is, health is related to food security, which is deeply rooted in poverty. It’s not just about having inadequate skills or nutrition knowledge to prepare healthy food, or that the distance to supermarkets is too far – the main reason is the lack of adequate disposable income for food2.
The allocation of Thunder Bay as a designated pilot site of the Ontario Basic Income Pilot was an exciting opportunity to explore the impact of basic income in our community and to gather local level data. Poverty and food insecurity pose a risk for certain individuals in our District. Most recent data from Statistics Canada indicates that 13.8% of all households in the District of Thunder Bay are considered low- income, of which 19.8% are children aged 0 – 174. This represents approximately 1 in 7 households being food insecure. As an example of how the basic income pilot positively impacts food security, I will use the most recent information from our local Nutritious Food Basket (2018; Appendix 1). The monthly cost of food for a family of four in the District of Thunder Bay is $828.68 per month. If the family relies on Ontario Works, the income remaining for other living expenses is limited and increases risk for financial strain, whereas the same family enrolled in the basic income pilot would be in a much better position to meet their basic needs. Furthermore, the on-going effectiveness of the Guaranteed Income Supplement for Premier Ford and Minister MacLeod Page 3 of 5 November 21, 2018 seniors provides evidence of how overall health is improved from ensuring financial security5,6. As an advocate for promoting socio-economic and health equity within my community, I am supportive of the Ontario Basic Income Pilot and increased social assistance rates as it is based on evidence informed research indicating the strong relationship between income, food security and health.
I strongly urge the province to maintain the continuation of the Ontario Basic Income Pilot and the scheduled increases of Ontario Works and Ontario Disability Support Program. The need for adequate income from basic income and social assistance rates provides socio-economic stability and equity, and is highlighted in the report: “Income Security – A Roadmap for Change”7.
Ontario has the opportunity to champion an initiative that could have a profound impact on informing future policies that could expand to the international level. But more importantly, it could provide the residents of Thunder Bay and Ontario with improved livelihood, healthy equity, and the opportunity to live with dignity.
Yours Sincerely,
Original Signed by
Joe Virdiramo, Chair, Board of Health for Thunder Bay District Health Unit cc. Michael Gravelle, MPP (Thunder Bay-Superior North) Judith Monteith-Farrell, MPP (Thunder Bay-Atikokan) All Ontario Boards of Health
References: 1. PROOF Food Insecurity Policy Research. (2017). Household Food Insecurity in Canada: Factsheets. Accessed at: http://proof.utoronto.ca/resources/fact-sheets/ 2. PROOF Food Insecurity Policy Research. (2016). Household Food Insecurity in Canada – Research to identify policy options to reduce food insecurity. Accessed at: http://proof.utoronto.ca/resources/proof- annual-reports/annual-report-2014/ Premier Ford and Minister MacLeod Page 4 of 5 November 21, 2018
3. Public Health Agency of Canada. (2016) The direct economic burden of socioeconomic health inequalities in Canada: an analysis of health care costs by income level. Accessed at: http://vibrantcanada.ca/files/the_direct_economic_burden_-_feb_2016_16_0.pdf. 4. Statistics Canada. (2016). Census Profile, 2016 Census (Income). Accessed at: https://www12.statcan.gc.ca/census-recensement/2016/dp- pd/prof/details/page.cfm?Lang=E&Geo1=CD&Code1=3558&Geo2=PR&Code2=35&Data=Count&Search Text=thunder%20bay&SearchType=Begins&SearchPR=01&B1=Income&TABID=1 5. Government of Canada. (2016). Canada’s most vulnerable single seniors will see an increase of up to $947 annually to the Guaranteed Income Supplement. Accessed at: https://www.canada.ca/en/employment-social-development/news/2016/06/canada-s-most-vulnerable- single-seniors-will-see-an-increase-of-up-to-947-annually-to-the-guaranteed-income-supplement.html 6. Mcintyre, L, Kwok, C, Herbert-Emery, J.C, Dutton, D.J. (2016). Impact of a guaranteed annual income program on Canadian senior’s physical mental and functional health. Can J Public Health;107(2):e176- e182 7. Income Security Reform Working Group, First Nations Income Security Reform Working Group, Urban Indigenous Table on Income Security Reform. (2017). Income Security – A Roadmap for Change. Accessed at: https://files.ontario.ca/income_security_-_a_roadmap_for_change-english-accessible_0.pdf Premier Ford and Minister MacLeod Page 5 of 5 November 21, 2018
Appendix 1 - Comparison of Household Income and Expenses for Families (2018) Low-income households often live in rental housing. Using the average costs of renting in the District of Thunder Bay for 2018, and the results from the NFBS, here are five family scenarios outlining their respective monthly costs of living.
Family of 4 Family of 4 Family of 4 Family of 4 Family of 3 Ontario Basic Full-Time Minimum Median Income Ontario Works Ontario Works Income Pilot Wage (After Tax) (2 parents; 2 (1 parent; 2 Scenarios (2 parents; 2 (2 parents; 2 (2 parents; 2 children) children) children) children) children) Monthly i $2601.00 $3353.00 $3622.00 $7871.00 $2382.00 Income $1194.00 $1194.00 $1194.00 $1194.00 $959.00 Rentii (3 Bdr. Apartment) (3 Bdr. Apartment) (3 Bdr. Apartment) (3 Bdr. Apartment) (2 Bdr. Apartment) Cost of $828.68 $828.68 $828.68 $828.68 $595.84 Foodiii Income Remaining for Other $578.32 $1330.32 $1599.32 $5848.32 $827.16 Living Expenses i. Incomes (except those including the Ontario Basic Income Pilot) derived from NFBS Income Scenario Spreadsheet (May 2018), developed by the Ontario Dietitians in Public Health - Locally Driven Collaborative Project Food Insecurity Working Group ii. Rental cost calculations are from the Rental Market Report – Canada Mortgage and Housing Cooperation (June 2017) iii. Based on the NFBS for the District of Thunder Bay (May 2018)
4.8
February 11, 2019
The Honorable Caroline Mulroney Ministry of the Attorney General McMurtry-Scott Building, 720 Bay Street Toronto, ON M7A 2S9 [email protected]
Dear Minister Mulroney:
Smoke-Free Ontario Act, 2017 and Cannabis legislation
On behalf of our board of health, I am writing you in support of Peterborough Public Health’s (PPH) call to action and shared concern regarding funding associated with the cannabis legislation and the introduction of the Smoke- Free Ontario Act 2017.
The Windsor-Essex County Health Unit (WECHU) applauds the ministry on the modernization of smoking regulations in Ontario and welcomes the additional restrictions outlined in the new legislation due to their alignment with local and regional goals related to reducing places of use for harmful products. The consequences however, of the inclusion of electronic cigarette-use and the smoking of cannabis as prohibited products in prescribed places involve the added responsibility of public health tobacco enforcement officers in enforcing these regulations. In addition, the transfer of responsibility from the province to local public health units related to the oversight of tobacconist and specialty vape store authorizations represents an additional burden on administrative and enforcement resources.
Although boards of health were permitted to submit for reimbursement of costs incurred due to the legalization of cannabis, through a one-time grant application process in which the Windsor-Essex County Health Unit requested $197, 392 , there are concerns about the ability to ensure effective enforcement and oversight over the long-term without sustained resources dedicated to enforcement, administration, and public education. To date, no such resources have been received by the Windsor-Essex County Health Unit and there is no guarantee that resources allocated to municipalities to assist with the costs associated with cannabis legalization will be redistributed to public health agencies.
With the introduction of a sustained and dedicated funding model to account for the additional responsibilities introduced through the Smoke-free Ontario Act 2017, as well as those associated with cannabis legalization, public health units across Ontario will be able to efficiently and effectively enforce and provide oversight over these new requirements. Without these supplementary resources, WECHU has significant and legitimate concerns related to its ability to maintain existing programming when these new requirements are taken into account.
The Windsor-Essex County Health Unit thanks you for your consideration.
Sincerely,
Gary McNamara Theresa Marentette, RN, MSc Chair, Board of Health Chief Executive Officer, Chief Nursing Officer https://www.wechu.org/board-meetings/january-2019-board-meeting
Encl. Peterborough Public Health – Letter to Hon. Caroline Mulroney – Nov 2018 c: The Hon. Doug Ford, Premier of Ontario The Hon. Christine Elliott, Minister of Health and Long-Term Care, Deputy Premier Association of Local Public Health Agencies (alPHa) Association of Municipalities of Ontario (AMO) Ontario Boards of Health Local Municipal Councils Windsor-Essex MPPs Windsor-Essex Board of Health
4.9
February 11, 2019
Hon. Ginette Petitpas Taylor Minister of Health, Canada House of Commons Ottawa, On K1A 0A6
Dear Minister Petitpas Taylor:
Petition for an adequately-funded national cost-shared universal healthy school food program
On behalf of the Windsor-Essex County Health Unit, we are writing to express our support for Toronto’s Board of Health and Senator Art Eggleton’s call for a federal universal health school program, passed at WECHU’s September 2018 Board of Health meeting.
Student nutrition programs (SNPs) are community-based meal and snack programs that operate primarily in schools. School food programs are increasingly seen as vital contributors to students’ physical and mental health, and academic achievement. A growing body of research demonstrates the potential of school food programs to improve food choices, prevent disease, and support academic success (including academic performance, reduced tardiness, and improved student behaviour) for all students.
In Windsor and Essex County, SNPs have been a driving force in ensuring children have access to healthy food and beverages throughout the school day. This is especially important because our region has low rates of vegetables and fruit consumption in children.
In Ontario, SNPs are run locally by students, parents and volunteers, and are funded through multiple sources including provincial funding, local community groups and organizations, grants, and local fundraising. For most programs, the current funding available does not cover the full cost to run the programs at full capacity. As well, many schools lack the infrastructure to support cooking healthy meals.
To deal with these funding shortfalls, programs resort to a variety of methods including reducing the number of meals served, offering fewer servings with smaller portions, relying on ready-made food more often, or decreasing the quality of food offered. These can significantly undermine the potential positive health effects that SNPs can have on Canadian children.
Given the documented benefits of SNPs, we urge the federal government to support an adequately-funded national cost-shared universal healthy school food program. Sustained federal investment, as proposed by Senate Motion no. 358, would leverage local efforts and allow SNPs to expand their impact and improve children’s health and educational outcomes, while lowering future healthcare costs.
The Windsor-Essex County Health Unit thanks you for your consideration.
Sincerely,
Gary McNamara Theresa Marentette, RN, MSc Chair, Board of Health Chief Executive Officer, Chief Nursing Officer http://app.toronto.ca/tmmis/viewAgendaItemHistory.do?item=2018.HL28.5 https://www.wechu.org/board-meetings/september-2018-board-meeting c: Cheryl Hardcastle, MP Windsor-Tecumseh Brian Masse, MP Windsor West Tracey Ramsey, MP Essex Dave Van Kesteren, MP Chatham Kent-Leamington Hon. Christine Elliott, Deputy Premier, Ontario Minister of Health and Long-Term Care Ontario Boards of Health Windsor-Essex County Board of Health Association of Public Health Agencies (alPHa) Association of Municipalities of Ontario (AMO) Federation of Canadian Municipalities Ontario Student Nutrition Program, Windsor-Essex Region WEC local school boards HL3.024.10 REPORT FOR ACTION
Expanding Opioid Substitution Treatment with Managed Opioid Programs
Date: February 12, 2019 To: Board of Health From: Medical Officer of Health Wards: All
SUMMARY
The opioid poisoning crisis continues unabated in Toronto in large part due to the illicit drug supply, which has become increasingly toxic with fentanyls and other potent drugs. There is a critical need to expand treatment options to include managed opioid programs. This strategy is part of the response to the overdose crisis in British Columbia and Alberta, and is urgently needed in Toronto and elsewhere in Ontario.
Methadone and SuboxoneTM are the most commonly offered opioid substitution treatments. These need to be expanded to include managed opioid programs which provide patients with oral or injectable hydromorphone or diacetylmorphine (pharmaceutical heroin) under medical supervision. Managed opioid programs are evidence-based programs that have been shown to increase retention in treatment, reduce the use of street drugs, and decrease crime.
The Province of Ontario recently announced a $102 million funding agreement with the federal government for drug treatment. In the context of the current opioid poisoning crisis, the Ministry of Health and Long-Term Care should target some of this funding to rapidly scale up implementation of managed opioid programs in Toronto and elsewhere in Ontario to help save lives, and improve health outcomes for people who use drugs.
RECOMMENDATIONS
The Medical Officer of Health recommends that:
1. The Board of Health urge the Ministry of Health and Long-Term Care to:
a. Immediately target operational and capital funding to support rapid scaled up implementation of managed opioid programs (including low barrier models) in Toronto and elsewhere in Ontario given the urgency of the opioid poisoning crisis.
b. Take immediate action to ensure the required concentrations of managed opioid medications (i.e. 50 milligrams/milliliters and 100 milligrams/milliliters Managed Opioid Programs Page 1 of 7 hydromorphone) are accessible to treat people with opioid use disorder in Ontario. And further, to take the necessary steps to add these medications at the appropriate concentrations to the Ontario Drug Benefit Formulary for the treatment of opioid use disorder.
c. Seek authority from Health Canada to import diacetylmorphine (pharmaceutical heroin) for use as a managed opioid program medication in Ontario.
d. Work with Health Canada and other necessary federal bodies to address barriers to procuring, storing and transporting diacetylmorphine (pharmaceutical heroin) and/or mitigate their effects to facilitate use of this managed opioid program medication, and
e. Ensure that managed opioid medications are universally accessible to all Ontarians who could benefit from these kinds of programs, and that cost is not a barrier.
FINANCIAL IMPACT
There are no financial impacts associated with this report.
DECISION HISTORY In June 2018, as part of a status report on implementation of the Toronto Overdose Action Plan, the Board of Health approved a recommendation supporting urgent implementation of managed opioid programs, including low barrier options. http://app.toronto.ca/tmmis/viewAgendaItemHistory.do?item=2018.HL27.1
In March 2017, the Board of Health endorsed the Toronto Overdose Action Plan, which included recommendations for the provincial and federal governments to expand access to diacetylmorphine (pharmaceutical heroin) and/or hydromorphone as an opioid substitution treatment option. http://app.toronto.ca/tmmis/viewAgendaItemHistory.do?item=2017.HL18.3
COMMENTS
Opioid deaths in Toronto The opioid poisoning crisis continues unabated in Toronto as it is elsewhere in the country. In 2017, there were 308 opioid toxicity deaths in Toronto, which is a 66 percent increase from 2016, and a 125 percent increase from 20151. Most of these deaths were accidental, and 71 percent were due to fentanyl as a contributing cause2. More detailed information from the Office of the Chief Coroner for Ontario about deaths caused by opioids (for the period of July 1, 2017 to June 30, 2018) found that fentanyl or its analogues were a contributing cause in over 77 percent of these deaths in Toronto, higher than in the rest of Ontario (69 percent)1.
Managed Opioid Programs Page 2 of 7 Preliminary data from the Office of the Chief Coroner for Ontario for the first six months of 2018 shows there were 111 opioid toxicity deaths in Toronto1. This number is expected to rise as the cause of death is confirmed for more cases.
Toxic illicit drug supply The illicit drug supply in Toronto and elsewhere in the province has become increasingly toxic. In 2017, Health Canada’s Drug Analysis Service3 found fentanyl or its analogues 2469 times in drugs seized by Ontario police services, which is a 178% increase from 2016. In the first three months of 2018 (most recent data available), 59% of all heroin samples analyzed in Ontario also contained fentanyl or analogue(s).
Toronto Public Health (TPH) works with community partners to compile and share information about toxic substances, including issuing alerts when there are widespread reports of probable adulterated or particularly harmful drugs. Most recently, in January 2019, TPH issued an alert following many reports of concerning symptoms after use of a particular opioid in the illicit market. Toronto Overdose Prevention Society members worked with the laboratory at the Centre for Addiction and Mental Health to have post- use residue tested from this substance. The results found a toxic mix of different drugs, with a particularly toxic synthetic cannabinoid, AMB-FUBINACA, present along with opioids, cocaine, ketamine, methamphetamine, and other drugs.
Managed opioid programs Comprehensive substance use treatment in Toronto needs to include a range of options to meet the diverse needs of people with substance use issues. Methadone and Suboxone are the most commonly offered opioid substitution treatments. Slow-release oral morphine has also emerged as a more recent opioid substitution medication4. These treatment options should be expanded to include managed opioid programs (MOP), which provide patients with oral or injectable hydromorphone (HDM) or diacetylmorphine (DAM or pharmaceutical heroin), along with methadone or slow release oral morphine for overnight relief.
Managed opioid programs have been shown in research and practice to be effective4 and cost-saving5. In reviews of scientific evidence, MOP have demonstrated that they increase people's retention in treatment, reduce use of street drugs, and decrease crime6. Cost-effectiveness studies have shown that providing MOP to people for whom current treatment for opioid use disorder (such as methadone) has not worked is good value for the resources invested. Managed opioid programs that provide DAM to people with opioid use disorder who have not responded to other forms of treatment have been in place in several cities in Europe for decades8. Diacetylmorphine is available in The Netherlands and Switzerland, where it accounts for about 9 percent of all opioid substitution treatment, and is also available in Germany, England, and Denmark9. Managed opioid programs can be delivered in a variety of different models10 including regulated low-barrier distribution programs11.
Due to the unpredictability of the current illicit drug supply, there is an urgent need to expand treatment options, and implement managed opioid programs. This strategy is a
Managed Opioid Programs Page 3 of 7 key aspect of the response to the overdose crisis in British Columbia and Alberta, and is urgently needed in Ontario.
The Ministry of Health and Long-Term Care (MOHLTC) has just negotiated a new treatment funding agreement ($102 million) with the federal government. Details of how this new funding will be allocated have not been announced, but ensuring some of the funds are targeted to MOP is critical. It is therefore recommended that the MOHLTC immediately target operational and capital funding to support a rapid scale up of MOP in Ontario (including low barrier models) given the urgency of the current opioid poisoning crisis. Canadian managed opioid programs In Canada, MOP began in 2005 as a research trial in Vancouver and Montreal12, and have included the provision of both DAM, and/or HDM. These research trials demonstrated the effectiveness of this treatment option in decreasing both crime and improving retention in drug treatment12, 13. Programs based on this research have expanded and are now being delivered by several health care providers in Vancouver to respond to the overdose crisis14. New clinics in Surrey, British Columbia and Calgary, Alberta have recently opened, and more are planned. In Ottawa, there is one shelter- based MOP run by Ottawa Inner City Health, which has been successfully stabilizing a small group of people on HDM since late 201715. New innovative programs that distribute HDM pills are being planned in British Columbia.11. In addition, clinical and other guidelines have been produced to guide practitioners in the effective delivery of these programs based on best practices10, 16. The foundations are therefore in place to scale up the implementation of these kind of programs in Ontario.
The stories from people participating in MOP in Vancouver demonstrate the kind of recovery that is possible with this form of treatment17:
"My life is starting to become more manageable… and I’m only two and a half months into it… I’m putting on weight, that’s one thing. I’m eating better… It’s stabilized my life…I don’t wake up in the morning having to figure out what crime I’m going to do to pay for my drugs…and I’m actually looking for other things in my life, like even going swimming, leisure and stuff like that. …And this is only at the start."
"I don’t get sick. I sleep all night. I don’t do crimes. That’s really good."
Barriers to implementation Despite the evidence on the effectiveness of MOP, and the precedents of programs in other parts of Canada, there are a number of barriers to implementing MOP in Ontario, many of which could be addressed by the MOHLTC.
The current medications used in opioid substitution treatment (methadone and Suboxone) are listed on the Ontario Drug Benefit Formulary. The costs for these medications are covered for people who are eligible for the Ontario Drug Benefit program (i.e. people aged 65 or older, and people enrolled in the Trillium Drug Program, Ontario Works, or the Ontario Disability Support Program). However, the concentrations of injectable HDM (50mg/ml and 100mg/ml) required as treatment for opioid use
Managed Opioid Programs Page 4 of 7 disorder are not listed on the Ontario Drug Benefit Formulary. It is therefore recommended that the MOHLTC take immediate action to ensure the required concentrations of MOP medications (i.e. 50mg/ml and 100mg/ml hydromorphone) are accessible to treat people with opioid use disorder in Ontario. For example, the MOHLTC could provide funding to health care providers or other related organizations to cover the costs of these medications. Because many people who are treated for opioid use disorder are eligible for the Ontario Drug Benefit program, it is also important for the MOHLTC to take the necessary steps to add these medications at the appropriate concentrations to the Ontario Drug Benefit Formulary for the treatment of opioid use disorder.
Diacetylmorphine (pharmaceutical heroin) is currently not available in Ontario. Health Canada must authorize use and importation of this medication, and provinces must request special access. It is therefore recommended that the MOHLTC seek authority from Health Canada to import diacetylmorphine for use as a MOP medication in Ontario.
There are also considerable barriers to procuring, storing and transporting DAM, which make it inaccessible for most potential MOP providers. These regulations are federal as well as provincial, and there is a lack of information from the MOHLTC about who would pay for this medication even if the regulatory barriers to procuring, storing and transporting it were reduced or managed. It is therefore recommended that the MOHLTC work with Health Canada and other necessary federal bodies to address barriers to procuring, storing and transporting diacetylmorphine (pharmaceutical heroin) and/or mitigate their effects to facilitate use of this MOP medication. It is further recommended that the MOHLTC ensure that MOP medications are universally accessible to all Ontarians who could benefit from these kinds of programs, and that cost is not a barrier.
Treatment programs that offer opioid substitution therapies need to offer more than just medication. Supports for people in these programs should include case management, and other psychosocial supports. Health facilities may need to be renovated or expanded to accommodate the supervision of injectable medications. The MOHLTC often provides the funds to support these kind of services in community-based settings.
Conclusion Managed opioid programs are an important part of a comprehensive response to the opioid crisis, which is associated with considerable preventable and premature deaths. Better treatment options and other services are urgently needed in Toronto to meet the needs of people who use substances and are at high risk of overdose. These treatment options help move people out of the illicit drug market, which is currently contaminated with very potent opioids (such as fentanyl and other analogs), and onto a safe supply of pharmaceutical opioids under medical supervision.
Urgent action and investment is needed from the MOHLTC to rapidly scale up the implementation of MOP in Toronto and elsewhere in Ontario to help save lives and improve health outcomes for people who use drugs.
Managed Opioid Programs Page 5 of 7
CONTACT
Jann Houston, Director, Strategic Support, 416-338-2074, [email protected]
SIGNATURE
Dr. Eileen de Villa Medical Officer of Health
Managed Opioid Programs Page 6 of 7 REFERENCES
1. Toronto Public Health. Toronto Overdose Information System 2019 [Available from: https://www.toronto.ca/community-people/health-wellness-care/health- inspections-monitoring/toronto-overdose-information-system/. 2. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Interactive Opioid Tool 2018 [Available from: https://www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx. 3. Health Canada. Drug Analysis Service: Summary report of samples analysed 2017 - Canada.ca 2018 [Available from: https://www.canada.ca/en/health- canada/services/health-concerns/controlled-substances-precursor-chemicals/drug- analysis-service/2017-drug-analysis-service-summary-report-samples-analysed.html. 4. Ferri M, Davoli M, Perucci CA. Heroin maintenance for chronic heroin-dependent individuals. Cochrane Database Syst Rev. 2011(12):CD003410. 5. Bansback N, Guh D, Oviedo‐Joekes E, Brissette S, Harrison S, Janmohamed A, et al. Cost‐effectiveness of hydromorphone for severe opioid use disorder: findings from the SALOME randomized clinical trial. Addiction. 2018;113(7):1264-73. 6. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Leece P, Tenenbaum M. Evidence Brief: Effectiveness of supervised injectable opioid agonist treatment (siOAT) for opioid use disorder. Toronto, ON; 2017. 7. Linas BP. Commentary on Bansback et al. (2018): Estimating the cost of stigma against injection. Addiction. 2018;113(7):1274-5. 8. Strang J, Groshkova T, Metrebian N. New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond. Luxembourg: European Monitoring Centre for Drugs Drug Addiction; 2012. 9. Uchtenhagen A. The role and function of heroin-assisted treatment at the treatment system level. Heroin Addiction and Related Clinical Problems. 2017;19(2). 10. BC Centre on Substance Use. Guidance for Injectable Opioid Agonist Treatment for Opioid Use Disorder. 2017. 11. Tyndall M. An emergency response to the opioid overdose crisis in Canada: a regulated opioid distribution program. CMAJ. 2018;190(2):E35-E6. 12. Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, et al. Diacetylmorphine versus methadone for the treatment of opioid addiction. The New England journal of medicine. 2009;361(8):777-86. 13. Oviedo-Joekes E, Guh D, Brissette S, Marchand K, MacDonald S, Lock K, et al. Hydromorphone Compared With Diacetylmorphine for Long-term Opioid Dependence: A Randomized Clinical Trial. JAMA psychiatry. 2016;73(5):447-55. 14. Lupick T. The Secret Housing Program Giving Safe Drugs to Addicted Residents2018, Feb 5. Available from: https://www.vice.com/en_ca/article/j5bx7k/the- secret-housing-program-giving-safe-drugs-to-addicted-residents. 15. Lunn S. As opioid overdoses spike, Ottawa health workers try giving addicts 'clean drugs' 2017, Oct 26. Available from: http://www.cbc.ca/news/politics/opioid- ottawa-clean-drugs-replacement-1.4372838. 16. College of Pharmacists of British Columbia. Policy Guide: Injectable Hydromorphone Maintenance Treatment. 2018. 17. Boyd S, Murray D, SNAP, MacPherson D. Telling our stories: heroin-assisted treatment and SNAP activism in the Downtown Eastside of Vancouver. Harm Reduct J. 2017;14(1):27.
Managed Opioid Programs Page 7 of 7 4.11
Ministry of the Attorney General Ministère du Procureur général
Ontario Legalization of Cannabis Secrétariat ontarien de la légalisation Secretariat du cannabis
720 Bay Street 720 rue Bay 11th Floor 11e étage Toronto ON M7A 2S9 Toronto ON M7A 2S9
Cynthia St. John Dr. Joyce Lock Chief Executive Director Medical Officer of Health
Southwestern Public Health St. Thomas Site - Administrative Office 1230 Talbot Street St. Thomas, Ontario N5P 1G9
Dear Ms. St. John and Dr. Lock:
Thank you for your letter dated January 10, 2019 and my apologies for the delay in my response. I have noted the concerns you share with Peterborough Public Health and, as the Executive Director of the Ontario Legalization of Cannabis Secretariat, I am pleased to provide a response.
As you are aware, Ontario has passed the Cannabis Licence Act, 2018 that will enable the implementation of a private retail and distribution system aimed at protecting youth and combatting the illegal market.
The Alcohol and Gaming Commission of Ontario (AGCO) is the provincial regulator authorized to grant cannabis retail store licences, with private retail locations opening as soon as April 1, 2019. Only in-person sales of cannabis from private retailers will be allowed and the OCS will be the wholesaler to private retail stores.
Through regulation of the alcohol, gaming and horse racing sectors in Ontario, the AGCO has developed experience with licensing, registration, auditing, conducting inspections, investigations and providing education, training and awareness to licensees, with a focus on compliance. The AGCO will leverage this extensive experience and infrastructure to regulate cannabis retail stores, building on its mandate to regulate in the public interest.
Operating Parameters
Ontario has established strict regulations under the Cannabis Licence Act, 2018 for the licensing and operation of private cannabis stores including: o A minimum distance buffer between cannabis retail stores and schools. o A requirement that stores be stand-alone and age-restricted (must be 19+ to enter). o Individuals with a store authorization, cannabis retail managers, and all retail employees will be required to complete the approved “CannSell” training program to ensure that any individual who works in the cannabis retail market is trained in the responsible sale of cannabis. o Specific instances in which applicants will be denied a licence, including cannabis-related criminal offences. Notably, illegal cannabis retailers who were operating after October 17, 2018 are not eligible for Ontario cannabis sales licenses. o A prohibition on the issuance of a licence to any individual or organization who has an association with organized crime. o Maximum permissible retail cannabis stores operating hours between 9:00 a.m. and 11:00 p.m. on any day, consistent with on-site retail stores for alcohol.
In terms of store hours of operation, please note that stores do not need to stay open from 9:00 a.m. until 11:00 p.m. Those are simply the maximum hours that are permitted by law. Currently, nothing would prevent a municipality from enacting a bylaw regarding store hours. However, the government will continue to monitor the issue to ensure the province’s objective of combating the illegal market is achieved.
Retail Siting
In terms of store siting, for municipalities that did not opt-out by January 22, 2019, cannabis retail stores could be located anywhere that other retail is permitted, subject to a minimum distance buffer of 150 metres between cannabis retail stores and schools, including public, private, and federally-funded First Nation schools off-reserve. This distance buffer will help protect students and support the government’s policy objective of protecting youth. It also aligns with the range of distance buffers established in other jurisdictions, such as Quebec and Alberta.
The federal government’s task force report recommended against the co-location of cannabis and alcohol at the point of sale. As such, the Cannabis Licence Act, 2018 will restrict private retailers from selling any product other than cannabis and cannabis accessories.
Public Notice Process
When the AGCO receives a cannabis retail store application, the AGCO will inform the public through a local notice process, which includes posting a notice on its website and displaying a placard at the proposed retail store location.
The local community, including the municipality, will have a 15-day window to provide written submissions on the store application, including objections to the store’s proposed location. The AGCO will assess written objections and determine whether issuing the retail store authorization would be in the public interest. In determining whether the issuance of the authorization is in the public interest, the AGCO will consider the following principles: 1. Protecting public health and safety. 2. Protecting youth and restricting their access to cannabis. 3. Preventing illicit activities in relation to cannabis.
For more information on the provincial cannabis framework and other resources please visit Ontario.ca/cannabis.
Thank you again for writing.
Sincerely,
Renu Kulendran Executive Director Ontario Legalization of Cannabis Secretariat
c. Honourable Christine Elliott, Minister of Health and Long-Term Care
4.12
February 20, 2019
The Honourable Doug Ford Premier of Ontario Legislative Building Queens’s Park Toronto, ON M7A 1A1
Dear Premier Ford:
Re: Public and Environmental Health Implications of Bill 66, Restoring Ontario’s Competitiveness Act, 2018
On behalf of the Simcoe Muskoka District Health Unit (SMDHU) Board of Health, I am writing to express concern about the Government of Ontario’s decision to enact Bill 66, Restoring Ontario’s Competitiveness Act, 2018.
We appreciate the intention to enhance employment opportunities throughout Ontario, and recognize good quality employment as a key element which influences health. Individuals who are unemployed, have precarious employment, or experience poor working conditions are at higher risk of stress, injury, high blood pressure and heart disease. However, the proposed bill will amend a number of acts and regulations intended to protect and promote public and environmental health.
In consideration of the proposed amendments, Bill 66 was assessed by SMDHU staff for implications to public and environmental health. We are apprehensive of unintended negative consequences which may arise from the implementation of this bill. The attached appendices outline concerns related to Schedule 3 (Appendix 1) and Schedule 5 (Appendix 2). Schedule 10 (Appendix 3) is also included, though the Board of Health is aware of media reports and social media remarks made by Honourable Minister Clark indicating “when the legislature returns in February, (the Government) will not proceed with Schedule 10 of the Bill.” This is welcomed, however, from our assessment of Bill 66 as it is presently written, its implementation to amend and repeal current legislation will potentially result in:
• Negative impacts to Ontario’s natural and built environment; • Degradation of important water sources; • Decreased preservation of greenspaces including agricultural lands, forests, parks and natural heritage features; • Decreased opportunities for physical activity; • Impacts to child safety; and • Increased risk of the spread of infectious diseases. We request the government consider the impacts on the public health and safety of residents of Ontario prior to Bill 66 proceeding through the legislative process. We thank you for the opportunity to provide comment and your consideration of our feedback.
Sincerely,
ORIGINAL Signed By:
Anita Dubeau Chair, Board of Health
AD:BA:cm cc. Honorable Christine Elliot, Minister of Health and Long-Term Care Honorable Steve Clark, Minister of Municipal Affairs Honorable Lisa Thompson, Minister of Education Honorable Rod Phillips, Minister of the Environment, Conservation and Parks Dr. David Williams, Chief Medical Officer of Health Members of Provincial Parliament for Simcoe and Muskoka Ontario Boards of Health Ms. Loretta Ryan, Association of Local Public Health Agencies Association of Municipalities of Ontario Ontario Public Health Association Members of Provincial Parliament Municipal Councils Central Local Health Integration Network North Simcoe Muskoka Local Health Integration Network
Appendix 1: Concerns and considerations related to Schedule 3 – Ministry of Education
SMDHU recognizes the efforts to enhance child care availability to families by increasing the total number of children under the age of two that can be cared for by home child care providers. Though evidence on optimal infant to caregiver ratios is inconclusive, the current limits in Child Care and Early Year’s Act, 2014, were chosen to ensure child safety1. We urge the government to evaluate the effects of this legislation on child safety and developmental outcomes if implemented. The proposed changes will not adequately address issues of access, affordability, and quality child care for families. Similar to our high quality education system, a child care strategy that prioritizes accessibility, affordability and quality is best addressed through a government system that ensures universal access to high quality care.
In addition, there may be implications to infection prevention and control due to the proposed amendment to paragraph 4 subsection 6 (4) of the Child Care and Early Years Act, 2014, which recommends the reduction of the age restriction from six years of age to four for registration in authorized recreation and skill building programs. Authorized recreational and skill building programs are not proactively inspected for food safety nor infection prevention and control by local public health units. With immunization follow-up doses for several diseases (e.g. measles, pertussis, and chickenpox) not occurring until a child is between 4 – 6 years, coupled with the potential for decreased hygienic practices and larger numbers of children congregating in one location2, there is the potential for the spread of vaccine-preventable diseases. Facilities that are not required to be inspected may not have the administrative (e.g. policies on when to exclude ill children) or physical (e.g. appropriate disinfectants) infrastructure to prevent infections. By lowering the age from six years to four, a potential increased infectious disease risk will occur for children 4-6 years attending these programs.
1 Ontario Ombudsman. 2014. Ombudsman Report: “Careless about Childcare” Investigation into how the Ministry of Education responds to complaints and concerns relating to unlicensed daycare providers .Available at: www.ombudsman.on.ca/Files/sitemedia/Documents/Investigations/SORT%20Investigations/Careless AboutChildCareEN-2.pdf 2 Canadian Paediatric Society. 2015. Well Beings: A Guide to Health in Child Care – 3rd edition. Appendix 2: Concerns and considerations related to Schedule 5 - Ministry of Environment, Conservation and Parks
The purpose of the Toxics Reductions Act (TRA) is to prevent pollution and protect human health and the environment, through reducing the use and creation of toxic substances within Ontario. While SMDHU supports efforts to avoid duplication of existing provincial and federal regulations, it is important to recognize the need to reduce the availability of toxic substances within Ontario. Existing federal requirements through the National Pollutant Release Inventory and the Chemical Management Plan have limitations to supporting further reduction of toxic substances that the province of Ontario hoped to address. The TRA can provide important economic benefits which lead to potential cost savings, creating new markets, and supporting employee health and safety. Similar legislation has shown to be effective in other jurisdictions in the United States that have required toxic reduction plans. Thus, SMDHU encourages the province to not eliminate the TRA, but to evaluate more effective opportunities for toxics reduction in Ontario that can support creating healthy environments while reducing barriers for business Appendix 3: Concerns and considerations related to Schedule 10 - Ministry of Municipal Affairs and Housing
The Planning Act and associated provincial regulations support effective planning, by ensuring development meets community needs, allows for sustainable economic growth, while protecting green spaces such as agricultural lands, forests, parks and natural heritage features which provide multiple health, economic and environmental benefits. The health benefits of well-designed communities based on provincial policies include better air quality, protected drinking water supplies, availability of locally grown foods, reduced urban heat islands, increased climate resiliency, mitigation of vector-borne diseases, increased opportunities for physical activity, general wellbeing and lower health care costs. Conservation of natural heritage features such as the Greenbelt addresses climate change mitigation (carbon sequestration) and adaptation (mitigating flood risks). For example, the Greenbelt actively stores carbon, with an estimated value of $4.5 billion over 20 years; annual carbon sequestration is valued at 10.7 million per year1. Benefits of greenspaces are communicated within the ‘Preserving and Protecting our Environment for Future Generations: a Made in Ontario Environment Plan’ which identifies the government’s commitment to protect the Greenbelt for future generations2.
SMDHU is concerned that the proposed amendment to the Planning Act will allow the use of Open for Business planning by-laws to permit the use of these important lands for alternative purposes without adhering to existing local planning requirements, such as official plans. Employment land needs are explicitly identified within local planning documents, and thus the use of the by-law will compromise long-term planning decisions. While the by-law may provide short-term economic benefit through the expansion of employment lands, this will be at the expense of long-term, sustainable economic development and protection of green space currently prescribed by the Planning Act.
In addition, Bill 66 allows municipalities to bypass important environmental legislation and discount protections for clean water and environmentally sensitive areas across Ontario. After the events of 2000 in Walkerton, where seven people died and thousands were ill3, Ontario put legislation in place to protect the over 80% of Ontarians who get their drinking water from municipal sources. The Clean Water Act, which directly addresses 22 of the 121 recommendations made following the Walkerton Inquiry, supports the adoption of a watershed based planning process, and serves as the instrument for the creation of source water protection plans.
Current legislation protects drinking water sources and greenspace. The changes proposed in Bill 66 will weaken a number of noteworthy acts including the Clean Water Act, the Great Lakes Protection Act, the Lake Simcoe Protection Act, the Greenbelt Act, the Oak Ridges Moraine Conservation Act, and the Places to Grow Act. Currently these acts prevail in the case of conflict between a municipal plan and the noted act; under the proposed changes this would no longer be the case.
1 Tomalty, R. 2012. Carbon in the Bank: Ontario’s Greenbelt and its role in mitigating climate change. [Vancouver]: David Suzuki Foundation 2 Ministry of the Environment, Conservation and Parks. 2018. Preserving and protecting our environment for future generations: A Made-in-Ontario environment plan. [Toronto]: Ontario Ministry of the Environment, Conservation and Parks. 3 Walkerton Inquiry (Ont.) and Dennis R. O’Connor. 2002. Report of the Walkerton Inquiry: A strategy for safe drinking water. [Toronto]: Ontario Ministry of the Attorney General. Notably, Section 39 of the Clean Water Act currently requires all Planning Act decisions to conform to policies in approved source protection plans that address significant drinking water threats prescribed by the Clean Water Acti. This important provision must remain applicable to all municipal planning and zoning decisions in order to protect public health and safety.
Bill 66 not only impacts drinking water, but also moves back progress made on protecting Lake Simcoe. The Lake Simcoe Protection Act was created to safeguard the watershed and protect our Great Lakes and Lake Simcoe from environmental damage. Lake Simcoe attracts 9 million visitors on an annual basis and accounts for approximately $1 billion dollars in annual spending. Due to the economic, environmental and health impacts that the Open for Business planning bylaw will present, we urge the government to remove the amendment to the Planning Act, from Bill 66. At minimum, public health authorities should be granted the ability under the Planning Act to review and comment on open for business bylaw applications, due to potential risk and hazards to health and for the protection and promotion of public health and safety.
i Threats identified in the act include landfills, sewage systems, and the storage or handling of fuel, fertilizers, manure, pesticides, road salt, organic solvents and other substances on lands near wells or surface water intake pipes used by municipal drinking water systems 4.13 Jackson Square, 185 King Street, Peterborough, ON K9J 2R8 P: 705-743-1000 or 1-877-743-0101 F: 705-743-2897 peterboroughpublichealth.ca
Serving the residents of Curve Lake and Hiawatha First Nations, and the County and City of Peterborough
December 7, 2018
VIA ELECTRONIC MAIL
The Honourable Doug Ford Premier of Ontario Legislative Building Queen’s Park Toronto, ON M7A 1A1
Dear Premier Ford:
Re: Support for Provinical Oral Health Program for Low Income Adults and Seniors
I am very pleased to write to you on behalf of the Board of Health for Public Health Sudbury & Districts to share our sincere appreciation for the provincial government’s support of a provincial oral health program for low-income seniors. This is a welcome addition to oral health programs already available for children and youth in low-income families through Healthy Smiles Ontario.
The Board of Health for Public Health Sudbury & Districts has a keen interest in oral health. In reviewing our 2018 data on oral health, we identified that to further support oral health for all Ontarians, programs are needed for low-income adults, in addition to those in place or planned for children, youth and seniors.
At its meeting on November 22, 2018, the Board of Health carried the following resolution #42-18: Letter Re: Support for Provinical Oral Health Program for Low Income Adults and Seniors December 7, 2018 Page 2
WHEREAS as compared with other provinces, Ontario has the lowest rate of public funding for dental care, as a percentage of all dental care expenditures and the lowest per capita public sector spending on dental services, resulting in precarious access to dental preventive and treatment services, especially for low-income Ontarians; and
WHEREAS the Ontario Progressive Conservative party pledged to implement a comprehensive dental care program that provides low income seniors with quality care by increasing the funding for dental services in Public Health Units, Community Health Centres, and Aboriginal Health Access Centres and by investing in a new dental services in underserviced areas including increasing the capacity in public health units and investing in mobile dental buses;
THEREFORE BE IT RESOLVED THAT the Board of Health for Public Health Sudbury & Districts fully support the Premier’s plan to invest in oral health programs for low income seniors and further encourage the government to expand access to include low income adults; and
FURTHER that this motion be shared with area municipalities and relevant dental and health sector partners, all Ontario Boards of Health, Chief Medical Officer of Health, Association of Municipalities of Ontario (AMO), and local MPPs.
Thank you for your attention to this matter and I look forward hearing more about the role public health can take in support of a new oral health program for low income adults and seniors that is cost effective and accessible.
Sincerely,
Penny Sutcliffe, MD, MHSc, FRCPC Medical Officer of Health and Chief Executive Officer cc: Honorable Christine Elliott, Minister of Health and Long-Term Care Dr. David Williams, Chief Medical Officer of Health, Minister of Health and Long-Term Care Mr. Jamie West, MPP, Sudbury Ms. France Gelinas, MPP, Nickel Belt Mr. Michael Mantha, MPP, Algoma-Manitoulin All Ontario Boards of Health Constituent Municipalities within Public Health Sudbury & Districts Ms. Loretta Ryan, Executive Director, Association of Local Public Health Agencies Association of Municipalities of Ontario Dr. David Diamond, President, Sudbury & District Dental Society Dr. Tyler McNicholl, vice-president, Sudbury & District Dental Society Ms. Jacquie Maund, Alliance for Healthier Communities 4.14
4.15 Renfrew County and District Health Unit "Optimal Health for All in Renfrew County and District"
March 04, 2019
The Honourable Doug Ford Premier of Ontario Legislative Building, Queen's Park Toronto, ON M7A 1A 1 [email protected]
Dear Premier Ford,
Re: Support for Provincial Oral Health Program for Low Income Adults and Seniors
At the February 26, 2019 regular meeting of the Board of Health for the Renfrew County and District Health Unit (RCDHU) the Board considered the attached correspondence from Sudbury & Districts Public Health regarding support for the oral health program for low income seniors and encouraging the government to expand access to include low income adults.
The following motion, recommended to the RCDHU Board of Health by the Stakeholder Relations Committee, was accepted by the Board on February 26, 2019:
Resolution:# 3 SRC 2019-Feb-08 A motion by J. Dumas; seconded by M.A. Aikens; be it resolved that the Stakeholder Relations Committee recommends that the Board endorse correspondence from Sudbury and Districts Public Health regarding support for a provincial oral health program for low income adults and seniors and further that it be cc'd as per the Sudbury Board of Health letter with the addition to alPHa and the Honourable MPP John Yakabuski. Carried
Sincerely,
f�Yr- u)� Janice Visneskie Moore Chair, Board of Health Renfrew County and District Health Unit cc (via email): The Honourable Christine Elliott, Minister of Health and Long-Term Care Dr. David Williams, Chief Medical Officer of Health
7 International Drive, Pembroke, Ontario K8A 6W5 • www.rcdhu.com • Health Info Line 613-735-8666 • Health Promotion/Healthy Families 613-735-865 l • Dental 613-735-8661 • Immunization 613-735-8653 • Healthy Environments 613-735-8654 • Reception 613-732-3629 • Fax 613-735-3067 Toll Free: 1-800-267-1097 The Honourable John Yakabuski, MPP, Renfrew-Nipissing-Pembroke Ontario Boards of Health Loretta Ryan, Executive Director, Association of Local Public Health Agencies Pegeen Walsh, Executive Director, Ontario Public Health Association Association of Municipalities of Ontario Jacquie Mound, Alliance for Healthier Communities
7 International Drive, Pembroke, Ontario K8A 6W5 • www.rcdhu.com • Health Info Line 613-735-8666 • Health Promotion/Healthy Families 613-735-8651 • Dental 613-735-8661 • Immunization 613-735-8653 • Healthy Environments 613-735-8654 • Reception 613-732-3629 • Fax 613-735-3067 Toll Free: 1-800-267-1097
December 7, 2018
VIA ELECTRONIC MAIL
The Honourable Doug Ford Premier of Ontario Legislative Building Queen’s Park Toronto, ON M7A 1A1
Dear Premier Ford:
Re: Support for Provinical Oral Health Program for Low Income Adults and Seniors
I am very pleased to write to you on behalf of the Board of Health for Public Health Sudbury & Districts to share our sincere appreciation for the provincial government’s support of a provincial oral health program for low-income seniors. This is a welcome addition to oral health programs already available for children and youth in low-income families through Healthy Smiles Ontario.
The Board of Health for Public Health Sudbury & Districts has a keen interest in oral health. In reviewing our 2018 data on oral health, we identified that to further support oral health for all Ontarians, programs are needed for low-income adults, in addition to those in place or planned for children, youth and seniors.
At its meeting on November 22, 2018, the Board of Health carried the following resolution #42-18: Letter Re: Support for Provinical Oral Health Program for Low Income Adults and Seniors December 7, 2018 Page 2
WHEREAS as compared with other provinces, Ontario has the lowest rate of public funding for dental care, as a percentage of all dental care expenditures and the lowest per capita public sector spending on dental services, resulting in precarious access to dental preventive and treatment services, especially for low-income Ontarians; and
WHEREAS the Ontario Progressive Conservative party pledged to implement a comprehensive dental care program that provides low income seniors with quality care by increasing the funding for dental services in Public Health Units, Community Health Centres, and Aboriginal Health Access Centres and by investing in a new dental services in underserviced areas including increasing the capacity in public health units and investing in mobile dental buses;
THEREFORE BE IT RESOLVED THAT the Board of Health for Public Health Sudbury & Districts fully support the Premier’s plan to invest in oral health programs for low income seniors and further encourage the government to expand access to include low income adults; and
FURTHER that this motion be shared with area municipalities and relevant dental and health sector partners, all Ontario Boards of Health, Chief Medical Officer of Health, Association of Municipalities of Ontario (AMO), and local MPPs.
Thank you for your attention to this matter and I look forward hearing more about the role public health can take in support of a new oral health program for low income adults and seniors that is cost effective and accessible.
Sincerely,
Penny Sutcliffe, MD, MHSc, FRCPC Medical Officer of Health and Chief Executive Officer cc: Honorable Christine Elliott, Minister of Health and Long-Term Care Dr. David Williams, Chief Medical Officer of Health, Minister of Health and Long-Term Care Mr. Jamie West, MPP, Sudbury Ms. France Gelinas, MPP, Nickel Belt Mr. Michael Mantha, MPP, Algoma-Manitoulin All Ontario Boards of Health Constituent Municipalities within Public Health Sudbury & Districts Ms. Loretta Ryan, Executive Director, Association of Local Public Health Agencies Association of Municipalities of Ontario Dr. David Diamond, President, Sudbury & District Dental Society Dr. Tyler McNicholl, vice-president, Sudbury & District Dental Society Ms. Jacquie Maund, Alliance for Healthier Communities 4.16 Renfrew County and District Health Unit "Optimal Health for All in Renfrew County and District"
March 04, 2019
The Honourable Christine Elliott Deputy Premier of Ontario Minister of Health and Long-Term Care [email protected]
Dear Minister Elliott,
Re: Strengthening the Smoke-Free Ontario Act, 2017 to address the promotion of vaping
At the February 26, 2019 regular meeting of the Board of Health for the Renfrew County and District Health Unit (RCDHU) the Board considered the attached correspondence from Peterborough Public Health urging the Ontario government to strengthen the Smoke-Free Ontario Act, 2017 to prohibit through regulation, the promotion of vaping products.
The following motion was recommended by the Stakeholder Relations Committee and accepted by the Board on February 26, 2019:
Resolution: # 3 SRC 2019-Feb-08 A motion by M.A. Aikens; seconded by J. Dumas; be it resolved that the Stakeholder Relations Committee recommend to the Board that the RCDBH support the correspondence from Peterborough Health Unit urging the province to strengthen the Smoke-Free Ontario Act 2017 and prohibit the promotion of vaping products and further that it be cc as per the Sudbury letter. Carried M wtilf Janice Visneskie Moore Chair, Board of Health Renfrew County and District Health Unit
cc (via email): The Honourable Doug Ford, Premier of Ontario Dr. David Williams, Chief Medical Office of Health The Honourable John Yakabuski, MPP, Renfrew-Nipissing-Pembroke
7 International Drive, Pembroke, Ontario K8A 6W5 • www.rcdhu.com • Health Info Line 613-735-8666 • Health Promotion & Clinical Services 613-735-8651 • Dental 613-735-8661 • Immunization 613-735-8653 • Environmental Health 613-735-8654 • Reception 613-732-3629 • Fax 613-735-3067 Toll Free: 1-800-267-1097 Ontario Boards of Health Loretta Ryan, Executive Director, association of Local Public Health Agencies Pegeen Walsh, Executive Director, Ontario Public Health Associations Association of Municipalities of Ontario Jacquie Mound, Alliance for Healthier Communities
7 International Drive, Pembroke, Ontario K8A 6W5 • www.rcdhu.com • Health Info Line 613-735-8666 • Health Promotion & Clinical Services 613-735-8651 • Dental 613-735-8661 • Immunization 613-735-8653 • Environmental Health 613-735-8654 • Reception 613-732-3629 • Fax 613-735-3067 Toll Free: 1-800-267-1097 BOH - CORRESPONDENCE - 5
Jackson Square, 185 King Street, Peterborough, ON K9J 2R8 P: 705-743-1000 or 1-877-743-0101 F: 705-743-2897 peterboroughpublichealth.ca
Serving the residents of Curve Lake and Hiawatha First Nations, and the County and City of Peterborough
1 Health Canada (2018). Canada’s Tobacco Strategy. Retrieved from https://www.canada.ca/content/dam/hc- sc/documents/services/publications/healthy-living/canada-tobacco-strategy/overview-canada-tobacco- strategy-eng.pdf
2 Statistics Canada (2018). Canadian Tobacco, Alcohol and Drugs Survey (CTADS): Summary of results for 2017. Retrieved from https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs- survey/2017-summary.html
Serving the residents of Curve Lake and Hiawatha First Nations, and the County and City of Peterborough 4.17
Health Canada’s Consultation on Cannabis Regulations (New Classes of Cannabis) and the Proposed Order amending Schedule 3 and 4 to the Cannabis Act 1. What do you think about the proposed THC limits for the new classes of cannabis products?
Canada’s Lower-Risk Cannabis Use Guidelines recommend limiting the amount of THC-content in cannabis products to help mitigate the risks of both acute and chronic problems associated with cannabis use. High THC content in cannabis is linked to mental health problems and dependence (Fischer, et al. 2017). Recognizing that there are risks associated with high potency products, we agree that limiting the amount of THC-content in new classes of cannabis products is critical. The Canadian Task Force on Cannabis Legalization and Regulation acknowledged that there is insufficient evidence to identify a “safe” potency limit. As such, future changes to legislation may be warranted as further research and evidence becomes apparent on what is best for the public’s health and safety.
The proposed limit for edible cannabis products (i.e. 10 mg THC per discrete unit and per package) is reasonable and aligns with edible cannabis products currently available for sale in Colorado, California, and Washington (State of Colorado, 2018; Orenstein & Glantz, 2018). We are in support of Health Canada’s proposed total package size limit of 10mg THC for cannabis edibles as it is a more conservative limit than Colorado places at 100mg per package, or Alaska at 50 mg per package (State of Colorado, 2018; State of Alaska, 2018); however, too further prevent potential overconsumption and encourage Canadians to consume cannabis responsibly by design, we recommend a mandatory requirement that multiple lower potency options (e.g. under 5mg THC) are made available on the market. This would allow novice users to select a lower potency option and follow Canada’s Lower Risk Cannabis Use Guidelines. Other jurisdictions such as Alaska and Oregon have individual serving size, discreet unit and package size starting at 5mg THC (State of Alaska, 2018; Oregon Liquor Control Commission, 2016). If the serving size exceeds 5mg THC per serving of edible cannabis, we recommend that there should be a requirement to include a warning on the label, to advise first time/novice users that the THC quantity contained in one serving may be in excess of their individual tolerance.
The rationale for the 1000 mg limit of THC for cannabis extracts and cannabis topicals was not made apparent in the background document. To prevent overconsumption and reduce the risk to children and others who unintentionally ingest these products, Canada should place greater restriction on the maximum total THC allowed in a container of cannabis extracts or topicals than the currently proposed 1000mg. While California limits non-edible cannabis products such as topicals and concentrates to 1000mg THC per package, Washington State has restricted capsules, tablets, tinctures, transdermal patches, and suppositories to a maximum of 500 mg THC per
package (Orenstein & Glantz, 2018). In Colorado, the total amount of THC allowed in a container with multiple servings as a tincture, capsule, or other ingestible product is 100mg (State of Colorado Department of Revenue, 2018). Similarly, Oregon has set a maximum container or package size of 100mg THC for capsules (Oregon Liquor Control Commission, 2016), and Alaska has set a maximum package content for THC of 50mg for cannabis products which are to be eaten or swallowed (State of Alaska, 2018). Setting a maximum container size of 50-100mg THC for extracts and topicals would offer a significant improvement for consumer safety as compared to the proposed 1000mg THC per multi-serve container.
In terms of the potential variability for the doses of THC in edible cannabis, we recommend the variability should be no more than +/- 10%, applicable for edible cannabis and cannabis extracts, regardless of the dosage amount in one serving. This is in alignment with the current acceptable dosage for medicinal ingredients in Canada’s Food and Drug Regulations (C.01.062 (1)) which is not less than 90% or more than 110% of the amount of the medicinal ingredient shown on the label.
2. Do you think the proposed new rules addressing the types of ingredients and additives that could be used in edible cannabis, cannabis extracts, and cannabis topicals appropriately address public health and safety risks while enabling sufficient product diversity?
Cannabis Edibles (Solid and Beverage) Consumption of edible cannabis products has become a popular route of administration in states that have legalized cannabis. From a health perspective, eating or drinking cannabis products may be preferred to smoking cannabis given that ingestion has, to-date, not been associated with the same negative health impacts on lung function or cancer risk (Barrus, 2016). However, cannabis- infused edibles pose their own set of risks, including unintended consumption, inconsistency in potency and effect, and delayed onset of intoxication (Barrus, 2016). Studies from California further suggest that cannabis-infused edibles may be particularly popular among young users (Orenstein & Glantz, 2018), a group who has been shown to be especially vulnerable to the social and psychological harms associated with cannabis use (Fischer et al., 2011). In this context, and given the limited scope of evidence currently available, it is important that a precautionary approach be taken to the regulation of these products.
We support Health Canada’s proposal to prohibit added alcohol in cannabis edibles and believe that it is crucial for this restriction to remain in place. We also support the proposed prohibition on added vitamin and minerals for these products to ensure consistent public health messaging regarding the risks and harms of cannabis products and limit opportunities for conflating the health benefits of vitamins and minerals with the consumption of cannabis edibles.
In order to strengthen these regulations we would recommend that both nicotine and caffeine be prohibited as additives to cannabis edibles, allowing for a restricted amount of caffeine if it is naturally occurring in some ingredients. The current proposed limit of 30mg of naturally occurring caffeine per serving is conservative and in line with a public health approach. The recommendations to prohibit nicotine as an additive in all forms of manufactured cannabis products, and prohibiting caffeine as an additive (with allowances only for a maximum amount of caffeine if it naturally occurs in some food products such as chocolate and tea), are in line with
those put forward by Orenstein and Glantz in their summary review of cannabis regulation in California (Orenstein & Glantz, 2018).
Additionally, we recommend Health Canada consider restricting the daily values (DV) of fat, sugar, and salt contained in a single cannabis edible package to under 5%. This is in line with the World Health Organization (2015), the Heart and Stroke Foundation (n.d.), and Diabetes Canada (2016), all of which recommend restricting total free sugar intake to less than 10% of an individual’s daily calories, and ideally less than 5%. It is further in line with the Dietitians of Canada’s interpretation of under 5% DV as ‘a little’ of the nutrient (unlockfood.ca, 2019).
Cannabis Extracts (Ingested, Inhaled, Concentrated THC) Research has shown that flavoured tobacco products are more appealing to young people (Carpenter et al., 2005) and that e-cigarette use is often initiated through flavoured products (Ambrose et al. 2015). Research has further shown that cannabis extracts and concentrates may resemble food (Abda-Santos, 2013) or market on food-like flavors (Goncus, 2016) and also pose a risk for unintentional ingestion (Orenstein & Glantz, 2018).
We support Health Canada’s proposal to prohibit the use of sugars, colours, or sweeteners, as well as nicotine or caffeine in cannabis extract products.
With respect to extracts, it is imperative that Health Canada clearly defines what is meant by “appealing to youth.” We recommend that all considerations included in vaping and tobacco regulations be included in edible cannabis requirements with respect to ensuring these products and their flavourings are not considered “appealing to youth.” We recommend they not contain any flavouring that might make the product more appealing to youth, for example, if the product is a fruit-, dessert- or candy-type product.
Given the possible appeal and risk of unintentional ingestion we would further recommend a prohibition on adding characterizing flavours (e.g. menthol) to these products. This recommendation is in line with those put forward by Orenstein and Glantz in their summary review of cannabis regulations in California.
3. Do you think that proposed rules for other classes of cannabis will accommodate a variety of oil-based products for various intended uses, even though cannabis oil would no longer be a distinct class of cannabis?
Based on public health best practices from tobacco control, we recommend that cannabis regulations also incorporate a comprehensive ban on flavours and addictive additives and strict limits on the potency of all cannabis extracts and topicals (Orenstein & Glantz, 2018), just as potency regulations were proposed for cannabis edible food, beverage and ingestible extracts.
Due to the risk of accidental or over consumption of edibles (Canadian Centre on Substance Abuse, 2015), we strongly urge Health Canada to acquire best practice evidence and address this issue.
Further we commend the federal government for its proposed regulation to include: • Plain, child-resistant packaging
• No cosmetic, health or dietary claims; and must not be appealing to kids • Caffeine limits (naturally occurring, under a threshold) and restrictions; no added vitamins, minerals or alcohol in edible cannabis and ingested cannabis extract; and no nicotine, sugars, colours or sweeteners in cannabis extract
4. What do you think about the proposed six-month transition period for cannabis oil? Is a six-month transition period sufficient?
We feel the proposed six-month transition period for cannabis oil is sufficient. A stop should be put on the manufacture of new stock and labels for the ‘cannabis oil’ class on October 17, 2019, a notice of this stop approximately 1-2 months prior.
5. What do you think about the proposed new rules for the packing and labelling of the new classes of cannabis products?
Edibles, Extracts, Topicals: Packaging is an important marketing element. Companies use packaging to advertise their products and target them to specific demographic groups. Research suggests that plain packs of tobacco are viewed as less attractive than branded packs and are perceived as lower quality products, and even influences the perception of taste.
With a few additions, the proposed regulations for packaging and labelling could be strengthened.
• We recommend all classes of cannabis include a message from Canada’s Lower-Risk Cannabis Use Guidelines in addition to Health Canada’s cannabis health warning messages currently proposed.
• We recommend the mandatory addition of a warning on all dried cannabis, edibles, extracts and concentrates stating, “do not combine with alcohol or other drugs”. Given the increased risk of harms when cannabis and alcohol are combined, it is critical the public is aware of this message.
• We would like to see the federal government commit to updating health labelling for cannabis products as new and effective practices are discovered. Regularly updating the content and style will help ensure health warnings are noticeable, memorable and engaging; labels could be reviewed for relevancy every five years for example.
• We recommend that mandatory information such as health warnings, THC and CBD content, and the cannabis symbol be on the immediate packaging (the actual product) as well as packaging that may be exterior to the immediate packaging. For example, this standard of practice is used in tobacco where cigarette cartons abide by the mandatory health warning label regulations.
• We recommend the current approach of tobacco labeling be adopted in the cannabis regulations; that health warnings cover at least 75% of the two largest sides of the package or primary display areas. This does not have to be limited to just the health warning, but could include all mandatory information in the style, size and format which is outlined in the proposed regulations.
• We recommend including standard packaging to the regulations to curb the marketing potential of products to certain demographics. We recommend product packaging be standardized to consist of rectangular or square shape cardboard with all sides meeting at 900 angles, while prohibiting specialty packaging that would target specific demographics. This would limit specialty targeting as well as limit environmentally unfriendly packaging. This recommendation applies to immediate packaging when possible as well as external packaging to the immediate container when the product is packaged within another box, for example, a tube of cream may be packaged inside a box for display purposes.
• We recommend prohibiting packaging which directly targets a specific demographic, including youth but not limited to youth, for example mothers and seniors.
• We recommend that packaging include information on the expected effects, how long that effect may last for, and safe disposal. For example, edibles should have an additional warning that states the delayed onset of psychoactive response and the estimated amount of time before effect may be felt and how long the effect is expected to last, and how to safely dispose of the product. This would help to reduce the risk of over consumption and accidental consumption.
6. With respect to edible cannabis, what do you think about the requirements for all products to be labelled with cannabis-specific nutrition facts table?
We recommend mandatory information for edible cannabis to include a list of ingredients, common name of product, indication of source of allergen, gluten, or sulphites that have been added, durable life date only on ALL products that deteriorate in 90 days or less, and a cannabis- specific nutrition facts table. There should be NO nutrient and/or health claims on these labels.
We also recommend the inclusion of the % Daily Value footnote, to improve the ease consumers to interpret food labels. According to the newly published Canada’s Dietary Guidelines, food labels help make the healthy choice the easier choice. The increased ability to interpret a % Daily Value, especially when it comes to ingredients that should be limited, is a necessary component of all food labels, including cannabis edible products. It is further recommended that mandatory front-of-package food labels for foods high in saturated fat, sugars, and/or sodium also be a requirement for all cannabis edible products. This is to ensure that Canadians can be quickly informed when making a purchasing decision.
With respect to the cannabis-specific Nutrition Facts Table (NFT), we are in agreement with the requirement of a cannabis-specific nutrition facts table (NFT) for all cannabis edible products, as Oregon continues to require. We strongly recommend the font size, font type, leading, and spacing of the NFT be completely consistent with the existing labelling requirements specified in the Canadian Food and Drug Act for pre-packaged foods (i.e., as per changes to the NFT specified in 2016). Edible cannabis is a type of food and as such, the NFT should be a standardized label on all edible cannabis foods. It will be confusing to the consumer if there are different types of labels for different food products. This product information of active ingredients and warnings must be easy to locate on each package, and follow a unified, consistent format that Canadian consumers are familiar with and can understand. It is also recommended
that both caffeine content as well as THC content be displayed as part of the core list of declarations such that the consumer can make an informed decision with ease.
We are also in support of the proposal to prohibit any health claims to the consumer for all products (i.e. increases appetite, helps you sleep, increases energy) and nutrient claims (i.e. high fibre, low fat, low calorie, good source of calcium) which may entice the consumer and affect their decision-making.
7. What do you think about the proposal for the labelling of small containers and the option to display certain information on a peel-back or accordion panel?
We support the proposal of labeling small containers with the option for extended panels. This proposed regulation should be strengthened with the addition of the mandatory information (THC and CBD content, cannabis symbol and health warning) on the extended panel as well as the container itself. This would increase visibility of the messaging, while the consumer is reviewing other product information.
8. What do you think about the proposal that the standardized cannabis symbol would be required on vaping devices, vaping cartridges, and wrappers?
We support the proposal of the standardized cannabis symbol on all vaping devices, products, accessories, packaging and wrappings. The proposed regulation should be strengthened to include health warnings, and THC and CBD concentration on all vaping devices, products, accessories, packaging and wrappings. We also recommend that the standardized cannabis symbol should be visible on all products that contain cannabis even if the amount in the product is below 10 mcg/gram.
9. Do you think the proposed new good production practices, such as the requirement to have a Preventive Control Plan, appropriately address the risks associated with the production of cannabis, including the risk of product contamination and cross-contamination?
The proposed new regulations appear to be consistent with standard food production safety measures.
The proposed amendment that the Quality Assurance Person (QAP) be required to proactively conduct an investigation any time they suspect that cannabis or an ingredient may present a risk to human health or does not meet requirements will help enforce good production practices and prevent risk to human health.
The requirement that the production of edible cannabis be done in a building separate from conventional food products is an important requirement to prevent cross-contamination.
Since the legal production of many of these new classes of cannabis products is brand new to both the licenced processing facilities and whomever is deemed to enforce Health Canada’s national compliance and enforcement approach, we recommend additional inspections, mandatory and standardized preventative education, and progressive measures for non- compliance be implemented for the first 6-months that the regulations come into effect in an
effort to proactively mitigate risk. We also recommend that the enforcement agency that is responsible for ensuring compliance with the regulations have sufficient staff, from the onset, to support the licenced processors before and after implementation.
We request clarity as it pertains to protocols in the event of a recall. After the two-year record retention period presented in Section 88.94(3), and following the one-year retention of sample after last batch sold outlined in Section 92(2), there is a concern that affected recalled products may no longer have a means of tracking.
10. What do you think about the requirement about the production of edible cannabis could not occur in a building where conventional food is produced?
The proposed requirements for the separation of buildings producing edible cannabis and conventional food appear to be aligned with Health Canada’s aim to reduce the risk of unintentional consumption. While production of edible cannabis in separate buildings from conventional food production may be effective in reducing the risk of cross-contamination and unintentional consumption, we recommend the following measures to further mitigate these risks:
• Completely separate cannabis-only sites (conventional food would not be permitted to be produced or packaged on or shipped from these sites), and • Shipping procedures for edible cannabis that are completely separate from conventional foods.
Additionally, we feel the regulations should specify that all edible cannabis products can only be sold in its original package and not outside of its approved packaging in places where they are sold.
11. What do you think about the overall regulatory proposal? No comment.
12. Are there any additional comments you would like to share on proposed regulations for the new classes of cannabis?
Reducing product appeal to young persons
Under the Cannabis Act, “it is prohibited to sell cannabis or a cannabis accessory that has an appearance, shape or other sensory attribute or a function that there are reasonable grounds to believe could be appealing to young persons,” (Government of Canada, 2018). We support the proposed regulations for edibles, extracts, and topicals which state that products cannot be appealing to young persons. We strongly recommend Health Canada to include strict regulations related to advertising on television, radio, social media, the internet, and other media sources.
The Federal Government should provide explicit definitions in the regulations for manufacturers which clearly identify prohibited elements of products which may be appealing to youth. Prohibitions should follow the Task Force on Cannabis Legalization and Regulation’s recommendation to “prohibit any product deemed to be appealing to children, including products that resemble or mimic familiar food items” (2016). For example, as of April 2019, Washington
State will be explicitly prohibiting certain cannabis edible products, including hard candies, tarts, fruit chews, colourful chocolates, jellies, cotton candy, and other products that are especially appealing to young children. Cookies cannot contain any sprinkles or frosting and mints must not be coloured anything other than white. These recommendations are based in part on the research identified by Washington State Liquor and Cannabis Control Board (2018). In order to prevent unintentional ingestion of cannabis by children and adults alike, the Federal Government should also consider a ban on such products, as well as other confection and snack foods such as soft candies, brownies, chocolate bars, muffins, cakes and cookies. Alternatively, prohibiting characteristics of these edible products so that they are not appealing to children and youth, as Washington State has done, would be a positive step.
In addition, the Federal Government needs to consider key factors that influence children’s food choices. There is research to support that certain factors can influence children’s decisions to consume food and beverages. These factors include: • Colour - children prefer foods that are red, orange, yellow or green. • Shapes - children are more attracted to novel shapes such as animals, stars, etc., over plain shapes such as circles or squares. Colorado has banned edibles in the shape of fruit, animals or humans. • Odours – children are more attracted to sweet, fruity and candy-like odours. (University of Washington School of Law, 2016; Colorado General Assembly, 2016).
To make the regulations easy to follow for manufacturers, it is recommended that Health Canada provide a list of examples to cannabis edible manufacturers with regards to prohibitions on the appearance, shape, or other attribute or function that could be appealing to young persons.
13. Are there any additional comments you would like to share on the proposed regulations for the new classes of cannabis?
Public Education The Federal Government should continue to educate Canadians and enhance awareness of the health risks associated with cannabis, especially among priority populations such as pregnant and breastfeeding women, young adults aged 18-25, and individuals at risk of or living with a substance use disorder or mental illness. In addition to proper and safe storage of edible products, Canadians should be informed of the unique risks associated with the delayed onset of effects of edibles, extracts, and topicals which may cause overconsumption. Individuals need to be warned that the use of such products may cause stronger and longer-lasting effects than comparable doses of smoked cannabis (Barrus et al., 2017).
As well, public education initiatives should focus on key cannabis legislation, and Canada’s Lower-Risk Cannabis Use Guidelines. In a focus group study in Colorado and Washington State, participants suggested that education in a variety of formats, such as web and video-based education, would be useful in informing consumers about the possible risks of edibles (Kosa, Giombi, Rains, & Cates, 2017).
Places of Use
To reduce public health risks of consumption of edibles, the Federal Government should consider a ban on the sampling and ingesting of cannabis edible products in a retail storefront or in specialty consumption cafes or lounges. This will encourage individuals to use these products in the home, reducing the risk of impaired driving, public intoxication, and the co-use of cannabis edibles in public with other substances such as alcohol.
Retail Spaces As it will be the provincial and territorial responsibility for distribution and retail sale of cannabis, we recommend that Health Canada advocate for provinces to restrict the sale of edibles to standalone, specialty stores, and not co-located in a premise with other substances or non- cannabis products, nor sold alongside any other product or substance (i.e. edible products, extracts and topicals that do NOT contain cannabis, alcohol, tobacco, etc). Having a restriction on selling cannabis alongside other products will reduce the risk of co-use of alcohol and cannabis for instance, as well as reduce the risk of consumers in unintentionally purchasing or consuming products that contain cannabis. Maintaining that cannabis products be sold only in standalone specialty stores will also make it easier to restrict access and exposure to minors.
Cannabis Production and Manufacturing Facilities Discussion should occur with the Ministry of Labour for current health and safety practices of the growing, manufacturing and producing of cannabis products to assess and mitigate any risk to the health and safety of the worker. For example, UV exposure and indoor air quality issues should have to follow standard workplace health and safety regulations.
Research and Evaluation We emphasize the need for investing in baseline surveillance systems and research, and the importance of a comprehensive policy monitoring and evaluation framework. Ensure mechanisms to share data across sectors and levels of government are established, and appropriate indicators are chosen to monitor the impacts on communities.
References
Abad-Santos, A. 2013. The amateur’s guide to dabs. The Atlantic. Retrieved from https://www.theatlantic.com/national/archive/2013/05/amateurs-guide-dabs/315221/
Ambrose, B. K., H. R. Day, B. Rostron, K. P. Conway, N. Borek, A. Hyland, and A. C. Villanti. (2015). Flavored tobacco product use among US youth aged 12–17 years, 2013–2014. JAMA 314 (17):1871–3.
Barrus, D.G., K.L. Capogrossi, S.C. Cates, C.K. Gourdet, N.C. Peiper, S.P. Novak, T.W. Lefever, J.L. Wiley. (2016). Tasty THC: Promises and Challenges of Cannabis Edibles. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5260817/
California Department of Public Health. (2018). California universal symbol. Retrieved from https://www.cdph.ca.gov/Programs/CEH/DFDCS/MCSB/PublishingImages/UniversalSymbol.pd f
Canadian Centre on Substance Abuse. (2015). Cannabis Regulation: Lessons Learned in Colorado and Washington State. Retrieved from: http://www.ccdus.ca/Resource%20Library/CCSA-Cannabis-Regulation-Lessons-Learned-Report- 2015-en.pdf#search=all%28cannabis%29
Canadian Public Health Association. A Public Health Approach to the Legalization, Regulation and Restriction of Access to Cannabis. [document on internet]. Toronto: November 2017. [cited 2019 Jan 30]. Available from: https://www.cpha.ca/public-health-approach-legalization- regulation-and-restriction-access-cannabis
Carpenter, C. M., G. F. Wayne, J. L. Pauly, H. K. Koh, and G.N. Connolly. (2005). New cigarette brands with flavors that appeal to youth: Tobacco marketing strategies. Health Aff (Millwood) 24 (6):1601–10.
Colorado General Assembly. (2016). HB16-1436: Concerning a prohibition on edible marijuana products that are shapes in a manner to entice a child. Retrieved from https://leg.colorado.gov/sites/default/files/2016a_1436_signed.pdf
Diabetes Canada. (2016). Diabetes Canada’s position on sugars. Retrieved from https://www.diabetes.ca/about-cda/public-policy-position-statements/sugars
Fischer, B., Russel, A., Sabioni, P., van den Brink, W., Le Foll, B., Hall, W., Rehm, J., & Room, R. (2017). Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. American Journal of Public Health, 107(8).
Goncus, B. (2016). Review: Pineapple dream concentrate tropical wax. Retrieved from: http://www.dopemagazine.com/review-pineapple-dream-concentrate/
Government of Canada. New Health Labelling for Tobacco Packaging. [document on the internet]. October 2018. [cited 2019 Jan 30]. Available from: https://www.canada.ca/en/health- canada/programs/consultation-tobacco-labelling/document.html#a2.3
Government of Canada. (2018). Cannabis Act. Retrieved from https://laws- lois.justice.gc.ca/eng/acts/C-24.5/section-31.html?wbdisable+true
Hammond D. Standardized packaging of tobacco products: Evidence review. [document on internet]. Prepared on behalf of the Irish Department of Health; March 2014 [cited 2019 Jan 30]. Available from: https://www.drugsandalcohol.ie/22106/1/Standardized-Packaging-of-Tobacco- Products-Evidence-Review.pdf
Heart and Stroke Foundation. (n.d.). Reduce sugar. Retrieved from https://www.heartandstroke.ca/get-healthy/healthy-eating/reduce-sugar
Moodie, C., Stead, M., Bauld, L., McNeill, A., Angus, K., Hinds, K., et al. Plain tobacco
National Environmental Health Association. (n.d.). Food Safety Guidance for Cannabis-Infused Products. Retrieved from https://www.neha.org/sites/default/files/eh-topics/food-safety/Food- Safety-Guidance-Cannabis-Infused-Products.pdf
Oregon Liquor Control Commission. (2016). Medical & recreational marijuana packaging and labeling guide 2.0. Retrieved from https://www.oregon.gov/olcc/marijuana/Documents/Packaging_Labeling/PackagingandLabeling Guide_V2.pdf
Orenstein, D. G., & Glantz, S. A. (2018). Regulating Cannabis Manufacturing: Applying Public Health Best Practices from Tobacco Control. Journal of psychoactive drugs, 50(1): 19–32. doi: 10.1080/02791072.2017.1422816 Packaging: a systematic review. [document on internet]. Scotland, UK: University of Sterling; 2012 [cited 2019 Jan 30]. Available from: https://eppi.ioe.ac.uk/cms/Default.aspx?tabid=3327
State of Alaska. (2018). 3 AAC 306 regulations for the marijuana control board. Retrieved from https://www.commerce.alaska.gov/web/Portals/9/pub/MCB/StatutesAndRegulations/3AAC306.p df
State of Colorado Department of Revenue. (2018). Retail marijuana rules. Retrieved from https://www.colorado.gov/pacific/sites/default/files/Amalgamated%20Retail%20Marijuana%20R ules%2001012018.pdf
Task Force on Cannabis Legalization and Regulation. (2016). A framework for the legalization and regulation of cannabis in Canada: The final report of the task force on cannabis legalization and regulations. Retrieved from https://www.canada.ca/content/dam/hc-sc/healthy- canadians/migration/task-force-marijuana-groupe-etude/framework-cadre/alt/framework-cadre- eng.pdf
University of Washington School of Law: Cannabis Law & Policy Project. (2016). Concerning cannabis-infused edibles: Factors that attract children to foods. Retrieved from https://lcb.wa.gov/publications/Marijuana/Concerning-MJ-Infused-Edibles-Factors-That-Attract- Children.pdf
Unlockfood.ca. (2019). Decoding the Nutrition Label. Retrieved from http://www.unlockfood.ca/en/Articles/Nutrition-Labelling/Decoding-the-Nutrition-Label.aspx
Washington State Liquor and Control Board. (2018) Marijuana infused candy. Retrieved from https://lcb.wa.gov/sites/default/files/publications/Marijuana/infused_products/Marijuana-Infused- Edible-Presentation-10-3-2018.pdf
World Health Organization. (2015). Guideline: Sugars intake for adults and children. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/149782/9789241549028_eng.pdf;jsessionid=389 CC2CB5D692EB828FDB211EE9CC859?sequence=1
World Health Organization. Evidence brief plain packaging of tobacco products: measures to decrease smoking initiation and increase cessation. [document on internet]. 2014 [cited 2019 Jan 30]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0011/268796/Plain- packaging-of-tobacco-products,-Evidence-Brief-Eng.pdf?ua=1
World Health Organization. Plain packaging of tobacco products: evidence, design, implementation. [document on internet]. 2016. [cited 2019 Jan 30]. Available from: https://apps.who.int/iris/bitstream/handle/10665/207478/9789241565226_eng.pdf;jsessionid=1A4 DBF4011A463D0DB53F2D371A9A4D3?sequence=1
4.18
EXPANSION OF NICOTINE REPLACEMENT THERAPY TO COMMUNITY PARTNERS
Ashlyn Brown, Health Promoter Board of Health Meeting April 10, 2019 Tobacco use continues to be the number one preventable cause of disease and death in Ontario. SMOKING RATE FOR OXFORD COUNTY, ELGIN COUNTY AND THE CITY OF ST. THOMAS
Reference: Canadian Community Health Survey (2015-2016), Statistics Canada, Share File, Ontario MOHLTC. BACKGROUND
2013 Jan. 2017 2018 Program Formal quit Elgin St. implemented clinics at Thomas Quit with 8 both sites Clinic community stopped partners in taking new Elgin St. clients Thomas Quit Clinic in Oxford continues Program Decision to Pilot program continues change the with 2 with 7 delivery of community partners in smoking partners in Elgin St. cessation in Elgin St. Thomas and Elgin St. Thomas 3 new Thomas partners in Apr. – Oxford Dec 2016 Sep. 2017 2019 2018 PROGRAM RESULTS
• 349 clients enrolled in Oxford clinic and Elgin St. Thomas partnership program
• Priority populations:
Indigenous Low Income Mental Health Pre/Post Natal Young Adult (age Diagnosis 18-29) 1 283 169 1 21
Note: some clients are classified as more than one priority population 2018 PROGRAM RESULTS 2018 PROGRAM RESULTS 2017 PILOT COMPARED TO 2018 FULL PROGRAM 2017 PILOT COMPARED TO 2018 FULL PROGRAM SMOKING CESSATION PARTNERSHIP MODEL
• This model focuses on clients living with a low income and/or mental health diagnosis
• Clients get support at organizations they are accessing other services for
• Tripled the number of clients seen compared to ‘Quit Clinic’ with the same amount of staff time allocated
• The model has promising outcomes HOW DOES THE PROGRAM WORK?
Nicotine Nicotine Clients self- Partners Monthly replacement replacement enroll or are distribute reports therapy is therapy is referred by nicotine submitted to received from the distributed to public health replacement Southwestern Centre for partners by or their therapy and Public Health Addiction and SWPH Ontario Works provide from partners Mental Health Case Worker counselling to and purchased eligible clients by SWPH NEXT STEPS
• Continue work with community partners
• Continue engaging priority populations in making quit attempts
• Continue to expand this model within Oxford County
• Continue to monitor program data QUESTIONS
• Can you think of examples in your community of agencies where existing services could be built upon to offer smoking cessation? • What agencies, if any, do you believe community members think of when wanting to quit smoking?
POSITION STATEMENT Position Title: Electronic Cigarettes Approved by: Cynthia St. John, Chief Executive Officer Dr. Joyce Lock, Medical Officer of Health Board of Health for Oxford Elgin St. Thomas Health Unit Date Approved: Date Effective: Date Revised: Contact: Ashlyn Brown, Health Promoter Michelle Alvey, Youth Engagement Coordinator Gemma Urbani, Tobacco Control Coordinator
Position of Southwestern Public Health:
1. There is substantial evidence that e-cigarettes have short-term negative health effects and that e-cigarette aerosol contains many harmful chemicals.
2. The long-term health effects of e-cigarettes are unknown. Further scientific research is needed to determine possible health effects of long-term use.
3. There is conclusive evidence that e-cigarettes contain and emit many potentially toxic substances posing a risk to bystanders. When compared to combustible tobacco, the chemicals in e-cigarette aerosol are found in lower levels.
4. Southwestern Public Health does not recommend using an e-cigarette to quit smoking. Until further evidence supports the use of e-cigarettes as an effective cessation device, Southwestern Public Health will continue to promote and support the public with quit attempts using evidence informed cessation methods, including nicotine replacement therapy (e.g., patch, gum, lozenge, inhaler, quick mist).
5. Nicotine has been shown to alter the adolescent brain. Some e-cigarettes products contain as much or more nicotine in a single pod as a pack of cigarettes and pose a serious risk to youth. E-cigarettes that do not contain nicotine also contain many potentially harmful chemicals.
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6. E-cigarettes have the potential to re-normalize smoking and act as a gateway to traditional tobacco use among youth. Conclusive evidence finds that using an e- cigarette increases the risk of ever using a combustible tobacco product among youth or young adults.
7. Southwestern Public Health will enforce the Smoke-Free Ontario Act 2017, including provisions related to e-cigarettes.
Rationale:
E-Cigarette Use
Electronic cigarettes are also known as e-cigarettes, vapes, e-cigs, e-pens, tank systems, or vape pens. E-cigarettes are battery powered devices that heat a liquid and turn it into a vapour that is inhaled by the user. The e-substance in the device or device pod may or may not contain nicotine. E-cigarettes usually consist of a battery, mouthpiece, heating element, and tank that contains the e-substance.1
In 2015, among Canadians 15 years of age or older, 13.2% reported having ever tried an e-cigarette, representing a significant increase from 2013 (8.5% reported ever tried an e-cigarette). People who use combustible cigarettes were much more likely to report that they had tried an e-cigarette with 62.8% of Canadians who used e-cigarettes in the past 30 days also reporting that they smoked combustible cigarettes. Additionally, 33.5% of current smokers reported using e-cigarettes as a quit aid in 2015, up from 22.9% in 2013. E-cigarette use is most prevalent among young people. In Ontario, vaping among youth is increasing. In 2016-2017, 10% of youth in grades 10-12 were past 30-day e-cigarette users, representing a 46% increase from 2014-2015.2
Health Effects
There has been some evidence assessing the short-term health effects of e-cigarette use. The long-term effects are still unknown.3 The e-cigarette aerosol inhaled by the user of an e-cigarette has been found to contain potentially harmful chemicals, including nicotine, ultrafine particles that can be inhaled into the lungs, flavourings such as diacetyl, which is linked to serious lung disease, volatile organic compounds like benzene, and heavy metals like nickel and lead. Additionally, research on a common ingredient in e-cigarettes, propylene glycol, has shown some side effects, including dry mouth, throat irritation, dry cough, and nose bleeds.4 A recent study has also shown that when propylene glycol is heated and vaporized, it is associated with increased levels of formaldehyde and acetaldehyde in the vapour.5 Moreover, the National Academies of Sciences, Engineering and Medicine (NASEM) report conclusions find there is substantial evidence that e-cigarettes can result in symptoms of dependence, increases in heart rate shortly after using the device, formation of reactive oxidative species/oxidative stress, and acute endothelial cell dysfunction.6
Additional health concerns from e-cigarettes include conclusive evidence that e- cigarette devices can explode and cause burns and other injuries. This risk is increased when the batteries for the devices are poor quality, are modified by users, or stored
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inadequately. Also, there is conclusive evidence that the exposure to e-substances through ingesting or through skin or eyes can result in health effects including seizures, brain injury, vomiting, and lactic acidosis.6
E-cigarettes produce a vapour that has the potential to pose a risk to bystanders. The NASEM report shows that e-cigarette use increases airborne concentrations of particulate matter, nicotine and other toxicants such as propylene glycol, glycerol, volatile organic compounds, carbonyls, and heavy metals. There is conclusive evidence that, in addition to nicotine, e-cigarettes contain and emit many potentially toxic substances. When compared to combustible tobacco, the chemicals in e-cigarette aerosol are found in lower levels. More research is needed on the impact of exposure to e-cigarette aerosol in outdoor settings and on the health risks of exposure to e-cigarette aerosol.6
Smoking Cessation
Overall, there is limited evidence that e-cigarettes are effective smoking cessation aids.6 Results from a Public Health Ontario literature review found a lack of evidence that e- cigarettes are successful cessation aids and more recent evidence from randomized control trials and observational studies do not provide support for e-cigarettes as a cessation aid. As well, it is suggested that further research is required to determine the effectiveness of e-cigarettes with or without nicotine on smoking cessation.3 The World Health Organization concluded that, “population-based longitudinal studies that reflect real-world e-cigarette use found that e-cigarette use is not associated with successful quitting”. Additionally, the NASEM concluded there is limited evidence that e-cigarettes may be effective aids to promote smoking cessation.7
Harm reduction involves strategies to reduce harm such as reducing the number of cigarettes smoked. E-cigarettes do not contain tobacco and do not involve combustion, posing potentially less risk to health compared to smoking combustible cigarettes.8 Though available research suggests that e-cigarettes have the potential to reduce the number of cigarettes smoked, often individuals continue to use both the e-cigarette and combustible tobacco.3 Currently, it is unknown whether a reduction in harm occurs from dual use of tobacco and e-cigarettes.3 While there is potential for smokers to reduce their combustible tobacco consumption by using an e-cigarette, at this point in time, studies have indicated that continuing to smoke any amount of combustible tobacco still poses risks.7
Youth and E-Cigarettes
Evidence has shown the use of nicotine has negative impacts on adolescent brain development.9 Nicotine is known to alter brain development, affect memory and concentration, and may also predispose youth to addiction to nicotine and possibly other drugs.13 Of concern is the JUUL product and other similar pod-based systems which were introduced to the Canadian market in August 2018. These products are marketed to Canadian youth and contain as much nicotine per pod as an entire pack of cigarettes or more.
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Evidence shows that common reasons for youth beginning to use an e-cigarette include because they are accessible, healthier than cigarettes, and more aesthetically pleasing.10 This perception by youth can be attributed to the rapid diffusion of e- cigarettes into the market place and industry’s campaigns that are marketed toward young people. The use of youth friendly packaging, designs, and flavours such as Bubblegum, Snickerdoodle, and Sweet Tarts is a major marketing strategy of e- cigarette manufacturers.8 E-cigarette marketing is showing similar advertising tactics as traditional cigarette companies before regulations took place in 2006. The use of Hollywood celebrity endorsements, free product, provocative advertisements in magazines and social media, and the use of attractive flavours and packaging are arguably all tactics to target sales to youth and re-normalize smoking.11 The use of youth friendly packaging, designs, and flavours can also be linked to the increased number of nicotine poisonings in the last five years.12
A major concern surrounding the e-cigarette industry is its effect on not only youth uptake of e-cigarettes but also the potential for e-cigarettes to act as a “gateway” to traditional cigarette use. A review by the NASEM concluded there was substantial evidence that e-cigarette use increases the risk of ever using combustible tobacco cigarettes among youth and young adult.6
Enforcement and Regulation
Southwestern Public Health will continue to enforce the Smoke-Free Ontario Act 2017 (SFOA 2017) and the provisions in the Act related to e-cigarettes. There is a need to ensure that vaping products are regulated consistently along with tobacco products, including prohibiting the advertising and promotion of e-cigarettes, regulating packaging, regulating ingredient labelling, mandating health warnings, and eliminating e-liquid flavours. While there have been Federal and Provincial Government regulations on vaping products in the last two years, additional measures must be put in place to regulate these products and protect the public, especially youth from potential harm.
Implications for Southwestern Public Health:
Southwestern Public Health will:
1. Continue to support clients who are making a quit attempt with evidence based, recommended and regulated cessation products. Until further evidence supports e- cigarettes as an effective cessation aid, Southwestern Public Health will not recommend their use to quit smoking. 2. Include cautionary messages for youth and parents around the use of e-cigarettes in parenting resources, programs and services. 3. Advocate to ensure e-cigarettes are regulated and enforced like tobacco products. 4. Continue to evaluate new research as it becomes available and review the organization’s position on e-cigarettes as necessary.
References
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1 Health Canada. (2018). About vaping. Retrieved from https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping.html
2 Propel Centre for Population Healthy Impact, University of Waterloo. Canadian student tobacco, alcohol and drugs survey: Overview of results, 1994-2016/17; 2018. Retrieved from https://uwaterloo.ca/canadian-student-tobacco-alcohol-drugs- survey/
3 Ontario Agency for Health Protection and Promotion (Public Health Ontario). (2018). Current evidence on e-cigarettes: a summary of potential impacts. Toronto, ON: Queen’s Printer for Ontario; 2018. Retrieved from https://www.publichealthontario.ca/-/media/documents/literature-review- ecigarettes.pdf?la=en
4 Surgeon General. (2018). Know the risks. Retrieved from https://e- cigarettes.surgeongeneral.gov/knowtherisks.html
5 Kosmider, L., Sobczak, A., Fik, M., Knysak, J., Zaciera, M., Kurek, J., & Goniewicz, M. L. (2014). Carbonyl compounds in electronic cigarette vapors: Effects of nicotine solvent and battery output voltage. Nicotine & Tobacco Research, 16(10). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4838028/
6 National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. Retrieved from https://www.nap.edu/read/24952/chapter/1
7 World Health Organization. (2014). Electronic delivery system report. Retrieved from http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf?ua=1
8 Non-Smokers Rights Association (2013). E-cigarettes: Understanding the potential risks & benefits. Retrieved from http://www.nsra-adnf.ca/cms/file/files/E- Cig_Fact_Sheet_NSRA_17Oct13_final.pdf
9 Centre for Addiction and Mental Health. (2012). Adolescent Brain Development and Smoking. Retrieved from https://www.nicotinedependenceclinic.com/English/teach/SiteAssets/Pages/Smoki ng-Fact- Sheets/Adolescent%20Brain%20Development%20and%20Smoking%20Fact%20 Sheet%20for%20Patients.pdf
10 Constantindis. T. C., Nena, E., Paraskakis, E., Perikleous, E. P., Steiropoulos, P. (2018). E-cigarette use among adolescents. An overview of the literature and future perspectives. Frontiers in Public Health, 6(86). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5879739/
11 Non-Smokers Rights Association (2012). The Buzz on E-Cigarettes. Retrieved from
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http://www.nsra-adnf.ca/cms/file/files/e-cig%20Brochure%20FINAL.pdf
12 Centers for Disease Control and Prevention. (2014). Notes from the field: Calls to poison centers for exposures to electronic cigarettes — United States, September 2010–February 2014. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm?s_cid=mm6313a4_ w
Definitions:
Electronic Cigarette (e-cigarette): E-cigarettes are battery powered and contain an atomizer that heats the liquid and turns it into a vapour that resembles smoke. E- cigarettes are sometimes called e-cigs, vapes, vape pens, and e-hookahs. E-cigarettes sometimes look like regular cigarettes, cigars, pipes, pens, USB flash drives or other everyday items.
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POSITION STATEMENT Position Title: Smoke-Free Outdoor Spaces Approved by: Cynthia St. John, Chief Executive Officer Dr. Joyce Lock, Medical Officer of Health Board of Health for Oxford Elgin St. Thomas Health Unit Date Approved: Date Effective: Date Revised: Contact: Ashlyn Brown, Health Promoter Gemma Urbani, Smoke-Free Ontario Coordinator
Position of Southwestern Public Health:
1. Public Health supports outdoor restrictions for smoking and vaping in locations where children, youth, and adults play, work, and enjoy leisure activities, including parks, playgrounds, trails, beaches, and outdoor recreation settings. 2. No amount of second-hand smoke exposure is safe. Breathing in any amount of smoke can negatively impact health. 3. Smoke-free and vape-free outdoor spaces help create healthy, supportive environments for children, youth and adults alike. Elimination of second-hand smoke, potentially harmful aerosols, and littered cigarette butts in parks, playgrounds, beaches and outdoor recreational settings creates a healthy environment for all. 4. Smoke-free and vape-free outdoor space policies contribute to the de- normalization of tobacco, nicotine, and other substance use in public places and thus encourages young people to live smoke-free and vape-free lives. 5. Smoke-free and vape-free spaces provide a supportive environment for people who wish to quit smoking, vaping, and using other tobacco products.
Rationale:
Smoking Prevalence
From 2015-2016, there were higher proportions of adults who were current smokers (daily and occasional), daily smokers and former smokers in the Southwestern Public Page 1 of 8
Health (SWPH) region compared to Ontario (Figure 1). The SWPH region consists of Oxford County, Elgin County, and the City of St. Thomas. About one-third (34.0%) of adults living in the SWPH region completely abstained from smoking cigarettes in their lifetime compared to 44.8% of adults in Ontario.1
Figure 1. Age-standardized smoking status, adults 20 years and older, Southwestern Public Health and Ontario, 2015-20161
Health Effects
Tobacco use is the leading cause of preventable death in Ontario with 13,000 Ontarians dying annually of smoking related illness.2 Both smoking and exposure to second-hand smoke have been linked to several cardiovascular diseases, respiratory diseases and other chronic conditions.3 In fact, over 1000 non-smoking Canadians die every year from heart and lung diseases caused by second-hand smoke exposure.4
Almost all organ systems are negatively affected by smoking. Respiratory, cardiac, vascular, neurological, metabolic, obstetric and pediatric issues arise from smoking tobacco and create a significant burden on public health and health care resources. Smoking is a risk factor for lung cancer, heart disease, stroke, chronic respiratory disease, among many other conditions.5
According to the Smoke-Free Ontario Strategy Modernization Report, smoking accounts for 41% ($3.65 billion) of healthcare costs incurred from unhealthy behaviours in Ontario. The social and economic costs of tobacco use (lost productivity, lost income, etc.) equates to a staggering $5.3 billion.Error! Bookmark not defined.
In addition to direct tobacco use, there is no safe level of exposure to second-hand smoke.6 Second-hand smoke contains over 4,000 chemicals, at least 70 of which are known to be carcinogenic or otherwise toxic.6 A study conducted by Stanford University found that during periods of active smoking, peak and average outdoor tobacco smoke levels near smokers could rival indoor tobacco smoke concentrations.7 The World
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Health Organization also cites research demonstrating that outdoor second-hand smoke can be significant and sometimes reach levels observed indoors. Concentration levels depend on the number of cigarettes smoked, location of adjacent walls, and meteorological conditions (wind speed and direction).8
As well, e-cigarette aerosol is not harmless and can contain harmful and potentially harmful constituents including nicotine, ultrafine particles; flavourings such as diacetyl, a chemical linked to serious lung disease; volatile organic compounds such as benzene, which is found in car exhaust; and heavy metals, such as nickel, tin, and lead.9
There are a number of reasons to restrict or prohibit smoking and vaping outdoors, including protecting children from social exposure to smoking, vaping and other industry products, assisting smokers who are trying to quit, supporting ex-smokers from starting to smoke again, reducing butt litter and risk of fire, and in some circumstances, offering protection from exposure to second-hand smoke, third-hand smoke, and potentially harmful e-cigarette aerosol.Error! Bookmark not defined.
Denormalization and Role Modeling
In 2015, young adults were most likely to smoke compared to other age groups.Error! Bookmark not defined. School and community environments play an important role in influencing young people’s smoking behaviour. Strong and well-enforced tobacco policies in these environments have demonstrated positive effects on controlling the prevalence of smoking behaviours.10
Smoking restrictions, both indoors and outdoors, help decrease the social acceptability of smoking and challenge the perception among youth that “everybody smokes”. If children and youth are not exposed to smoking behaviour, they may be less likely to think of it as normal and be able to resist peer pressure and other incentives to start smoking.9
Impact on Quitting Smoking
Smoke-free public spaces provide a supportive environment for people who wish to stop smoking. Research has demonstrated that when smoking bans have been implemented in workplaces and communities, many smokers have chosen to cut back or quit smoking entirely.11 The Ontario Tobacco Research Unit conducted a survey in 2015 regarding outdoor Smoke Free Ontario Act regulations and found that almost half of smokers (42%) believed that the new smoking regulations would help them quit or cut down the number of cigarettes smoked.12
The Tobacco End Game for Canada Background Paper lists banning smoking in additional settings as one of five areas including (post-secondary school campuses, public spaces/workplaces on First Nation reserves, social and other multi-unit housing, and some outdoor public places) that should be scaled up as part of Canada’s Tobacco End Game and highlights that by not doing so, substantial parts of the population continue to be subjected to physical and social exposure to smoking.13
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Community Support and Evaluation
In 2016 a poll was conducted both at Port Stanley Beach and online, to determine if respondents were in support of smoke-free beaches. Overall, there were a total of 1612 poll responses, 72% of which were in favour of smoke-free beaches. When the results were analyzed by poll source, the poll conducted at the beach showed 88% in favour of smoke-free beaches versus the online survey.14 In a 2009 survey conducted by the City of St. Thomas, 75% of respondents were in support of smoking restrictions in parks.15
The evaluation City of Woodstock Outdoor Smoke-free Spaces Bylaw found that most smokers (73%) and non-smokers (92%) supported the bylaw one year after implementation and one third (33%) of smokers felt the bylaw helped them to reduce the number of cigarettes they smoke. The bylaw has had no impact on the way people use city facilities or businesses.16
This figure (right) from the Ontario Tobacco Research Unit’s 2017 Smoke-Free Strategy Monitoring Report, shows rates of agreement that smoking should be banned in many outdoor spaces.17
Bylaws in Other Jurisdictions
The Propel Centre for Population Health Impact at the University of Waterloo conducted research regarding the impact of smoke-free bylaw implementation on municipal resources. No area municipality surveyed reported that they hired additional enforcement staff as a result of their community's smoke-free by-law. Most municipalities (95%) posted signage to support awareness of their by-law; signs costs ranged from $40-$150/sign with most municipalities reporting signs were made in- house. Most communities reported actively enforcing the by-law; six communities reported they had issued tickets to people not in compliance with outdoor smoking restrictions. Their research concluded that the implementation, promotion, and enforcement of outdoor smoke-free by-laws have required municipal staff time and, in most cases, have promotional costs, but these have come from existing budgets and using existing staff. Outdoor smoke-free by-laws have not created significant burdens on municipal enforcement staff or on municipal budgets.18
Many municipalities in Ontario have introduced bylaws that go beyond the Smoke-Free Ontario Act to protect people from the dangers and potential dangers of smoking,
Page 4 of 8 vaping, and second-hand smoke. Examples of municipalities with smoke-free bylaws are below:
Municipality Year Bylaw Smoking Prohibited Products Passed/ Amended Amherstburg19 2016 Beaches; Cigarettes, Cigars, Outdoor Events; Pipes, Electronic Playgrounds, which may Smoking Devices, include Splash Pads and Other Tobacco Wading Pools; Products, Other Sports and Recreational Weeds and Fields and Facilities; Substances, Trails; Waterpipes Waterpipes (outdoors). Township of 2016 Beaches; Cigarettes, Cigars, King20 E-cigarettes (indoors); Pipes, Electronic E-cigarettes (outdoors); Smoking Devices, Municipal Property; Other Tobacco Parks; Products, Other Playgrounds, which may Weeds and include Splash Pads and Substances, Wading Pools; Waterpipes Sports and Recreational Fields and Facilities; Trails; Waterpipes (indoors); Waterpipes (outdoors). Cobourg21 2015 Beaches; Cigarettes, Cigars, Doorways, air intakes, Pipes, Other operable windows; Tobacco Products Municipal Property; Parks; Playgrounds, which may include Splash Pads and Wading Pools; Sports and Recreational Fields and Facilities; Transit Shelters/Stops. Chatham- 2014 Beaches; Cigarettes, Cigars, Kent22 Doorways, air intakes, Pipes, Other operable windows; Weeds and Municipal Property Substances, Parks; Waterpipes Playgrounds, which may include Splash Pads and Wading Pools; Sports and Recreational
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Fields and Facilities Trails; Transit Shelters/Stops; Waterpipes (outdoors).
Implications for Southwestern Public Health:
Southwestern Public Health will:
1. Include cautionary messages to the public regarding the known and potential risks associated with second-hand smoke and vaping aerosols exposure in outdoor spaces. 2. Continue to evaluate new research as it becomes available and review the organization’s position on smoke-free outdoor spaces, as necessary. 3. Advocate for smoke-free outdoor public spaces and municipal property inclusion in local by-laws and policies, not included in the Smoke-Free Ontario Act. 4. Promote bylaw/policy changes, including possible signage. 5. Support bylaw enforcement officers with enforcement of the Smoke-Free Ontario Act, as it relates smoke-free outdoor spaces.
References:
1 Canadian Community Health Survey (2015-2016), Statistics Canada, Share File, Ontario MOHLTC. 2 Pipe, A., & Papadakis, S. (2014). Ottawa model for smoking cessation in Ontario primary care teams: annual report 2013-14. Ottawa. Retrieved from https://ottawamodel.ottawaheart.ca/sites/ottawamodel.ottawaheart.ca/files/omsc_w hatsnew/omsc_in_pc_annual_report_2013-14_final.pdf
3 Public Health Agency of Canada. (2016). Health status of Canadians 2016. Ottawa: Public Health Agency of Canada. Retrieved from https://www.canada.ca/en/public- health/corporate/publications/chief-public-health-officer-reports-state-public-health- canada/2016-health-status-canadians.html
4 Clean Air Coalition British Columbia. (2018). Tobacco statistics. Retrieved from https://www.cleanaircoalitionbc.com/newsroom/tobacco-statistics
5 Smoke-Free Ontario Modernization Steering Committee. (2017). Smoke-free Ontario modernization. Retrieved from http://www.health.gov.on.ca/en/common/ministry/publications/reports/sfo_moderni zation_esc_2017/sfo_modernization_esc_report.pdf
6 Health Canada. (2017) Risks of Smoking. Retrieved from https://www.canada.ca/en/health-canada/services/smoking-tobacco/effects- smoking/smoking-your-body/risks-smoking.html
7 Klepesis, N., Ott, W., & Switzer, P. (2007). Real-time measurement of outdoor tobacco
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smoke particles. Journal of the Air and Waste Management Association, 57(5). Retreived from https://dph.georgia.gov/sites/dph.georgia.gov/files/Real%20- time%20Measurement%20of%20Outdoor%20Tobacco%20Smoke%20Particles.pd f
8 World Health Organization. (2007). Protection from exposure to second-hand tobacco smoke. Geneva: World Health Organization. Retrieved from http://www.who.int/tobacco/resources/publications/wntd/2007/PR_on_SHS.pdf
9 U.S Department of Health and Human Services. (2016). E-Cigarette use among youth and young adults: a Rerport of the surgeon general. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved from https://e- cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf
10 Shields, M. (2015). The journey to quitting smoking. Health Reports. Statistics Canada Catalogue no. 82-003. Vol. 16, no. 3. Accessed October 3rd, 2018. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-003- x/2009003/article/10904/findings-resultats-eng.htm
11 Barnoya, J., Corral, J. E., Hyland, A. (2012). Smoke-free air polices: Past, present and future. Tobacco Control, 21(2). Retrieved from https://tobaccocontrol.bmj.com/content/21/2/154
12 Dubray, J., Minichiello, A., & Schwartz, R. (2017). Evaluation of the Smoke-Free Ontario Act outdoor smoking. Toronto: Ontario Tobacco Research Unit. Retrieved from https://otru.org/wp-content/uploads/2017/07/Special-New-Measures-March- 2017.pdf
13 Tobacco Endgame Steering Committee and Action Groups. (2016). A Tobacco Endgame for Canada. Retrieved from https://www.queensu.ca/gazette/sites/default/files/assets/attachments/EndgameSu mmit-Backgroundpaper%20.pdf
14 Elgin St. Thomas Public Health. (2017, January 11). Board of Health meetings. Retrieved from Elgin St. Thomas Public Health: https://www.elginhealth.on.ca/sites/default/files/file-attachments/basic- page/january_board_package_-_open_session.pdf
15 City of St. Thomas. (2009, October 5). City of St. Thomas. Retrieved from https://www.stthomas.ca/
16 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to guide action: comprehensive tobacco control in Ontario. Toronto: Ontario Agency for Health Protection and Promotion. Retrieved from https://www.publichealthontario.ca/en/eRepository/Evidence%20to%20Guide%20
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Action%20-%20CTC%20in%20Ontario%20SFO-SAC%202010E.PDF
17 Ontario Tobacco Research Unit. Smoke-free Ontario strategy monitoring report. Toronto: Ontario Tobacco Research Unit, Special Report, March 2018. Retrieved from https://www.otru.org/category/strategy-monitoring-reports/
18 Kennedy, R., Zummach, D., Filsinger, S., & Leatherdale, S. (2014). Reported municipal costs from outdoor smoke-free by-laws-experience from Ontario, Canada. Tobacco Induced Diseases, 12:4. Retrieved from https://tobaccoinduceddiseases.biomedcentral.com/articles/10.1186/1617-9625- 12-4
19 NSRA's Smoke-Free Laws Database. (2016). Retrieved March 23, 2017, from Non- Smokers' Rights Association: http://database.nonsmokersrights.ca/bylaw/amherstburg/
20 NSRA's Smoke-Free Laws Database. (2016). Retrieved March 3, 2017, from Non- Smokers' Rights Association: http://database.nonsmokersrights.ca/bylaw/king- township/
21 NSRA's Smoke-Free Laws Database. (n.d.). Retrieved March 03, 2017, from Non- Smokers' Rights Association: http://database.nonsmokersrights.ca/bylaw/by-law- no-019-2015-a-by-law-to-prohibit-smoking-and-the-use-of-tobacco-products-in- public-places-in-the-town-of-cobourg-by-law-no-02-2003-by-law-no-063-2010-by- law-no-12-2011-and-by-law-no-077/
22 Non-Smokers' Rights Association. (n.d.). Retrieved from NSRA's Smoke-Free Bylaws: https://database.nonsmokersrights.ca/bylaw/chatham-kent/
Definitions:
Electronic Cigarette (e-cigarette): E-cigarettes are battery powered and contain an atomizer that heats the liquid and turns it into a vapour that resembles smoke. E- cigarettes are sometimes called e-cigs, vapes, vape pens, and e-hookahs. E-cigarettes sometimes look like regular cigarettes, cigars, pipes, pens, USB flash drives or other everyday items.
Second-Hand Smoke: tobacco smoke that is exhaled by smokers of is given off by burning tobacco.
Third-Hand Smoke: Smoke that persists for months and even years that settles on surfaces (carpets, curtains, furnishings) and in dust form which can produce off-gassing.
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POSITION STATEMENT Position Title: Second-Hand Smoke in Multi-Unit Housing Approved by: Cynthia St. John, Chief Executive Officer Dr. Joyce Lock, Medical Officer of Health Board of Health for Oxford Elgin St. Thomas Health Unit Date Approved: Date Effective: Date Revised: Contact: Gemma Urbani, Tobacco Control Coordinator Ashlyn Brown, Health Promoter
Position of Southwestern Public Health:
1. Southwestern Public Health supports both for-profit and not-for-profit landlords creating a smoke-free multi-unit housing policy to protect the health of tenants. 2. No amount of second-hand smoke exposure is safe. Breathing in any amount of cannabis or tobacco smoke can negatively impact health. Furthermore, cannabis and tobacco smoke have been shown to have many of the same toxic chemicals. 3. There is a dose-response relationship with exposure to second-hand smoke. The more exposure one has, the greater damage is done to one’s health. Second- hand smoke is more concentrated in enclosed settings such as homes and vehicles. 4. Drifting second-hand smoke is an environmental carcinogen that travels through ventilation systems, underneath doors, through window cracks and by other means. 5. Children have higher breathing rates than adults and are subsequently more vulnerable to the effects of second-hand smoke exposure, particularly in enclosed settings. 6. Regular exposure to drifting second-hand smoke, particularly in enclosed settings such as multi-unit housing, can lead to chronic diseases such as lung cancer, heart disease and even death. 7. Third-hand smoke which is the residual gases, chemicals and heavy metals that remain long after a cigarette is extinguished can produce off-gassing for weeks, or even months after vacancy and is now understood to be a public health hazard. Third-hand smoke like second-hand smoke is of concern for young children, 2
especially when exposed long-term. 8. There is increasing public demand for smoke-free housing in the province of Ontario and within Southwestern Ontario. 9. Residents of low-income housing do not have the same options as mid-to-high income earners to live in housing free from exposure to second-hand and third- hand smoke. This disparity must be addressed by increasing the availability of smoke-free housing.
Rationale:
Smoking Prevalence
From 2015-2016, there were higher proportions of adults who were current smokers (daily and occasional), daily smokers and former smokers in the SWPH region compared to Ontario (Figure 1). About one-third (34.0%) of adults living in the SWPH region completely abstained from smoking cigarettes in their lifetime compared to 44.8% of adults in Ontario.1
Figure 1. Age-standardized smoking status, adults 20 years and older, Southwestern Public Health and Ontario, 2015-20161
Health Effects
Second-hand smoke contains over 4000 chemicals, over 70 of which are known to cause cancer.2 Scientific evidence indicates there is no risk-free level of exposure to second- hand smoke and breathing any amount can be harmful to health.2 Non-smokers who are regularly exposed to second-hand smoke have a higher risk of getting lung cancer, heart disease as well as other types of cancer.2 While a number of multi-unit residents take precautions to ensure second-hand smoke does not seep into their units, it cannot be fully controlled by ventilation or air duct cleaning.3 In June 2005, the American Society of Heating, Refrigerating and Air Conditioning Engineers stated that, “the only means to effectively eliminate health risks associated with indoor exposure [to second-hand smoke] 3
is to ban smoking activity”.3
Data from the Ontario Tobacco Research Unit about third-hand smoke (gases, chemicals and heavy metals that persist after a cigarette is extinguished) indicates that off-gassing of toxic substances can occur for weeks and even months after a cigarette is extinguished. Some of these substances are carcinogenic or otherwise toxic for human health. This presents a health risk for people exposed to third-hand smoke, especially small children who are physiologically vulnerable and may be directly exposed through contact with contaminated surfaces such as carpets, upholstery and clothing4.
Statistics Canada reports that having a low income is associated with having more chronic health conditions [including those precipitated by smoking] than individuals with a higher income5. The social determinants of health explain that individuals and families with less education and subsequently less income are more likely to suffer from poor health and engage in unhealthy behaviours such as smoking which may lead to exposure to second- hand smoke, than those with a higher income and education.
Since families and tenants living in multi-unit housing, particularly those living in geared-to- income housing, are more likely to have a low household income and lower level of education than families living in single homes, they are already at increased risk for chronic health conditions.5 Residents of multi-unit housing, particularly young children, do not have the choice or ability to remove 100% of drifting second-hand smoke from their unit/home, unless they are able to move out. Due to financial circumstances, moving out is often not an option. Implementing smoke-free policies in affordable and community housing addresses health inequalities that tenants may face from disproportionate second-hand smoke exposure and limited options for housing that is affordable and safe.5
Public Support
Evidence from survey data suggests that there is strong support for smoke-free housing and that 80% of tenants, if given the choice, would choose smoke-free housing.8 In 2018, Public Health conducted a smoke-free housing survey of all social housing units owned and operated by Oxford County. The results from the survey indicated that 51.9% of those who responded to the survey indicated they wanted some parts of their housing community to be smoke-free, 34.7% did not want their housing community to be smoke- free and 13.4% did not know whether they wanted their housing community to be smoke- free.1
The Region of Waterloo Public Health conducted a post implementation smoke-free housing policy survey which indicated tenants of Waterloo Region Housing often did not complain even when they were affected by second-hand smoke because they did not want to create conflict with neighbouring tenants6. This indicates the extent of the negative effects of exposure to second-hand and third-hand cannot be determined solely based on the number of complaints received.
Safety and Fire Risk
According to the Office of the Ontario Fire Marshall, cigarettes, pipes and cigars are the
4
leading sources of ignition in fatal residential fires in Ontario. From 1998 to 2007, cigarettes were responsible for almost 600 fires per year, and over one quarter (29%) of all fire deaths. Data from the St. Thomas Fire Department indicates that 6 fires in 2015, 4 fires in 2016 and 7 fires in 2017 were caused by smoking materials. Multi-unit housing that become 100% smoke-free can reduce their risk of fire and be a safer place for people, non-smokers and smokers alike to live7.
Cost
Smoke-free housing policies can have economic benefits. Landlords typically report that it cost two to three times more to turn over a smoking unit verses a non-smoking unit. Items such as sanding and cleaning to remove tar and nicotine, stain killer primer, and extra paint contribute to these costs. Annual economic savings from prohibiting smoking in all U.S. community-based public housing were estimated at $521 million per year, including $341 million in second-hand smoke related health care expenditures, $108 million in renovation expenses and $72 million in smoking-attributable fire losses.8
The Rights Debate
There is no inherent “right to smoke” anywhere in Canadian law. Second-hand smoke has been identified as a breach of the covenant of reasonable enjoyment at the Ontario Landlord and Tenant Board. There have been multiple cases at the landlord tenant board where tenants have been evicted for smoking by affecting someone else’s reasonable enjoyment of their rental space. It is important to note that smoke-free housing policies do not prohibit smokers from renting or buying accommodation, do not mean people will be evicted for simply being smokers, and do not force people to quit smoking.9
Gaining Momentum in other Jurisdictions
In recent years, more and more municipalities have acknowledged the implications of drifting second-hand smoke and have subsequently begun to pass smoke-free indoor policies. As of December 2016, 26 Ontario municipal providers of community housing have adopted, or are in the process of adopting, smoke-free policies.5 Leading private sector property managers and landlords such as Realstar, Skyline Living, and Drewlo Holdings have also implemented smoke-free policies. The table below includes a sample of some of the municipalities that have passed smoke-free policies. For a list of municipalities that have implemented smoke-free housing policies, please visit http://www.smokefreehousingon.ca/sfho/directory.html.
5
Municipality Haliburton Community Kingston & Frontenac Housing Corporation Housing Corporation South Chatham Village District of Timiskaming Social Services Apartments Spruce Lodge Non-Profit Millbrook non-profit Housing Housing, Stratford Waterloo Region Housing Durham Region Non-Profit housing Bruce County Housing Corporation Nepean Housing Corporation County of Lambton Housing Services Port Hope Housing Corporation Department Grey County and Owen Sound Housing District of Thunder Bay Housing Corporations Ottawa Community Housing City of Timmins Huron County Housing Region of Niagara Housing Simcoe County Housing Windsor Essex Community Housing Barrie Municipal Non-Profit Housing Durham Region Non-Profit housing Hastings Local Housing Corporation County of Wellington Housing Cambridge Non-Profit Housing Kingston & Frontenac Housing Corporation Corporation Chatham-Kent Housing District of Timiskaming Social Services Huron County Housing Corporation Millbrook non-profit Housing County of Northumberland Housing City of St. Thomas Social Housing
Implications for Southwestern Public Health:
Southwestern Public Health will: 1. Include cautionary messages to the public regarding the harms associated with second-hand smoke exposure in multi-unit housing. 2. Continue to evaluate new research as it becomes available and review the organization’s position on smoke-free multi-unit housing as necessary. 3. Support and advocate for municipally owned social housing, other social housing providers, supportive housing providers, and private landlords in developing and implementing smoke-free housing policies in Elgin County, the City of St. Thomas, and Oxford County. 4. Southwestern Public Health will work with housing providers to create and implement policies that protect the health of residents. 5. Respond to complaints received by the public on drifting second-hand smoke exposure in multi-unit housing and providing both tenants and landlords with relevant information and suggestions to improve or amend the health and safety concerns. 6. Work with community and public health partners such as the South West Tobacco Control Area Network to educate about smoke-free housing and advocate for smoke-free housing.
References:
1 Canadian Community Health Survey (2015-2016), Statistics Canada, Share File, Ontario MOHLTC.
2 Canadian Cancer Society. (2019). What is second-hand smoke? Retrieved from http://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/make- healthy-choices/live-smoke-free/what-is-second-hand-smoke/?region=ab
3 American Society of Heating, Refrigerating and Air Conditioning Engineers. (2016). Environmental Tobacco Smoke. Retrieved from: https://www.ashrae.org/about- ashrae/position-documents
4 Ontario Tobacco Research Unit. (2012). Putting third-hand smoke on the policy and research agenda: knowledge user survey results. Retrieved from https://otru.org/wp-content/uploads/2012/11/update_nov2012.pdf
5 Non-Smokers’ Rights Association (2012). Smoke-Free Affordable Housing: Picking on Poor People or a Case for Social Justice. Retrieved from http://www.nsra- adnf.ca/cms/index.cfm?group_id=1901
6 Program Training and Consultation Centre. (2010). The Development of a Smoke-free Housing Policy at the Region of Waterloo: Key Success Factors and Lessons Learned from Practice. Retrieved from: https://www.ptcc- cfc.on.ca/common/pages/UserFile.aspx?fileId=104038
7 The Ontario Office of the Fire Marshal. (2017). Fire Loss in Ontario 2011-2016: Causes, Trends and Issues. Retrieved from https://www.mcscs.jus.gov.on.ca/english/FireMarshal/MediaRelationsandResources/Fi reStatistics/OntarioFires/FireLossesCausesTrendsIssues/stats_causes.html
8 Smoke-Free Housing Ontario. (2014). Smoke-Free Policies Make Good Dollars and Sense: The Business Case for Smoke-Free Multi-Unit Housing. Retrieved from http://smokefreehousingon.ca/wp-content/uploads/2014/10/business-case-for-sf- housing-2014.pdf
9 Non-Smokers Rights Association. (n.d.). Human Rights and No-Smoking Policies for Multi-Unit Dwellings. Retrieved from https://smokefreehousingon.ca/wp- content/uploads/2015/12/human_Rights_and_SF_MUDs.pdf
3.4 CEO REPORT Open Session
MEETING DATE: April 10, 2019
SUBMITTED BY: Cynthia St. John, CEO
SUBMITTED TO: Board of Health Finance & Facilities Standing Committee Governance Standing Committee Transition Governance Committee
PURPOSE: Decision Discussion Receive and File
AGENDA ITEM # 6.6
RESOLUTION # 2019-BOH-0410-6.6
1) Ontario Minister of Health Announcement re: Ontario Health Super Agency (Receive and File):
As you are aware, on February 26, 2019, Health Minister Christine Elliott announced the launch of Ontario Health, a super agency which will represent the amalgamation of the province’s 14 Local Health Integration Networks (LHINs) as well as six significant provincial health care agencies: • Cancer Care Ontario • eHealth Ontario • Trillium Gift of Life Network • Health Shared Services • Health Quality Ontario • HealthForce Ontario Marketing and Recruitment Agency
The announcement included information on the formation of 30-50 Ontario Health Care Teams that will be created across the province and made up of hospitals, long term care homes, home care agencies and other local partners. These teams will come together as “integrated care entities” supporting the health are journeys of approximately 300,000 patients each. All of
1 | Page
these changes will be contained within The People’s Health Care Act, 2019, which Minister Elliott tabled in the legislature on February 26, 2019.
There was no specific mention in Minister Elliott’s messaging about public health. I will continue to watch closely for updates that impact our reporting relationship with the Ministry and our funding model and I will update the Board accordingly.
2) SWPH General Update (Receive and File):
2.1 General Matters
2.1.1 Quarterly Meeting Evaluation (Receive and File): In 2018, the Board adopted a quarterly Board of Health meeting evaluation tool. Evaluation supports the organization by gathering evidence to strengthen effectiveness and evaluation is a core element of public health work. Results from each quarterly Board of Health meeting evaluation will be tabulated and shared with the Board. The first evaluation for 2019 will occur at this meeting.
Please click here to access the quarterly meeting evaluation form. Board members are asked to complete this evaluation following the April 2019 Board meeting and no later than April 19, 2019.
2.1.2 Board Member Attendance at alPHa Conference (Receive and File): Joyce Lock and Lee Rowden attended the Association of Local Public Health Agencies Winter 2019 Symposium on February 21st and 22nd representing SWPH. I was unable to attend due to a family illness.
In addition to key areas of focus including Making the Connection Between Public Health and Mental Health and Managing Risk in Public Health, a Board of Health Orientation Session was provided to Board of Health members in attendance with information related to their roles and responsibilities as Board of Health members. Attendees also had the opportunity to hear from special guest speakers such as Dr. Rueben Devlin, Special Advisor and Chair of the Premier’s Council on Improving Health Care and Ending Hallway Medicine.
In addition, alPHa has released a draft program (attached) for the 2019 Annual General Meeting and Conference on June 9-11, 2019 in Kingston, Ontario. Online registration will open in April. If any member of the Board is interested in attending, please let either Tiffany or I know.
2.2 Previous Meeting Follow Up
2.2.1 Request for Vision Screening Funding (Receive and File): Staff was asked to draft correspondence to the Ministry of Health and Long Term Care concerning funding for the new vision screening program outlined in the new Ontario Public Health Standards. That letter has been completed.
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2.3 Corporate Services Matters
2.3.1 Records Information Management Update (Receive and File): During the month of April, SWPH will be going live with the full-scale deployment of SWPH’s records information management and classification retention system. SWPH commenced this project in October of 2018 with the intent of establishing consistent records management, to mitigate the risk of managing volumes of public health records, to ensure that staff have readily available access to records and information for day-to-day operations and program delivery, and to enhance efficiency in our work. SWPH will also create fully customizable forms that will help to reduce the volume of paper used, accelerate reviews and approval processes, and strengthen our accountability with immediate notifications to approvers. SWPH will be able to track exactly where documents are stored and who is working on them. This new system will also allow SWPH to have multiple users working simultaneously on a single process without file duplication and potential loss of a record.
2.3.2 Roll-out of Web/Video Conferencing Capability Across SWPH Sites (Receive and File): SWPH rolled out a new web/video conferencing software contained in our current suite of office computer software. This software allows teams to videoconference and collaborate regardless of physical geographic site. SWPH identified the need and implemented a user-friendly digital tool that will increase our face-to-face familiarity with one another, allow teams to connect with one another, share documents to enhance the meeting experience and reduce the need for individuals to travel between sites to attend team meetings.
MOTION: 2019-BOH-0410-606 That the Board of Health for Southwestern Public Health accept the Chief Executive Officer’s Report for April 10, 2019.
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MINDING PUBLIC HEALTH 2019 alPHa Annual Conference June 9 – 11, Four Points by Sheraton, 285 King St., Kingston ON
DRAFT PROGRAM-AT-A-GLANCE *
*all events held at conference hotel unless otherwise indicated updated 2019-03-04
Sunday, June 9, 2019 2:00 – 4:00 Guided Walking Tour of Downtown Kingston
Meeting place: Lobby of Four Points hotel (to be confirmed)
Tour Guides: • Dr. Charles Gardner, Medical Officer of Health, Simcoe Muskoka District Health Unit • Susan Cumming, RPP, Adjunct Lecturer, Queen’s University and Past President, Ontario Professional Planners Institute
2:00 – 5:30 Registration
4:00 – 6:00 alPHa Board of Directors Meeting Offsite – see description Location: KFL&A Public Health, 221 Portsmouth Ave., Kingston
Trolley buses depart hotel 5:30 pm to health unit; depart health unit 7:00 pm to hotel.
Special thanks to trolley sponsors Shoalts and Zaback Architects Ltd., designers of KFL&A Public Health’s new office.
6:00 – 7:00 Opening Reception Offsite – see Greetings by Mark Gerretsen, MP, Kingston and The Islands (to description be confirmed)
Location: KFL&A Public Health, 221 Portsmouth Ave., Kingston
Special thanks to KFL&A Public Health for sponsoring the reception.
Monday, June 10, 2019 7:00 – 8:00 Continental Breakfast & Registration
8:00 – 10:00 Annual General Meeting and Resolutions Session
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AGM and Resolutions Chair: Robert Kyle, alPHa President (to be confirmed)
10:00 – 10:30 Fitness Break
10:30 – 10:35 Welcoming Remarks by Bryan Paterson, Mayor of Kingston (to be confirmed)
10:35 – 11:45 Opening Plenary Session • Dr. Theresa Tam, Canada Chief Public Health Officer (confirmed) • Hon. Christine Elliott, Minister of Health & Long-Term Care (to be confirmed)
11:45 – 1:30 Distinguished Service Awards Luncheon
1:30 – 3:00 Plenary Session: Panel on Mental Health & Public Health – Part I (Downstream Focus) Much of public health’s work centers on upstream approaches to keep the population healthy. In times of crisis and emergencies, however, public health finds it must employ downstream interventions and strategies to save lives. This session will examine how public health and community partners can best work together to address mental health issues from a downstream perspective using the current opioid epidemic as an example.
Moderator: Nadia Zurba, Senior Manager, Ontario Harm Reduction Distribution Program (confirmed) Panelists: • Antje McNeely, Chief of Police, Kingston Police (confirmed) • Monika Turner, Director of Policy, Association of Municipalities of Ontario (confirmed) • TBD
3:00 to 3:30 Break
3:30 to 5:00 Plenary Session: Panel on Mental Health & Public Health – Part II (Upstream Focus) Amidst the growing mental health crisis, there is increasing recognition that getting at the root causes of mental illness and preventing them in the first place will mitigate their negative health impacts at personal and societal levels. This session will focus on the upstream approach that public health and education partners are taking to address the mental health crisis both individually and collectively.
Moderator: TBD
Panelists:
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• Dr. Andrea Feller, Associate Medical Officer of Health, Niagara Region Public Health (confirmed) • TBD • TBD
5:30 to 7:00 Reception (sponsored by Lone Star Texas Grill) Offsite – see Refreshments provided; cash bar. description
Location: Lone Star Texas Grill, 251 Ontario St., Kingston (a 5- minute walk from the Four Points hotel)
7:00 onward Delegates on their own for dinner
Tuesday, June 11, 2019 7:30 – 8:30 Continental Breakfast
8:30 – 9:00 Plenary Session: Lyme Disease Update
Speaker: Dr. Kieran Moore, Medical Officer of Health, KFL&A Public Health (confirmed)
9:00 – 12:00 Concurrent Section Meetings (Boards of Health Section, COMOH)
12:00 Conference Ends
Delegates on their own for lunch
12:30 – 1:30 Inaugural alPHa Board of Directors Meeting
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