The Committee met at 9:00 a.m. in the House of Assembly.

MR. CHAIRMAN (D. Gilbert): Order, please!

I think we can now open this committee meeting. There are a couple of little formalities we have to take care of first. I believe the Clerk is supposed to conduct an election, or is that already done from last year?

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: That's alright; we're alright, are we? We're confirmed from last year, so I don't have to subject myself to a vote today. I am very glad of that.

In that case, I will welcome the Minister of Health and his officials to this meeting. The procedure for these Estimates Committee Meetings is that the meeting will go on until 12:00 and if we feel that we can get the heads closed at 12:00, or a short time thereafter, we will carry on for a short time thereafter. If we feel that it's going to require more than ten or fifteen minutes past the three hours, we will adjourn at 12:00 to meet again another day.

Maybe for the sake of some of the officials I'll introduce the Committee before I ask the minister to introduce his staff. I point out that the Committee will introduce themselves, and then any members who are here who are not on the Committee can introduce themselves.

The way that they are recognized is that I will start off and the minister will have an opening statement. Then, as I understand, Mr. Sullivan will be the critic and he is going to have ten minutes - fifteen for the minister and ten for the critic - to respond, I think is the way that it has been done. Then, it goes into a period and the member can use the ten minutes to talk to the minister, or they can use the ten minutes in between to question the minister and get the answer back, but that's the procedure, is it?

AN HON. MEMBER: Ten minutes total.

MR. CHAIRMAN: Ten minutes total.

If the member wants to talk to the minister and praise him up or whatever for ten minutes, that's fine, I am sure he will take that; or if he wants to ask a question and then wait for a response, the ten minute period will be in effect.

The members who are not members of the Committee, the members of the House, are allowed to ask questions, but it is by leave of the committee, as I understand it, is the way it has worked; is that not so?

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: Very good.

My name is David Gilbert; I am the MHA for Burgeo - Bay d'Espoir, and I am Chairman of this committee.

MS. VERGE: Lynn Verge, MHA, Humber East.

MR. HARRIS: Jack Harris, MHA, St. John's East.

MR. LANGDON: Oliver Langdon, MHA, Fortune - Hermitage.

MR. SMITH: Gerald Smith, MHA, Port au Port.

MR. SULLIVAN: Loyola Sullivan, and I am sitting in as the Opposition health critic.

MR. HODDER: Harvey Hodder, MHA, Waterford - Kenmount.

MR. CAREEN: Nick Careen, MHA, Placentia.

MS. YOUNG: Kay Young, MHA, Terra Nova.

MR. CHAIRMAN: Welcome, Mr. Minister. If you would now introduce your officials, make your opening remarks, then we will get on with the Estimates Committee which we hopefully can conclude this morning.

I would say for the members of your executive, that if they are going to question, that they identify themselves first for the sake of the people who are doing the copying up there. They recognize some of our voices. Yours they might not recognize as readily.

Mr. Minister.

DR. KITCHEN: Thank you, Mr. Chairman.

Ladies and gentlemen, it is a privilege for us to be here today and to be able to tell you all the wonderful things we have done in the Department of Health and all the things we hope to do, and some of the problems we have encountered and are encountering.

On my right is the Deputy Minister of Health, Dr. Robert Williams. On his right is Ms. Joan Dawe, who is the assistant deputy minister in charge of community health. On her right is Ms. Primrose Bishop, who is the assistant deputy minister responsible for all institutions except the Waterford, which comes under Ms. Dawe, and then the assistant deputy minister, Gerald White, who is responsible for policy and just about everything else, odds and ends.

AN HON. MEMBER: Policy and programs.

DR. KITCHEN: Policy and programs.

On the far right is Mr. John Downton, whose responsibility has to do with drug programs; Mr. Chris Hart, who is the Assistant Deputy Minister in charge of Finance and Administration and next to him is Max Osmond who is the Director of Finance and Operations and then our new member, just recently here, Mr. Denis Davis who is the Director of Ambulance and Emergency Health Services which includes the (inaudible).

We are very pleased to be here and I would like to set the stage for indicating some perspective as far as the departments are concerned. Health is changing very rapidly everywhere and is certainly changing rapidly in Newfoundland. We are putting a lot more emphasis than we have been in the past on things like illness prevention, health promotion, early recognition of diseases so we can do something about it and certain other points. Let me have a few words about health promotion first.

We have launched as you know, our smoking campaign, it was talked about a lot last year and that's going ahead fairly well, with the new legislation to be implemented in June. We are concerned also about alcohol, the ease with which alcohol is available in this Province, we recently had a very private conference here we had seventy or eighty people gathered together to try to get some new initiatives in this whole question of alcohol which probably is more serious in this Province than is smoking even, because of the tremendous social implications it has, virtually all crime in the Province is related to alcohol, not all but almost all. The battering and the abuse and things of that nature. a lot of it is health related; a lot of the reasons people are in hospitals. Excessive alcohol exacerbates the problem so we want to move into that but we haven't yet, not in a very great way.

We are also thinking, and we have had some discussions about where we should go and putting a heavier focus on nutrition. I think nutrition is very important in disease prevention and so this whole question is push, we are pushing quite heavily. Now the other measure, the early recognition of diseases, for example: may be not generally known but half the diabetics in Canada and half in Newfoundland roughly, are unknown; they don't know they have this disease and that's a disease in many cases, which, if arrested early can prevent even more serious consequences from happening because things can happen by appropriate diet and taking care of ourselves and so on, so if we put more emphasis on prevention, our health care budget - people will live longer and happier and healthier lives and health care, and hospital budgets may decline.

Also, we are putting emphasis on community health. We have set up some community health boards and hope to set up others which have the responsibility of bringing in more appropriate home care. We have home care in some parts of the Province fairly well developed and in others parts there is virtually none, very little except what can be delivered by a public health nurse, so what we want to do with these boards is to have a very carefully well-integrated system of home care and that too will take the pressure off the hospitals. It will enable hospitals to make earlier discharges and to keep people home longer before they are admitted to hospitals and also, it will take the pressure off our very expensive nursing homes, and also, in addition to that many people would prefer if they can, to remain in their homes if they can be appropriately taken care of so these are the initiatives that we are working on and there is more money in the Budget for that.

We have made a fair move on the establishment of these community health boards. We have the St. John's one up and running. The CEO is hired, the board is in place and having meetings, and they will be taking over the budget from the St. John's Home Care Program that was there before and was extended more widely than was. They now have responsibility for all the public health in the area, public health inspectors, for alcoholic and drug dependency, and all those other things that help prevention in this whole general area. We also have the board up and running in Central, not quite up and running, they are in the process of hiring their Chief Executive Officer and a board has been appointed.

We are almost ready to do the same thing in the Eastern Region to appoint the board and to look after the community health in that whole area in the Eastern Region and that is between St. John's and Central, and then we will see what we will do in Western Newfoundland and we are in the process of just trying to figure out what we are going to do in Northern and in Labrador. On the hospital boards: they did report that the St. John's Hospital Board has been appointed for all the hospitals in this area and they are in the process of hiring a Chief Executive Officer so that they should be up and running in several months; it takes a while to get these things finished and there are a number of details to be ironed out with respect to the circumstances under which various hospitals will be coming in. We are working out the details of that now and should be coming along fairly well.

The Central Boards have been established and they are in the process of hiring their Chief Executive Officer, we have made this move and have made it very deliberately and it has great cost implications because we feel that we can reduce administrative costs and by reducing administrative costs we feel that we can preserve money where it can be appropriately spent, which is on the front line health care workers, on the hospital themselves, on the nurses and the doctors and the drugs. There are a few major problems in health care in the Province which I am very concerned about, and one has to do with our drug programs.

We have no comprehensive pharmacare program in this Province, we do have a relatively good pharmacare program for seniors and we have one for people who are on social assistance, neither one of these is perfect but they are there. The weakness occurs for people who are not on those programs and who are not on private programs; we call them the working poor if you like or people who are working for private organizations or who are not working at all and are not on welfare, and if they really get sick, they go into hospital. Their hospitalization is taken care of, doctors are taken care of but if a drug happens to be prescribed they have to figure out whether they are going to eat or buy drugs and for many people we are trying to come up with a program. It is very expensive, our officials are working on it and I have raised it at national meetings to try to get the Federal Government to get in on this and the first time I raised it there wasn't any response, the second time I raised it, several of the other provinces picked up on it. I don't know how far we are going to go on it but that will be a great thing for this Province so that there will be some uniformity across Canada when people get sick because the emphasis on medicines is much better now than it was.

I think, Mr. Chairman, I will conclude here and we are ready for some questions.

MR. CHAIRMAN: Thank you, Mr. Minister.

It was agreed that Mr. Sullivan as the health critic would have ten minutes to respond so, Mr. Sullivan.

MR. SULLIVAN: Thank you, Mr. Chairman.

I have been a little perturbed overall on the basis on which the government is moving in the re-organization of the institutional hospital boards and community health boards, and the minister of the department to my knowledge, has never tabled anything in this House, and I am not aware of any basis upon which this re-organization is occurring from a cost-efficient or a patient services basis.

Now the Dobbin Report does not address the economics of reorganization, it doesn't address in any specific way the improvement of patient care services and these should be the two reasons why we will want to reorganize. Now I am all for efficiencies and all for savings, administratively, and I feel that more dollars should be going into the front lines as the minister stated but really what we have occurring here in the Province - in cases I'll admit and be first to admit there are efficiencies I can see, some efficiencies in some areas but there seems to be nothing more then what an architect could have drawn or an engineer and divided the Province into seven regions and said: here is going to be the regional areas here and here's what we're going to do. If bigger is better, not necessarily at all, I haven't seen any comparisons of the cost of administering larger boards. I'll give just one example, the Burin Peninsula, Bonavista, getting the board together, the cost associated with setting up that board, running the board, scheduling the meetings, reimbursement of operational expenses, et cetera, for people on boards that serve larger regions that could be localized in smaller areas, I haven't seen that. If the department has it I'd very much like to see that.

We have taken this Province and divided it along hypothetical lines. We've attempted to fit the health care system into those specific regions without any strong foundation for doing that. I'm a little perturbed that we proceed without doing analysis and identifying savings. If we're going to spend dollars efficiently in the health care system we must do it on a planned basis and show that there's a rationale for what we're doing and not find out when the next budget is filed on what our costs were for the previous year. It's not the way that I'd like to see it done.

Now, I have great concerns in combining the schools of nursing, the hospital based ones, without any advanced planning. Again, without any consultation occurring in the nursing profession when people in the spring of the year have set career options and probably have waited for a year, two or three to get into nursing schools and do not know, as of this time, what they're going to be doing in September.

We got into a situation in Corner Brook last year, a very similar situation, and again this year. It doesn't show very well the planning that's occurring within the health department. If there are a surplus of nurses in this Province then maybe limiting the entry in the nursing profession could be very well the way to go but if that's the way to go it's got to be done on a planned basis identifying the projections of the nursing requirements in the future so that the nursing schools can meet the expectation level that you need.

We know we're training nurses to go out of this Province, we don't want to do that. We don't want to train doctors to go out of this Province at a cost to taxpayers of the Province. We'd like to be able to serve our own market here with our own people who have a vested interest and want to be here in the Province. That hasn't happened and I don't know but maybe when we get to questions a little later I'd certainly like to know what's happening there. Where is the centre going to be, is it going to be in one area, the number of people, how they're going to be notified? Some of these areas here haven't been addressed and it's very, very unfair to the individuals that are seeking a career in the health care field.

We have limitations on fees for service and limitations on setting up practice here in the City of St. John's and there are drawbacks to that. We are forcing some people to leave this Province. I know doctors who have punched twenty and twenty-five years in rural Newfoundland and have certainly paid their dues in serving the people of rural Newfoundland. With families raised, they have a tendency to move to the City when their kids go to university and elsewhere, and are now prevented from doing that. New doctors are coming out of school with new ideas, new techniques and are more cost efficient.

It's part of their training to be able to make a decision on a certain medical procedure that's cost efficient, too, and still get the desired result. We're losing that new input of ideas and so on that are very effective in maintaining a certain level and a certain degree of efficiency within the medical system here, and that's a big concern of mine.

I have a grave concern with reorganization of boards for the Janeway, for example, which is encompassed under a larger area. Will the Janeway receive its proportionate amount under this budget over all at the most preventive stage of development?

I know from calls I get from all over the Province, too numerable to even mention in cases, that people have been waiting for months - almost nine months - with a psychiatric problem; to get into the Janeway Hospital is impossible. There are four psychiatrists there. I understand there is probably one leaving, for example, not going to be replaced.

Cutbacks of beds is putting an increased pressure upon the community, and this Province, while it's in the embryonic stage of doing it, has not reached a stage whereby reducing hospital beds is going to be positive for the overall health of the people, because we haven't developed a community health system that's going to be able to care for these shorter stay visits at hospital.

We're not going to increase the number of nurses out in community health who are going to have to attend to people who stay in a hospital, even day procedures at the outpatients' department; visiting the hospital probably reduced to two days for certain procedures, and they are having extra pressure upon the people out in the field, and we are pushing people out of hospital beds and reducing numbers when the people are overworked as it is and are not ready to be able to involve that in the process. This has to be a gradual lessening of hospital beds, if that's in the direction we're going, and build a structure out there to be able to encompass that there and be able to deliver health at a cheaper price.

I don't see any indication where there are going to be new people hired in the front lines out in the field. I do see, in this budget, where there's an increase from $1.5 million to $2.5 million in transportation and communications over the health budget. I total up the headings under transportation and communications, $1,552,700 to an increase of $2,588,500. I see an increase in transportation and communications, and I see increases in certain other areas of service, but I don't see an increase in the front line service. I see a reduction in the number of positions and people employed in the front lines. I see people pushed out of hospitals and out into the community where they have to be cared for by community people with no increase in the number of personnel there, I am seeing in the system.

I am delighted to see cardiovascular surgery addressed because I think it's a very life threatening disease, and $800,000 allotted there to bring the numbers down to an acceptable level, at least where now you can perform an operation that's not on an emergency basis. That's one positive area over all, but I haven't seen, at least the department hasn't done a good job of letting us know how they're going to achieve efficiencies within the overall confines of the system. They are attempting to achieve efficiencies by limiting what they're going to pay doctors. That's not necessarily going to get the results you want. We're finding that it's very difficult to get specialists in certain areas, where they have less than the number of specialists in certain areas.

We are finding that there are increased pressures on rural Newfoundland now with more outpatient surgeries, with shorter hospital visits. We're finding an increase in rural Newfoundland because people who live greater distances from the hospital can't step in the hospital in five minutes if an infection occurs, or something gets out of control. I know they have doctors in their areas, and that's a cost to, to visit a doctor in an area when a nurse out in community health could be attending to it, so we haven't been structured to incorporate that phase or shift from an institutional type care overall to the hospital care, into a community care, and I believe strongly in developing a strong community care.

Prevention promotion you speak very strongly of, this budget shows an increase under that heading from $14,000 to $43,000 - a $29,000 increase in prevention promotion under that line item there in the budget. I think we need a stronger effort to be put in under prevention promotion. We're not going to see the results today, or probably in ten years time, but I think we have to accelerate our emphasis in that area, and we've got to make decisions that are going to be done on a cost efficient basis, and we have to give a lot more thought to a planning process, and not reacting after the fact.

Thank you, Mr. Chairman.

MR. CHAIRMAN: Mr. Minister, you have ten minutes to respond to that.

DR. KITCHEN: Thank you very much.

I appreciate the comments that the hon. critic has made. Let me try to address the first question as to why we're putting these boards together, and there are a number of reasons.

I take it that we have to accept the proposition that the amount of money we spend on health is going to be pretty restricted. The budget is what we have. Unless times improve greatly, or things change, we will have to live within that budget for a long period of time, for a number of years. Now that means that we have to make sure that the money we have is properly spent rather than improperly spent.

Each board in this Province, and up until recently there were fifty boards in the Province, nursing homes and hospitals, each one of them prepares its own payroll, has its own human resource department, does its own purchasing, basically, does its own accounting, hires its own auditors, and by combining boards this can be done centrally, with much fewer staff, that is a major cost saving. How much it will be I don't know, because it depends on how things work out on these various boards, but it will be substantial. That's one reason for making the move.

Another reason is to try to get a handle on the health care in the Province. Dealing with fifty hospital boards, nursing home boards, individually, is a horrendous undertaking for all the officials in the Department of Health, just look at the communication back and forth between the Department of Health. The boards come in, they want to meet with the officials, they want to meet with the minister.

I won't say every town council in the Province, feel that they have a mandate for health care, so when they come to St. John's on their annual visits, or semi-annual visits, they drop in to see how the hospital is coming on, or how this is coming on.

The time that is spent dealing with all of these multifarious institutions is almost - and that's part of it. Then you have to realize that every health profession has its own professional body. We have a denturist body, you have a denturist association, you have a denturist board. You have the dental association, and you have a board to regulate dentists. We have nursing assistants, and a council of the union, as well as the board that regulates them; nurses and the professional association of nurses, doctors, and so it goes. Then you have every disease, pretty well, with its own association as well. You name the disease and you have an association.

Everyone is at the department's door, so the whole thing is horrendous, meetings and discussions, and back and forth all the time, and what we have to do is rationalize the system so that we can get on with the business of planning and monitoring and controlling. This is the job of the department, to monitor and to plan and to make policy, but we spend a great deal of our time dealing with all sorts of individual boards and organizations, many of whom are at cross purposes all the time. There are a lot of cross purposes going on here.

A board comes in and doesn't want to amalgamate with another board, or they want to preserve services which are presently obsolete and this is part of the problem. The other reason is that we need regional planning. For example, in the Bonavista - Burin area - in the Clarenville area there's no nursing home, yet there's a good nursing home in Bonavista and there's two nursing homes on the Burin Peninsula. The St. Lawrence one we're not opening all of it and there's no great reason to open it. We haven't got enough cash - we could fill all the place if we wanted to but what we want to do is have people think about a region and if necessary share where it's possible. If it's not necessary to share then they don't have to share but they should think on a regional basis rather then each person thinking of their own town or their own defined area. Some people are able to make that transition but others can't and I believe that that's the third major reason that we have for forming boards, to get people thinking regionally rather than - I don't want to use the word parochially but pretty well that - so that people are thinking of their health care. We had to do that because of the limited budgets under which we work and I think it's working out pretty well, it's working out quite well.

We thought we were going to run into major problems in St. John's but we didn't. We thought we were going to have major problems in this tremendous region of central-west which takes in the area from Baie Verte and Fleur de Lys, actually, up as far north as, pretty well as far as you can go on that peninsula, and right down to Harbour Breton. That's a tremendous board and it goes out as far as Lewisporte as well and takes in Springdale, Buchans, then there's the geography there and yet people are thinking regionally but they came along very, very well.

There was a bit of discussion, we had some discussions and were able to make certain accommodations for people. They wanted appropriate representation on the board so they were sure that their interests would be looked after and some of them wanted certain assurances which we were able to give. So that's the give and take that's going on. It's very difficult and rather pointless to start saying we're going to save $150,000 or $160,000. The savings to me are obvious and that means that we can redirect that money into prevention and into some of the other health care things that we need to do.

On the schools of nursing - there is the issue of the schools of nursing - there are four schools of nursing in the city; the Faculty School of Nursing at the University and there are three hospital schools of nursing; one at the General, one at St. Clare's and one at the Grace. They each turn out something like sixty-odd graduates per year - and the one in Corner Brook similarly - and most of those people are unable to find jobs at the moment. It's true we're going to need people in community health nursing, more then we do.

I don't know if you realize how the budget works but we were confronted with a fixed budget. This is how we started off, your budget this year is fixed, it is the same as last year but we know that our costs are increasing. The people we have employed very often get step increases and that's their right. The cost of supplies in hospitals and other places have gone up. So to live within a fixed budget means you have to cut certain things. You have to look at what you can cut out and then you try to adjust and say; gee whiz, we can't allow that particular group to be cut - we have cut them to the bone - we'll have to do some cutting somewhere else. We saw all these schools of nursing in St. John's - we have to do something here.

Now here in St. John's what people are doing is planning a common curriculum. One of the difficulties that emerge in these schools is to get a common curriculum so that the curriculum is exactly the same and they can teach the same things. We've been working on this common curriculum for some time but it's not quite done, and so we had some preliminary discussions with the people in the schools of nursing to see how we might accommodate this budgetary cut and they are going to meet with me shortly, I think it is this week, and at that time we will see how they are going to come up with this budgetary money, this money they have to come up with; eventually there will be a merger but at the moment we are looking at cash.

You also raised the question of doctors, our 50 per cent rule in St. John's which will be extended to other places where, in the opinion of the joint committee of the Newfoundland and Labrador Medical Association and the department, we will be looking at that. There are two committees actually. There is a short-term committee and there is a long-term committee called PRAG. If you want to know what it stands for, you can ask in a form of question and you may have someone answer it but it is a long-term committee which will report eventually on how we can properly accommodate the physician supply, to make sure that the physicians are where they are needed rather than where they are not needed.

One of the problems with physicians is that they nearly always make a good income wherever they are because of the way patients are referred and so on but that's alright and when you have a capped budget it wouldn't cost the government any more for physician's salaries because that's capped for five years but, what happens is that they order all sorts of procedures which are not capped and that's why we can't have too many physicians in one place because of these extra procedures that cost so much money, and in St. John's we have to make some changes right away, so we agreed that we would put in the 50 per cent rule as a temporary measure in St. John's.

MR. CHAIRMAN: Your time is running out.

DR. KITCHEN: Just a minute or two. It seems to be working out well but I am a bit concerned about the physicians who are graduating from Memorial; they tell me if they can't practise in St. John's, they are going to practise in Texas or somewhere like that. Well, you know, I find that hard to accept, that they wouldn't practise anywhere else in Newfoundland; their commitment to the Province is limited. I don't know but I guess they want us to give them more money for going out there than they do by practising in St. John's. That is a problem, but I am also concerned about the attitude of people who seem to be totally motivated by dollars. The dollars are there in the Province, they don't have to have 50 per cent, they can go to many places in this Province and earn 100 per cent of the fee schedule, but they can't do it in the City of St. John's, and there are other places which we will be bringing it in now because there are other places too who are over supplied with doctors.

One more point and I will quickly finish up and it has to do with the waiting lists that you mentioned at the Janeway. I might add that the waiting lists for hospital admission in this Province is the best in Canada, on almost everything except the cardiac area which we have been able to clear up and I believe plastic surgery. Apart from these two and maybe one or two little items, we are really good as far as the Canadian averages are concerned in other provinces and we are very proud of that; we knew that for a number of years and it is improving. I am sure the committee will be very glad to know that.

Thank you, Mr. Chairman.

MR. CHAIRMAN: Thank you, Mr. Minister.

Mr. Harris.

MR. HARRIS: Thank you.

I would like to ask a few questions of the minister and staff in the areas that you have mentioned and some areas that I have been on over the past several years at estimates committees. First of all, in the area where, I suppose perhaps the largest chunk of the Budget might be spent, aside from institutions themselves, is the area of physicians' salaries and it seems to me that the 50 per cent rule for new graduates is a rather crude tool out of administration to handle that problem, and while it may well be agreed to by the senior members of the medical profession who make up the other half of a committee, it's a severe treatment for new entrants to the profession.

Have other methods been considered - and perhaps some of the officials can handle this question - it strikes me that within the medical profession there are what one might call expensive doctors versus doctors who earn the average salary, and it's based, because it's a fee for service system, on the number of patients or the number of services provided in a particular day.

Has the department considered looking at that issue, because the number of patient services is really what we are talking about here when we are talking about cost. I am sure you have statistics from MCP as to how many patients per day a doctor might see, or some doctors may see, doing a thorough examination, spending time with a patient. I know there have been variations in the amount of time that doctors spend with patients, and it seems the ones who are spending more time with the patient may be doing a more, I will say thorough, some doctors might say slower, job, but that there are others who might see thirty, forty or fifty patients in a day and therefore make more money themselves, but at the same time will be having a cause in limiting new entrance to the profession in the St. John's area, for example, or others.

Would you care to comment on that issue, and what other alternatives were considered?

DR. KITCHEN: I will speak briefly, and I will later ask Dr. Williams to comment in more detail.

We thought about various arrangements. There are a couple of other arrangements we could make. We could hire everybody. All doctors could be salaried doctors. We have some now. That is one way of looking at it; we will hire so many for St. John's and so many for everywhere else.

Another way might be to use the capitation system, where you get paid for the number of patients you have. You would look after a number of patients, and if the patients didn't like you they would go somewhere else; but there is a variable fee right now in place. We brought it in for seniors. When seniors usually come to see a doctor, they come with several complaints, usually, at a time, and the fee for that visit is more than the normal fee for a quick doctor's visit.

I might add, too, that the higher earning doctors are cut. There's a formula in place by which after they go over, I think it's $300,000, they get 75 per cent?

AN HON. MEMBER: I think two-thirds and then (inaudible).

DR. KITCHEN: Two-thirds, and then after it goes over three fifty they get half their salary. So there may be some specialists who earn quite a bit of cash, but not very many, and this is kept under control.

I might also add that we are hoping that this long-term committee, the PRAG committee, Provincial Physician Resource Advisory Group, is it?

AN HON. MEMBER: (Inaudible).

DR. KITCHEN: Got it, right. That group would bring in - that is the one that is chaired by Ian Reid.

We're hoping they will bring in this long-term plan to deal with this problem. What is there, I should say, is a crude index, a crude measure. It was done as a temporary measure. We had hoped that the big committee would be able to report earlier. I think they will report this fall; is it this fall?

DR. WILLIAMS: In September.

DR. KITCHEN: In September.

DR. WILLIAMS: We were hoping to have an interim report in April. We were hoping to have a full report by April, but that won't be possible.

DR. KITCHEN: I don't know if you would like to add some more to that, Dr. Williams, because you are on the joint committee. Is there anything else you would like to add to that about the physicians salaries and so on?

DR. WILLIAMS: Not much, Dr. Kitchen. I guess the problem we are dealing with is common to the problem that they are having in some other provinces of Canada. The whole world for physicians has changed dramatically in the past perhaps two or three years, and many provinces are putting restrictions on the number of physicians, or practice locations of physicians. This Province is no exception.

I just took a look at the latest Needs Assessment Committee Report. Right now we could accommodate thirty-four general practitioners throughout the Province. We have jobs for up to thirty-four people according to our latest report but we do have an appropriate supply in some of our larger centres in the Province. We have what we call, as the minister says, a Physician Resource Advisory Group which was put in place last year to look at the issue of physician resourcing, management of the physician human resources on a long-term basis and looking at appropriate policies that would provide for the appropriate number of physicians, the appropriate kind of physicians in the appropriate settings in the Province that deal with health care services.

As the minister says, unfortunately they haven't come in with their long-term recommendations, apparently because many of the issues they're dealing with are so complex. Some of the issues the minister discussed may be a fundamental change in the way medicine is practised or funded but some of these issues have to be grappled with, in a short term, as a measure so that we wouldn't have new physicians coming into areas, not necessarily new graduates but physicians who are in other locations coming into areas where we already have an adequate supply or over supply. They put in some short term measures which were only in the short term. Hopefully by the fall, when the Physician Resource Advisory Group reports, we'll deal with some of the long term issues and then some of the short term measures can be removed.

MR. HARRIS: On the same point, it's also been said that physicians who see a lot of patients - and I mean well more than the average -are also very quick with the prescriptions and that of course ends up costing a lot more money to the system. What I want to ask is, is the government serious about doing something to provide, shall we say, a disincentive for that type of medical practice and some way of providing an incentive or rewarding a kind of practice that is - one of the other options that Dr. Kitchen mentioned perhaps looking after your patients - you'll get rewarded for looking after your patients as opposed to writing out prescriptions. You'll get rewarded for providing a practice that is a care base as opposed to generating income. Is the government prepared to take some strong measures to both reduce costs and provide better care in that way?

DR. KITCHEN: Well there's two points to be made, one is that we're hoping that the joint management committee will eventually be able to address this issue, because, as you say, this part of the quality practice of medicine - but there's nothing, I know of, at the moment on the go on that except the whole question of fair review of physicians. I don't believe there's anything on the go in this Province at the moment in that but I'll let you speak on it.

The other point I wanted to make is that, for patients who see a variety of doctors looking for various drugs - that's another problem which is related here to. We had thought we'd be able to launch this year a triplicate prescription program by which a report of prescriptions would come to the department. One would go to the Medicare Commission and the physician would keep a copy of each prescription so that we could correlate what was going on here. Then if we have some high users of various drugs and so on, we could keep track of that and perhaps take some action on it because some people get a lot of prescriptions but we're unable to do that, it's not in our budget. We may even be able to proceed during the year with it if we can save a few dollars here and there but at the moment we are not moving. Doctor Williams I don't know if you'd like to add a few more points?

MR. HARRIS: All those prescriptions are given by doctors, stop blaming the patients.

DR. KITCHEN: Some of it may be the doctors fault but some of it may be the patients fault too because the patient doesn't have to stay with the one doctor.

MR. CHAIRMAN: Mr. Harris your time has expired now and I recognize Ms. Verge.

MS. VERGE: I would like to ask the minister about the Memorial University School of Medicine. The minister indicated that in St. John's there is, if anything, an oversupply of physicians and despite efforts to attract Memorial graduates to rural parts of the Province, there is still a shortage of physicians in rural areas and the minister talked about his disappointment with graduates opting for Texas if they can't stay in St. John's. What kind of value are the taxpayers getting out of the medical school these days and since resources for health are limited and difficult choices are being made, how can we justify continuing a school of medicine in the Province?

DR. KITCHEN: Thanks very much for that question.

Generally speaking, I think the Province is well-served by Memorial School of Nursing. We are able to attract people here because of the school specialists and people who are interested and that helps increase the quality of care here very much, and there is also a research component at Memorial which we hope to build on as well, but the basic question is what value are we getting?

I like the Family Practice Unit at Memorial and we encourage that very much; we have a clinic at Shea Heights which we put in so that they can practice in a community setting close to the city which helps, and we also have one in Whitbourne which is a little farther away and we also have one (inaudible) in Goose Bay, and it is generally recognized that the Family Practice Unit at Memorial can take pride in being a leader in the field, but I am concerned and I am hoping to be able to meet with people in Memorial to see why it is that graduates don't want to go to rural Newfoundland and perhaps something can be done about that, I don't know what the problem is.

I thought about many things and right now the fees at the School of Medicine is about $2,000 I think or something of that nature, but the cost is tremendously more than that to the Province and of course, so is every other program, more costly than the fees generally, but maybe we should charge higher fees and then put those who are going to practise in Newfoundland on a long-term contract, to take care of their fees or something of that nature. Maybe we have to bring in some new plans on that to make sure that people who we train, a lot of the Newfoundlanders who we train will either pay their own way or else, at little cost to the government, some little cost, the same practices as any other student, and then they can practise wherever they want but if they want to be heavily subsidized, then there should be a return for service and we ought to be able to send them to rural areas, so my only concern is with the School of Medicine and has to do with the fact that they can't get the graduates to stay and practise where we want them to go, but I suppose that is the problem.

MR. CHAIRMAN: Ms. Verge.

MS. VERGE: I would like to ask the minister about the long, drawn out, apparently not very well planned process of re-organizing boards. I concur with the remarks make by my colleague the health critic. What is going on in the western region? I ask this question every year and I am always told that it is coming soon but it never seems to happen, and to my knowledge there is no public consultation taking place, I don't think that was ever even contemplated.

More than a year ago health administrators in the region indicated to the public, through the news media, that they, meaning both public health administrators and institution administrators had come together and decided among themselves that the best model was one super board with responsibility for public health, hospitals, nursing homes, the works, and having a territory ranging from Port Saunders in the north to Ramea in the south.

The minister's earlier schedule and his predecessor's schedule had the western region at the top of the list and now we see St. John's and central and eastern coming ahead of western, and we hear this morning that central isn't up and running, eastern not even off the ground. Can the minister give me any indication that I won't have to ask him the same question this time next year?

DR. KITCHEN: Well, I hope you won't.

There are a couple of problems with western. You're right that some of the administrators and the board chairs did come to me and made a proposal to government that everything be rolled in, all aspects of health in that area would come under one board. There are two snags there. One, I am not sure that is the right approach and not everybody over there agrees with it, and I haven't had time I suppose to sort it out; maybe they are right and maybe they are not. You see the community health part has to be built up, we all agree with that, it has to be built up everywhere in the Province pretty well, and I am nervous that - you see the western merger is going to include a very heavy merger; it is going to probably include as you said, the Port Saunders Independent Board, the Western Memorial and its associated institutions, the Bonne Bay Hospital, the Western Memorial and the O'Connell Centre and the -

MS. VERGE: Roddickton, Stephenville and Stephenville Crossing, Port aux Basques -

DR. KITCHEN: Yes, they run the hospital in Burgeo, that's a large thing as well and then along with that comes the Inter-Faith Home in Corner Brook we hope and the Board in Stephenville which runs the hospital there and the Independent Board in Stephenville Crossing which runs a tremendous nursing home there, so that itself, a merger of these various boards and institutions is a major thing to do; it's a major thing to do and you want to be sure that the organization that is put up can handle that well.

That is the first thing you have to be sure of and on top of all that, we have to develop regional community health service, take over the public health nurses, responsibility for promotion for single point of entry into all the nursing homes and personal care homes in the area. That too, is a very major responsibility and the question is: can we put that under one board and one city (inaudible)? That was their proposal and that's my question and quite honestly I have questions -

MS. VERGE: I would like to ask for some clarification. What I am hearing the minister say is that he has pretty well decided that at the very least the institutional boards should be merged, but the question that has to be - to use his phrase, sorted out - is whether to combine institutions with public health. Is that the basic question?

DR. KITCHEN: Yes, that's one of the problems we have; that's one problem. There's another one.

MS. VERGE: I am sure the minister realizes that his own public health people in the western region are in the forefront of advocating the combination of public health with institutions under the one super board.

DR. KITCHEN: Yes, I've heard representations from our people over there, too. They believe that it's right, but that doesn't make it right.

The other problem I want to mention that adds to it is what's going to happen in the northern region. The northern region right now includes the tip of the Northern Peninsula and Labrador. We have had tremendous representations from some parts that they are not very happy with the existing arrangement. There are several boards there. There's the Grenfell Regional Health Services, which operates in most of the area. We have a board in Labrador West which operates the hospital.

MR. CHAIRMAN: Your time is up now, so I will now recognize Mr. Harris.

MR. HARRIS: I want to ask about the community health efforts in the area of smoking, for example, as one of them. Can you show us where in the estimates the budget for the smoking campaign is presented?

DR. KITCHEN: I think the amount - what is the amount?

AN HON. MEMBER: Right here.

DR. KITCHEN: The amount is $80,000 is it?

AN HON. MEMBER: Yes.

MR. HARRIS: How much?

DR. KITCHEN: Wait now; there is $65,000 in the budget to undertake educational and promotional campaigns relating to the implementation of the Tobacco Control Act.

MR. HARRIS: Where would that -

DR. KITCHEN: I am trying to find out where it is.

DR. KITCHEN: It's not under prevention and promotion. It's on page 238 -

MR. HARRIS: It's under administration and consultative services, is it?

DR. KITCHEN: 2.1.01.06 - $168,900.

MR. HARRIS: It's part of that $168,000?

DR. KITCHEN: Yes.

MR. HARRIS: So approximately $65,000 is related to the Tobacco Control Act?

DR. KITCHEN: Yes, Sir.

MR. HARRIS: And what is the implementation date on that now?

DR. KITCHEN: June?

AN HON. MEMBER: June 17.

MR. HARRIS: June 17, because I still don't see lots of signs around stores quoting the federal act, and the federal age limit of eighteen, and all that sort of stuff. How is that going to be overcome? Is that going to be readily accepted? Are they going to take down these eighteen signs and put up the nineteen ones? Is that what's expected to happen, Mr. Minister?

DR. KITCHEN: Well, let me see. It will be moving in fairly quickly there now, because that comes into force in June. The regulations are currently being developed. It's not just the act; there are the regulations. The information packages for employers have been developed, and so have radio and television ads, and a flyer for households throughout the Province. So the implementation should occur in the next several weeks but, as you say, it's not on the go yet.

Would you like to add some more to that, Ms. Dawe?

MS. DAWE: Thank you, Dr. Kitchen.

As Dr. Kitchen had indicated, we have been, over the last few months, involved in developing educational promotional packages dealing with the implementation of the legislation, and that should be ready by the end of April for mass public distribution to employers, households, the media, both radio, TV and newsprint.

MR. HARRIS: And the regulations themselves are not passed yet?

MS. DAWE: No, not passed yet. They have been developed and they are working through the mechanism within the department.

MR. HARRIS: And of that $168,000, sixty-five is allocated to this particular program. That still represents an increase of about $60,000. In addition to that, under purchased services, under that vote, what is the other increase for, I suppose, the other increase of $60,000? Is that allocated to another health promotion program, and can you tell us about that?

DR. KITCHEN: $80,000 of that is for AIDS. It's for the education and prevention of AIDS among young people.

MR. HARRIS: About $80,000?

DR. KITCHEN: $80,000 yes.

MR. HARRIS: And what does that program consist of? I know there are some good materials out. I know the National Film Board film Talking Positive that was done here in Newfoundland is a very good program. I know that's being used in the schools. What does government's program consist of for the $80,000?

DR. KITCHEN: Ms. Dawe, would you like to respond?

MS. DAWE: Mr. Harris, you may be aware of the comprehensive strategy that was released in December by the minister. A number of the first recommendations indicated the need for education prevention targeted at some high risk areas, the youth being the first group that we are planning the educational programs. So the development of these programs is under way now, and that's going to take into consideration the use of some of that funding, specifically targeted at some of the high risk categories.

MR. HARRIS: Would the $80,000 be used for promotional materials, or is that consulting fees?

MS. DAWE: Both consulting and promotional, targeted at education particularly.

MR. HARRIS: So it would -

MS. DAWE: I may say, it's not really finalized yet. We are in the process of discussions with people in the field, and some of the voluntary associations as well, trying to really focus to make the best use of the dollars that are available.

MR. HARRIS: So you can't say at the moment what proportion of that is consultative fees?

MS. DAWE: No, because the details have not been sorted out yet.

MR. HARRIS: In vote 2.2.01 under community health services there is an increase of about $500,000 in grants and subsidies for community health services. I know a number of organizations in particular were complaining last year about having their support from the government removed. Some of the organizations that in St. John's operated out of the King George V Institute Building were amongst a group of agencies that had support from the Department of Health. I see that there was, in fact, last year, in terms of grants and subsidies, an underspending from the budget of about $300,000 and it appears that the grants and subsidies are, in fact, $1.4 million more than was actually spent in 1993-'94. Can these organizations look forward to an increase in support of the government as a result of this vote, or what's the explanation for that?

DR. KITCHEN: You are asking why the grants and subsidies went down and then went up since we got $1.2 million over last year's budget, and almost $1.5 million over our revised budget. Might I ask you, Ms. Dawe, to give the details of that?

MS. DAWE: Mr. Harris, the funding under grants and subsidies, really, for the home care, home support programs, not those that you have identified, the voluntary agencies. That funding, if you consider St. John's, would be additional funding to the St. John's home care program had it been still in place, okay? So that's a different level of funding.

The reason for not utilizing all the funding that was approved last year is that some additional funding for home care, home support services, was approved in anticipation of having the community health boards in place in several regions of the Province, and increased funding is there again of $500,000 for continuing care services in the 1994-'95 budget for these services, which will be allocated out through the community health boards if they are in place, and if not through the public health units.

MR. HARRIS: Can we get a copy of the breakdown of that grants and subsidies under vote 10 there?

MS. DAWE: Sure.

MR. HARRIS: You say some of that will be just passed out next year, for example, to the community health boards and won't appear in this. They're in a different form in this budget, I take it.

MS. DAWE: It will be a different format next year.

MR. HARRIS: I would still like to, if I could, get a listing and breakdown of that.

MS. DAWE: Yes.

MR. HARRIS: Similarly I see a difference on vote number 1 there, as part of that, of approximately $250,000 in difference, or in money that wasn't spent. Is that part of that same situation?

MS. DAWE: Yes.

MR. HARRIS: Okay.

AN HON. MEMBER: (Inaudible).

MR. HARRIS: I have half a minute? Well, I can't do very much in half a minute except to say that I am interested in the operation of the programs at Humberwood and Talbot House, and there won't be any time for a response, but I would like to have an idea from the department as to what the level of care is there. How many individuals have been treated at Humberwood? What's the waiting list for that, and what's the demand for that service?

AN HON. MEMBER: You will have to wait for that answer.

MR. HARRIS: Yes.

MR. CHAIRMAN: Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman.

My first question relates to page 237, item 1.3.04, the vital statistics registry. Just for clarification there under line 12, information technology, $46,500; does that refer to just purchasing computer equipment, or an upgrading? What exactly would that refer to?

DR. KITCHEN: We want to improve the efficiency of the vital statistics, and that has to do with... I don't know if it's new; it's a computerization program. Mr. White, do you want to address that?

MR. WHITE: (Inaudible) new computer program system installed in vital statistics over the last couple of years, and this is in connection with that, and fully implementing that. It's actually implemented, but there are some modifications being made to register events and store data on a computer base so there will be quicker retrieval, and better organization of the data. So this is really, if you will, the finalization of that process.

MR. SMITH: Okay, thank you.

3.1.01, this relates to Memorial's Faculty of Medicine as well. We had some questions about that this morning and my question was: in terms of the graduates of that program right now, first of all the percentage of graduates of that program who are residents of the Province of Newfoundland, and the second part do we have any stats as to how many of these graduates remain in the Province, remain to practise within the Province?

DR. KITCHEN: I can give you the breakdown by students at Memorial. Of the first years up to now, in medicine, there are fifty-six, forty are Newfoundlanders or come from Newfoundland. In second year, there are fifty-six, forty-one are from Newfoundland; in third year, there are sixty-two, forty-five are from Newfoundland and in fourth year, there are fifty-six, forty from Newfoundland. Now, as to whence they come and where they go, I don't know if anyone can answer that question as to basically how many of those can be expected to practise in Newfoundland. I don't know what to say. Maybe Dr. Williams - you met recently with the group and you probably know as much about it as we do because the talk is that some of them don't particularly want to practise in Newfoundland. I don't know if we had any historical records as to how many of the graduates from Memorial end up in Newfoundland.

DR. WILLIAMS: We do have some historical documentation. I think Mr. Sullivan may have asked that question the last time around and I provided something to him about eight or nine months ago or a year ago now and I will get that information out to you, but it is based on prior years up to last year. I can get that information for you and give it to you but our retention rate for Newfoundland residents going into Memorial is consistent, in fact it is better than some other medical schools across the country, but it is consistent with the retention rates of Saskatchewan for instance, or Dalhousie for Maritime provinces residents, so our retention rates for our students, residents of Newfoundland to go into medical school and eventually practise in Newfoundland is equivalent.

Sometimes there is a lag period between when a medical student graduates and when they actually set up practise especially if they are in a specialty becomes sometimes it takes five years sometimes six years to train as a specialist, so while it might seem like they are gone because they are not in the Province, five or six years later they will come back when they have finished their specialty training programs, but our figures are consistent with other provinces. If I could recall correctly our retention rates are probably a little bit better than some other provinces for residents of Newfoundland who actually practise in the Province but I will get that data for you.

MR. SMITH: Yes, I am just curious about it and I think I raised it last year and I believe it has been referred to today. I live in a rural area of this Province, and lived there all my life and live in an area that has always had difficulty in attracting and retaining doctors and in the whole of my district it is a problem, and in recent years, to my knowledge, there certainly has not been a graduate of Memorial who has chosen to come out and practise in my area of the Province, and I am just wondering is that the situation with rural Newfoundland generally? I know with the hospital board that serves my area, they are constantly recruiting and most of the recruitment is from outside the country, to get people to practise in the rural areas of the Province.

Now I was around in the days when Memorial was being called upon by the government of the day to try to redress the problem that was plaguing the rural areas of the Province. It began first of all with the program that was brought in to support students, encouraging them to go in and to pay their way through and subsequently, I guess the ultimate would have been to me, that when we construct and set up our own medical school but it appears to me that in the interim, that certainly that problem that has plagued us is still there and having a medical school in the Province certainly doesn't seem to have helped it, it certainly hasn't solved the problem so I am just wondering if you would like to respond to that.

DR. KITCHEN: It's a very important point you have raised, from our point of view, we have the same problem and also, Canada is sort of closing the door to people from other countries now too, and also some medical schools are cutting down on the number of people who are being admitted because the general shortage of physicians is no longer there but the problem remains. I think we will ask Memorial to provide a list of their graduates of the past years and tell us which of these are presently practising in Newfoundland and where they are practising; that may be a good statistic for us all to have a look at, I think that is possible isn't it, to get that?

DR. WILLIAMS: I would like to make a few comments on that. That is possible to get and we will update it for you over what we had last year. Having been involved in the previous program back in the 60s, where we did not have a medical school here and we had to go to Halifax which was the nearest medical school, and as somebody who has been involved in the program, I think the program was successful at that time when most of us came back and practised in rural Newfoundland and some of us stayed a lot longer than we had anticipated when we came back.

Then Medicare came in in 1969 and I think that's when things changed in getting physicians to fulfil some of the commitments to rural Newfoundland; the whole economics of medical practise changed in 1969 in this Province when Medicare came into effect, and that was a factor, however we started up three years ago, a new bursary program for residents of the Province who wished to make a commitment to practise in an underserviced area and students, after they finished their first year, are eligible to apply for this program.

We have ten grants a year and it carries a student for the second, third and fourth years so that at any one time we could have up to thirty people receiving money; they get $12,500 a year in their second, third and fourth years and in return they have to practise in an underserviced rural setting. We just started the program, it is the third year of its starting up now and I find it interesting, it is not fully subscribed, I think there were nine students who went in one year, seven took up the ten grants that were available in the next year. The students have to spend a year for a year of each grant and the arrangements this time around are not made with the government but the Department of Health.

What we have done is, we have allocated the money to the regional hospital boards around the Province and so the student makes the commitment with the hospital board that is responsible for providing the medical service in that area. For instance, if you had a student who was committed to Jeffrey's, then that arrangement would be with the Board of St. Thomas Roddick Hospital, so that is not a departmental arrangement but it is with the board and in that way the student over those three years and the student's spouse can develop a relationship with the hospital board, go out and see the area, get to know some of the administrative people, the other staff and physicians who are there and hopefully that will make the commitment a little bit more binding, a little bit more morally binding anyway, than having it with somebody in government or in a department where they don't actually have that relationship.

MR. SMITH: I think what might be worthwhile it seems to me, in talking to the University, would be talking with some of these students as well who are about to graduate and just getting their views as to why they would opt to - because personally, I can see some of the concerns. If I were, right now graduating, because as attractive as my area of the Province might be, being in a clinic where you are in sole charge for that entire area, which basically is a twenty-four-hour a day, seven-day week, is not very attractive for anyone. I mean, you do need some time to yourself and especially if you have a family, but I am wondering in terms of talking with these people, are there some alternative ways that we can deliver these services to the rural areas whereby we can eliminate some of these problems that are there right now?

AN HON. MEMBER: Well -

MR. CHAIRMAN: You will have to wait for the next time round.

MR. SMITH: Thank you.

MR. CHAIRMAN: Mr. Langdon.

MR. LANGDON: (Inaudible).

DR. WILLIAMS: That's a very good question, it is something that has been discussed. Over the years the department has gotten away from the solo-practise settings and tried, even though maybe the population in itself wouldn't justify more than one physician, we have tried to put in two physician practices in certain areas of the Province.

One discussion we had, and Mr. Langdon might relate to this, because it is in an area with which he is very familiar and represents, the issue of servicing places like Mose Ambrose and Hermitage, these were always solo physician practices but some years ago we made them two physician practices even though as I said, the population base may not be there to support two, because physicians can have time off and can go into some other centre and work with their colleagues and this type of thing, and keep in touch more, that way it is a better lifestyle for them.

One other suggestion that has come from some of the physicians down there is, why not, instead of having physicians spread around over so many different communities, why not have instead of three positions as Harbour Breton has, six or seven there who would then practice out of there and every day they would go out to the practice locations and have a clinic every day of the week, you know five days of the week so that way the physicians would have a better lifestyle and they may be more amenable to stay there.

The issue of lifestyle, on calls responsibilities, are very important to physicians even though, if you are the solo doctor there and even though you might feel that you need to be off, the fact that you are there and something happens people are going to call you so really, you are never off when you are there; so these are some issues we might want to be exploring I guess, in terms of how to best service rural areas, in terms of getting service to people, yet in terms of keeping physicians there on a long-term basis.

MR. LANGDON: I would like to comment in the same vein that Mr. Smith did.

I have a daughter who is at MUN now studying for a Master's in Nursing and Community Health and my son-in-law is a resident pediatrician at the Janeway, and daily I hear them commenting on the department's, if you wish, ostracising them from this Province to Texas or wherever the case might be, and I think there is some merit in what Mr. Harris said earlier, the fact that you have a board that is probably made up of senior people in the medical profession and of course, with the cap on the board and so on, they can, almost at will provide prescriptions which take dollars out of the particular fund but it might very well be that some of the younger people could also be a part of that particular board and find ways of which you are working at to accommodate them more.

Like, for example, the people who are close to me have said: I don't want to be in Harbour Deep. I just don't want to go there. The situation there would not be advantageous for a family that would have all the different sorts of licensing and skills. Also the pediatrician is saying; twenty-four hours a day, seven days a week, what type of a lifestyle do I have there? I know in my area especially, in Mose Ambrose, we go through doctors almost like somebody would go through candy. It's the same thing in Hermitage, they stay there for a little while and off they go but it is changing. Your idea of having them operate out of Harbour Breton probably would make some sense because recently the town itself, due to recreation and other things, has made life better for these people that practice there. I understand that one of the graduates at Memorial now, a graduate, a Newfoundlander from the Burin Peninsula has agreed to go into Harbour Breton when he graduates. That is a positive sign and hopefully we can work at that.

Another point of contention for me, especially the area that I represent, the Connaigre Peninsula, is the quality of the health care as provided for the structure that's there now. I talked to the minister about it a number of times and earlier I was somewhat interested in the comment - I don't know if I listened attentively and got it right from the minister, I'll get him to comment in a minute - on the Burin Peninsula, I thought he said in St. Lawrence right now the long-term care, chronic care, is not filled and I don't know if he said there's a partial need for it or they didn't have the dollars and so on. I see the rationale of what the department is doing and I commend the department on the reorganizing as far as boards are concerned. I think that once these regional boards are in place then you'll have a better grip on what's needed in a particular area. With the scarce number of dollars that we have, we'll make sure that in a particular area where there is acute need, then that would be taken care of.

In the Harbour Breton area for example - I don't have to tell Dr. Williams, he's familiar with it from that part of the coast - it takes us three hours to get to any medical facilities in Grand Falls. There's not much being done at the Harbour Breton Hospital now. The terrain is such in the wintertime - I challenge anybody to try to get over what they call the highlands. It's practically impossible, so you're cut off. The need has to be addressed and I believe that the minister and the department will, so let the minister respond to that.

DR. KITCHEN: The two points you raised, one concerns the new positions going out - I might indicate that on this Physicians Resources Advisory Group that's looking in a long-term way and which they hope to report on in September, there are two students, one representing the organization PAIRN, Professional Association of Interns and Residents of Newfoundland and one representing the union and the other is, I suppose, selected by the medical students at Memorial. So there are two students, two people on that PRAG Committee and hopefully the points that you made will be introduced by them into that committee.

MR. LANGDON: Are the students, these two people on that board voting or non-voting?

DR. WILLIAMS: On the PRAG committee they have an equal say.

DR. KITCHEN: You're thinking about on the Newfoundland and Labrador Medical Association where they're associate but non-voting members?

DR. WILLIAMS: I don't know the details on the medical association, council or board or whatever you call it, that council or board is elected every year at an annual meeting. All physicians have a right to go to the meeting and vote.

There is representation on there from the medical students, but I don't know how much. I think there is one person on the board out of a number. There is regional representation, and there is a provincial executive; then there is regional representation, and together they make up the council.

DR. KITCHEN: There are how many on the total committee that Mr. Reid is chairing, I wonder?

DR. WILLIAMS: I think there is Mr. Reid and about three or four others, plus the two that you referenced. I will have to check that.

DR. KITCHEN: Okay, so that's a fair component on that, and we are looking forward to doing something in the Harbour Breton area as soon as we get cash to do it, and as we line up the many priorities that we have, so hopefully things... But I think in Harbour Breton the service that is provided by the staff is extremely good service, from what I have heard, and I think that's more so, even though a new building is nice to have, the service is the main point. If you have good staff, good nurses, good doctors and all the other staff who are committed to providing good care, I think that probably makes up for an awful lot of other things, and we have a number of small hospitals in the Province which are providing extremely good care because of the quality of the staff. That's not meant as an excuse for not putting in a new building, but sometimes there is a tendency to put all our emphasis on buildings, and health care is only part delivered by a building.

MR. CHAIRMAN: Thank you, Mr. Minister.

Your time has expired now, Mr. Langdon, so it might be a good time to take a break. The Clerk tells me that coffee is going to be served in the board room upstairs, so everybody will have to follow the government members who know where the board room is upstairs.

We will return at 10:45 a.m. Mr. Hodder will lead off, followed by Ms. Verge, Mr. Harris, Ms. Young and Mr. Smith, so we have an interesting little group here this morning.

MR. CHAIRMAN: Order, please!

Mr. Hodder.

MR. HODDER: I want to ask a question to the minister relative to the 911 system in the St. John's region. It's been a persistent problem. It's been raised on a number of occasions by the municipal councils, and it's been raised here in the House.

I know that the minister is well aware of the protocol that supposedly operates, and I am wondering if the minister has looked at that system and if he has made recommendations to the Health Sciences Centre to change some protocol, and if he can give some assurances as to what new procedures will be put in place, if any.

DR. KITCHEN: Thank you very much for that question. Part of the 911 service has to do with health emergencies - not all of it, but part of it. Some has to do with fire, and some has to do with other things, but we had recently a couple of complaints with respect to the 911 service, and I have asked for a report, and I have had a report, as to both the short-term one, that sort of thing, what happened, and also trying to evaluate the system as presently in place.

We had an initial discussion with the people who prepared the report, and I asked them to go back and get some more pertinent information as to how things go, and when I get that information we will have to work on it.

I don't know if there's anything more we could add to that at this time. Some of the problems have to do with the volunteer fire departments. There is a problem there because volunteer fire departments are great for responding to fires and to look at any first-aid that is there, but most of the volunteer fire people are not trained to handle the emergency medical problems. We can't really put them on a full-fledged response program because a full-fledged response program under 911, for health emergencies, requires appropriately trained people to be in that ambulance to respond to that emergency. That is part of it.

I don't know if there is anything else to be added. Dr. Williams or Mr. Hart? How would you like to handle that?

DR. WILLIAMS: As the minister said, there are probably two components to the issue that we are dealing with in the 911. There is the issue of the protocol and the first responder issue, when we do have a fire department that is not volunteer but is fully funded and have people who are very well trained to respond to emergency health care situations. It is that proportion of the 911 that we are working on and it is a proportion that relates to, in some of the peripheral areas, volunteer fire departments, and are they going to be involved as first responders. There are certainly issues related there to training. There are issues related to insurance coverage, in case something goes wrong in terms of their responding. We are looking at those two issues and we've asked for some more information.

We do get quite a number of calls to the 911 on an annual basis and we do get a number of complaints. I think there were three recently: two related to situations in Mount Pearl, one of which the General Hospital has said publicly that there was an improper following of the procedures in place and they've taken measures to correct that. Once we get the report to the minister I guess then we are going to look at these two issues and try to resolve them.

MR. HODDER: A supplementary question on that. Several of the other provinces - Nova Scotia in particular - have initiated procedures to do a province-wide review of their emergency responses. Nine-one-one covers a whole gamut of things, not just emergency health response. Has the Province examined the need to do a province-wide analysis of the 911 system similar to what is being done in Nova Scotia?

MR. HART: Yes, Mr. Hodder, maybe I can address that question.

MR. CHAIRMAN: Would you please identify yourself?

MR. HART: Chris Hart, Assistant Deputy Minister with the Department of Health.

There was a committee struck some three or four months ago through the Department of Municipal and Provincial Affairs actually. The mandate of that committee, as I understand it, is to look at the advisability of putting in place what they call an E-911 system for the Province of Newfoundland. "E" stands for "enhanced," I believe. There is a number of representatives obviously on that committee because it deals with a wide range of services - police, fire, and health related. We have from the department our Director of Emergency Health on that committee. We also have a representative from the Newfoundland Private Ambulance Operators Association. There are private individuals on there, I understand.

Mr. Peckham, the Assistant Deputy Minister with Municipal and Provincial Affairs, is heading up that group. I'm not exactly sure at what point they are. I know they've met on three or four occasions now. Whether they are ready to release the results of their review or not, I'm not sure. Maybe that is a question you might keep in mind once you talk to Municipal and Provincial Affairs.

MR. HODDER: To switch to another topic. I wanted to raise the question of the Burin Peninsula health care regional board. Those people who know my family history, they would know that is where my roots are. There are probably 700 relatives of mine who live in that part of the Province.

One of the real issues there, and I raise this as well on behalf of my colleague the Member for Burin - Placentia West, is the issue of governance. I attended the rally that was held up there two weeks ago. I just happened to be up there visiting my aging father and went to the rally. Twenty-five hundred people turned out for it. The issue on the Burin Peninsula seems to be one that they already feel that when we close a hospital in Grand Bank and we close a hospital in St. Lawrence, and then all of the joint town councils got together and build this hospital which is really in neither community. It is within the municipal boundaries of Burin but it is not really in Burin. It is partway between Marystown and Burin, kind of neutral, and suppose to be a regional approach that was kind of setting the way, you might say.

I wanted to ask the minister if he has done any - again he says he (inaudible) do any cost benefit analysis, and to point out there is a difference here with the other regional boards. In the other boards, Grand Falls, with which I have some familiarity, there is, shall we say, an existing regional centre that is operating. On the Bonavista Peninsula you have no what we call main centre like you have in Grand Falls operating in that region. You have the hospital in Burin, the one in Clarenville and one in Bonavista. Is the minister reviewing that particular decision, or that proposal, I should say?

DR. KITCHEN: A group met with the Premier some time ago and we did make a commitment to look again at the decision. We gave no assurances that we would change it or not change it, so we are in the process of whether we will do that before long. It is true that in the eastern region we will say, there is no single hospital to which everybody gets referred as there would be in the western region or in the central east or central west, but there are three more or less equivalent hospitals. There is the one in Carbonear, which is larger than the one in Burin, and which in turn is larger than the one in Clarenville although they are similar in the services they offer, but at the same time recognizing that difference is there, the question comes up: can any good come out of putting Clarenville, Burin, and Bonavista together as one board? It is a governing board and we are not attempting to merge services. It is not a matter of emerging services in the hospitals or in the clinics, it is a matter of board services and administration.

We think there will be some savings there. Certainly the savings will not be there as would be in St. John's because there is tremendous duplication in the city here, and we may be able to do other things here as well. It would be of some value, I think, to put all under one board. The other problem is this, I wanted to cut down on as many as possible of the number of boards that we have operating for the reasons I mentioned.

MR. CHAIRMAN: Ms. Verge.

MS. VERGE: Thank you.

Coming back to board mergers and reorganization, perhaps some people in the western region, before a decision is made about reorganization, would like to see the report the Department of Health did last summer on the instructions of the Premier. The Premier, last July, told people in Western Newfoundland, following the furore over the cancellation of first-year nursing intake and then the reinstatement, that he personally had ordered an immediate assessment of aspects of management at Western Memorial Regional Hospital. The media in Western Newfoundland at intervals since then have asked the Premier about the report and most recently when he was asked by CBC Radio, the Premier said he'd have the Minister of Health release it.

Now, people in Goose Bay were interested in getting a three-year-old report about the Grenfell Regional Health Services and the contents of that report, while being three years old, are undoubtedly affecting their thinking about the best organization of boards in their region. I would think people in the western region should have the benefit of the contents of the Premier's report, and I am wondering when the minister is going to do what the Premier said he would do and release that report to the public.

DR. KITCHEN: It's a straight question; I don't know if I can give you a straight answer.

We have had a report on the `doings' last spring and the difference between that and the one in Grenfell - Grenfell was an operational review of the services there - a comprehensive operational review - which we looked at because there are certain things you can release, but where individuals can be clearly identified you don't particularly want to release that because it's not appropriate.

I think that's the basic difference here between the two reports. The one in Grenfell was on individuals that can be identified. It was just a general statement about the way things should be done in that general area, while this had to do with a series of events whereby a decision was made and then changed.

MS. VERGE: When I've asked the minister about this before, on occasion he has described the report about Western Memorial Regional Hospital as an operational review report. Now this morning he seems to be indicating that the report, in fact, has to do with the nursing school fiasco. Are there two reports done since last summer about Western Memorial Regional Hospital?

DR. KITCHEN: There are two reports; one is an operational review of Western Memorial and subsidiaries, whatever you call it, that system over there, which was conducted by - was it conducted by our department, by our officials?

DR. WILLIAMS: Yes.

DR. KITCHEN: And some of them are here now, I think. The other was a special report having to do with the decision to stop enrolment and then to -

MS. VERGE: (Inaudible) report. The Premier has told people in Western Newfoundland that he would have the minister make public that report and I'm wondering when the minister will do that.

Since we now know that there is an operational review report, and the GRHS report was an operational review report, will we have to wait three years to get our Western Memorial operational review report, or do you think we might get it now while it's fresh.

DR. KITCHEN: Well, we'll have to see. We don't normally like to release these things because, what it is, we send our staff in to have a frank look at what's going on in the system and they look at various things and make various suggestions as to what may happen. This is not the be all and end all; it's just our staff's opinion of what goes on. Then the operational review, the people there in the system respond to it and they make some of the changes or all of them or none of them. So, that's basically what it is. Now, the question comes up: What good can be served by making this available to the general public? Perhaps in some cases it can.

I think the other one in Goose Bay was released under the Freedom of Information Act. Somebody asked for it, and because it didn't offend the guidelines for releasing it we decided to release it. I suppose we could have a look at that to see if anyone who really wanted it might have a look at the operational review and that individual wouldn't be compromised by it. I'm a bit reluctant to have a general policy of releasing publicly all operational reviews for the media and others to be commenting on because it may destroy the effectiveness of the review. The officials who go to review, or the consultants who do these things, might be a bit constrained in what they say if it's known that whatever they say is going to come out and be subject to the interpretation of the news media and other people. There is a sensitivity there but we could have a look at that to see if it's appropriate, if anyone really wanted it, and ....

MS. VERGE: Obviously people want it or I wouldn't keep asking for it.

DR. KITCHEN: No, but the news media want it and I don't dance to the tune of the news media. I refuse to do it.

MS. VERGE: I'm not a reporter.

DR. KITCHEN: And I refuse to dance to the Opposition too, by the way, but we'll listen to appropriate requests.

MS. VERGE: We've noticed that. I'm got another question now about the non-emergency medical transportation program. I've asked the minister about this in the context of representations by cancer patients and relatives of cancer patients in the western region who say that the cost of travelling to St. John's and staying in St. John's for six weeks or five weeks or seven weeks for radiation therapy is prohibitive. The minister has acknowledged the shortcomings of the former non-emergency medical transportation assistance program - we have to get an acronym for that - which reimburses people only 50 per cent of allowable costs exceeding $500 a year. I'm wondering if the minister has done anything to provide adequate assistance to cancer patients who have to come to St. John's for lengthy periods of radiation therapy.

DR. KITCHEN: Thanks for that question we are on the same wavelength. I agree with you that there is a problem here. That people who must come to St. John's are sometimes subject - we have this general policy which in my view is not totally adequate. It is far from adequate. Whereby we pay, as you say, half the cost over $500 in a given year, in a given twelve month period. We have not been able at this stage to adjust that formula. I wish we could. I look forward in the future to be able to adjust that formula, but at this moment it has not been adjusted. There is a shortcoming and I'm sorry about it. We are on the same wavelength.

MS. VERGE: I appreciate the minister's honesty. A quick word of praise. I was glad to see in the Budget Speech the announcement of the breast cancer screening program. I would like the minister to explain what will be done this year.

DR. KITCHEN: We've got a fairly large sum of money to examine that whole program because we want to have an appropriate program for breast screening in place. The details have not all been worked out. We know that the cash is there. We have to have some discussions in the department as to the precise methods by which that be expended. I think I would like to ask Ms. Bishop who chaired the committee which brought in the report on breast screening to have a few words on this.

MS. BISHOP: Thank you, Dr. Kitchen. As Dr. Kitchen has indicated our committee worked very diligently in bringing together the report. We will in 1994-1995 be initiating a three-year pilot project for an organized breast screening program. This is the same route that the Province of New Brunswick has decided to pursue, as other provinces have done. The program will consist of professional and public education that will be designed to target all women in the Province to promote breast self-examination and to discuss breast screening.

The program will draw on other agencies to assist with the component of the program - for example, the Canadian Cancer Society and the Breast Cancer Information Exchange project sponsored by the federal government for Atlantic Canada. The second component will be clinical breast examination. Women over the age of forty will be encouraged to have their breasts examined by a trained health professional on a regular basis. The third component: breast self-examination. Women of all age groups will be taught breast self-examination, will be given literature, and shown videos on the subject. Then the fourth component will be screening mammography. Asymptomatic women between fifty and sixty-nine years of age will be offered two view screening mammography on a biannual basis. Referrals for screening will be accepted from physicians, from other health professionals, family and self. The screening pilot will initiate and maintain a system of client follow-up to ensure continued attendance for screening. Quality control mechanisms will be implemented as part of the screening pilot project, an evaluation protocol will be integrated in the plan for delivery. The breast screening program will not replace the current service of diagnostic mammography which is available in eight centres already established in the Province but will be an enhancement.

MR. CHAIRMAN: Thank you, Ms. Bishop.

MS. VERGE: Just for clarification? Will there be a mobile screening unit or will the screening be available at the same eight centres as the diagnostic?

MS. BISHOP: (Inaudible).

MR. CHAIRMAN: Mr. Harris.

MR. HARRIS: Thank you, Chairperson. I guess the questions I asked the last time, I'm sure you've had lots of time to think about the answer. Just some information on the take up rate at Humberwood and Talbot House. I know they are different types of operations but I would like to know some statistics on the operations of Humberwood and Talbot House.

DR. KITCHEN: (Inaudible) we have these two institutions. The one in Humberwood is for the treatment of people who have been referred there, for alcoholics and problems similar to Don Wood in Ontario. I've asked for an evaluation to be done on Humberwood because we've had some proposals to extend that whole area of treatment. Before doing so I want to know just what the success rate is and things of that nature. I know some people who've gone through it who've had severe recidivism problems there. I'm not doubting it, I agree with you, that we need some evaluation of what is going on. Because we want to do what is appropriate.

I don't know if we do have statistics as to the number - Joan, do you have all that? Ms. Dawe.

MS. DAWE: Thank you, Dr. Kitchen. Just to explain the difference, Mr. Harris. The Humberwood Centre is an in-patient treatment centre whereas Talbot House is strictly detoxification. In Humberwood there are ten in-patient beds. There we operate a twenty-one day treatment program. The normal waiting period for admission to Humberwood is just the one program, so within the month people can be accepted for treatment. That component, then, is linked with the out patient counselling the follow-up service which is offered by the drug dependency services.

As Dr. Kitchen had said, we had contracted with Dr. Dennis Kimberley from the School of Social Work at the university. He has conducted a review of the Humberwood program and we expect a report in May month on that.

The Talbot House, as a detox component, we have twenty-one beds there for admission for males and females in the detoxification area. The normal length of stay is from three to six days in that area, and that as well is linked with the drug dependency out-patient services as well, so we are endeavouring to provide for the full continuum of service from the treatment to out-patient counselling.

MR. HARRIS: Is it safe to assume that given a twenty-one day treatment program and ten beds that we might have between 120 and 150 people a year go to Humberwood? Is that about right?

MS. DAWE: Yes, in that range. It's normally fully occupied.

MR. HARRIS: And it's referrals from physicians only?

MS. DAWE: No.

MR. HARRIS: How is it done?

MS. DAWE: A person will have to be seen by a physician, but it can also come through the out-patient counselling services, and would have to be seen by one of the addictions counsellors before actually being admitted to the unit, and then followed up after with the out-patient service.

MR. HARRIS: I wasn't questioning the success rate, Dr. Kitchen, although obviously it is of interest. I wouldn't be surprised at all if there was a recidivism - I wouldn't say healthy, an unhealthy recidivism, but a not uncommon recidivism. I suppose I would have to compare that with what happens at Don Wood and other centres, but given your opening remarks, Dr. Kitchen, about the importance of alcohol as a problem in society, I am very interested in the success of that program. I don't know what the cost of that is compared to the Talbot House. Is there a per patient cost you can just dab at?

MS. DAWE: The per patient cost for the Humberwood is in the range of $110 or $115 a day.

MR. HARRIS: Per day?

MS. DAWE: Per day.

MR. HARRIS: The other question I had of that nature, looking at page 247 in grants to hospitals, 4.2.01, the overall budgeted amount, or the voted amount, is $454 million. From that is a revenue from the federal sources of $1.07 million, down about $200,000 from the budgeted figure for last year, and revenue from provincial sources increased from $5.4 million to $7.4 million, which is almost a 50 per cent increase, perhaps 40 per cent plus increase. What is that revenue from provincial sources? Is that fees and charges to patients, or is it something else?

DR. KITCHEN: The provincial is revenue from third parties who are financially liable for the cost of hospitalization. That would be that. Am I right there?

AN HON. MEMBER: (Inaudible).

DR. KITCHEN: Then there is reciprocal billing from other provinces. That would be under provincial as well. The third party is about $4 million, reciprocal billing is $3.4 million; that's about it, and there's a very small amount there for rentals from environmental health services of $4,000, so basically it is third party liability and the reciprocal billing. That is what it amounts to, but I guess your question is, why are they up?

MR. HARRIS: Well, there is a fairly substantial increase there and if the provincial sources are other provinces under third party billings I guess they are doing a very good job of recovering the monies from insurance companies through motor vehicle accidents and things like that. Is that what we are talking about here in third party?

DR. WILLIAMS: Probably, Mr. Harris. Government recently made a policy decision with respect to third party liability issues and going to a levy system as they have in other provinces of Canada whereby the insurance bureau would pay the Province a certain amount based upon the number of vehicles in the Province and in turn we would not have to go through this long exhausted process of collecting third party liabilities through insurance companies. Therefore, because it often takes two or three years to collect third party liabilities because the cases have to go to courts, sometimes they are settled out of court and sometimes they are settled in court, there will be a period where we will have increased revenues for a number of years.

The levy system will come in this year and we will get money for this year with the levy system, but we will also be collecting revenues from last year and the year before. So, for the next three years we will have sort of a windfall in terms of increased revenues for two or three years. That is the main reason.

DR. KITCHEN: Now, what was the other question as to it being up about $800,000? Did you ask a question on that one, too?

MR. HARRIS: Well, the decrease in the other one is covered there, but certainly there is a decrease in the federal source of slightly under $250,000. I also see a decrease in dental services, a budgeted amount for dental services of about $300,000. In fact that budgeted figure for the current estimates is the same as the revised estimates from last year. Has there been a decrease in services? Has there been some policy changes that have resulted in that decrease? Is there an explanation for that?

DR. WILLIAMS: Mr. Harris, I will give you the overview of it and if you want some more details I will get Mr. White to respond.

Over a year ago there were some changes in the dental health services plan for children and we estimated that to implement those changes would cost some $6,040,000, but actually this year within the changes that were made only $5.7 million was spent. As this is an open ended-Budget the estimates are based on this year's revised Budget, so it is $5.7 million put in this years because that is what we spent this current fiscal year. The figure of $6,040,000 was an estimate based on changes to the program but it actually came in as $5.7 so this is the amount in this year's Budget, but if the amount goes to $5.8 then that is the amount it will be next year, sort of an open-ended type of system.

MR. CHAIRMAN: Ms. Young.

MS. YOUNG: Mr. Chairman, I certainly want to congratulate the department on its initiatives, especially on the restructuring, I guess, or the regionalization of the hospital boards, as I am certainly looking forward to it in the eastern region. I think the duplication of services in the administration area will certainly be an improvement. As well the breast screening program is something that I am sure will be very well accepted by the female population of this Province.

There is some clarification that I need in some of the areas. I am thinking specifically of homes for ex-psychiatric patients, just wondering how well that is working, and what is the cost per patient. Do you have any breakdown on that? That is 2.3.02, page 241.

DR. KITCHEN: Psychiatric patients.

MS. YOUNG: Approximately how many patients are availing of that particular service?

DR. KITCHEN: Yes, we will have all that for you now in a second. We have 255 individuals residing in twenty ex-psychiatric homes across the Province. Most of them are close by St. John's. (Inaudible) mostly in Conception Bay South. There are 255 individuals in twenty ex-psychiatric homes.

MS. YOUNG: How well is that working? Has it been assessed recently?

DR. KITCHEN: I have had, as far as complaints are concerned, no complaints about that. Some of the money goes for care and personal care allowances and there is a feeling that perhaps these allowances should be increased. Not only for ex-psychiatric patients but also for other people who are in similar situations, which we call personal care homes. That allowance is a bit light, but at the same time we feel that we can't afford to increase it at this point in time.

Some of the cost goes towards the night security personnel because people who are in these ex-psychiatric homes, the operators get a special allowance to cover the cost of night security. Also, for some supplies that they use for their patients like dressings and lotions and things of that nature.

MS. YOUNG: Thank you. Also, 3.3.03, Dental Services. I notice there that in your budget for 1993-1994 you budgeted for $6,040,000 and you actually revised it to $5.7 million. That is the estimate for this current year. Can you tell me why the budget had to be revised? That is page 244.

DR. KITCHEN: Oh yes, that is basically the question that Mr. Harris asked there, why it went from $6 million down to $5.7 million.

MS. YOUNG: Yes, I'm sorry, I didn't hear his question.

DR. KITCHEN: That was the dental service budget that was decreased from $6 million to $5.7 million. That is basically the take up. This is, as Dr. Williams says, an open-ended budget. The take up this current year was $5.7 million. If more people had come to avail of the services then we would have spent more than $5.7 million. That means that the current year, the coming year, we budgeted for what we actually spent last year.

MS. YOUNG: I'm wondering. In the school where I taught there was a program whereby the dentist came in and he saw a high number of students. I just forget whether they needed a permission slip from parents or not. It seemed to me a very good program. There were kids who probably would never have been referred to a dentist and received the kind of work that these kids availed. It was really good. I thought it was an excellent program. I don't know how much of that has gone on throughout the Province.

DR. KITCHEN: We are thinking about changing the program a little bit now. Because now the children who partake of this program go to dentists' offices and they get fluoride treatment and other things, but we are hoping that we can change that - in fact, we've agreed to change the fluoride treatment so that it will be done on as a pilot project. Go ahead, Ms. Dawe, give us the details on that one. It is a nice program.

MS. DAWE: Thank you, Dr. Kitchen. Over this last year we have been in dialogue with the Newfoundland Dental Association regarding establishing a preventive program for children in the school setting called a fluoride mouth rinse program. Whereby children from grades I to VI would rinse their mouth with a fluoride rinse once a week as a preventive program. As I said, we are in dialogue with the dental association. This whole proposal will be brought to the dentists' association at their annual meeting next month and some final decisions will be made there.

The cost, if you consider the cost of the topical fluorides in the dentist office now, around $300,000 annually, and they are able to care for less than 45 per cent of the children in the Province in that age range of grades I to VI. The proposal that we've been working on with the dental association will be using that same amount of money but reaching over 90 per cent of the children in the same age category throughout the educational system in the Province. We hope with the approval of the dental association over the next month to be able to start instituting that program in the Central Newfoundland region to begin with in September, and then gradually across the other regions as well. Hopefully within a year and a half, if all goes well, we should have this preventive program in place in the Province. A very effective one.

MS. YOUNG: I also want to ask a question as to have there been any studies done with regard to the effects of the school milk program on the overall well-being of our Newfoundland school population.

DR. KITCHEN: Yes. The reason we're huddling here is because that is not in the Department of Health's program. It is the Department of (inaudible) comes from the milk producers, I think, and is supported by the Department of Health but it is supported morally rather than financially. Is that right? Apparently we are on the committee that administers it, but it is basically an initiative from the milk producers to sell more milk.

MS. YOUNG: Yes, I realize that, but I also saw it as being an excellent source of calcium and the other great things that we see in our milk product.

With regard to Pay Equity, and that is 4.2.03, page 247. Could you just clarify for me what is being done with that issue?

DR. KITCHEN: Basically this is the conclusion I think of this particular round on pay equity. Quite a number of employees in the health care sector are receiving pay equity adjustments. These have resulted in an increase in pay rates of approximately 85 per cent of the female dominated job classes, affecting about 5,000 employees. These adjustments range from $0.09 to $1.99 an hour, with the average adjustment being $1.05. As I understand it, and somebody can correct me if I'm wrong, the extra amount of money that is in there this year is to conclude this round of negotiations? Who would know about that?

AN HON. MEMBER: Dave Saunders.

DR. KITCHEN: Did you want to say a few words about that Dave?

MR. CHAIRMAN: Actually your time is up. So if it's by leave of the committee to clue up Mr. Saunders, we'll give you just a short time.

MR. SAUNDERS: Yes, the March 20, 1994 pay equity adjustment was annualized and there's one more instalment to come on March 20, 1995.

MR. CHAIRMAN: Now before I recognize Mr. Smith we have two more - Mr. Langdon and Mr. Hodder. Ms. Verge has indicated she'd like to speak but she said if it was a time she would be willing to give over to Mr. Harris who wants to speak. So we're in a situation that - Ms. Young tells me that she has an appointment. She has to leave here at about 12:15.

MS. YOUNG: At 12:00 o'clock actually.

MR. CHAIRMAN: At 12:00, that would put the committee in some degree of jeopardy if we had to come to a vote. The people who are asking the questions; Mr. Smith, Mr. Langdon, Mr. Hodder and Ms. Verge, if they could shorten it up from ten to five minutes for the questioning we could conclude this this morning, otherwise I'm afraid we're going to have to adjourn at 12:00.

MR. HARRIS: Mr. Langdon has suggested before he left that he would be prepared to give up his time if that would conclude matters.

MR. CHAIRMAN: Well that will certainly help it. Now we need a little more concession from somebody along the way because we need to get it into 12:00 for this. So will we assume that we'll be able to call a head by 12:00 with all the questions we have?

MR. HARRIS: (Inaudible) twenty-eight to twenty-four, I guess, that'll give us eight minutes each instead of ten.

MR. CHAIRMAN: Alright, I now call on Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman. I'll try to be brief and I'll ask for brevity in the answers as well, maybe that'll facilitate matters.

If I could just get back to the medical school, there's one other point with regards to it that I wanted to raise in that - it's not necessarily something that you would have right now but possibly, if you can't respond to it, as part of your review which is something that you could maybe look at and make the information available. With the figures that you gave me it looks like the - just doing some rough calculations, it would appear that about 70 per cent, approximately 70 per cent of the graduates of the school are residents of the Province. I would assume that that's the arrangement that's agreed to - arrangement that we had with other provinces that are buying the service from us, is that the set ratio?

DR. WILLIAMS: That was in the range that was set years ago when the medical school started up. There are ten seats that are purchased by the Province of New Brunswick every year, forty seats are from Newfoundland residents and usually most medical schools in Canada take in other residents of the country. All people admitted to the medical school are Canadian citizens. To provide for some mixture of people from across the country, there are six seats that are for residents of Canada but not necessarily residents of Newfoundland, forty from Newfoundland and ten that the Province of New Brunswick pays for. As well, residents of Newfoundland are able to get into other medical schools across the country but there's no transfer of dollars in terms of that. That's just a policy decision.

MR. SMITH: Okay. The other part of that question and you may not have that information in terms of - I'm just wondering, in terms of the ability of the university to respond in the number of applications that they're receiving, how would this be reflected here? How many students are we - are we getting 100 applications from within the Province and we're able to -

DR. WILLIAMS: I understand this year, and I can't tell you for other years, there was approximately 200 applicants for the forty positions for Newfoundland graduates. Now these are applicants, not all of these would be - when you weed them down - would be qualified to get in but that's 200 applicants of which I think they did 100 interviews and of which they'll select forty people.

MR. SMITH: Okay, thank you.

The other area I wanted to just focus on for a minute because it is an area of some interest to me, 3.4.02, the Road Ambulance service. Having recently, within the last three or four years, had the experience of working at establishing a service in the rural area I can relate to some of the difficulties that are involved in trying to set up a community service. I notice under Allowances and Assistance that there is a slight increase. Does this refer to the assistance given to, let's say, in my home town of Lourdes where we've set up a volunteer group that runs a road ambulance service, that they are the - I think it is on the basis of fifty cents a kilometre right now that they are reimbursed for the runs that they make.

Because I had been contacted by the committee a few months ago and they were of the opinion - I don't know where they got the information - that this was under review and in fact that there were going to be some changes there. Does this confirm - am I reading this right now, that that has not changed? That the rate will continue as it has been up to this point in time.

DR. KITCHEN: There has been a rate increase approved for road ambulance. Dr. Williams, would you want to go into more detail on that?

DR. WILLIAMS: It is in the range of $200,000. It is $200,000 approved this year. It is linked in with the provision of quality. We are developing a program in consultation with the ambulance operators and Treasury Board that will utilize these funds in terms of the attendant package. There is an attendant component to the mileage subsidy and this will link into having a qualified attendant on various trips. They will get more money if they have a qualified attendant. It is related to quality. We are trying to use this money to improve quality of service. There is $200,000 extra going into the mileage rate, yes.

MR. SMITH: So would that move beyond what is the present level or...?

DR. WILLIAMS: Yes, it will be $200,000 beyond the current mileage rate but it will be linked into the issue of having people trained, trained attendants.

MR. SMITH: Okay, but my question is, bringing it back down at the local level, how will that translate, for example, in the situation that I referenced? Say in Lourdes to the ambulance system there. Right now I think they are receiving fifty cents. They do use qualified ambulance attendants. Will they see an increase beyond that or will it remain at that fixed rate?

DR. WILLIAMS: No, there will be an increase depending on the level of attendant and the attendant's training that they provide.

MR. SMITH: Okay. The other matter that I wanted to raise with regards to the Road Ambulance service is that - I know we are pressed for time - we were about three years trying to establish the service. We fund-raised in the local area to come up with $25,000, had made the agreement with the Province, purchased the vehicle, had it sitting in our garage in Lourdes, only to find out that no one had told us that it was going to cost us an astronomical amount to put insurance on the vehicle. We were ready to establish service, had trained attendants, had the vehicle sitting in the building, only to find out when I started contacting the insurance companies that the best quotation that I could receive is something in the area of $4,200. At no point in time had we ever - I didn't have the vaguest notion that it would be so expensive.

We managed to get through in the first year but since then, I understand from the committee, that they, through the ambulance association, the independent operators, that I think they have worked out some sort of an arrangement now for better rates. But I'm just wondering in terms of the department, is this something that is being addressed? Because it seemed to me to be a - first of all I think up front, when I had the initial meetings with representatives of the department, I think it would have been very worthwhile from my perspective that someone had said to me: We would just like to alert you to the fact that it is going to cost you a lot of money to ensure this vehicle so you can build this into your fund-raising effort.

Also, another part of that, is the department, or has the department been active in trying to lobby to do something at improving the insurance rates? Because in this instance, when you are talking about communities that set it up, run it on a voluntary basis, it is certainly a deterrent to have to go out and raise those additional funds to purchase insurance. When we started out we were looking at a service that we thought would probably mean fifteen runs a year, sixty miles return, but still the best that we could look at was in excess of $4,000 for insurance. I'm just wondering if someone would like to respond to that.

MR. HART: I can address that. I would just like to say that generally speaking we have dialogue on a regular basis with the operators of the ambulance business in the Province. Primarily that has been the private operators, but we have been trying to establish a relationship with the volunteer or community organizations because that has been (inaudible). I know there have been some discussions as to the possibility of the volunteer or community organizations forming their own association to have direct representation with the department; or alternatively they've been looking at linking in with the Private Ambulance Operators Association. Because a lot of the issues are very common.

On the matter of operating costs, we've recognized for some time that a lot of these volunteer organizations have - when they were set up initially they were set up in areas of the Province that were remote, I guess, to a large extent, that wouldn't be viable for a private operator to move in because they just wouldn't be able to make a go of it with the existing subsidization rates. Because their trip statistics wouldn't be up there in an area where there would not be a lot of volume in that sense.

There is a separate arrangement that went in place years ago for volunteers in terms of the department will subsidize 50 per cent of the cost of acquiring an ambulance unit, with the understanding that the community then would pick up in various forms - through volunteers, driving, and through fund-raising efforts they were able to operate. It appears that over the last little while we've seen a trend where volunteers are not as free with their time any more. I guess they have their own financial problems to a large extent. We've seen a lot of stress on the community or volunteer organizations where a lot of them have been coming to us and indicating that it is much more difficult to operate than it was in the past. It is an issue that has been on our agenda for some time.

Dollars are short as you are aware throughout government so what we are trying to do is accommodate where we can through developing efficiencies in the whole road ambulance program. That is something that is going to take some time. It is not something that can happen overnight but we are seriously looking at it. We are hoping too that this volunteer group - actually I attended a meeting out in Gander about a month or so ago. That was the first indication that they wanted to get together, form their own group, so they could discuss common issues. The problem is, when you deal with segmented groups it really is difficult to get a handle on the whole thing, but I think with an organization formed that will make that process much more efficient.

MR. CHAIRMAN: Thank you, Mr. Hart.

Your time has expired now.

Mr. Langdon, I understand that you have in the interests of time decided that you wouldn't require your time.

Mr. Hodder.

MR. HODDER: Just one basic question and it is to do with the vote that is 2.2.03, Prevention and Promotion. If we look at the total vote there, $443,400, and take that as a percentage of your total budget, which is $872 million - that might not be a fair comparison because as you know that doesn't quite work that way - but at the same time I'm very interested in prevention and promotion, both as it applies to the Department of Health and the manner in which prevention and promotion is integrated as a function of all departments of government.

I can't think of any department that hasn't a role to play in prevention and promotion of good public health, whether it is seat belts, whether it is the industry, in the environmental health, and so on and so forth.

I want to get a comment about the commitment of the Department of Health to: a) an integrated approach with all the departments, or b) the manner in which we are going to make the public of Newfoundland and Labrador more conscious of the need for everybody in every part of the Province and every aspect of industry, recreation, senior citizens, teenagers in school, and get a total focus. Because that is where real dollars can be saved.

DR. KITCHEN: Let me say in response to that, that particular vote there, I don't know why someone called it Prevention and Promotion. It is basically the cost of operating a printing service that we have down in Pleasantville.

MR. HODDER: Yes, I realize that.

DR. KITCHEN: It really doesn't pull together all the health promotion activities in the department. I agree with what you are saying, that it is very important that we perhaps coordinate our efforts. It is a major priority in the department. We are trying to shift the whole focus, put more emphasis on health promotion that we mentioned in our opening remarks. We are in line with what you are saying there, I think. There is no doubt that in the future we will be spending even more money, but we can't spend - first we have to have the program in place, rather than just throw the money at it. Our initiatives at the moment are in trying to get the programs in place, rather than just go out and spend money on health promotion as such.

MR. HODDER: All of the literature that is coming from the Canadian Medical Association and the people who are involved in the public administration parts of the medical profession are very strongly advocating a total integrated approach with all aspects of government, federal, provincial and municipal.

For example, one of the things that I would like to just bring out is although the aspect say of vehicles is really in the Minister of Works, Services and Transportation, however, the Janeway would tell me that they have an alarming rate of incidents of children hurt with bicycles - you know, lack of wearing bicycle helmets. We have children out who will spend $500 equipping the child to play hockey but we won't go and buy him a set of shin pads so he can have his skateboard, or we have those roller blades. We have so many things out there that are counterproductive to health prevention that I think we have to look at it.

If you look at the Janeway stats, 886 people have been treated at the Janeway in the last five years as a result of bicycle incidents alone, and that kind of thing. As you know, Ontario now has mandatory helmets for bicycles. We have to move in these kinds of directions. Although the data on it is not conclusive - there are people in the business who are saying: Maybe helmets work, maybe they don't work. It is like the seat belt thing. The preponderance of evidence shows that bicycle helmets prevent injuries. One child alone treated at the Janeway for a year as a result of a serious accident, if we had that prevented, would give us a lot of money to promote safety.

I would like to ask the minister if he would bring that matter to not only his department but to all of his colleagues so it becomes a total government initiative.

DR. KITCHEN: I'm going to ask Dr. Williams to comment on it in a minute but I would like to say that on the bicycle helmets, as you say the evidence is in. Some people are saying that not only should we be after bicycle helmets but there are other things with respect to a bicycle that we should also be looking at very carefully, like reflectors and rear-view mirrors and so on. That all these things should be looked at very carefully.

I believe, Dr. Williams, there is a committee at the Janeway that you are on. Could you say a few words about that?

DR. WILLIAMS: I guess there are a lot of comments Mr. Hodder made about the whole issue of having a healthy public policy that spreads across various government departments and agencies. Certainly the Department of Health has been working with other departments and with agencies in the health promotion sector, private agencies, through the association of school health agencies, with the Department of Health, who deal with the issue of health promotion and disease prevention in the classroom.

The Newfoundland Medical Association has been putting a fair dollar in the last year into the issue of health promotion and disease prevention through some of their initiatives. I think probably you've seen some of their ads in the paper about appropriate use of the health care system and measures that people can take to prevent disease and ill health. Again, the department has started a joint process through Ms. Dawe's group and linking in with the medical association in working with them to enhance that effort.

As regards to the Janeway and the issue of children accident prevention, accidents and injuries are a major component of ill health in the very young children. I think it is one of the leading causes of death in fact in the younger age groups. The Janeway and the department jointly got an injury prevention program for the Province for children in place and internal child health is actually working very closely with the Janeway on those issues.

As well there are ongoing major efforts in the whole issue of disease prevention, health promotion, or public health nursing. A lot of their function is the whole issue of health promotion and disease prevention through the well baby clinics that they have with parents through the school health programs. Immunizations. They are all in the area of health promotion, disease prevention. There is a whole heart health promotion thrust in the Province that we are carrying out with a number of agencies. Especially we are concentrating on the smoking issue and the nutritional aspects of preventing heart disease through lowering the intake of fat and eating fresh fruits and vegetables, whole grains, this type of thing, this type of promotion.

There is the whole HIV-AIDS issue, as Ms. Dawe spoke about earlier. It links (inaudible) the community in trying to prevent this. Because that is where we have to put most of our emphasis, on prevention, because we don't have any treatment for the disease right now, or any effective treatment to be honest with you for the disease. The whole issue of tobacco that we talked about earlier. The dental health promotion program that we are doing with the Newfoundland Dental Association in terms of by targeting the program at the school level we will get 90 per cent or almost 100 per cent uptake rather than the 40 per cent uptake we are getting now.

Then there is an issue that has recently come on the scene. It is the whole issue of preventing neural tube defects. The incidence of neural tube defects - spina bifida, (inaudible), these types of things - are higher in the Newfoundland population than in other areas of Canada. We've recently worked with a number of agencies and we have now going out to the system for women who may be getting pregnant or before they get pregnant to start taking the appropriate dietary measures, and supplement their diet with folic acid. Because we know that the issue of neural tube defects links in very closely with folic acid deficiencies.

These are just a few examples as you talked about that link in the health department with other agencies, either out in the sector or across other government departments.

MR. CHAIRMAN: Thank you, Dr. Williams. Ms. Verge.

MS. VERGE: A couple of quick questions. I understand that our Province per capita isn't getting our fair share of pharmaceutical research but that there have been efforts under way by the government to attract to the Province more drug research or pharmaceutical research. Would the minister tell us what we can look forward to in the next year in the way of projects, jobs, money spent, patients involved, et cetera?

DR. KITCHEN: We've had some discussions with pharmaceutical companies about that and hopefully something will happen. I don't know if there is anything particular on the vine right now, Dr. Williams. We are also going to be talking shortly with the people at Memorial to see if we can mount some sort of thrust there, a greater thrust than is presently there. Because the expertise is there in the pharmacy school in Memorial to do great research and we should get at it. Is there anything specific on the go that you would like to mention?

DR. WILLIAMS: Time goes quickly, but I think about six months ago there was a symposium at Memorial where a number of agencies attended, including the Department of Health, Industry, Trade and Technology provincially, and the federal government, to have an exposé of the talent that is available at the medical school and in the University generally in the area of I guess health care delivery research issues and bio-medical research issues. Arising out of that I think it was announced recently that there has been some federal funding and provincial funding coming to set up an infrastructure, working with the medical school to set up an infrastructure.

We at the department have worked very closely with the medical school. They have some very good people there. They have a Newfoundland centre for health care evaluation and research which has the capacity to carry on those two forms of research. The drug companies we understand are interested in putting some money into this research. The money that was announced I think last week will help the University build an infrastructure that will enable them to tap into this research.

MS. VERGE: What does infrastructure mean?

DR. WILLIAMS: The type of an organization and staffing that will enable them to go out and attract research funding that is available.

MS. VERGE: Does that mean they have to hire new people or just reorganize the people they have and give them new titles?

DR. WILLIAMS: There is a small number of new people hired on the administrative side to bring this stuff together, but we already had the scientists and researchers there. It is a matter of organizing that a little bit better and tapping into the money that is available. I think the medical school in fact brings in close to $4 million in terms of research money now from outside the Province that comes into Newfoundland. I think there is more to be gotten. We have some excellent people there and we have some expertise that they don't have in other centres. By putting this little bit of seed money we are hoping that new initiatives - and there are very good jobs there in that particular sector, high-paying and good jobs.

MS. VERGE: But we are not getting our fair share of that now, are we?

DR. WILLIAMS: We are not now but we think with this infrastructural support and that we will be able to compete and get our fair share and maybe more.

MS. VERGE: Home care. In the Corner Brook area we had a set back over the past year. Western Memorial Regional Hospital closed the day hospital which provided respite care, but also occupational therapy, physiotherapy, for stroke patients and others living at home, and gave baths to disabled people living at home. There has been a partial replacement with the VON adult day care centre but that is simply a social program.

The hospital facilities are still there lying idle and we now have the VON talking about raising money to build some of these specialized facilities which are already five minutes away in a public building. Is there some way the government, the hospital and the VON can cooperate and pool resources and offer to the Corner Brook area once again a day hospital to support people living at home? Stroke patients, people with disabilities, and the elderly frail.

DR. KITCHEN: Basically you are wondering if we can get the VON to use the Western Memorial Hospital facilities.

MS. VERGE: It seems a bit ridiculous for the VON to be out raising money to build facilities which are lying idle five minutes away. We all pay somehow, whether it is as donors to charitable causes or as provincial taxpayers or federal taxpayers.

DR. KITCHEN: We'll have a look at that, is that fair to say? Unless somebody knows anything about it already, if not we will have a look at that. We'll talk to - I guess Dr. Murphy is heading VON over in western is he?

MS. VERGE: No -

DR. KITCHEN: Not now?

MS. VERGE: Well Pat Pendergast is the senior staff person, the executive director but the president of the Corner Brook Chapter of the VON is Margaret Barker.

DR. KITCHEN: So we'll check into that and see if something can be arranged because, as you say, it doesn't make sense to have facilities vacant and somebody raising money for other facilities.

MS. VERGE: Another quick question, there has been a severe shortage of speech pathologists in the western region and it may be true elsewhere in the Province as well, has there been any headway made in augmenting speech pathologist services?

DR. KITCHEN: We have one over in western we pay?

MS. DAWE: Through the western public health unit we have the speech language services. Over the beginning of the last fiscal year, we added one additional speech pathologist. Part of our discussions at the moment, in terms of the interdepartmental needs as addressed earlier, is to talk with the Department of Education and try to best utilize resources from both departments in the area of speech language. So these discussions are underway so that we don't be duplicating one anothers efforts in trying to better utilize the resources that are there throughout the Province.

MS. VERGE: There's no duplication now. As of the last couple of years the hospital public health speech pathologist doesn't do anything with school children?

MS. DAWE: Yes.

MS. VERGE: I know of two cases where parents kept their children home for an extra year so the children could keep going to the Department of Health hospital speech pathologist. That's another ludicrous example of public systems not interconnecting.

MS. DAWE: If I could comment, part of our initiative in the area of continuing care is to try to bring all the component services of home care, home support, the rehab services included and respite together under the regional boards. Some of the monies that had been targeted, the additional $1 million last year and $500,000 this year, will be to enhance these continuing care services. The discussions that are underway now with the regions is: what are the greatest needs? Are they home care, home support or some of the allied health needs? So there will be improvements over the year because we have some additional funding this year but I can't say specifically which area until we have the discussion with the regions.

MR. CHAIRMAN: Thank you, Ms. Dawe. Mr. Harris.

MR. HARRIS: I was also interested in the drug program, the drug research and I don't know if anyone in government - perhaps you can tell me whether you went back to the speeches and representations made by the drug industry when they travelled around the country over Bill C-33, I believe it was called - and they tried to extend their copyrights. They promised all kinds of drug research, including specific amounts in Newfoundland. Has government taken them up on their promises? Specifically, instead of us, the taxpayers, spending more money to start building infrastructures to now attract them - there seems to be a quid pro quo that they foisted upon the public for this and they did promise specific amounts to drug research, has that come to fruition?

DR. KITCHEN: The PMAC, is that the group?

MR. HARRIS: Pharmaceutical Manufacturers Association.

DR. KITCHEN: They were in to see us recently and we raised that question. I am going to ask Mr. White if he would respond to any specifics here.

MR. WHITE: Mr. Chairman, in response to the question by Mr. Harris. As Mr. Harris said there was a lot of debate and discussion at the time as to increasing research and development in Canada and I guess the drug industry and their association, the Pharmaceutical Manufacturers Association are making claims, I am not sure of the specifics, that they have indeed enhanced research and development in Canada. As to what is actually happening on a regional basis or in Newfoundland I am not sure of the specifics except to say that it is part of the process, I guess, Dr. Williams was talking about earlier where Memorial University Medical School and other centres are going after the companies, making representations to get more funding to do more research here, clinical research at the university, at the medical school.

I am not aware of any specific dollars that I could tell you, any specific amount. I do not know if Mr. Downton has the information.

MR. HARRIS: Well, I cannot tell you the amounts but I can tell you that at the time, and in was in the spring of 1987, that the senate committee were holding hearings across the country. They were here in St. John's and I made a representation to them as I was a federal candidate at the time, and the drug industry was there at those hearings telling people how much money they were going to spend. I cannot remember the exact figure.

MR. WHITE: Yes, they did make the claims and I am aware of them saying they would be spending more money. This would enable them, I think, the gist of it was, to spend more money in Canada to develop more research and development.

MR. HARRIS: They were specific about how much they were going to spend in Newfoundland as well, but I do not know whether they did it or not.

On the same topic the estimates shows a $20 million federal revenue under the indigent program on Page 242, line 3.2.02 of the Budget. For last year that is, which is $6 million more than what was budgeted for, and as of the 1994-95 estimates there appears to be approximately half the cost of indigent drug services, so-called, coming from federal sources. Is there an explanation for why that jump from $14 to $20 and now back to $16?

DR. KITCHEN: The indigent budget which last year was budgeted at $16 million?

MR. HARRIS: Well, it was budgeted for $16 million and $9 million was spent. The difference was that the federal contribution went from the projected amount of $14 up to $20 million and now it is back to $16 million. It seems to be a substantial difference.

MR. WHITE: In response to the question by Mr. Harris, my understanding is that there were increased recoveries under the Canada Assistance Plan on a retroactive basis for certain aspects of the program and that these actually came in during the old fiscal year and these are nonrecurring recoveries.

MR. HARRIS: Can I ask the minister, and I have been asking this question ever since I have been at these committees, well two things, and they are not particularly related although they are a form of alternate delivery of medical services in some cases regarded as being closer to the community and in other cases as an approach that could also save money and be more related to community health. Nurse practitioners: whenever I have asked this question, I have been told that we are having this wonderful study done in Trepassey. I know about it, it was a three-year program and I have been asking these questions for four years, and I am wondering are we at the point now where the government is prepared to say that they now have learnt something of their own or, is there any progress being made in government coming to some conclusion about the use of nurse practitioners in the health care system in primary service?

DR. KITCHEN: Yes, that report on the Southern Shore has just been passed to us but we haven't had a chance to look at it yet. In that connection we have to be very careful about this because there are some major issues involved here and it has to do with the relationship between nurses and doctors and -

MR. HARRIS: Oh I know, but can you make the report public Dr. Kitchen, so we can all have a look at it and we can all engage in the debate.

DR. KITCHEN: Let me read it first, and then we will judge whether it should be made public. I have no reason not to make it public.

MR. HARRIS: Maybe we should all be involved in the debate and not leave all the responsibility on your shoulders.

DR. KITCHEN: Absolutely.

MR. HARRIS: Because usually what happens is that you come to some kind of compromise with the medical profession and you give us a fait accompli and then we have to decide whether there could have been a better way of doing it. Similarly, with the other question that I ask annually is about midwives, I know there has been some progress made on that and we now have a report. What about a time frame for dealing with that, is the government considering the model of separate midwives registry, or are they trying to integrate them into the nursing profession or, what is the plan at the moment and what kind of time frame do we have?

DR. KITCHEN: We have had a report commissioned but it is not in yet, it is due somewhere around the end of March or something like that and we are looking forward to it, very much.

AN HON. MEMBER: (Inaudible).

MR. HARRIS: It was due in March, yes.

DR. WILLIAMS: The question came up because there was so much interest.

DR. KITCHEN: Okay, it has been delayed and when it comes up we will have a look at it but again we have similar questions. What do we do with the physicians who normally deliver babies if the midwives are going to do it? Do we take the salaries of the midwives out of the physicians' budget? There are very interesting things here to be contemplated so we are looking forward very much to getting this report and having some debate and discussion about it because obviously we have to move somewhere in that direction.

MR. HARRIS: Thank you.

MR. CHAIRMAN: Now before I call the heads, I understand from Ms. Young that she has made an arrangement with Mr. Hodder in case there is a formal vote that he will abstain so it will be even. I will now ask the Clerk to call the heads.

CLERK (MS. E. MURPHY: (Inaudible).

MR. CHAIRMAN: Yes.

CLERK: 1.1.01 to 4.4.05

MR. CHAIRMAN: Shall those heads carry, shall 1.1.01 to 4.4.05 carry?

CLERK: Total?

MR. CHAIRMAN: Shall the total carry?

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: In that case I declare the Estimates of the Department of Health have passed the Committee Stage.

On motion, Department of Health, total heads, carried.

MR. CHAIRMAN: I would like to thank everybody for participating here today; before we adjourn, would the Clerk advise the members of this Committee when they are to meet again so we will have no doubt about it and everybody will be up to scratch?

CLERK: Monday, the 25th.

MR. CHAIRMAN: The 25th, Monday in the morning.

MS. VERGE: Yesterday I was told that we meet this Thursday night, the 21st.

CLERK: That has been changed.

MR. CHAIRMAN: Apparently they must have had a meeting yesterday.

MS. VERGE: So that meeting is Monday morning at nine for Justice?

MR. CHAIRMAN: Yes.

The Committee adjourned.