Pursuant to Standing Order 68, Wally Andersen, MHA for Torngat Mountains, substitutes for Mary Hodder, MHA for Burin-Placentia West for part of the meeting.

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

MADAM CHAIR (Ms Jones): Order, please!

Good morning, everyone. I would like to welcome you to the Social Services Committee for the Estimates for the Department of Health and Community Services. I welcome Minister Smith and his officials this morning.

We won't adopt the minutes of the previous evening, as they have not been prepared yet, but will do so later this morning.

I would like to start by asking the Committee members to introduce themselves by name and district, and then we will ask the minister to introduce his officials.

Maybe we will start with the Member for Port de Grave.

MR. BUTLER: Roland Butler, MHA for Port de Grave.

MS HODDER: Mary Hodder, MHA for Burin-Placentia West.

MR. MERCER: Bob Mercer, MHA for Humber East.

MR. MANNING: Fabian Manning, MHA for Placentia & St. Mary's.

MS S. OSBORNE: Sheila Osborne, MHA for St. John's West.

MR. ROSS WISEMAN: Ross Wiseman, MHA for Trinity North.

MADAM CHAIR: Okay, Minister.

MR. SMITH: Thank you very much, Madam Chair.

Good morning, everyone.

First of all, just to introduce the officials I have with me, I think most of them would be known to the members opposite. Robert Thompson is the deputy minister of the department. To my left is Donna Brewer, ADM for Finance. Bev Clarke, who is behind me, is ADM for Policy and Planning. I think Gerry is next to her, the ADM for Government and Community Relations. Robert had this in an awkward order, or at least the crowd didn't sit the way that he gave me the listing. We have Moira Hennessey, the Director of Board Services; Lynn Vivian-Book, the Executive Director of Programs; and Jim Strong, the Director of Financial Services.

MADAM CHAIR: Thank you, Minister.

I would just like to ask all Committee members and your officials to identify themselves before they speak. We have only one camera, which is the one directly in front of me, and the switching for the microphones is done in the basement of the building. Sometimes it is very difficult for them to find out which microphone, so just make sure that it is on before you speak. We need to have your name in order to ensure that it is recorded properly for the House. I will ask the Clerk to call the first head.

CLERK: Subhead 1.1.01.

MADAM CHAIR: We will have discussion on any aspect of the department under the first head, if that is acceptable to the Committee members.

I will now ask the minister to make his opening comments and then we will move to questions.

MR. SMITH: Thank you, Madam Chair.

It is a pleasure for me to have the opportunity this morning as the Minister Responsible for Health and Community Services, just recently appointed, to bring forward the Estimates for that particular department.

My previous work as the Minister Responsible for Human Resources and Employment, my experience as Acting Minister of Health and Community Services last year, and my participation in the Social Policy Committee of Cabinet and Treasury Board have certainly made me aware of the challenges that lie ahead. I look forward to working with all of you to lay out a vision for health for the future. I am sure the Member for Trinity North is pleased to hear that. I look forward to presenting to the people a Strategic Health Plan for the Province. As I indicated in the House yesterday, we are hoping to have that later this spring.

I look forward to working with the people on a health charter for the Province, which I think is an interesting initiative. It is something that was referenced in the presentation which I made to the Romanow Commission. I think it is something I would like to have the opportunity to explore with my colleagues and members of the House in some detail as we continue to move forward on that particular work.

As I referenced, I recently had the privilege to present to Commissioner Roy Romanow, the government's views on the future of health care in Canada. This submission calls upon the federal government to increase its funding for health. Further, it outlined the future plans for the health system in this Province, in particular the need to focus on wellness and primary care reform. The Province also called for the implementation of mechanisms to identify, on an ongoing basis, the services that should be included, medically necessary, under the Canada Health Act.

The submission by the provincial government reflects the feedback from Health Forums 2001 and reflects the health care needs of the population. The Government of Newfoundland and Labrador is committed to building on its current strengths to create a better health and community services system for the future.

Some of the budget highlights from this year, as I have repeated in this House and elsewhere in response to questions from the general public and the media, certainly health care remains a top priority of this government and to the residents of the Province. Those of you who have been in the House for a number of years would know that we went through a period of time of declining budgets, generally, when virtually all of the budgets of governments were being reduced. I did sit through that period. Health was one budget that, in every year, managed to grow. Some years it was very little, but there was always some growth. That budget was not cut.

In terms of the priority, we heard time and time again in the health forum consultations - and the Minister of Health also heard this during the pre-Budget consultation - the importance of health care and the fact that it does remain the number one priority for the people of this Province. Forty-five cents of every dollar is presently spent on health and community services. The department's budget for the fiscal year 2002-2003 approximates $1.5 billion. This includes spending for hospitals and nursing homes, physicians and dental services, drug subsidies, road ambulance operations, blood services, and numerous community-based programs delivered by the four Health and Community Services and two integrated Boards.

Our spending per person on health care in Newfoundland and Labrador is among the highest in the country. According to the Canadian Institute for Health Information, Newfoundland and Labrador is projected to spend $2,550 per person on the public sector health care in 2001, up from $1,713 in 1995. This is $154 per person above the Canadian average in 2001, which the actual figure was $2,396. Specific details of the increased investments in health care are contained in the Budget Highlights document, the Speech and department's press releases, and certainly today we will be pleased to answer any specific questions which hon. members may have. However, I would just like to briefly highlight the following:

Since 1996-1997, $462 million has been added to the department's gross operating budget, an increase of 46 per cent. On a cumulative basis, $427 million has been added to the base budgets of boards since 1997. Since 1995-1996, over $500 million has been committed in this Province for health related capital projects and equipment. The total value committed by this government in 2002-2003, for capital spending to support ongoing construction of new health facilities, renovations of existing facilities and equipment, is $52 million. New funding commitments this year include $2.7 million annually to provide a 4 per cent increase to the rates paid to home support workers; $1.1 million provided for a wellness strategy, which would include expansion of the breast and cervical cancer screening programs and a renewed commitment to the provincial tobacco strategy; $1.3 million to increase rates to personal care homes and a number of subsidies for individuals; $300,000 to increase students admitted into the nursing program by thirty-two seats, up from the current 220 seats; and $800,000 has been provided to establish a psychiatric assessment short-stay unit in St. John's. Of course, this is a project that has long been advocated by a number of people in this House and certainly within this Province as being a need.

Madam Chair, these are some of the highlights from the Budget, just some brief comments with regard to the department itself. I am going to stop there and we would certainly welcome any questions which the hon. members may have.

MADAM CHAIR: Thank you very much, Minister.

We will now open it up to questions and we will start with the Member for Placentia & St. Mary's.

MR. MANNING: I open my comments with a welcome to the minister and his staff. I certainly say, I do not envy your positions on most days.

Just to start this morning, I would like to run through some of the Estimates and the figures that we are looking at, just some questions on those. We may get some more questions brought forward from these. I am just going to go over some in-line figures here.

Under Executive Support, subhead 1.2.01.01., you had a budget last year of $822,000, which was reduced to $765,000 - I am just going to round off the figures - and this year we have a budgeted amount of $835,000. Could you explain the difference on that?

MR. SMITH: Donna, do you want to speak to that?

MR. MANNING: Page 187 in the Estimates. Maybe you are not dealing with that.

MS BREWER: The $822,000 was the original budget for the staff complement when the budget was prepared back in early 2001. During the year there were some (inaudible) of staff. We had lost our Executive Director for Communications for a period of time, and there was a vacancy in one of the ADM's secretaries, and that position was kept vacant for a period of time.

Going into $835,100, those positions are now filled. Instead of an Executive Director for Communications we have an Executive Director position now in the form of Lynn Vivian-Book for the Programs side. Also, what is reflected here is the salary increases, the 5 per cent that has been awarded to all public service employees; plus, there was a reclassification of our medical consultant along the lines of a recent reclassification that occurred last year for the medical directors in the system, so that would account for the increase in that.

MR. MANNING: Under Administrative Support, 1.2.02.01, Salaries. We had a Budget amount of $3.7 million and our Revised Budget was $4.1 million. Again, our Estimates this year are $3.8 million. I am just wondering about the difference in the amounts.

MS BREWER: I just asked Jim to confirm, but it is my understanding that the salary increases are now being reflected in the Revised, or did they restate the budget for those two?

WITNESS: (Inaudible).

MS BREWER: But is that the reason the Revised is up from $3.7 million to $4.1 million?

WITNESS: (Inaudible).

MS BREWER: Okay.

There was a restatement here, the audit staff for the Medical Care Commission. We are budgeted over in another activity and it got restated here in the projected Revised. Then for 2002-2003, they reflected back over under the Medical Care Commission again. So our salaries in total are correct, but there was a brief misstatement there on the projected Revised for that activity. The audit staff were included and they should not have been included.

MR. MANNING: The audit staff will be put somewhere else in the -

MS BREWER: Yes, in the Revised. The audit staff were double counted there.

MR. MANNING: Just further down under Administrative Support, Purchased Services, exactly what does that mean? There is a $50,000 increase from your budgeted amount to your Revised.

MR. STRONG: Purchased Services would cover things like the rental costs and general advertising costs that the department would be incurring. The costs for 01.02. are up slightly because of a slight increase in our rental costs.

MR. MANNING: Under Board Services, 1.2.04.01, Salaries. We had a Budget amount of $943,000 which dropped down to $692,000; a considerable amount. Why would that be?

MS BREWER: There were a number of positions - we had a retirement last March of our Director of Board Services. Our Director of Service Quality, Moira Hennessey, was successful in getting that position but then the director position, plus one of the consultant positions, have been held vacant for the balance of the year. The increase that you will see then in the following year basically reflects the salary increases for the staff that are on staff today.

MR. MANNING: So these people will be brought back in?

MS BREWER: No, our salary plan for next year continues to assume that those two positions will be held vacant.

MR. MANNING: Okay.

Under 1.2.05, Policy and Program Services, 05. Professional Services, $138,000 budgeted, $204,000 revised, $148,000 this year. Why the increase? Exactly what would those professional services be under Policy and Program Services?

MS BREWER: Subject to Jim confirming this, I believe that is where the money for the professional services relating to the health care forums that Minister Bettney had last fall were charged.

MR. STRONG: That is correct.

MR. MANNING: 1.2.06, Government And Agency Relations. Again, Purchased Services, budgeted $18,000, revised is $76,000, and then budgeted for this year $3,500.

MS BREWER: Last year, up until - was it October, Robert? - the department was the lead province for the federal-provincial territorial Ministers of Health and conference of deputy ministers. So we were given extra funding that was cost-shared with the federal government and all of the other provinces. That was a one time expenditure that has been incurred in 2001-02 that will not occur again in 2002-03.

MR. MANNING: Okay.

Over to Senior Citizens, 2.2.02, page 191. You haven't got the book, okay. I guess it has to do with drug costs and GIS. Allowances and Assistance, I am just wondering about the increase. I partly guessed why it has increased. There must be more dollars spent on drugs and GIS. Have you seen an increase there? Is that something that is going to continue? Because you went from $28.9 million, we will say $29 million to $32 million, an increase of $3 million and you are at $32.5 this year. Is that a progression of an aging population? Why the increase? Are you expecting - you had a $3 million increase last year but you are only increased by $500,000 this year. So I am just -

MR. THOMPSON: That is right. Every year, in recent years, we have seen a general climb in the increase of the two drug programs. With senior citizens the price increases come from inflation and also from substitution of new drugs into the formulary and other drugs. Sometimes we have drugs that have less utilization because new drugs come in. So there is a constant mix that is going on in the program. In the upcoming year we would expect some of the same pressures to occur but we are also going to try to institute new measures to manage the total amount of drug costs.

If you look to the original budget last year - as you noted it was $28.9 million - there was considerable growth in-year. We are going to try to manage with the same budget this year and balance out at the higher level that we had as a projected Revised in the last year.

MR. MANNING: Again, would that follow true for Special Drug Programs, 2.2.03? The Budget was $600,000 last year, the Revised amount was still $600,000, but we see an increase of $631,000 this year. Would that follow under the same -

MR. THOMPSON: Subject to correction by Donna, this is a little bit different than that. There are a much smaller number of recipients and it is there for a very targeted one or two types of drugs. We think we will be much more comfortable fitting within the allocated budget there and it is subject to less volatility. The seniors' program operates under different pressures and demands than the Special Drug Programs.

MR. MANNING: The Special Drug Programs will not be for everybody. It is just for -

MR. THOMPSON: It is for a very designated -

MR. MANNING: Not for everybody. I mean, it is not an age - like where you have your seniors' program. Special Drug Programs are for anybody, I guess, who needs the service of a special drug, whatever age they are.

MS BREWER: One example would be cystic fibrosis and the other ones are people who suffer from lack of growth hormone.

MR. MANNING: Yes, okay.

Under 2.3.01, Administration. Salaries again, we had budgeted $1.77 million, the Revised is $1.20 million, and this year - well, I guess that is the increase of about 5 per cent, but I am just wondering, there is almost $500,000 there revised on Administration. Could you give some explanation on that, please?

MS BREWER: Administration, that was for the Medical Care Plan. There was some one-time money provided in the budget that was estimated on account of regionalization that we did not spend.

I am just going to turn to Jim for clarification on how the audit staff are being reflected here.

MR STRONG: We were restating the audit staff, so there was a misstatement here. When we reflected our projected revised position we overstated Administration slightly and we understated the Administration in MCP slightly by about $300,000.

MR. MANNING: Purchased Services again, there is a Budget amount of $2,200, the actual Revised is $41,000; 06 under Administration.

MS BREWER: Again, that would have been one-time costs that would have been incurred as a result of regionalization that we do not expect to occur again in the next fiscal year. There was about $33,700 of that $41,400 that was directly related to the regionalization; the moving of the staff from St. John's to the Grand Falls-Windsor office.

MR. MANNING: Physicians' Services, 2.3.02.09, Allowances and Assistance. I realize it is fee for service. The Budget amount is $5.8 million, Revised is $5.1 million, but we are budgeting $5.8 million again this year. I will ask both questions now at the same time. Grants and Subsidies, $57.2 million and the Revised is $53.7 million. There is a large decrease there. I am just wondering, could someone explain what happened there exactly?

MS BREWER: On the Allowances and Assistance, those payments relate to people who are travelling outside of Newfoundland and receive medical services in other provinces or those eligible residents who are out of the country and have to seek medical treatment. We cover those costs through that vote. So the activity during the year was less than had been anticipated.

MR. MANNING: Would all that be for that purpose?

MS BREWER: All that is for that purpose. We think that part of the problem may be a timing issue where the Ontario government was in a strike situation.

MR. MANNING: Okay.

MS BREWER: We found that last month their bills have not been coming in as quickly as possible. So, it may be a timing issue.

Grants and Subsidies; that provides for our salaried physicians. What happens is that the salaried physicians are employees of the boards. The boards indicate to us what positions they have approved and we fund, but through turnover - or there has been some vacancies within the boards which has resulted in less cash flow that was required in 2001-2002. Plus, there is also funding included there - we cover physicians' medical malpractice insurance. The costs there were less than had been anticipated.

MR. MANNING: You must be anticipating - your increase this year is up to $59 million.

MS BREWER: Yes, because the boards are in the process of recruiting and we anticipate that there is going to be some successful recruitment in 2002-2003.

MR. MANNING: Dental Services, 2.3.03.05, Professional Services. You have a Budget amount of $5.5 million, the Revised is $4.945 million, and this year we are up to $5.5 million. There is $500,000 there, I am just wondering about the difference.

MR. STRONG: The Revised is based on the level of activity in the program. The program, basically, provides services to children under the age of twelve or if they are over twelve, between the age of twelve and seventeen, if the children are on income support. The level of activity for next year is based on the forecast. As well, we are reviewing the program.

MR. MANNING: I guess there is a less amount of children partaking in the program. Would that be...?

MR. STRONG: Yes, but what we are looking at is, we are estimating there will be a higher take-up rate next year than in the current year.

MR. MANNING: I will go back to that one now in a minute.

Under Community Services, 3.1.01., Purchased Services, again, $5,000 budgeted, $38,000 actual with a budget this year of $63,000, if somebody were to elaborate on that.

MR. STRONG: The reason for that increase is due to the gearing up of some of the new projects under the ECD programs and NCB programs. The project (inaudible) were required to engage some consulting services to do some of the work.

MR. MANNING: Under Professional Services, there is no money budgeted but there was $115,000 allocated under the revised, under 05., Professional Services, under Community Services. There is none in the budget but there was $115,000 allocated afterwards.

MS BREWER: The $115,000 would reflect two reviews that the department commissioned during the year. One was a contract with Goss Gilroy to do a review of certain cost drivers in the health and community services system, primarily the home support program for seniors, and family and rehabilitative services, and also a contract - Bev Clarke can help me here. I forget who we contracted with, but it was to begin a review the mental health services in the community.

MS CLARKE: Through the Colleen Hanrahan shop; she has a small consulting company and they are doing the review now.

MR. MANNING: Who is that again?

MS CLARKE: Colleen Hanrahan.

MR. MANNING: Okay.

WITNESS: (Inaudible).

MS CLARKE: Yes.

MR. MANNING: Okay.

Under 3.2.01., Health Facilities Operations, we have under 05., Professional Services, a budgeted amount of $250,000 and the actual amount revised was $690,000 with a budgeted amount this year of only $220,000. I am just wondering why.

MS BREWER: Subject to Jim's concurrence, I believe that is where the HAY operational review for the Health Care Corporation of St. John's was charged.

MR. MANNING: What was the total amount on that? Was there a contract on that report? Is there a specified amount for that, or is it...?

MS BREWER: I will have to get you the exact number. My recollection was four forty or four sixty, in that range.

MR. MANNING: Under 10., Grants and Subsidies, $809,000,000, revised $818,000,000 with a new figure this year of $834,000,000, can you just explain? I think that covers hospital services and the operations of the hospitals. Would that be correct?

MS BREWER: Yes, that is correct. It also would include funding for out-of-Province hospital payments. It would include grant money for the Canadian Blood Services. It would include some miscellaneous boards, like the Pentecostal Senior Citizens' Homes, the Newfoundland and Labrador Centre for Health Information, and the Newfoundland and Labrador Centre for Applied Health Research, and also the public health labs. By and far the majority of the money is for the ten institutional health boards.

MR. MANNING: So you are seeing an increase in the need this year. It has increased to $834,000,000.

MS BREWER: The majority of that would have been negotiated salary increases and there was also an occupational review that occurred last year that you are seeing carried forward; the annualized, in fact, going into 2002/03.

MR. MANNING: On 3.3.01., Health Care Facilities and Equipment, Capital, 07., Property, Furnishings and Equipment, the budgeted amount was $13,600,000 to a revised amount of $27,600,000 and this year you are not going to buy many furnishings by the looks of things. You are down to $1,000,000 for this year. I was just wondering if you could elaborate on that a bit. There was an increase of $13 million.

MS BREWER: As announced in the actual Budget Speech, I believe it was three years ago the government made a commitment of an allocation of $15 million for three years. What you are seeing here is the final year, $15 million. From a cash flow perspective, they asked us to flow $14 million in March of 2002, so you are seeing the project revised being increased by $14 million and the $1 million that is in 2002/03 is basically the balance of that $15 million commitment. It is the final year of that $45 million, three $15 million commitment. They asked us to cash flow at $14 million old year, $1 million.

MR. MANNING: So you are just carrying $1 million into next year?

MS BREWER: Into next year.

MR. MANNING: On 3.3.02., Health Care Facilities, appropriations are for repairs and renovations. There is, under 01., Salaries, $100,000 budgeted, $223,000 revised and $222,000 estimated for this year. Were there new people hired here to do some work?

MS BREWER: There was a change in budget approach this fiscal year. If you happened to have the Estimates from last fiscal year, you would have seen a line item amount voted in other government departments. This, in reality, is really the money that Works, Services and Transportation spends. It is their salaried employees, but the budgeting division of Treasury Board decided to vote the money directly within the department because it directly relates to health care projects verus voting it in Works, Services and doing what they call a transfer vote into our department. Basically, this would be their projection as to their salary and costs that they incur in terms of managing the various capital projects such James Paton, et cetera.

MR. MANNING: Are these people paid by your department or by Works, Services and Transportation?

MS BREWER: They will be on government's payroll and the cost will be journalized to our department.

MR. MANNING: Just under Salaries again, Professional Services, the budgeted amount is almost $6 million and we actually spent $1.4 million or $1.38 million. What happened there? There must have been a possible need for the $6 million but the actual amount spent was $1.86 million. I am just wondering.

MS BREWER: I am going to turn that question to Moira Hennessey because she can give you details of the status of the capital projects last year. I believe there are certain projects that did not proceed as quickly as had originally been thought last year.

MS HENNESSEY: I am not sure I clearly understand the question. I wonder, would you mind repeating it?

MR. MANNING: No problem.

Subhead 3.3.02., Health Care Facilities, 05., Professional Services.

I might talk a bit too fast sometimes; it is the blood.

MS HENNESSEY: I will have to make a good guess at this one. This is the former Works, Services vote as well. My understanding is that with respect to some of the Professional Services, the design fees, perhaps there would be a decrease in that. Many times the design fees associated with projects are up front costs that occur on the first six or nine months of planning, but I am not as familiar with that particular vote as -

MR. MANNING: This would be for new facilities, would it?

MS HENNESSEY: Yes, it would be.

MR. MANNING: So, the design costs were reduced?

MS HENNESSEY: No, not that they would be reduced but the design costs occur up front in our capital projects. As we move further into the construction period, the amount of money being expended on professional services would be less because the design has been done at the start of the projects.

MR. MANNING: Okay.

Under 06., Purchased Services, under the same heading, we had a budgeted amount of $25,450,000 and the actual was $28,938,500, almost $29 million. This year the budget is again around $29 million. I am just wondering about the increase there of, give or take, around $3.5 million.

MS BREWER: The numbers are going to vary from year to year based on Works, Services assessments as to particular contracts that are going to be let. The purchased services would be the actual construction work. For example, like in the James Paton contract in 2001-2002, there was a higher cost. Again, I refer more to the details on the actual fit up of some of the contracts within the James Paton. What Works, Services would have done would have been, if there was a cash flow decrease on another project, as you pointed out the decrease in the professional services, they would have had the flexibility within the vote to reallocate the dollars.

MR. MANNING: So the total vote on the bottom line has not really changed a lot from up here; it is just the movement around inside that particular heading, right?

MS BREWER: The way government works with the capital projects, they approve a total capital project and then the cash flow will flow depending on how quickly contracts are let and how long our construction session is.

MR. MANNING: Some of that could be carried into another year.

MS BREWER: Yes.

MR. MANNING: Under 10., Grants and Subsidies, under Health Care Facilities, I see an increase of almost $5 million; a budgeted amount last year of $2,500,000, revised to $7,200,000, and this year it is reduced to $1,500,000.

MS BREWER: Again, as announced, in my recollection, in the Budget Speech, government has committed $5 million for additional fire and life safety enhancements through our various facilities throughout the Province. Again, they cash flowed $3.5 million, they asked us to spend before March 31, and the remaining of the $5 million is being reflected as $1.5 million in our 2002/03 Estimates, the same approach as they did with the capital equipment.

MR. MANNING: So you are just carrying it over into the next fiscal year.

MS BREWER: Yes

MR. MANNING: Okay.

If I could go back to 2.4.01., Road Ambulance, just for clarification, I guess, there are community-based ambulance services and there are private operators and then there are the health care facilities that have some of their own. Could you give us a breakdown of the numbers of those? How many community services, how many privates, how many...?

MS BREWER: These are gradually changing, but at the time that we did the development of this budget there were thirty private operations and twenty-three community. Since that time, I understand, there have been at least two that have switched from community to private.

MR. MANNING: How many government facilities have them? How many government operations, like the Health Sciences, I am just wondering, elsewhere in the Province, like the hospitals here in town?

MS BREWER: That is not reflected here in this budget. I would have to get you that, Mr. Manning. I do not have it, unless Robert knows it.

MR. THOMPSON: I do not know it offhand. As Donna said, those budgets are reflected in the board budgets and not in this ambulance budget. Maybe Moira Hennessey would have a better idea as to how many facilities would have direct ambulance service.

MS HENNESSEY: We have hospital-based ambulance services in Carbonear, Gander, Grand Falls-Windsor, Corner Brook, and in Labrador City.

MR. MANNING: The private ambulance operator receives a subsidy per vehicle. What would one subsidy be?

MS BREWER: It varies, depending on the operation and the number of ambulances that they are expected to man.

MR. MANNING: Just for one ambulance, a private operator, would that be uniform across the Province? Joe Blow in Norris Arm has an ambulance and John has an ambulance in Bay Roberts - two private operators, one ambulance each - would they receive the same subsidy?

MS BREWER: I am not 100 per cent sure, Mr. Manning. I know it was negotiated and was outlined in that MOU that they negotiated with the operators, but, just looking at the list, by far the majority seem to be getting twenty-eight. No, sorry, that is community. Like Brigus, for example, the grant there for Broughtons is $62,000, and there are a number of operators that are getting $62,000, but there are others like Baie Verte regional ambulance services - $122,206.

MR. MANNING: What I am trying to get at is: one vehicle, one operator. With Baie Verte, would that be two vehicles?

MR. THOMPSON: Just on your first question, there are two components to a rate for a private ambulance. One is a base or a block fund component, and then there is a variable component -

MR. MANNING: On mileage and -

MR. THOMPSON: - on milage and other elements of the service. So, if you have one ambulance you might have one block and then that is a set rate. Then there are variable costs over that. If you have two ambulances, you require maybe two blocks. Sometimes when we allocate half a block, I do not know all the details of the structure but there is a base that is common, and the variable component.

I am sorry, I didn't hear your second question.

MR. MANNING: The base is common across the board?

MR. THOMPSON: That is what I understand, yes.

MR. MANNING: And the variables will be based on if someone travels 200 kilometres versus someone who travels six. That is where you come into the difference on subsidy.

MR. THOMPSON: There may be other elements to the rate structure but those are the main elements.

MR. MANNING: Would it be possible - not this morning, I do not expect - to get a breakdown of how those operate? Because I am sure, as some of you are aware, I have some problems in my own district. I am trying to get around but I just have a problem knowing exactly the guidelines and the layout of how it is done, the subsidies and the breakdown.

Now, you are saying there is a base subsidy to private operators and then there is a base subsidy to volunteer operators. You mentioned $62,000 - not to nail you down on $62,000 but I am just wondering, there seems to be, across the board, around $62,000 on private, give or take. I am not saying that is the exact number.

MS BREWER: Yes, $62,000 was an example of a private operator -

MR. MANNING: Of several, yes.

MS BREWER - and it looks like a lot of the community operators are at $28,000. There are a few as high as $50,000.

MR. MANNING: That would be on base?

MS BREWER: That is their block funding, yes.

MR. MANNING: I have to ask the question, because from $28,000 to $62,000 is an incredible amount of difference from community based to private. What is the rationale for that? We depend on the volunteer sector to operate these community services in most cases but at the same time, I mean, a vehicle is a vehicle is a vehicle; I am just wondering.

MR. THOMPSON: That is right, it is a volunteer component. That is the main difference. So that is a huge determinate in the cost structure of the ambulances. You are right, as well, an ambulance is an ambulance and gasoline is gasoline. Those components are supposed to be equalized between the two, but volunteer labour is the main difference; and administration of course.

MR. MANNING: All these people who are operating or working on, or volunteering their time on community based and the private, all receive the same training? They all have to be of the same qualifications?

MR. THOMPSON: I don't know the answer to that in detail. We do have new training requirements and we are trying to bring both community and private ambulance operators to a new level of certification and training. I do not know, for sure, if we have the exact same requirements of the attendants on both sets. Does anybody have any? No? We will have to get you that answer.

MR. MANNING: Yes, okay. I know on private operators there is an onus on them, as private operators, to have a certain level of expertise in their ambulance service in order to receive their subsidy and in order to receive their licence to operate. I am just wondering from a private sector, we have twenty-three communities. I just want to ensure that the same level of service is uniform across the Province; not necessarily who operates what but that the individual, not the operator, more so the individual out in the community.

MR. THOMPSON: I apologize, I do not have the answer specifically. Just to reiterate, emphasis is on bringing the level of training and certification in all sectors up to an appropriate minimum. Whether there are any specific differences between the two sectors, we will get you the answer to that.

MR. MANNING: I have a couple of questions now for clarification. I do not know if it will be any clearer when I am finished because I am not too good at - I may not have the questions clarified yet, but I am going to ask a couple of them anyway.

In relation to policies of ambulance services; you have your health care facilities. There is a policy at the Health Sciences. There is a policy, as the lady mentioned, in Grand Falls-Windsor and Labrador City. Is there a uniform policy for ambulance operators - I am more interested in the private operators with this question - a uniform policy that I could lay my hands on or someone could give to me to see exactly how the ambulance operator is supposed to operate, the medical facility that they attend? Is there anything in relation to an ambulance policy?

MR. THOMPSON: Anybody else can join in on this.

First of all, there is a memorandum of agreement that the government has with the private and community ambulance sector and that, in itself, is a statement of policy and have some rules and standards in it. In addition to that, there are standards or rules related to areas of coverage in which how far an ambulance may go within their own zone or outside their zone and under what circumstances. There are standards related to training and certification. So those all exist, and we can supply them to you. There may be several different documents, not all in the one. I am not sure, but we can certainly supply them to you.

MR. MANNING: Does each private ambulance operator have, what one would call, a base hospital or base medical facility?

MR. THOMPSON: I am not exactly certain if they have a base facility, but every ambulance operation does have a defined zone in which they are permitted to operate and they will have a defined health facility to which they will normally take patients. But, there are circumstances - I am sure because I have heard of them - where they can operate outside their zone, depending upon the nature of the case. So, there are - I do not know if you would call it a base hospital but there are defined zones in which ambulances must operate.

Moira, can you add to that?

MS HENNESSEY: What the deputy minister has said is accurate. There are also some guidelines with respect to what we call routine transfers and emergency transfers in which ambulance services can do one role or both roles. In a case where someone only operates one ambulance, it is pretty well localized to emergency transfers.

MR. MANNING: I am going to cut to the chase because I have a problem in my own district, and with all you people here I should be able to get some answers.

I have a situation in my district on the Cape Shore, an ambulance operator, the Cape Shore Ambulance Service, from what I understand the operator receives one subsidy. A couple of years ago he requested some additional operations but they said that he could not do that because he only has one subsidy, one vehicle. He went and acquired a couple of more vehicles.

I will give you an example, I live on the Cape Shore in St. Brides's myself. If I am travelling to Placentia tonight and for some reason or other have an accident in my car and I call the Cape Shore Ambulance to pick me up in Patrick's Cove and they transfer me to Placentia hospital. It might take four or five hours to ascertain whatever is wrong me, to either transfer me to St. John's or whatever the case may be. The Cape Shore Ambulance has returned to St. Bride's and I have to hire another ambulance service, which is Power's in Placentia, to take me to St. John's. Now, if I am lucky enough to roll my car in Placentia, I would only need one ambulance.

I am sure that some of you people are aware of this situation because it has been ongoing for a long time, and I am in the process of meeting with the minister on it. I am just trying to find out why - I will throw this out because this is how it came through to me. The ambulance operator on the Cape Shore has approximately, I would say, a population now - we are lucky if we are talking 1,300 or 1,400, tops. That ambulance service is supposed to be for that area, but Placentia is our hospital. If I am sick tomorrow in St. Bride's and I end up out at the Placentia hospital, I either go on to Carbonear or I go on to St. John's.

If a person is in the Placentia hospital from the Cape Shore and he wants to - we had a situation there two weeks ago. As a matter of fact, I got off the phone with his daughter last night where an elderly gentleman was in Placentia hospital and needed, as far as the doctor was concerned, an ambulance service to take that person back home. The people at the hospital insisted that the Placentia ambulance service would take that person to Branch, this happened to be, but the elderly gentleman who had traveled with the Cape Shore ambulance on numerous occasions over the past several years because he is on a breathing ventilator and was comfortable with that, but wasn't comfortable travelling with, what he deemed to be, a stranger. Now there are no strangers to be me, all of them, but he is up in his years. All hell broke loose and they ended up putting him in the back seat of the car and bringing him home because he just refused to travel that way. You know, there is something wrong somewhere. There seems to be a major lack of communication somewhere along the line or a clear policy.

My understanding is, from conversations I have had, that there is a policy brought down from the board level. That is why I asked the question earlier of the policy of the department because I would not want to be in any part of Newfoundland or Labrador and be relegated down the line to another policy, if there is a policy across the board here that every Newfoundlander and Labradorian should be treated equally.

I do not know if anybody can elaborate on that or if I am making any sense on this side of the floor this morning but, I mean, it is a -

MR. SMITH: I would like to speak to that issue because it is - well, the hon. member and I have had a discussion on this and I have committed to meet with this service from his area, and it is a very (inaudible) concern.

In terms of my discussions with the officials as it relates to the broader question, I think the issue that the hon. member raises with regard to so-called routine transfers, and not the emergency service end of it, I think there is a concern that when the service is being involved in doing routine transfers that the equipment is not available to be on standby to address the emergency end of it. I think you are right in saying that - obviously in that whole area of ambulance service there are certainly growing concerns. Personally, I have already made a commitment to meet with the groups as soon as possible to just talk in general terms about the delivery of service. We all recognize that they are an important component of primary health care. We certainly have to do everything we can to make sure we sustain the service.

You mentioned the community ambulance service. I am quite aware of the concerns there. As a matter of fact, my own hometown, I established the community ambulance service in my community prior to getting into politics, and I have worked closely with them in intervening years. We have another service in my district and they have been encountering difficulties. It is interesting, the issue is so broad and complex because when the hon. member raises the issue as it relates to training and training requirements of - on the community side right now, we are trying to insist that we increase the standards because obviously there is this whole issue of liability and we want to make sure that the people who are being transported are being given the proper care. Also, there is a concern for the people who provide the service.

We understand that for volunteers this is a tremendous undertaking. I served in that myself. I trained with our own ambulance service initially, and I can tell you, I remember the first call that we received was for a snowmobile fatality. If you are a volunteer and you are doing a community, when you get called out these are people you know. These are not strangers you are picking up by the side of the road. We are well aware that it is a really challenging area. Right now I certainly want to give this a priority with regard to the particular issue that the hon. member raises. Certainly, when I finish, if anyone has particulars that they can share I am sure they will, or if they cannot we will undertake to provide them to them.

I am really interested, when we have a meeting with the service from your area, to get that kind of perspective because I agree that we have to do everything we can to make sure that we sustain this service. If there is the possibility that without some accommodations being made then the service is put at risk then we all have to be concerned because the last thing that we need is to see services going under.

I have had a number of interventions in the short time that I have been with the department. I have been contacted by the private ambulance operators and I have been in constant contact with the community ambulance operators because of the concerns in my own district. I share some of the hon. members concerns with regards to that whole service and I would hope that as we move ahead - I think the meeting that you have requested will be very beneficial along those lines to hear from somebody who is providing that service, what needs to happen in order to accommodate this individual, and if in fact the department and the system, as it presently exists, has the capability of accommodating.

I am going to stop here. I do not know if anyone has anything specific that they can add.

MR. THOMPSON: I will just add that I believe the situation being encountered there has to do with the roles that are assigned to different ambulance services. Some ambulance services have a role related to emergency transfers only and as soon as that transfer is complete they must go back and await the next emergency. Their role does not encompass routine transfers which would be the return of an otherwise stable individual back to their home.

The problem you raised though, with a small population area, is there going to be enough transfers and therefore enough revenue to have a stable service? I think that is the issue that needs to be examined, to make sure the policies we have or the roles that are assigned are going to support a stable service because we do not want to have rules that are built in and are going to cause instability in an otherwise (inaudible) service. So when the meeting occurs, we can look into that issue.

MR. MANNING: We thought long and hard to put an ambulance service on the Cape Shore at the time. I watched my own brother lie in a ditch for three hours waiting for an ambulance back years ago. I do not understand the financial situation that the operator is in, only what he explained or what he wants to tell me, I guess.

It will be a sad day to lose the ambulance service. When you look at a map and it says fifty kilometres from St. Bride's to Placentia, it does not look like very much. It is not very much when you are on a double highway but anybody who has been out to the Cape Shore lately or has been - I know you have, as the deputy minister - it is a treacherous road. My understanding is that the person only wants to take care of the people who are in the Cape Shore area.

I look forward to the meeting and explaining it. I want to request, from anywhere in your department, any policies that relate to the operation of the ambulance services. I have some meat on the bones when I sit down and have some information also. My understanding is, and I stand to be corrected, that there are policies at a departmental level and then there are policies at a board level. I realize that the department passes over certain amounts of money to a board, and says: operate A, B and C. At the same time you don't want to - I would like to have something clear on that, and only by gathering information that -

MR. SMITH: I would offer to the hon. member as well, because I know that it is genuine concern with regard to his area. We could certainly arrange, if he wanted to, to meet with the director, to sit down and just have a discussion along those lines. That way you could probably even move beyond just having some written material, to be able to pursue those in terms of questions so you will have a clear understanding so that when we go into our meeting - I am sure that is where you are coming from - you will have all the information you require.

MR. MANNING: I just have one more quick question that has to do with ambulances.

In relation to the board's responsibility, I have different situations in my district that arise from time to time which the board makes decisions on. It is the decision of the board whether there are going to be a certain amount of positions - I will use Placentia hospital because it is in my district again, where there are going to be a certain amount of LPNs - is that 100 per cent made at the board level?

MR. SMITH: My understanding, as I have stated on occasion here in the House, is that our role, obviously, is that we have responsibility for setting certain standards. It is the responsibility of the department to ensure that we have standards in place across the Province. In terms of the actual delivery, it does fall to the boards themselves. They do generate a budget to us in which they outline what they are planning to do, which gives us an opportunity to have some interface at that level, but it is basically their responsibility. I think we recognize, as we are moving forward, that one of the reasons for now wanting to do the strategic health plan is to clearly define and layout what services people can expect in what areas of the Province, in terms of primary, secondary and tertiary health care.

Maybe the Deputy might want to speak a little further to that.

MR. THOMPSON: Thank you.

Just to clarify a little. The basic principle is that we provide a global budget and then boards make the decisions about who they will employ and what ratios of different staff. That is the general approach. From time to time we may work directly with all boards or subset on the standards or the ratios for particular types of units or particular job classifications. For example, in long-term care we may work with boards to help establish a provincial standard for the ratio of nurses to LPNs. When we do that, it reverts back to the board to actually define how many are in each facility or in each unit and make the decisions regarding hiring and allocating a budget. So the final decision, the final implementation, is at the board level.

MR. MANNING: Is there at Placentia hospital - I keep referring to Placentia hospital because it is my district. At Placentia hospital now there are ten beds in the hospice part of it. It is built onto the Lion's Manor Home. Is there a review carried out at certain times? As a matter of fact, I was in the hospital on Thursday to visit a couple of people and I was there again on the weekend, and it seems like every time I go there it is pretty full. As a matter of fact, there are people, at times, who are sent home. I know that happens right across the Province and we are not looking for the perfect world here. I am just wondering: Is there, at times, an annual review or whatever done, on the use of the amount of beds that are there?

I talked to the people and the staff there and some people say to me: You know, if we had four or five more beds we could do so much. There are ten beds there now. They have been there for x number of years. Is there a departmental review or a board review or something that is carried out, and if there is at what time it is carried out, to see the need? I know there are extra costs associated with that and nobody wants to hear tell of the extra costs, but I am just wondering: How do you determine whether there is a need or not a need for that?

MR. THOMPSON: In a moment I will ask Moira to comment on this as well.

We do not do an annual review process of the adequacy of the number of beds in each facility. We are sure that individual boards do that. In fact, they are, on a constant basis, looking at their occupancy rates, the needs of the population, the global budget that they have, and then making adjustments as necessary to try to manage within that total budget. This is the balancing act that we ask them to make, to stay within their budget and to have high occupancy rates, but not allow wait times or backups in emergency rooms, to have any deterioration of the quality of service. We are asking them to go and do that balancing all the time, because the most efficient utilization of resources is when you have a relatively high occupancy rate with some margins for turnover and accommodating emergency patients or surges in activity. So we ask them to do that.

I am going to ask Moira to address, more specifically, how those reviews might get done.

MS HENNESSEY: We do reviews, what we call staffing and operational reviews of individual health facilities. They are usually at the request of the individual boards. With respect to Placentia Hospital, we did do a review about two years ago. At that point in time we did add an additional nursing assistant to the staffing compliment. During those reviews we would look at things like the average occupancy rate and the lengths of stay. These reviews, if they are of a small nature, are done by your own internal staff. If it is something really significant, like the Health Care Corporation Review, we engage external consultants to do the work, but most times now they are at the request of the individual boards.

MR. MANNING: If the issue is raised with me, as the MHA, I could contact the board and ask them to conduct a review; you know, would they be interested in conducting a review.

I have one more question. As an MHA, we deal every day with all the different boards and committees and organizations in our districts. As a matter of fact, a couple of weeks ago I had somebody do a review of my own. In my district, I have 318 that I know of, different organizations and committee to deal with. It gets confusing, to say the least, and that is just in my district. We deal with institutional boards, we deal with community health care boards, we deal with RED boards, we deal with every board you can think of.

I am just wondering: Is there any thought given to - I know it was discussed in the health care forum that I attended on Salmonier Line - realignment, because for the ordinary citizen out there it has to be really, really confusing. I know for myself it is. Our health care board really goes up to Avondale, but our institutional board goes up to Carbonear. Then you have so many health care boards versus so many community boards. Has the department given any - because it was discussed at length by people who are involved in the system at the health care forums. I am just wondering has any consensus been reached on that, to realign, to have six health care boards and six community boards with the same geographical regions, or to have a combination of both, whatever the case may be? Has any thought being given to that? I know I run into it a lot with people who really have a problem understanding exactly where their jurisdiction is? I am talking about, as we will call them, "ordinary people" out there, not people who are in the system.

MR. SMITH: Just a brief comment, and then I will defer it to the Deputy. I know last year, when I was acting in the department, that was an issue that was raised with me at that time. I, like the hon. member, have heard it from time to time. My understanding is that it is certainly something that we are aware of and there has been some discussion about it.

The deputy tells me that there have been no decisions. Maybe Robert can speak in more detail on it. Is there anything else you can add, Robert?

MR. THOMPSON: Sure.

It is a subject of regular discussion and, as you said, it has come up in the forums. We posed the question, actually, in the discussion document, about whether there should be more board integration. The feedback from most of the forums was that it is worthy of some consideration, for the kinds of reasons you raised. The public, generally, does not consider it important, whether or not a service is this structure or that structure, as long as the service is provided and provided well.

Sometimes we encounter situations where, if an individual client needs to transfer from the service of one board to the service of another board, they actually have to cross an institutional boundary if not a geographic one. We want to make sure that is as seamless as possible, that there are no barriers. That is usually what is said by people who favour more integration.

Then there is also the issue of ensuring that the community health boards, that their role in health promotion and community level activity, if integration was to occur it does not get submerged or seen as a lesser priority than acute care, emergency rooms, technology, and all the things that are so immediate and so demanding of resources. If more integration was to ever occur, we would have to balance off that issue.

It is an issue that was raised in the forums and no decision has yet been made, but it is one of the issues that could emerge as a topic in the strategic health plan.

MR. MANNING: The people that are involved in the system, the health care professionals themselves: At the forums I attended anyway, there were some great discussions on that and they had some major concerns.

That is it for me. Thank you for your answers. I haven't anything at the present time, but God knows what will come up while I listen to the others ask questions.

Thank you.

MADAM CHAIR: Thank you, Mr. Manning.

I now call on the Member for St. John's West. Do you have any questions?

MS S. OSBORNE: Yes, I do.

Some of the questions I had have already been asked by my colleague. I guess I will ask a question first on Children's Protection Services. Is there somebody here who can answer some questions on that?

WITNESS: (Inaudible).

MS S. OSBORNE: You know, it is down, I guess, to the micro questions, but they are questions that I have come across in dealing with constituents and other people who have come to me, and they have caused me some concern.

The policy for interviewing a child: For instance, if a five-year-old child is brought in for an interview because he or she is possibly in a violent situation and the department wanted to determine that, there are no tapes done of that interview at all. It is just the social worker and the child. There is absolutely no taping, no video taping, no audio taping, and, in many instances, there is no observer from the outside, and that concerns me a lot. I am not going to say that a social worker could go in with a hypothesis, but I have seen some situations that have concerned me. I mean, I have a four-and-half year old granddaughter. I can ask her questions if I want answers. Do you know what I am saying?

I am wondering: Has there been any thought given to changing the policy? I have gotten a copy of the policy from the Director of Child Welfare in Nova Scotia. She was amazed, actually, that here in Newfoundland we do interview children and there is absolutely no record of the interview; just when the child and the social worker walk out of the room, there it is. Has there been any thought given to revising the policy, to probably have audio, video or any sort of taping like that?

MR. SMITH: Lynn or Bev?

MS CLARKE: I haven't had that question raised before. Certainly, it is something that we can look into further, but my understanding of one of the reasons why there hasn't been tapes is because of the very delicate nature of the situation with the child. Of course, if you have technology there, it is difficult enough sometimes to get child to answer questions in these situations.

What I will say is the staff are well-trained to do that kind of interview, but I certainly understand your concern about the record piece, and that is something we can certainly have some further discussion about.

MS S. OSBORNE: I understand that the staff are well-trained, and over the past couple of months I have run into situations that were very uncomfortable for me because I did not want to challenge that, but, at the same time, I did have feelings. You know, I was perceiving something was not right. It did work out okay in that, when it went before the judge it did work out. As it happened, it worked out the way I thought it would, but I was a bit worried about the process.

I know it is quite a delicate situation, but if you bring a five-year-old child in, or any age young child, and say: Look, there is a tape recorder here and this is being taped, or there is somebody on the other side of the glass and they are observing - in Nova Scotia, they have a person present in the room who is out of the sight of the child but they are in the room. They go for best practices and they find that that works really well. I thought I would bring it up here as opposed to in a more public venue, because it is very delicate. I thought that I would ask that it be looked into.

I have a copy - and I am sure that you can access it as well - of the policy manual from Nova Scotia. It is quite different. Ours is, as one psychologist said to me, almost Victorian; it is Archaic. I did not realize that, as I said, until I ran into this situation a couple of months ago. It was very, very uncomfortable, it was not a good situation.

You know, none of us are infallible. Personalities do come into play. As I said, if a worker goes into a room with a child it can be a hypothesis, they can have the feeling, yes, I know violence is happening in this home, or, yes, I know violence is not happening in this home. Any of us could be subject to asking the questions along that, no matter how well trained we are, okay. That is one question that I have.

Another question that I have is the home care. Is there still a freeze on all home care? What is the situation? I am asking that. I really do not know the answer. I have not come across anything in the past couple of months since the freeze was on, so I do not know if the freeze has been lifted with the new Budget or not.

MR. THOMPSON: There are new criteria that were introduced for home support services. I would not call it a freeze, but there are new criteria that are more rigid or have higher hurdles, if you like, to ensure that home support is being provided to certainly the most urgent cases, given the budget constraints that we have. So those criteria are still in place. Do you need more information on what the criteria are?

MS S. OSBORNE: If you have that in writing, that will be fine.

MR. SMITH: Sure.

MS S. OSBORNE: We have people here from institutional and community services boards, I guess. Are you still finding that there is a backup in hospitals because people have been medically discharged but they have no place to go? They cannot go home because there is no home care provided. Are you finding that to be -

MR. SMITH: Moira, do you have any information on that?

MS HENNESSEY: With respect to the modified criteria, the hospital discharges who are going home on home support, they are going home quickly across the Province so we do not have a backlog in our hospitals of medically discharged patients awaiting home support services. We continue to have a backlog in our hospitals of medically discharged patients who may be awaiting placements in some of our nursing homes across the Province. Oftentimes you can have upwards of twenty in city hospitals, particularly in the hospitals in Gander and Corner Brook.

MS S. OSBORNE: Okay.

I understand there is a policy - and some people have called me about this - where family cannot do home care. I understand completely why that policy is. Then I also look in a small community where probably the best person available is family, and I also looked where family - I will just say, for instance, if my mother were living with me but I was working outside the home, and then she became ill and I had to give up my job to take care of her because I felt that I would provide her the best care, can you do assessments that would determine that, as opposed to having it black and white, no family can do it?

In many instances, a person who is a family member - and I do not subscribe, for instance, if I were not working outside the home and my mother was looking for me and then I started to take care of her, I do not think I should come and ask for money to take care of her, but in terms of if I had to give up my job to take care of her, that is a different situation. Has there been any thought given to doing individual assessments on situations like that so that the best possible care can be provided to the individual?

MR. SMITH: I will ask Bev Clarke.

MS CLARKE: Actually, we had reviewed our policy last year about who, in fact, can provide home care in terms of payment, and we did revise our policy to some extent. As you know, there are certainly concerns about having relatives paid.

MS S. OSBORNE: Absolutely.

MS CLARKE: There are exceptional circumstances, and in our assessment of the situation we do take into consideration if there are exceptional circumstances. The exceptional circumstances usually are around because of the nature of the care that the person has to receive, or because of their disability, that the most appropriate person to provide that care is a family member. In that case an exception is made, but those are fairly rare.

Also, in terms of family members - and certainly we can get you a copy of the policy if you do not have it already - we have always had the concern about, if you live in the same home and then you are employed to provide the service, so we have certainly tried to keep that to a very limited number.

MS S. OSBORNE: As I said when I was asking the question, I understand that if I were living in the home and not working outside the home and then were to take care of my mother, that is one thing, but if I were working outside the home and were to give up my job to stay home, that is another circumstance. I am sure there are situations out there like that, where family members who are close to the person - especially if the person is in early stages of Alzheimer's or dementia, or something like that, the best possible person in many cases, the ones who understand them, and the ones that the person is most comfortable with, are family members. I would never argue with the policy that family members in the home, that is sort of crossing the line, but family members in the home who have to give up a paid position out in the community to stay home, if they are willing to do that, then that is possibly another circumstance.

I had an instance, actually, a woman came down from the Great Northern Peninsula and she had approved home care. She brought her home care worker with her because she came in with some kidney problems, and then it was determined that she had to remain in St. John's because there was no dialysis machine in St. Anthony. She had to remain in St. John's and she had a granddaughter here who was working. The woman was not used to living in St. John's; she had lived in a small community all her life. She asked for her granddaughter to give up her job to stay home and take care of her, but I don't think that ever got approval.

In that instance, this patient would have been most comfortable, the granddaughter would have been comfortable with her, and it is not like the granddaughter did not have a job but was going to use this situation to get money. That wasn't the situation. In instances like that, I wonder if you could go before a panel and explain the situation and have individual assessments done in cases like this, as we go before an appeal panel for human resources cases, for instance. I wonder, rather than just stick to the policy, no, not in any circumstances or in very few circumstances do we allow families to take care of patients at home, because in many instances the family is the best one.

I don't know if you want to take it for awhile now, Ross, or if I will carry on.

MR. ROSS WISEMAN: It is your call, whatever you want to do.

MS S. OSBORNE: Okay, I have a couple of questions here. One is on the movement of the MCP to Grand Falls. Is anybody in St. John's working on MCP cases in Grand Falls because the staff in Grand Falls were not able to do it? Have there been any circumstances where there still had to be people retained here to do the work?

MS BREWER: For a period of time, early on in the days of regionalization, there was a backlog that had been created, and there were some staff - actually, I believe they were some audit staff within St. John's - who provided some assistance. Sometimes they travelled to Grand Falls-Windsor to provide the assistance, and sometimes they stayed in their own office. As far as I am aware, there is no staff now currently in St. John's who are providing assistance in terms of claims to Grand Falls-Windsor. Now, the medical staff was retained in St. John's, so some complex claims - the staff out in Grand Falls-Windsor would have access either through phone or through video conferencing to Dr. Blair Fleming, who assists those staff in some complex assessments and complex claims.

MS S. OSBORNE: Okay. How many staff relocated to Grand Falls?

MS BREWER: There were two individuals who were employed in St. John's, who actually made the move to Grand Falls-Windsor.

MS S. OSBORNE: So the rest of the people were employed locally.

MS BREWER: Yes, there were competitions.

MS S. OSBORNE: Competitions, and they were employed out there.

What was the cost of the relocation?

MS BREWER: In 2001-2002, the department incurred directly $538,800 and there were some costs incurred by other government departments. There were redundancy costs paid by Treasury Board that was just over $200,000 and there was about $25,000 spent by Works, Services and Transportation to relocate office furniture, new signing. Forklift rental, I am not sure what that was for.

MS S. OSBORNE: The other thirty-something that was there for Purchased Services, I guess when Mr. Manning asked the questions - that is on line 06. in 2.3.01.

MS BREWER: There was a period of time that we actually rented some space, before our office was ready on July 3. The staff were hired anywhere from six to eight weeks in advance, and there was rental space incurred to provide some training for those staff.

MS S. OSBORNE: Is the cost of the staff travelling from St. John's in the transition period factored in there, the cost of transportation and things?

MS BREWER: Yes, it would have been travel for staff; like our HR staff would have actually done the interviewing on site in Grand Falls-Windsor.

MS S. OSBORNE: In the initial stages when some of the people in Grand Falls were not trained enough, when some of the staff from here had to travel back and forth, that is all factored in there, is it?

MS BREWER: Yes, that was part of that $538,800.

MS S. OSBORNE: So it was about $800,000 for the transition?

MS BREWER: It was probably closer to $740,000.

MS S. OSBORNE: Okay.

MS BREWER: And the majority of that is one time and will not recur.

MS S. OSBORNE: Yes, I understand.

In 3.1.01.05., you said there was a Goss Gilroy report. Did Goss Gilroy do a second report, or is that the report that was done four or five years ago that was included in that $115,000?

MS BREWER: The $115,000 is a report that is in progress, it is my understanding.

MS S. OSBORNE: Okay.

MS BREWER: Lynn or Bev can clarify that the work has not been completed.

MS S. OSBORNE: So that is not the Goss Gilroy. Because in the initial stage, first in your answer, I think you said Goss Gilroy. I wasn't sure if they were doing another report, because they had done a report in the beginning, I think, on the Perlin Training Centre and the Pre-Vocational Centre, and those services that were being provided.

MS BREWER: No, this is specifically a review of the four Health and Community Services Boards and the two integrated boards in terms of assisting us to better understand the cost drivers, the factors influencing their budget, particularly on the home support side.

MS S. OSBORNE: Okay.

I will turn it over to Ross now.

MR. ROSS WISEMAN: Thank you, Madam Chair.

Just to pick up on a couple of things that were raised by one of my colleagues before we move too far down our agenda, can I go back for a moment to the ambulance service operations? Right now there are agreements between each of the ambulance operators that, in terms of their contractual arrangement that expires some time in 2003, I understand - I appreciate, Minister, your comment yesterday about having to wait and see what is in the strategic plan, so this is not an attempt to get you to answer the question you did not answer for me yesterday. The question around ambulance services, and there have been a number of comparisons done by the people involved with providing ambulance services, and discussions they have had with our office around comparison between Nova Scotia and New Brunswick and Newfoundland. From what they are sharing with us, the Province spends roughly $9.3 million in private ambulance services and there is roughly a little over $3 million being spent by the government provided services through health boards throughout the Province, in comparison to somewhere in the range of $80 million to $90 million in Nova Scotia.

The current thinking by that group at least is that with the standards and the recently released manual for ambulance operations, and the standards you have in place for each service - which, by the way, I commend you for, because I think it is important that you have baseline standards for the provision of service, especially one when you are talking about the first responders to a critical situation and you don't want unqualified people out there responding. I commend you for having prepared that kind of standard document, but one of the things that they are suggesting to us is that as a government today you are getting good bang for the buck that you are spending - in fact, getting a pretty good deal in their terms, and underpaying for it. So, the comparison is that if you take the services that are provided in Nova Scotia and New Brunswick, which are very similar to the standards that you are proposing for use in this Province, and if you were to take those standards and implement them throughout the Province - because what we need to be careful of is that we don't have a two-tiered system in that you have some smaller services, which unfortunately tend to be in more of the more remote areas which don't have access to other kinds of health services as well - if you were to take those standards and implement them across the Province, there would need to be a significant infusion of money.

Can you give us some sense of whether or not, as you forecast into the year 2003, particularly because there is only twelve more months and this agreement is going to be expiring, had you envisaged a model very similar to what is being currently in operation in Nova Scotia and New Brunswick, for this Province?

MR. SMITH: At this point in time, as I indicated earlier, I mentioned in response to the hon. member's question earlier, in terms of the ambulance service generally, I guess from my perspective it is an area that I do have some sensitivity to because of my past experience and the fact that I have had to deal in my own district with a couple of operations who were going through difficult times.

First of all, I guess, the present situation: The groups are operating under an MOU that was put in place and runs until 2003, as the hon. member mentioned, and the fact is that they were aware when they entered into this that the new standards would be coming in.

What I have committed to the groups, and I sincerely want to do it - as a matter of fact, I am hoping to have the possibility to meet with the community ambulance operators representative group shortly because I learned on the weekend that they have a meeting coming up in Gander in the next little while. I am hoping that I will be able to, if they are willing to have me visit with them at the time, to take advantage of the opportunity of coming together to sit with them and to hear first-hand their concerns. Similarly, with the private ambulance operators, I have communicated directly with them and advised them that I am generally interested in sitting down with them and having a chat with them. As the hon. member characterized it, and accurately so, this is a very, very important service in the fact that these are the first responders, and there is no question that I think, as a government and certainly as a department, we have to be committed to try to maintain this high quality care service.

Now I am not familiar with the situation in the other areas, but I would hope that as I move forward with this in my meetings with the other group, I am sure that they will, as they have done with the hon. member - and I am sure he was probably aware in his previous work life, and was familiar with those operations anyway - I am sure, from my meetings with them, that they will be making me aware as to what is happening in other jurisdiction.

I guess it does provide us with the opportunity as we are moving forward, and once the present MOU concludes, to see where in fact we can go with this. As well, the hon. member mentioned the Strategic Health Plan which we will be bringing out later this summer. Obviously, that is a component of it. It is a very important service that we provide to the people of the Province, and it is certainly something that we want to maintain and improve.

MR. ROSS WISEMAN: Minister, just as a comment, I was very surprised a little while ago - and I mentioned this to your predecessor as well in a private conversation - to realize that there are only a few of those ambulance services who have malpractice insurance. Other than the public liability that they carry on their vehicles, many of those operators don't have malpractice insurance. It is kind of foolhardy of them, number one, to be like that but secondly, I guess, as a public policy issue for the protection of the general public it would be, I think, extremely important and somewhat critical to ensure there is that level of comfort in the public, that if something were to happen that were unfortunate, that they would have some recourse. Without having malpractice insurance, it puts them in a very awkward position. I suspect, and I don't know this and it is not a legal opinion, but I pose a question about whether or not it also puts the people who issue the licence in a very precarious situation as well for having allowed it to happen. I just throw that out as a comment.

MR. SMITH: If I could have a quick response, I was not aware of that. I am glad to hear that it is mentioned to the deputy, and it is certainly something I would want to pursue. It is very interesting because along those lines - I know in the discussions in my district with the community ambulance operators, they have been saying to me that because of the improved standards that we are bringing in, the higher level that we are bringing in, it is creating problems for them in terms of being able to recruit new volunteers.

What I have to argue with them and say to them is that this is, as much as anything - there are two tiers here. They say, first of all, we have a level of care that we have to offer to the people that we are providing the service to. Beyond that, the service providers themselves, I mean, it is a level of protection for them too because there is a liability thing. While we are very appreciative of the kind of commitment these volunteers make, if something happens, if you are out there, once you undertake to do that, it is not sufficient to say: Well, I am going to do it. We can all envision a situation where something happens and there is a tragedy and someone says: Well, gee, there wasn't the proper level of care administered here.

We have to be aware of all of these issues. I find that when I am talking with the groups in my area, I am just constantly reminding them of that. The standards are there as much for your protection as they are for the protection of the general public.

I am glad you raised that issue of the malpractice because I was not aware of that.

MR. ROSS WISEMAN: As I said, I commend the department for developing the standards that they have because I have had a look at them and I commend you for having done that.

Just one other point that was raised by my colleague, that I just want to pursue just a little bit with a couple of questions with respect to it, I won't get into discussion around the boards. You responded to his question around the future of boards and what you thought it might be in terms of the numbers that exist. There is one board I just wonder what the current status is: the St. John's Nursing Home Board. When they came together, or when that board was created, it was a reflection of bringing together the nursing homes in St. John's. As I understand it, and maybe you can clarify this and make some comment as to what it does, number one, to its operation and what it does, who makes decisions and who is spending money. The board that is in St. John's, as I understand it, is a board that has a mandate to operate the long-term care facilities in (inaudible) but there is still an issue around the former boards that have stayed in place and there is a question, I understand, around the ownership of the buildings. There is second piece, and I wonder if you could comment on it, and that is the issue of: those former boards, in addition to owning the actual buildings themselves - so it is a property ownership issue - what involvement do they have in the operation? Are they in some way layered in there in that governance issue and a part of the management?

In responding to the question, could you comment also - because I understand each of the sites have, I don't know the title they are using - a director, site manager, site administrator or something - I am given the impression that there is a dual reporting relationship somehow here. Can you give me an overview of what the current picture is in the St. John's Nursing Home Board.

MR. THOMPSON: The opening of your question seemed to indicate that there might be question in its continuance or in its future, but that is not the question.

MR. ROSS WISEMAN: No, no (inaudible).

MR. THOMPSON: Okay, (inaudible).

The St. John's, Nursing Home Board is one of the fourteen Health and Community Services Boards in the Province. It has a unique structure, though, different than any other. It has a Board of Directors appointed by the minister. It has a CEO and a corporate executive team with administrative services. It administers essentially the budget and the service delivery for the nursing homes in St. John's, but not all of them. The Hoyles -Escasoni is an exception because that facility is operated directly by the St. John's Nursing Home Board. The other facilities which were previously, I think, in the main denominationally operated, continue to have what we call owner boards in place. They have a role, which I will describe, but from the department's point of view there is one board that we deal with and that is the St. John's Nursing Home Board; one board to whom we give a budget and we hold accountable for the service delivery in all of those nursing homes. In turn, they administer all of the services and they operate to the extent possible as a single service delivery organization.

The St. John's Nursing Home Board has a Memorandum of Understanding with each of the owner boards that remain in place; for example, the owner board for St. Patrick's Mercy Home, or for Saint Luke's and so forth. Those agreements do specify that the owner boards continue to own the property, so there has been no transfer of ownership of the property as in comparison to the Grace Hospital where the ownership was transferred. The owner boards, each of them have two representative, I believe, on the St. John's Nursing Home Board itself, so there is cross-representation on those boards.

You are right, that there is a site manager in each case that has a dual reporting relationship. Hoyles-Escasoni, as I said before, is direct, and there is no intervening board, but each site manager has a responsibility to their owner board because that owner board does own the facility. The owner board is not responsible for the operation, that is for the budget, for the staffing, for the issues related to human resource policies, financial policies, placement in individual rooms or beds and so forth; that is all corporate. That site manager also reports to the CEO of the St. John's Nursing Home Board on all of those operational matters, so it is a unique structure. There is a burden or co-ordination involved there, as you can appreciate, but it does work and it delivers a good service.

MR. ROSS WISEMAN: The burden that you talked about is probably the one that is probably more problematic, I suspect, and somewhat handicaps the board in what it might do because it has to go through that layer of bureaucracy to vet things through in terms of what it might or might not want to do because there is the ownership issue.

MR. THOMPSON: Thank you very much for the clarification.

MR. ROSS WISEMAN: Just to, if I could, Madam Chair - and I apologize if I bounce around in terms of the layout of the Estimates - I would like to talk a little bit about services and programs. Maybe I can try to structure it in a fashion that falls under some kind of reasonable semblance in the Estimates.

Let's talk a little bit about board operations found on pages194-195. Can you share with us the mechanism for funding of health boards in the budgetary process for a moment? Let me preface my question by making the comment - and I guess it was raised in the House yesterday - the Budget came down six weeks ago and here we are today, and unless the letter went out yesterday or today or something, boards are out there today not knowing what their allocation is for this year. I guess, Minister, the question becomes one of how, if you are looking at board-operated health services and facilities in the Province, and their fiscal year runs from April 1 to March 31, the expectation is that they have a balanced budget, and they submit to you well in advance of the budget date their plans for next year, both fiscally and from a program perspective, the difficulties that may present to them in terms of what they want to do, and there is a lead time to implement their strategies and a lead time they need to be able to more forward, what would be the problem with having the boards have their budget allocation coinciding with the announcement of the Budget in this House? When the Budget comes down in this House, and the Estimates that we are talking about here today, that is the amount that has been voted to the Department of Health and Community Services. You are not going to get any more, or no less, so that is the amount you got. If your advanced planning has been done, then it would appear to be, at least, an exercise of then following through the next day and advising the boards what it is they get out of your piece of the pie that is allocated in these Estimates. Is there some difficulty with the boards getting to know earlier about their allocations?

MR. SMITH: Just to respond, I am glad to have the opportunity because yesterday the Chair had determined that the time had concluded on the Estimates debate. The hon. member was speaking by leave, so I thought it would be inappropriate for me to rise and ask for further leave.

I think in terms of the issue that he has raised, it is valid. First of all , I should say that I think the comment that boards have no idea is certainly not an accurate representation. The hon. member would, I am sure, acknowledge that, because obviously these boards do submit their budgets and they do their due diligence, and they do know these services that they have been maintaining for a number of years.

In terms of the exact numbers, he is accurate in saying that they don't have those. He was saying, in fact, the letter would be going out tomorrow, from what I understand, and they are ready to go.

I am going to ask Donna if she can speak with some detail on the process and why the reason for the delay, which is the issue that the hon. member raises.

MS BREWER: Certainly, since July, the boards certainly knew the parameters in which their operating plans would be developed for fiscal year 2002-2003. At that time, when we sent out the requests for the budget, we were quite clear that even though we had not yet received the Treasury Board budget guidelines, that we were making the assumption of status quo budget plus allowances for salary increases in any negotiated occupational reclassifications.

MR. ROSS WISEMAN: That would be July of -

MS. BREWER: July of - last summer.

MR. ROSS WISEMAN: Okay, so seven or eight months ago.

MS BREWER: Right. So boards certainly knew the parameters in which their operating plans would be developed for 2002-2003.

What was outstanding as of today was a budget announcement that again the department did not know 100 per cent until the Minister of Finance stood in the House, she had allocated an additional $5 million on top of those salary increases, and based on discussions with the CEOs they basically said to the department: Don't be in a hurry in terms of how you allocate that. We gave them the opportunity to come back with some suggestions and some methodologies as to how they would make recommendations to the minister as to how that $5 million would be allocated.

My understanding, Jim, is that about maybe two weeks before the actual Budget day we shared with them the budget schedules, because the boards came in. Despite our indication of saying that we don' t think the government can afford to provide any more money for health beyond the salary increases, some boards did still come in and say: We would like increases for X, Y and Z.

Basically we, within the department, over the three to four months from October to February, would have analyzed those and we would have advocated to Treasury Board on their behalf, but it was only since Budget day that we were able to tell to the boards that beyond the salary increases in reality the only extra funding that government allotted was the $5 million.

Then, late in March, we had gotten word from Treasury Board that there was $6 million allocated for the Health and Community Services Boards. Now, we allocated that on a one-time basis for the fiscal year 2001-2002, but Treasury Board has asked us to hold back that money until we await the report from Goss Gilroy.

My understanding is that the boards, even though they have not gotten the official sign-off from the minister, that they have been given a draft budget schedule which outlines for them their calculations for salary increases, pay equity, occupational reclassifications. Even then, over the year there will be changes, like the nurses agreement that was just negotiated. That is not yet in our budget; it is not yet in the board schedules. We only got word last week from Treasury Board about the precise impact of the arbitration award on pay equity, so my staff now are going to be working with the boards as to the allocation of that fund, which is roughly around $4 million to $5 million on an annual basis.

In terms of the parameters the boards have to work with, I would agree with the minister, they certainly know and have known for quite a while what assumptions they can make in terms of what funding will or will not be available to them.

MR. ROSS WISEMAN: Just for clarification, just so I make sure I understand, boards were told last year, in July of 2001, that basically what you now have as a budget is what you should assume you will get next year because you did not anticipate government giving you any more money. Is that the sense the boards are -

MS BREWER: Other than for the salary increases. I guess it is guidelines as to what they can expect they would get in funding increases.

MR. ROSS WISEMAN: If I could back up a little bit, because I wold like to understand for the Committee that I have a sense of the position the boards are now in financially today and where they may be going. As I understand, last year in September, when the minister announced that there were some major deficits in boards in the Province and that they had asked for a strategy to ensure that boards live within their budgets, I think at the time there was $17 million for the institutional boards and then there is another piece that was not identified for the community health boards. So there was a chunk of money - $20-odd million - that was anticipated to be in deficit for this year.

As I understand it, some of the strategies the boards came forward with in order to balance their budget last year were changes and adjustments that they were going to make that were one-time changes, deferring of certain expenditures for the balance of last year that were going to definitely happen in this year. So I guess the question becomes - and the picture as I am seeing it - if, last year in July, you tell boards that what you now have today is what you should learn to live with because next year that is all you are going to get as well, and two months after that in September you come out and say that collectively all fourteen of you have a $20-odd million deficit, and we want you to balance that and make adjustments in your programs and services so that come March 31 there is no deficit, and the strategies you get come across your desk include a number of one-time adjustments, so they are not to be permanent changes in the system, then, as I think through that, you have to come to realize that if you then follow through and incur those expenses come April 1, because you only deferred them from the previous year, then you automatically have positioned yourself to have a deficit in this year if there is no new money.

I guess, if my logic is correct, and I have that picture painted accurately, then it would have been reasonable, I guess, last year in September when boards came through with the strategies as one-time strategies, at that particular point, to sit down with those individual boards and map out what would be a very permanent kind of arrangement for those boards so that they could stay within their budget. I guess, in the absence of that having happened, it is safe to assume that they will now have deficits again this year. Is there any flow to my logic?

MS BREWER: There is a missing piece of the puzzle in terms of, yes, there were some savings that were one-time, but there were also some savings that the boards only accrued maybe in a month or two of savings. Next year they will have the full twelve-month benefit of those savings, and in total for all boards the annualization of the savings pretty much eliminated the negative impact of the one-time savings.

Now, it is true that maybe for two or three boards the math is not that exact, but I think the difference in total is like $600,000 or $700,000 on a $900 million budget. We, within the department, just did not think that level was that material. So again we are going out, subject to the minister signing the letter. The expectation is that the boards will manage within the funds that they are given this fiscal year - for the institutional boards, not the health and community services.

MR. ROSS WISEMAN: I guess on the flip side of that, there is an annualization of new programs that were implemented last year, too, I assume. Would that be the case as well?

MS BREWER: I am not aware of anything in particular. Part of the $5 million will deal with not necessarily new programs, but if a board has indicated - like, for example, a few boards have indicated that their dialysis caseload is increasing. That was some advice given to us by the CEO so we should at least, before we just do any kind of across-the-board allocation of $5 million, at least acknowledge that specific utilization and we intend to do that.

MR. ROSS WISEMAN: You just mentioned, you qualified your comment by saying the institutional boards and not the community health boards. Can we bring the community health boards into the picture? I guess, Minister, you have heard me make a few comments in terms of the reference to health boards. Frequently, the reference is made to health boards only to include the institutional boards. I keep reminding everybody that there are fourteen health boards in the Province who get money, and I guess they get it under these two headings here on pages 194-195.

When we are talking about health boards, I tend to talk about all fourteen health boards. So if we are looking at the deficits of health boards, and that is how I tend to look at it, in that context, does that same logic and same rationale apply to community health - like, where are community health boards going with their deficit in this year then?

MS BREWER: I will turn it over to Robert.

MR. THOMPSON: Last year, we did not ask the community health boards or the community components of the two integrated boards in Grenfell and Labrador, we did not bring them through the same budget reduction or deficit management exercise in September. Our priority last year was to focus on the ten institutional boards and components and try to ensure that they are stabilized on a balanced basis. That occurred last year and we came out of the year virtually balanced within those boards.

This year, our priority effort is to do the same for the community boards and the community components of Grenfell and Labrador, and to stabilize those boards on a balanced basis. It was referenced earlier, the Goss Gilroy report is being done in order to help us understand better the biggest cost drivers in those boards and then to work with the boards to come up with solutions to ensure that those budgets are balanced this year. That is our main priority for this year. Then we will have both sectors on a balanced basis, on a go-forward

MADAM CHAIR: Excuse me, Mr. Wiseman.

MR. ROSS WISEMAN: Yes, I just got your note.

MADAM CHAIR: I am hesitant to interject; the line of questioning is very interesting. I am just wondering, because we will go past 12 o'clock and we have arranged for a five-minute coffee break, if we could take that break now. The coffee has arrived. It is in the government members' caucus room. Then we will come back and resume in five minutes.

MR. ROSS WISEMAN: That is fine with me. It is no problem at all.

MADAM CHAIR: Thank you.

MADAM CHAIR: Order, please!

If everyone is ready, we will get started again.

I will go to the Member for Trinity North to finish up on the line of questioning that he was on, and then we will move to another Committee member. We will try and do this in twenty-minute intervals of questioning. Don't feel that you have to use up the full twenty minutes, but certainly that time is available to you.

The hon. the Member for Trinity North.

MR. ROSS WISEMAN: Thank you, Madam Chair.

When we broke for coffee, I was pursuing a line of questioning around the health boards; health boards meaning all fourteen boards in the Province, their deficits. I want to just pick up on that, if I could. We were talking about the stabilization of community health boards. I think the deputy was just finishing telling me how the focus for this year was going to be the stabilization of the community health boards, having done the institutional last year.

I wonder, could we talk a little bit about - because that stabilization process is an agenda item for this year, so obviously it has not yet happened. In terms of the budget here, the allocation that is in here for the stabilization, do I understand that to be the $6 million that the minister announced she wanted it spent in, or Finance had said there was $6 million that was being allocated in last year's budget, at the end of the year, that was costed out to that year - that $6 million - is that the $6 million stabilization fund?

MR. THOMPSON: No, we do not actually have a stabilization fund per se. The process I am referring to is one where we analyze the programming, identify what the factors are that are causing the cost to increase over time, where opportunities may exist for more efficiency, and then to develop a plan very soon, as soon as we can, so that we do not get too far into the fiscal year, where the set of programs in those boards can operate within the allocated budget and what other options might be available. Then, we would have to seek the minister's and government's approval for whatever plan or program profile that may entail. That is the process we are going through. We do not have a stabilization fund set aside.

MR. ROSS WISEMAN: Okay.

As a capsulized picture, the health boards, all fourteen of them, today, or as of March 31, the fiscal year just ending, can you tell us what the total accumulated deficit was of all those boards as of that date?

MR. THOMPSON: The community or all?

MR. ROSS WISEMAN: All. All fourteen health boards. What was the total accumulated deficit on not just last year's deficit on operation but the total accumulated deficits of those fourteen boards as of that date?

MR. STRONG: It would be for the institutional boards, all fourteen?

MR. ROSS WISEMAN: You can probably break it down, if you want to, if you have the figures like that.

MR. STRONG: Okay. Can you just give me a moment to get those figures for you?

MR. ROSS WISEMAN: Sure, by all means.

MR. BREWER: Just in terms of process, Mr. Wiseman, we will not know the exact figure for this fiscal year until the audits are completed. We would like to have the audits by the end of June. In reality, we get some at the end of June but the majority of them will come August and September months. So these will still be projections.

MR. ROSS WISEMAN: Yes, okay.

MR. STRONG: That will be around $110 million.

MR. ROSS WISEMAN: One hundred and ten million. Could you break that down for me? The institution is how much?

MR. STRONG: The institution will be about $80 million.

MR. ROSS WISEMAN: I do not want to contradict you, however last year in the House, in the fall, the minister tabled - the first week in December I think it was - a report that showed the total accumulated deficits of health boards as of March 31, 2001 was $97 million. I am assuming that this past year there has been some deficit on this year. So that would indicate there is only a $13 million deficit in total this year. That is a bit different than information that I have been getting.

MS BREWER: I think part of the confusion is the way Jim's table is laid out. It has a subtotal for the ten institutional boards, it has a subtotal for the four community, and then it has a subtotal for the two integrated. So we would almost have to go back to the office and put these numbers in the same format that the minister would have tabled to you back - I would assume it would have been last December.

MR. ROSS WISEMAN: The first week in December of 2001 she tabled those, $97 million or so.

MS BREWER: And that would have been to the end of 2001.

MR. ROSS WISEMAN: That would have been 2001, so we have a full twelve months on top of that. As I understand it, those fourteen boards have generated additional deficits in this year.

MR. STRONG: It would be $97 million in total, as was indicated last fall. The institutional boards are in the range of $3 million to $4 million and the community boards around $8 million or $9 million.

MR. ROSS WISEMAN: What about the cancer centre?

MR. STRONG: They are on budget, basically.

MR. ROSS WISEMAN: Minister, earlier you made a comment in reference to - and I appreciate you answering the question - with respect to boards getting their budgets tomorrow. If I understand it, tomorrow all fourteen health boards will get a letter from you indicating what their budget is, together with the attached schedules indicating the breakdown of that budget. Would that be correct? Is that the process? Is that something that I could ask the minister to table in the House tomorrow when he sends that to the health boards? Could he table that in the House of Assembly tomorrow?

MR. SMITH: I do not think there is any problem. It will be public knowledge tomorrow once the letters are released. I am assuming they are ready for my signature.

MR. ROSS WISEMAN: Okay, so we could have those tabled tomorrow. Does that schedule include a process for debt servicing of the accumulated debt?

MR. SMITH: Not in this.

MR STRONG: No, it is just current year budget.

MR. ROSS WISEMAN: But the current year's budget - I will just use Peninsula's Health Corporation because that happens to be in my district. If they get a budget letter tomorrow saying they have $45 million and the schedule is attached as to how that is broken down. Is there a figure on that schedule which shows them servicing that $9.6 million with whatever the service cost would be? Is the debt servicing in that schedule?

MR THOMPSON: Yes, sorry, I did not understand your question.

The cost to service their accumulated deficit is included in the total amount of money that will be provided. We will expect them to service their deficit out of the total amount of money that is provided.

As to whether there is a line item for interest, I do not think so, but the funding they will use for that purpose is included in the global figure on the schedule that they will get.

MR. ROSS WISEMAN: (Inaudible) qualify servicing now for a moment. When I talk about debt servicing I am referring to retirement of the debt which includes a repayment schedule based on somewhere between three to ten years, whatever the amortization becomes. So, my reference - and let me qualify my question. Does the schedule, and will the schedule, include a figure where the board has committed a figure for debt retirement? Not just debt servicing, debt servicing obviously meaning interest only; and to qualify the question -

MR THOMPSON: I understand.

We will not in this schedule have a line item that says build into this budget x amount for retirement of principle. No, that will not be in it. We will expect that some boards will be able to start accomplishing that in the upcoming year through efficiency measures. Maybe one or two boards may, in the past year, have been able to allocate a small surplus to that end. We will be working with all the boards, the institutional boards, during the course of this year to develop a provincial approach to addressing the debt retirement issue for the total amount of accumulated deficit, but with this letter we are not asking them to set aside a specific amount for that purpose.

MR. ROSS WISEMAN: Let me ask another question, if you do not mind, on that same issue.

MS BREWER: I want to clarify, just for the minister and the deputy, the letters for the ten institutional boards are ready. We do not yet have drafted the letters for the four Health and Community Services boards. The reason being, government has to April 30, which is today, to pay the bills for goods and services received for March 31. Myself and Jim, and some of his staff, have been really busy this past week making sure that we do not leave any unintentional, what we call, dropped balances on the table. We are making sure that whatever funds are left from old year - consequently, in our work schedule the ten institutional boards are done. We were planning to work on May 1, hopefully, to get the letters to the minister by Friday for the other four boards.

MR. ROSS WISEMAN: Deputy, I appreciate your comments and the clarification around what debt servicing and debt repayment means. I understand your comment about the plan to work with the boards in developing a strategy for the retirement of the debt, which is the repayment of the principal. That is going to occur in this year.

Is it fair to assume - no, I will not phrase the question that way. Is the expectation that repayment of that principal, when boards under - whatever strategy you develop, whether it is next month or the month after. But, when you develop that strategy and the repayment commences, that repayment will come from the current allocation they are getting in that letter. This is - and I am careful about how I phrase this because in response to a question a moment ago, said: The boards were given an understanding in July of 2001 what they could expect. When boards give understandings people have different interpretations of that. They lend their own interpretation to it, I suspect. So it needs to be clear, and I would like to have some clarity around it if you could.

When boards get their letters tomorrow or the next day and they are told that they have - let's say hypothetically, let's personalize it and look at peninsulas because it happens to be in my district. They have about a $9.6 million accumulated deficit and their budget is roughly $45 million. So, tomorrow you write that board and tell them that $45 million is their total bottom line. The breakdown in the schedule breaks out a bunch of things that are in there and includes in that figure - but not a line item. The assumption is that they continue to pay their service, the interest cost at the bank. So that is not broken out. Then in a months' time you sit down with that board, as a part of this provincial package, and the board now starts to realize: Hey listen, you really had expected them to free up another $600,000 or $700,000 this year to start repaying that principal. It is an understanding but it is not in here.

The expectation is that the board repay that principal from this amount you are giving them tomorrow in that schedule. Would it not be more prudent - and more, I guess, fiscally responsible - to facilitate much better planning? The board could decide how they are going to deliver programs next year if they had that piece of information tomorrow rather than spring it on them in September and tell them: Hey listen, you now need to service the principal. I am assuming that the money has to come from the same envelope. So, where is the strategy here? Where is the planning that talks about a board that allows them to map out the programs they need to deliver, and what programs they need to make some changes in and whether they can implement new programs? Because you cannot allow them to implement a new program tomorrow.

MR. THOMPSON: If we had a precise answer to that we would actually have the plan done, and we do not have the plan for retirement completed. As I said, that will be completed over the course of this year. But, one can outline certain generalities about what is logical that will be in - or some of the parameters that may exist there. One is that if there are any surpluses which occur in board budgets this year, that those surpluses can be allocated to debt retirement. The second is that if later in this year there is conversion of - if this is the course we take - accumulated deficits into long-term debt with an annual repayment schedule then the first payment may come due in the following fiscal year and might not have an impact on service levels in the current year.

At this point in time we are not asking the boards to carve out any allocation for current year repayment. We are asking them to join with us in a planning process for the current year and then we will have all the factors on the table. One of the points you focused on: Is there going to be a negative service impact this year? The answer is no, because we are not asking them to plan in that regard.

MR. ROSS WISEMAN: It is clear though that as you develop the strategy for debt retirement, that the debt retirement comes from that envelope of money they have been given now.

MR. THOMPSON: That, of course, has to be our operating assumption at this point because we have not been provided with any additional funds for that specific purpose. Where we do not have a plan developed yet we do not know what kinds of flexibility, creative solutions, short or long-term options that may exist. So it is premature to say exactly how it will all unfold. We have no additional revenue to apply to this problem at this point in time. That is one of the planning parameters that we will have going into this process this year.

MR. ROSS WISEMAN: Do you have some sense of what the interest cost is on that $110 million or $115 million?

MR. THOMPSON: It is a good question, because it is not simply taking the $110 million or $80 million, as the case may be, and taking an assumed interest rate and plotting it out over a full twelve months. As you may know, the way we flow cash to boards means that for a substantial portion of the year they will not have a requirement for any line of credit at all. Only towards the end of a fiscal year will they start accumulating that line of credit which represents the inherited accumulated deficit. As well, on top of that, some boards may have deferred revenues for specific capital projects or other programs that will help in their cash flow management. So it is not a precise figure that we can say - I don't know, Jim or Donna, if you have ever estimated what the total interest costs of carrying that deficit would be. What we can assume is that it is only there for part of the year and that it is there at whatever interest rate may be applicable to a line of credit.

MS BREWER: Any estimates I have Robert, has been a combined interest; and principal has been assumed (inaudible) payment.

WITNESS: For a future -

MS BREWER: Yes, I do not know if Jim has ever seen the analysis of just interest only.

MR. THOMPSON: No, we haven't got one.

MR. ROSS WISEMAN: Okay, so what you are relying on is board's - all the cash flow being flushed with money until the last quarter of the year so they do not incur an interest cost.

MR. THOMPSON: Well, that is part of the way that they help to manage their costs, that is right, by pushing out the need to use a line of credit as far as they can in the year and that reduces the cost of the interest charges.

MR. ROSS WISEMAN: Based on those, just as a wrap up on this particular point, Mr. Chair, I just hope I have captured what I have just heard over the past little while correctly. I guess what I am getting at is the implication for boards tomorrow when they get these letters, because in as much as many of them may have been given an assumption or given an understanding last year in July, maybe they should have prepared differently but I suspect, if history is held true, that boards will wait until they get that letter before they take any action because they say: Well, we still do not know what the department is giving us yet so we are not going to do anything.

When they get this letter tomorrow or the next day, are they all going to sit there and say: I have been given enough money in this letter to continue to operate the programs that I have in place today and I am allowed to now cover off those one-time deferments that I had from last year - we talked about a moment ago. So I have covered off the one-time deferments, I continue to maintain my current level of service, and there will not be any adjustments in service levels for any of the fourteen health boards for the coming twelve months.

MR. THOMPSON: In the time that I have been in the department I have never heard from a board that they have enough money. So we are not likely to hear that.

MR. ROSS WISEMAN: Will they have enough to do what I just said? Not enough to expand, not enough to add new, not the wish list, and all that kind of stuff. My question was very precise.

MR. THOMPSON: I understand and I apologize if I was a bit too glib.

MR. ROSS WISEMAN: No, not at all. I understand, because you are absolutely right, boards will never say: that's great, thanks very much and I am wonderful.

MR. THOMPSON: We expect that some boards will have one-time measures last year that they will say: this is a concern for us, how are we going to find efficiency to balance? By the same token, as Donna mentioned earlier, there will be some boards with annualized savings that create some flexibility but even those boards, and all boards, will have, on top of those two items, pressures from increasing utilization of services. For example, dialysis or cancer treatment and medical-surgical supplies. There is price inflation as well as utilization costs. Our effort has been to take the additional $5 million and spread it over these types of pressures, in order to reduce the level of pressure that a board will feel in terms of balancing the budget.

As you can appreciate, because you have been there, these are very complex organizations and there are cost pressures that are coming consistently from many, many different sources. There are sometimes flexibilities opening up in other sources as well. This is the puzzle of sustainability right across the country, that we have heard about for so long. The task that the department has is to try to manage the growth in health care costs, because there is more money going into the boards this year as there has been in recent years, and to work with the boards to ensure that they can target a balanced position, taking into account all of these things that are going up and down all the time.

I am not trying to be evasive. What I mean to say is that the factors you have isolated there are not the only factors that are occurring within board budgets. There are community pressures for more service. There are declining populations, which in theory, should indicate a lower requirement for some services, although it is sometimes hard to see where they may occur. There are new technologies which should replace the need for some types of services, some new drug therapies which should keep people out of hospital. So, there are pressures going back and forth. More generally, we see the things that are rolling up, the costs that are rolling up, rather than the offsetting savings.

Our stance is to listen to concerns that boards have about potential deficit pressures and to work with them to try to balance their budgets. That is a way of saying, we know that we will not hear from any of the boards that they think they have enough to easily manage the cost pressures that they have, but we think there is a sufficient amount of money there so that the department can work with them, over the course of the year, to balance their budgets.

MR. ROSS WISEMAN: Let me be more precise with the question.

VICE-CHAIR (Manning): Excellent line of questioning, but I have to lay down the gavel on you, that is all. Sorry, Mr. Chair.

Thank you.

Mr. Mercer.

MR. MERCER: Yes. Perhaps we should let the record show that we are now two hours and forty-nine minutes into the Estimates and this is the first opportunity that members on my side have had to ask a question.

VICE-CHAIR: You will have to take that up with the Chair. I am just sitting in.

MR. MERCER: It is hard to interrupt people when they are an hour and twenty minutes, or in this case an hour and forty minutes, into a line of questioning. Anyway, I guess courtesy is not the order of the day.

Minister, we hear a lot about budgeting, and we certainly have been led to believe over the last couple of years - and some health care boards have done that as well - but we have been led to believe: Well, we do not know what our budget is. You know, the budget was brought down last week or a month ago and we still do not know what our budget is. We have heard that, we have heard that from critics and we have actually heard it from a few institutional boards. What I am hearing here this morning is that the budgeting process in the Department of Health and Community Service, with a $1.5 billion budget, is somewhat robust, shall we say? I am hearing what you are saying, that as early as July of last year boards really knew that at least they had the budget that they had in the previous year to work with. So it is not a matter of not having a budget, it is just a matter of knowing preciously how much more they were going to get.

What I am hearing you saying here this morning is that there have been several iterations of the budget. Last year in July they were told, next year you got what you got, and then as more budget monies became available in the budget, as I heard this lady mention, letters have gone out and boards have been told. The image I am getting is kind of a dynamic process, it is not a stop now, start next year sort of thing. The budgeting process within the health care boards is kind of a dynamic ongoing almost weekly, monthly type of process. Could you comment on that?

MR. SMITH: As you have heard the officials indicate, in terms of the process, I think it is fair to say that - I mean, we are in constant communication with the boards at one level or the other. As I indicated earlier today in my comments, certainly, in the broadest sense, the boards have a good idea as to where they are at any point in time. Now, having said that, that is not to say that they do not have specific concerns or not always coming forward and saying - because things do change on the ground for them as well. The demographics of the boards and the regions are changing constantly.

In the short time that I have been within the department I have been dealing with an issue in Central Newfoundland where there has been an increase in the demand for dialysis. It is interesting, because when I was in the department last summer in an acting capacity, at that point in time one of the areas that we were looking at instituting that service was in St. Anthony. It was a surprise to me, when I went down some months later to the department, to find that the demographics have changed and right now we do not have the numbers in St. Anthony to warrant that kind of a service. So, there are changing dynamics there.

I think your observation, that I would certainly concur with - and we have heard the officials here say that boards certainly have a good understanding as to where things are. I guess, in this particular budget, it was really only the $5 million that we have had, and it has only been within the last week or so that we have kind of finalized, again, as you can appreciate, the kind of requests that came in, and we would certainly need a lot more than $5 million to meet all of the demands that are coming in from the various boards. I think your assessment of it is accurate.

MR. MERCER: I just thought it was important to get that out, because I guess if you were dealing with a smaller group of people and a smaller number of boards with a much smaller budget, it is much easier to say your budget for this year is $1.25689 million, and that is the end of that. I am kind of heartened to hear that it is not that way, because in the health care system things are very dynamic, and the caseloads today may be very high and tomorrow they may decline.

I know in Western Memorial in Corner Brook, the issue over the years has not been budgeting. From the information that I have been hearing from within the system, up until fairly recently the issue was accounting for what they had in trying to figure out how much they were spending. It is kind of disheartening to know that in the case of that board, up until fairly recently they were making comments to the fact that they really did not know how much they were actually spending. I just want to make that point, because from talking to the officials there now they have in place systems, and I think their accounting practices are much, much better than they were, say, five or eight years ago. It is a pity that Western spent more time doing other things than providing for health care in Western Newfoundland.

Another point I just want to raise is this whole issue of privatization, because we have heard some public commentary about nefarious plans of the Department of Health to privatize health care in this Province. When I scan the newspapers, apart from hearing a few commentaries from individuals, I do not see that. I do see pieces in the paper, though, like the one I am looking at here now from New Brunswick, where Premier Lord is telling Romanow the health care system needs privatization. I am hearing statements from other premiers in other parts of Canada saying something similar.

Can we, in an attempt to bring some clarity to the issue of privatization, get some commentary from you or your deputy as to where you might be heading on this whole issue?

MR. SMITH: As I have stated in the House and stated publicly in terms of privatization - I guess the reference that you make is to the presentation that we made to the Romanow Commission. I guess what we were drawing on was the input that we received from the health forums that were conducted throughout the Province. In the main, there is no support for privatization. People do not want to go down that road and our position, as a government, is we do not advocate privatizing of the health care system. What we have said in the presentation: If there are services at some point in time, if there is a proposal that comes forward that says that a certain service can be offered to people in the Province - still being subsidized by government - if it can be done more cost effectively, I think it would irresponsible for us to say: No, we would not entertain that.

One of the things that - I do not know, it is still premature in that sense, but there is one issue, for example, that we know is a concern for all of us in a number of regions of the Province right now, certainly in the area of the Member for Trinity North and your own area, Mr. Mercer, and that is long-term care facilities. We are now, within the department, trying to look at the whole area. There is a significant investment required there to meet the current demands. Is that an area that we can possibly pursue? I do not know, but I think it would be wrong for us to say that we would never ask the question and we would never pursue something, if, in fact, it provides us with an opportunity to provide a service to the people of the Province more efficiently, and reduces our response time.

I guess that is where we are in terms of that thinking, but certainly in terms of the broader question, as to privatizing the health care system, in this Province we are on record, and our presentation to the Romanow Commission clearly states, that we support a publicly funded health care system.

Also, we need to remind ourselves as well, that in this country, at the present time, there is a significant amount of privatization that is taking place. There are a number of services that we would all be aware of, that if you want to access them right now are not subsidized, that you have to pay for. Our concern is that we certainly do not want to grow that and we certainly want to make sure and ensure that health care, and good health care, is available to the people of the Province in a timely fashion. I guess that is where we are going in terms of the strategic health plan, and these are the kinds of things that we are hoping to address in the weeks and months ahead.

MR. MERCER: What I am hearing you say, perhaps - and I do not want to put words in your mouth, and maybe I am hearing what I want to hear - is that, in terms of a publicly funded health care system, where I go into a hospital for a gallbladder operation, that is covered by the state, a fee is paid on my behalf. We are not talking about my going into the Health Science Complex and receiving a bill for $10,000 because I had my gallbladder removed. We are not going anywhere that kind of a road.

MR. SMITH: Definitely not. I do not think there is any appetite, not only in our Province but indeed in the country, for that sort of thing.

MR. MERCER: Again, I guess, what I hear you say, when you talk about health care or long-term health care, insofar as it affects Western Newfoundland, is, in the facilities, there would be some opportunities for private, public partnering in the construction of those sorts of things? Is that -

MR. SMITH: I guess what I am saying is, at this point in time it certainly would be premature. We are just now at the point where we are starting to look at that whole area. I reference that as an area, because I think as we move forward, my perspective is that I do not think we should approach it from the point of view that we should close our minds to any possibilities, if it means we are able to provide a better health care service to the people of the Province. That is ultimately what we are all about. Certainly, we want a publically funded health care system available to the people of the Province.

Part of the presentation to Romanow, as well, talked about increasing the services that are presently publically funded. For example, one of the things that we hear constantly in the Province, and we have heard referenced here today, is with regard to home support. That is an area that is a challenge for us right now to meet, and we think that this is an area as well that needs to be revisited at the national level, and a debate to take place there. The demand, I know, in our own Province right now is growing, and our projections, just on the demographics, the fact that we are an aging population, certainly are not going to indicate to us that we are going to see a decline in the foreseeable future. So here is a service, on the publically funded side again, that we think we would like to see added.

I guess, getting back to your point with regards to the privatization: Certainly, this Province is clearly on record as saying that we do not support a privatization of the health care system.

MR. MERCER: I am glad to hear that, because when you have seniors come up to you and state that they have heard, over the airwaves or in the media, that as a government we are talking about privatizing health care services, and telling you of their stretched fixed-income budgets and how they are going to afford this and how they are going to afford that, obviously there is a message getting out there which is not in keeping with what I have heard you say here today. Perhaps they are not hearing what they should be hearing, but this is the message that some of them are taking from that. I think that is creating a public perception out there which is incorrect and unfair in my view.

It would be nice for me to be able to go back and say to those people, as I have already said, that government has absolutely no intention of privatizing health care delivery in this Province, that their health care is still going to be publically funded, and they need have no fear for stretching their declining dollars to pay for their declining years, shall we say. Anyway, it is unfortunate that that perception is out there. I am sure those who made the statements did not intend it to be that way. Unfortunately, I am hearing too many comments these days from people who are suggesting that government has something afoot: They have to find some way to come up with these monies to pay for these big bills in health care and pay all the dollars we are paying to our hospitals and doctors. Please, they say, do not tell me that you are going to be charging me for everything I have to get when I go to the hospital. It is unfortunate that people at that age have to worry about that having gone through some fifty years or so of, really, not being that much involved in terms of the cost of health care. So, anyway, glad to hear that.

You mentioned, as you were saying, about a plan. Again, another big statement that is being made is that there is no plan, strategic plan, for health care delivery in this Province. I guess the recent forums by the minister of the day, your predecessor, were focusing towards developing a "strategic plan". However, that sometimes carries with it the implication that there are no plans in the Department of Health, that all you are doing over there is spending money willy-nilly, and hopefully some of it will fall in the right places and do something good for someone.

Would you like to comment on what you are doing now and how that differs from your strategic plan or how the strategic plan will help you focus better on what you are doing? Give me a separation in my own mind as to how the two of these pieces work together.

MR. SMITH: I think it is an unfair characterization to say that there is no planning. We can always say, you know, what is sufficient or adequate planning. Certainly the boards themselves have to operate within plans. They certainly have to make projections, look at their operations and see where they want to go. So it is unfair to say that there has not been planning. I think we have to recognize that one of the things, from my perspective - and I did not participate in the health forums other than I took part in a couple of them, one in our own Western region. The health forums did a lot of things. In my opinion, it was a tremendous exercise. I think it helped to generate an awareness and to create a focus whereby people in the Province are now beginning to realize that the capacity of government to respond is not unlimited.

I talk to people in my own district in helping them understand in terms of services generally, like running the budget for your department or for government is no different than your own household budget. You know what you have and it is a matter of sitting down and deciding how you are going to spend it.

I guess, from my perspective, in terms of where we are as a government, at the present time I would suggest that we have pretty well maxed out as to where we can go, because at 45 cents on every dollar going into health care it is hard to visualize a scenario whereby we can go much further beyond where we are right now. Certainly, I am not suggesting that it will not continue to grow because it is my expectation that our budget and our capability to respond will continue to grow, so we will respond accordingly. There will still be that gap in terms of what the reality of the day is and where people would want us to be, in terms of the services that they want to offer.

I guess, in terms of our strategic health plan, we are at the stage now where we really feel it is time to lay out what the health system in this Province is going to look like in looking a few years out and beyond.

An interesting piece as well, as I referenced earlier in my remarks, is the charter that we are talking about developing, which is a simple concept really. For most of us, when we think about health care, we think in terms of people who have developed problems and are presenting themselves to have these problems corrected or remediated. A big piece, I think, that has been missing in the past is that whole wellness piece and the recognition that if we do a better job in terms of, if all of us, as citizens, accept more responsibility or added responsibility for looking after our own health - we know that people who engage in activities like smoking or alcohol abuse, people who do not live active lifestyles, people who do not pursue proper diets, that they are putting their own health at risk. The charter tries to reference that piece of it, to remind people that each of us, as a citizen of this Province and of this country, has a responsibility for our own health. First and foremost, the responsibility is ours.

I guess, from our perspective as a department and as a government, that our piece will be: Well, if your health does fail this is what you can expect from us. The charter is an interesting piece from the point of view that I think that it will help focus people in that we need to accept that responsibility. I guess we have heard reference to increased emphasis on wellness. That is certainly an important piece that we have to get more proactive on. This government has been very good, in my opinion, in terms of - for example, tobacco is one thing. The legislation that we brought in with regards to the control of tobacco, and especially as it relates to young people, I think is progressive and I think it is where we need to be going. It is more of these types of things that we need to do. I think we are well along in terms of at least our own thinking as to where we want to go. Now we are at the stage where we want to start getting some of these things put to paper, and this is where the Strategic Health Plan comes in.

MADAM CHAIR: Thank you, Mr. Mercer.

MR. MERCER: On the next round perhaps I will have a few other questions.

MADAM CHAIR: I now call on the Member for Torngat Mountains.

MR. ANDERSEN: Thank you, Madam Chair.

Minister, first of all, certainly the portfolio that you and your officials carry, I think everyone in the Province fully understands the difficult strain that is on you and your department to provide services to the people in this Province with limited funds. I do not think that I could find the time to stand and praise a federal politician in this House, when we look at the clawback and so on.

Minister, I just want to say this, that no one in the Province of Newfoundland and Labrador probably knows more about services provided by your department than the people in Nain who went through massive suicides two years ago. Furthermore, no one knows the- I am not sure what the right word is, I guess - anger, fear or hurt as to what went on with the people in Davis Inlet, the children. Minister, I just want to say that, through it all, the people in your department stood the task. Certainly, on behalf of all the people in the Riding of Torngat Mountains, and the parents of these children of Davis Inlet, your people here in St. John's, in the office in Goose Bay and who worked in the clinics, stood the task - certainly, when we look at, I guess, the Province, a have-not Province, to see what we may not be able to buy with dollars but the service that we can provide with human beings. The people who work in your department, Sir, are a credit to this department and this Province. I just want to say thank you to all your staff for that.

MR. SMITH: I just want to thank the hon. Member for Torngat Mountains for those comments. I certainly accept them on behalf of the officials of my department.

I guess that whole issue was starting to develop when I was here in an acting capacity. One of the things that I did - and I think it is good, as well, that we do recognize that we, in this Province, do have some tremendous people working on our behalf, that we have some very capable, competent people, people you see here today, people who work within the department and people who work out on the front lines. We have been very fortunate in the caliber of people who we have attracted, despite some of the comments we hear on times.

I was talking to the hon. member opposite there over coffee. If you look at the size of this department, I know when I came here - just looking at some background things; 20,000 employees. Just by sheer mathematics, if you extrapolate the number of interventions that take place on a daily basis, the possibilities for people having negative experiences, I mean they are tremendous. In the main, I think the interesting thing about our health care system generally and the services that they offer, is that other than isolated cases, in the main - and certainly studies support, where surveys have been done in terms of people who do have to avail of these services - there is a very high approval rating for the service that we do offer in this Province. So despite the fact that from time to time people try to create the impression that we do not have a quality service in this Province - no, it is not perfect, but I would defy anyone to find a system in this country that is perfect, operating under the present circumstances, under the strains and challenges that we all face. I really feel confident, certainly as a citizen of this Province, that we do have an exceptional health care system, and I think our capacity and our ability to respond has been demonstrated over and over again. So I thank the hon. member for his comments.

I recognize your role in the Opposition, but I think within the Province, generally, from time to time it doesn't hurt when we do acknowledge that there are, in fact, some good things within the system and there are cases where people are responding above and beyond the call of duty. The incident the hon. member refers to, I do know that some of the officials in our department really went all out in terms of dealing with that crisis situation. I concur with him, that I think they did a tremendous piece of work.

MADAM CHAIR: Thank you, Minister.

The hon. the Member for Port de Grave.

MR. BUTLER: Thank you, Madam Chair.

Mr. Minister, I, too, would like to thank you and your department for being here this morning and making your presentations. A couple of questions that I did have, have already been answered. I guess, the one that was highest on my priority list you answered for Mr. Mercer, and that was on the privatization issue.

I, too, want to say, before I ask you a couple of questions, that sure there is not an issue, I suppose, involved with government, regardless of what department it is, where everything is 100 per cent. However, I have been involved as a patient and as a visitor to the health care system in this Province, and I think the majority of people who go there have the greatest respect for the service that they are being offered, by not only the staff there but through the department as a whole.

A couple of years ago I had an opportunity to travel to a couple of states in the United States. I guess, due to the accent they knew I was from down East and wanted to know where I was from. The first question was, how much taxes do you pay, and I was ashamed at the time because it was around 19 per cent. They assured me that if they had our health care plan, they were well prepared to pay the 19 per cent rather than the 6 per cent that they were paying. I guess you have to go somewhere like that to really get the message and appreciate what we do have.

A couple of questions, Mr. Minister. I am pleased to see that a negotiated contract with the nurses has taken place. My question is: Are there any new placements to accept students in the nursing school this year, and what has the department done to address recruitment and retention?

MR. SMITH: Specifically, I think there was some money allocated for further recruitment in this year's budget.

I guess to the broader question, and I will certainly defer to Robert, to one of my officials, who would be more knowledgeable of it, but the recruitment thesis is done by the boards themselves in terms of physicians. I think that is what the hon. member is referencing. It is an ongoing challenge and we acknowledge - in recent days we have seen the issue of the oncologist and the concerns that they have raised.

I will defer to Robert, to one of my officials, if he might have some further information with regard to that.

MR. THOMPSON: I have a few comments and I will ask Donna to comment as well.

On recruitment and retention, there is a variety of initiatives at different levels. One initiative, which was announced in last year's budget, was a provision of funding for a central recruiting office in the Newfoundland and Labrador hospital boards association for purposes of physician recruitment. It is the area that tends to get the most public attention about whether we are able to fill the number of positions that we have, particularly in rural areas. Instead of having boards going out independently, or having a central office which is not as functional as it could be, we have created, with the boards association, a new central office with a new mandate supported by a committee of all the stakeholders, including the medical association. We have located that recruiter right in the Faculty of Medicine because the highest priority we have is to hold onto the medical graduates who are from Newfoundland and Labrador. Once we are able to retain them they tend to stay much longer than the people that we recruit from outside the Province. That is a major new initiative that we expect will pay dividends.

Another effort we have underway is a major human resource planning exercise where we are identifying the future demand and the future supply of graduates in the full array of health professions. We have recently completed some important work on nurses. That work showed, very quantitatively, how the bulge of the workforce is getting older. That means in the next ten years we are going to see a wave of retirement occurring in the nursing workforce. As a consequence of that, we measured that against the number of new graduates that we will have if we stayed at the present level of nurse education, and it showed a clear gap between the supply and the demand. That was the reason why, in this year's budget, there was money provided for an increase in enrollment to start to deal with the ultimate outfall of the demographic pressures.

Donna, maybe you could say a few words about the number of new placements for nurses this year.

MS BREWER: Sure Robert. Government actually budgeted $300,000. That should allow us to increase the number of seats in the three nursing schools by thirty-two. Currently, the complement is 220, so that is around a 15 per cent increase in enrollment.

Specifically, on the issue of recruitment and retention of nurses, particularly since 1999, government has taken a number of initiatives. They have created 125 new nursing positions back in late 1999. They also allowed money to create a whole bunch of support positions because what we heard in recruitment and retention, in addition to the wages, was the fact of the quality of work life and the workload issues. To assist the health boards, they actually created some support positions to try to take some of the support burden off the nurses to leave them more time to actually do hands-on nursing care.

Also, since 1999, nurses were one of the groups that benefitted from an occupational reclassification that cost around $17 million, and we had a three year pilot that was $225,000. It was to encourage students to take their practical out in rural Newfoundland because the research shows that people who practice in rural settings are more likely, when they graduate, to take a job in a rural setting just from the benefit of having that experience. Certainly, that three year pilot was a success and I believe government announced this year the continuation of that on a permanent basis; it is $75,000 a year.

Over the last two years we have added $1.2 million to allow for the addition of nurse practitioners throughout various boards in the Province. Up in Northern Labrador and Harbour Deep, back in 2000 there was an agreement signed to allow for recruitment and retention bonuses, particularly in areas that were not connected by a road, to assist with the recruitment of nurses in those particular areas.

MR. BUTLER: The other question, Mr. Minister, is - I just forget when it was now but I would like to compliment the department with their health care forums that were held. I know I attended one at The Wilds up on the Salmonier Line.

Just a couple of questions, and all in the one, I guess. Overall, I was impressed to see professionals coming in working with people - from business people, from the general community, all coming together to try to find a solution to help the health care system in our Province. Some of the major issues that were discussed in those hearings, and like I said, I only heard from the one, I was wondering: Were they similar all around the Province? What was the end result with regard to the issue, such as funds? I know it came up, $1.4 billion. How many more dollars do we need to take care of the situation, or is there enough money to even do that?

The other one with regard to - there was some issue that came up about the boards and if they were needed or how they operated and so on. I was wondering: Was that a general consensus around the Province from all the meetings that were held?

MR. SMITH: I am going to ask Bev to respond to that. Just before I do that, I will point out that my understanding of the forums, in terms that there were a broad range of issues that surfaced, but my general sense of what came out was that there was certainly an understanding and an appreciation that there was not unlimited funding. People did not come at it from the point of view that: more money for this, more money for that. People were very, very realistic and looked at it from the point of view: What do we need to do to sustain the health care system that we have? It may mean changing some things around, making some decisions that we do things differently; but certainly, people were very realistic. They did not come forward with a wish list saying: We need to spend more money here, more money there. They certainly demonstrated that they had a good understanding as to the broader picture, and that's the way they approached it.

Anyway, I will ask Bev if she can speak to some of the broader themes and the basic themes that came out of the forum itself.

MS CLARKE: Just a couple of things, with your particular question around the funding issue, as the minister said, there was actually quite a unanimous discussion across the Province. One of the points that people made clearly in every one of the sessions was that, in terms of funding, Health and Community Services could not continue to take funding from other government services. So, the forty-five cents of every dollar was really as far as we could go. We did not want, in this Province, to see other services being impacted in a negative way in order to provide health and community services. That was really quite a consistent message, that obviously we should be looking to the federal government for additional funding. That certainly was something people talked about.

The other thing that people talked about in terms of funding is that there is some room for us to find efficiencies within the current system and that we should be looking to find those efficiencies. In that respect, then there should be a reallocation as we move forward from those services that may be of low need to those services that are of high need, and that we need to do our research and do good evaluation and performance measurement work to look at those issues.

With respect to the boards themselves, there was no unanimous: Yes, this is how we should proceed in terms of further board integration. What people did say to us was that it should be considered and if we wanted to move forward on board integration it should be to ensure that what we are doing is improving the quality of services to the people of the Province. In fact, if we thought that would improve service in terms of that seamless continuum, then we should go down that road, but there wasn't necessarily a lot of money to be saved in terms of looking to further board integration because obviously most of the staffing would not change.

The other major theme that came out of the forums was the whole focus - the minister has talked about this several times this morning - on wellness. That, in fact, we really need to look at how we keep people healthy and begin to shift the system to change the balance so that more of our resources and more of our time is spent talking about health as opposed to illness. That was a really important focus as well.

Those are probably some of the main things that came out of the forums.

MR. BUTLER: The last question I have, Mr. Minister - and probably you touched on this earlier, if you did I missed the figures. I know you made a comment, I think it was in your opening remarks, about previous years there was a decline in funding within the health care system, if I understood you. I was wondering how much has been put into the health care system within the last few years and how does that compare with what we spend per patient here as versus other provinces?

MR. SMITH: Certainly, in terms - as I indicated, in the broader sense I think we have grown the budget by something close to $500 -

WITNESS: Annual increases.

MR. SMITH: Yes, we have grown it up to, right now, from - looking from the base of 1996-1997, it has grown by some $456 million.

In terms of the question that the hon. member raises with regard to - I guess in relative terms when you compare - I think an important point to remember is one that I did reference here today, that we do exceed the national average in terms of per capita spending that we do in health care, and I think that is significant. We need to constantly remind ourselves of that because keep in mind, while the base budgets for health in this Province were growing and increasing by $456 million we did not see - the federal component was actually declining, which meant that void had to be filled by the Province. It was filled by monies that came out of Municipal Affairs or came out of Works, Services and Transportation. It had to come out of some other departments. So government's capacity to respond in these other areas - and I guess that is the point that Bev was referencing, coming out of the health care forums. It was interesting to see that people at the grassroots level could see that. They recognized the only way that we could do that, to find those additional monies, was that it had to come out of some other department within government, and they recognized it. Lets face it, we recognize this. We hear this all the time, about increased demands from municipalities wanting more money to deal with their infrastructure, increased demands to deal more with the roads.

I guess the bottom line to your question, there is no doubt that the commitment is there on the part of government. We have grown the budgets over the last number of years. Every year budgets have grown. Even at times when we went through some difficult times, when other departments were experiencing net declines, health has always grown. I guess the proof is the fact that - people always tend to compare us with the rest of the country. I guess that is fair game but I think this is one instance where people are not always aware of the fact that on a per capita basis we do in fact exceed the national average in terms of per capital spending in this Province.

MR. BUTLER: Thank you.

I have no further questions now, Madam Chair.

MADAM CHAIR: Thank you, Mr. Butler.

I will now go to the Member for Trinity North.

MR. ROSS WISEMAN: Thank you, Madam Chair.

Just to make a comment before I ask a couple of question, Minister. I just want to comment on a point you made in terms of your understanding of the role of the Opposition. I really would like to believe, and want to reassure you, that any of the questions we have raised here this morning, or any of the questions we may raise in the House, are not intended to be critical of the people who provide the services or critical of the people who are within your department or you as individual minister. There are questions around issues that we think are important for the public to understand, and particularly this morning when we are here talking about the Budget Estimates for what is the largest single expenditure of government. As you have already pointed out, it represents 45 cents on every program dollar that we spend and is a large chunk of money, $1.5 million. The questions we raised this morning are to gain some understanding of how that money is spent, how programs are provided, where we may be going in the future, whether or not we are responding to what we are seeing in the community, the needs of the community, and whether or not we are going to have the kind of system we want five or ten years out. Our questions are purely from that perspective. I trust your staff do not take any questions we raise, or as we pursue questions and seek clarity around an answer - it is not intended at all to be critical of an answer or critical of the person, but purely to gain understanding and to share it with the public. That is purely our motivation.

Just to pick up on a couple of things. My colleague from Port de Grave talked about the issue of human resource planning. Just to follow on that vein of thinking for a moment - the response to the question focused a little bit on the issue of nurses. I could talk about two other groups. I could talk about the physician group and the second is the Allied Health Professionals.

Let's take the second first. As I understand, the Province participates with Dalhousie University in terms of its sponsorship of seats in physiotherapy and occupational therapy. It used to be speech therapy, but I do not think speech is sponsored anymore. Is it?

WITNESS: (Inaudible).

MR. ROSS WISEMAN: I think it is just the two of them now.

WITNESS: Just the two, but I am not sure which two.

MR. ROSS WISEMAN: I think it is physio and OT.

So, as a Province, we are paying for eight or ten in each of those professions, with an understanding that the people who participate in the programs have a return service agreement with the Province, and in turn they will come back to the Province and give them a return in service.

Let's take this year, for example. I understand there are eight or ten physio students and eight or ten OT students graduating about now. Can you give us some sense of how many of those may, in fact, already have positions in the Province or will get positions in the Province, and how many will be leaving to go elsewhere because there were no opportunities for them?

MR. SMITH: Donna advises me that we do not have that information, but we could certainly, if you want, get it for you.

MR. ROSS WISEMAN: Please, could you.

I ask it as a curiosity, but I think it is an important question. I had a call from a lady who lives in Glovertown, from Glovertown originally, and she, yesterday, accepted an offer of a position in Halifax at a long-term care facility there because there were no OT positions being offered in the Province, or there are very few vacancies this year. I understand that a fair number of those who are graduating will not be successful in returning to the Province. I guess that raises the question, because I think that is a valuable program - I think it was a valid decision to invest like that and I think for difficult to recruit positions, you will always need to do something like that.

I guess, with documents like the Hay Report out there, that make some recommendations for a significant number of reductions in that group at the Health Care Corporation, in particular, which would be the largest single employer in the Province, I raise the question now in terms of where the department might be in its re-evaluation of that program. If this year being the first year in a while that a large number are not getting positions, who are not able to return, you have in addition to that, the Hay Report sitting there that says: Pull out a large number of the allied health professions. In addition, forgetting the scathing comments it makes about difficult to work, measure the workload, and bringing into question whether or not they are productive, just on sheer numbers, where is the department now in re-evaluating its participation in that and what is its commitment to the ongoing support of that program?

MR. THOMPSON: I cannot give you a complete answer on that right now. We will have to provide you with some information from the Health Boards Association because they take the responsibility, on our behalf, for management of that program. I find it, though, a little puzzling to think that we would be providing for seat purchases in areas where we do not actually have open positions which is kind of the premise of your question. Therefore, I doubt that is the case and we will confirm that. If somebody has elected to take a job in Nova Scotia or somewhere else, and they were part of the seat purchase program then, of course, they can do that, but there is an obligation back to the Province, a financial obligation, if they decide not to come back and do a return of service of some kind. That is another issue involved there that needs to be mentioned.

I have left out part of the -

MR. ROSS WISEMAN: The other part was in light of what - I made a statement and phrased it somewhat as a question, but just to clarify it further and not to contradict her either. There had been circumstances last year and again this year, where it is not a matter of the student making a choice, it is a matter of there not being a position in the Province. Therefore, they were entitled to leave the Province, their commitment was totally forgiven and they never have any obligation to the Province again. That has happened in the past and it is happening this year.

The other part of my question was: What is the department's commitment to the ongoing support of that program in the future?

MR. THOMPSON: I could only suggest to you, then, that with that information we will have to go and talk to the Health Boards Association about fine tuning the level of seat purchase that is there, because there can be no justification in paying for seats for which there are no jobs, unless we want to hold onto those seats, sort of to hedge our risk against future vacancies It is a good question - unless somebody else has part of the answer.

Moira?

MS HENNESSEY: Just to add to Robert's comments: I agree that we need to ensure the long term with respect to the availability of graduates of that program. There is also a significant issue with respect to viability of the programs at Dalhousie, and that there is (inaudible) from the four Atlantic Provinces. For us to make a unilateral decision that we are not going to support students, it will have an impact on whether they can sustain the two programs. It would not be a decision that we would move forward with lightly. With respect to the upcoming year, we are certainly still committed to providing support to that program.

MR. ROSS WISEMAN: I would not want anyone to get the impression that I was suggesting that we not, because to be very frank with you it is a very worthwhile commitment. You are absolutely right, the Atlantic Provinces need to cooperate on that kind of initiative and we need to maintain that program at Dalhousie and protect its viability. So, I don't bring into question at all the Province's participation.

I guess what I am raising here is an issue from a human resource planning perspective. If we have ten seats, or eight seats, whatever the number becomes, and these students in those programs are coming out this month and next month, and they went into the program with a commitment that they would have to return to the Province because the Province was going to offer a job to them, and then they find, in the course of the last month that there is no one coming forward and saying, here is your job - they are saying: I have to start looking somewhere else. They have gone through a three or four year program not looking, not thinking, because they knew that when the thing was all over: I am going back home, because the government is paying for my seat and therefore everything is fine.

I guess that is the context in which I raise the question, from an HR planning perspective - recognize that these people are coming back and recognize that the system needs to try to accommodate them. The board will tell you: I do not have the money to pay them. It is your people and your staff who are actually participating in this program and making the commitment to them, so you might find yourself, in the interests of preserving not just the program but preserving the person, saying to a board: We will give you the extra $40,000 this year so you can actually preserve that person. That is not taking place and I guess that is more the focus of my question, rather than getting back to the program and participation with the other Atlantic Provinces. That is more my question, more my point, really.

MS BREWER: (Inaudible) Allied Health Subcommittee of the Health Human Resource Planning Committee and they are looking at the whole issue of financial incentives and the whole of recruitment and retention. We will be expecting a report back shortly from that group in terms of their recommendations, not only with regard to the existing program but also other suggestions they may have on the issue of recruitment and retention of the Allied Health Professionals.

MR. ROSS WISEMAN: Thank you.

The other piece of that HR Plan is the physician piece. We have had recently the issues around - because recruitment is one piece of it and retention is the biggest strategy. I think if you look at good retention strategies, the recruitment piece becomes, not secondary, but it kind of takes care of itself. We have the oncology situation that we have in the Province, and the oncologists making the announcement of their adjustment in services. We have had examples of family practitioners in small rural communities suggesting that they are leaving the Province, and we have had some recent examples of where people who had been recruited had made some choices and decided not to come. I guess it is coming down to a very critical point in the Province's history right now in terms of health car, to be able to very quickly roll out what it plans in terms of a recruitment strategy before we start having some more significant repercussions.

Can the minister share with us where you are right now, as a department, with it's overall physician recruitment piece of that human resource strategy, and whether you are in a position to roll that out fairly quickly, and will that be also a piece in the strategic plan that is coming out the end of May?

MR. SMITH: I am going to defer to Robert. He has more details, or what detail there is right now.

MR THOMPSON: The formal component of the overall human resource planning project that deals with physicians is a work in progress. During the phase of last year when the NLMA was taking certain limited job action in terms of withdrawing from committees, we did have a withdrawal of the physician co-chair of that committee. That delayed the work of that committee for a period of time. So unfortunately, it is not as far along right now as we had hoped. That committee, though, is working on identifying the appropriate number of physicians by speciality or classification throughout the Province. Then, what we will work on formally are supply strategies against that level of demand.

We are not just waiting for that report to be finished in order to continue recruitment and retention strategies. I mentioned earlier the Central Recruiting Office which is one of the key strategies for us, to centralize and do a better job on recruitment of our own physicians. Another element of it is the negotiation process that is just started with the NLMA towards the next memorandum of understanding, to ensure that we, within our fiscal means, provide the most competitive compensation structure that we can, and in particular, to produce the extent of or where the greatest anomalies may exist between the compensation of selected groups of physicians in this Province vis-á-vis other provinces.

Another really important issue - we are told by some doctors that compensation is important but it is not really the bottom line. The bottom line for many physicians is to have a balanced work life with family and home life. So, having the right number of physicians in place at the right time is key to making that happen. As we go forward, keeping a stable physician workforce is really important.

In the Strategic Health Plan, as the minister said on previous occasions, one of the priorities will be a reformed primary health care system. When we talk about that, we are mainly focusing at the level of general practitioner or family physicians. What we want to accomplish is a network of family practice, primary health care units throughout the Province where physicians are carrying out their practice of medicine within the scope of practice that they had but sharing their medical roles with an interdisciplinary team of health professionals. That, we believe, will help to spread out and balance some of that hectic work pace. When an individual physician is practicing in a small community and they are the only physician for a long way around, and practicing all by themselves, that can be a very stressful environment for an individual physician. So in the primary health sitting, having the interdisciplinary team will, in and of itself, put that physician or group of physicians in a broader network of health professionals and improve the quality of work life and by itself be a pretension strategy.

MR. ROSS WISEMAN: Based on that kind of model, are you suggesting that we won't see any more sole physician practices in the Province any more?

MR. THOMPSON: No, I am not suggesting that. We do not have a transition process worked out yet that will flow from the strategic plan, or the specific models or templates are not worked out. The key here is to ensure that there is physician choice about how they wish to practice as well so that we can preserve the important role of family physician, their professional independence, and the choice of whether to work in a fee-for-service environment or in a primary health environment. There will be physician choice, so there may indeed be some solo physician practices for some time. What we are saying is, for those who are really interested in a balanced approach to work and family and so forth, there will be an option, and an option that we believe will offer a better comprehensive array of health services in all areas of the Province.

MR. ROSS WISEMAN: The strategic plan that is coming out the end of May will lay out the model for primary care in the Province and that then becomes the cornerstone, I guess, for the rest of the system. Will that then kind of lay out how the practice will look in terms of where we are defining certain services and where specialist services will be located, and that it becomes then a part of that strategy? Is that what you are suggesting, so it will all be a part of - we will see. When the strategic plan comes out at the end of May, it will become very clear and obvious in the plan what component of that overall strategy reflects a human resource piece for physicians, because you will have mapped out what primary care looks like, you will have mapped out what secondary and tertiary services will be provided and in what locations, and that kind of stuff. Is that what we will see when it comes out?

MR. THOMPSON: I have only indicated that, as the minister has in past occasions, primary health reform will be an important part of the planning process. I have to leave it to the minister to indicate any other details because the plan is not complete; it has not been decided upon yet.

MR. ROSS WISEMAN: Okay.

MR. SMITH: I think it is fair to say that certainly it is an important first step. I think your suggestion, just on pure logic, would indicate that a lot of these other decisions are going to flow from that.

MR. ROSS WISEMAN: The other piece of that, obviously, the human resource planning piece with physicians particularly, is the environment they work in and the compensation, as you have alluded to, but also what they have to work with. I look particularly at the issue of the budget for next year for equipment. This piece here on page 195, is this the budget we have next year for medical equipment as well? Is this the piece we are talking about here?

MR. SMITH: Page 195, is that what you are looking at?

MR. ROSS WISEMAN: Yes, the budget for medical equipment for next year, is it all covered off in this piece here?

MS BREWER: That budget is for the medical equipment and other health care equipment within boards.

MR. ROSS WISEMAN: Within boards?

MS BREWER: Yes. It would not cover fee for service, private physician offices or anything like that.

MR. ROSS WISEMAN: For example, all the diagnostic equipment, things like that, scopes, anything that physicians are using in a hospital setting, then that is what is budgeted for next year?

MS BREWER: Yes, and resident care equipment like in nursing homes, like bed tables, beds, chairs, geriatric chairs, and things of that nature.

MR. THOMPSON: If I could, further to that answer -

MR. ROSS WISEMAN: Sure.

MR. THOMPSON: - you are referring to subhead 3.3.01.?

MR. ROSS WISEMAN: Yes, I am.

MR. THOMPSON: I just want to reiterate the point that was made earlier about the $27 million projected revised. It contains an allocation of $14 million that was issued at year-end. In essence, the $14 million plus the $1 million becomes $15 million essentially for this year.

MR. ROSS WISEMAN: The POs haven't been issued for the equipment. The money has been allocated and spent, per se, but the requisitions or the POs have not been issued to buy the piece of particular equipment.

So, that is $15 million in total. Does that include the - let's take a piece. Let's take the implementation of this new PACS system and the ensuing costs associated with having to go to digital technology. Does that include - that $15 million covers off the cost of that particular initiative as well?

MS BREWER: It would include the provincial share but it would not include the fifty cent dollars that we would have gotten from the federal government - Health Canada.

MR. ROSS WISEMAN: So that is a fifty cent dollar, is it?

MS BREWER: Yes, the Province's fifty -

MR. ROSS WISEMAN: The PACS is?

MS BREWER: Yes.

MR. ROSS WISEMAN: I understand there is Grand Falls, Carbonear, Clarenville -

MS BREWER: Janeway.

MR. ROSS WISEMAN: Janeway - and I say Clarenville, the PHCC, because it is going into two or three sites, I believe, Burin and in Clarenville, and I think one of the other sites is already done. Will that be sufficient to cover off the full implementation of that program? Because some of these facilities, as I understand it, are still using some old technology. The premise of this is that it is all digitized now so we will be forced into acquiring a lot of new X-ray equipment to be able to fully implement this process. Will this be enough to complete the implementation?

MS BREWER: The chip dollars only covered certain sites within boards. It did not cover all sites within all boards. It did not necessarily cover the cost of the X-ray equipment. Either the board had that equipment and it was already digitized, or you do not necessarily need to have digitized. You can buy another piece of equipment that will take the film and download it into a file that can be transported.

MR. ROSS WISEMAN: So the boards will have the opportunity to fully implement within their boards - the boards that you have chosen - the boards will have the opportunity for full implementation of this system within their boards with this allocation of money.

MS BREWER: Some boards will use some of their own, like board-generated funds. Like, central-west may use some of our money and top it up to provide for broader implementation than probably was originally envisioned in our original application to the federal government. Other boards, what they will do is, if they do not have the money now, when we do capital equipment allocations, every year we ask for a three-year budget from boards.

MR. ROSS WISEMAN: Okay.

MS BREWER: Then, based on the priorities and the amount of funding that we get from Treasury Board, we make funding decisions in future years.

MR. ROSS WISEMAN: So, this money did not include the operating cost of going with the communication technology, the expanded band width they needed to use for digital imagery over long distances. This money is not included to cover off; that is an operational cost, is it?

MS BREWER: That is an operational cost, yes.

MR. ROSS WISEMAN: The increased operational cost was funded to those individual boards so they do not have to absorb that, so that is a new line item when the budget letter comes out in the next couple of days?

MS BREWER: No, actually, the experience that we have with the one board is that there is a shift in operational costs. Over time, there will be a reduction in film costs and storage costs, so over time boards, from using this PACS technology, will get some operational savings.

MADAM CHAIR: I want to thank Mr. Wiseman for his questions. Unfortunately, your twenty minutes has now expired.

I now go to the Member for St. John's West.

MS S. OSBORNE: Thank you, Madam Chair.

I have several questions. I will start with 2.2.02. When the Member for Placentia & St. Mary's was asking his questions, I think one of the answers there was that you were going to try to work within the budget this year. Are there more seniors coming into the system? Will there be, I guess I could put it, a cutback per capita? Will there be any cuts in services for each of the seniors as a result of working within budget for more seniors this year than you were working with last year?

MR. THOMPSON: I do not have data on the caseloads. I do not know if Donna does. You have to remember that while the population of seniors is growing generally, this group here are those that receive Guaranteed Income Supplement. I do not know offhand whether that group is growing or not, so that is a piece of information, unless somebody else has it, that we will have to get back to you on.

MS S. OSBORNE: Okay. I guess I am thinking in terms of - this comes under drug subsidization, so would there be any cut in drugs? Would there be any drugs taken out of the formulary for senior citizens as a result of working within your budget this year for more people?

MR. THOMPSON: The practice would be, if the cost pressure tends to go up, or if it is continuing to rise, we will look at measures such as therapeutic reviews, and that is looking at the prescribing practices of physicians and work with them to prescribe in a matter which is according to best clinical practice, which oftentimes produces by itself a reduction in the number of prescriptions that are written. So those are the kinda of measures we would want to take. As a last resort, we would propose options for other measures but that is not where we would go first. We would work on clinical practice and the patterns of prescription.

MS S. OSBORNE: Okay.

Under 2.3.02. and 3.2.01., line 10. in both instances, included in the $59.3 million under 2.3.02., and included in the almost $835 million under 3.2.01., one of the answers was that there are services that people travel outside the Province to obtain. Can you tell me what services they travel outside the Province to get? In many cases, are they services that are not available here?

MS BREWER: People could be out even on vacation, Ms Osborne, and they could fall ill and have to require services, so it is not necessarily that services are not available within the Province. There could be a student who is attending Dalhousie, and if they are a Newfoundland resident we are still responsible for the fact that they get a flu and have to see a doctor. You know, if you go on vacation and, God forbid, something happens and you have to see a doctor -

MS S. OSBORNE: It is covered.

MS BREWER: We will cover the cost. It is not necessarily the services for outside. An example of a medical service that would be - for example, like a heart transplant.

MS S. OSBORNE: Under 2.3.02. and 3.2.01, under line 10 in each instance, do you have a breakdown on how much of each of those amounts was spent for people travelling outside the Province as opposed to students? I am talking, for instance, of people going to Cleveland for cancer treatment. There was a period there where people were going to Cleveland for cancer treatment.

MS BREWER: That would not have been spent out of this budget. That would have been considered a health facility and that would have been considered an out-of-province hospital payment. We would not have that level of detail here but we can certainly, when we go back to the office, dig out what we can.

MS S. OSBORNE: What line in the budget does that come under?

MS BREWER: That would be on page 195, under activity 3.2.01.

MS S. OSBORNE: Yes, that is the one I am referring to, under 10 there.

MS BREWER: Okay.

MS S. OSBORNE: Under Grants and Subsidies, that would be included there would it?

MS BREWER: Yes, there is roughly - the highest I can remember was $18.8 million to be spent on out-of-province hospital payments.

MS S. OSBORNE: Okay.

MS BREWER: But we would have to go back into our system to be able to get a breakdown by diagnosis as to how much this heart transplant or lung transplant (inaudible).

MS S. OSBORNE: And how many were -

MS BREWER: (Inaudible) people.

MS S. OSBORNE: Yes, okay. So, people on vacation are not covered under there, are they?

MS BREWER: They would be.

MS S. OSBORNE: They are covered as well?

MS BREWER: If someone was on vacation and had a heart attack -

MS S. OSBORNE: Or just anything?

MS BREWER: That's right.

MS S. OSBORNE: Okay.

So you can provide us with a breakdown of that and for what reason people are travelling outside the Province to receive medical treatment that is not available here.

I have another question on - it is in a different vein altogether. I understand that the Adoption Act is going to be proclaimed in June, I think.

MR. SMITH: That's the hope.

MS S. OSBORNE: That is the hope, yes. There have been some issues lately on international adoptions. I understand that there is somebody here looking to open an agency where it had to be licenced as a person who can facilitate international adoptions. Do you anticipate how quickly that will be? I understand that there is a fair demand. I think the waiting list for adoptions here in the Province is somewhere in the vicinity of 800 or 900, is it now? I know it is a ten year wait. I don't know -

MS VIVIAN-BOOK: Yes, there is about a ten year wait. We process about ten to twelve adoptions per year, domestic adoptions within the Province, and then approximately fifteen to twenty more international adoptions, and that is increasing.

MS S. OSBORNE: I guess what I am asking, how soon do you anticipate that the person who is waiting to be licensed would happen? I am getting calls on that from people who, because of the waiting list - and sometimes people decide when they are twenty-eight that they would like to adopt a child because they cannot biologically have one themselves and then they do not get the child until they are thirty-eight or forty. That was not what was in their plan, so they are looking to do international adoptions which are quicker. Of course, if we had a licensed agency here it would avoid a lot of the experiences that have gone on recently. How soon do you anticipate that we will have a licensed agency here?

MR. THOMPSON: If the act is proclaimed during the month of June then the policies that would govern licensing of agencies would come out very quickly thereafter, within days.

MS S. OSBORNE: Okay, because they are being worked on now are they?

MR. THOMPSON: Yes indeed, and training is going on for our social workers around the Province right now as well. We only know of one person who has an interest. We have not heard that that person definitely wants to apply for it to be an agency.

The final point I would make is that right now there is no impediment because we do not have a licensed agency here. People are still free to choose an agency in another province and then proceed. We facilitate that all the time. Nobody should feel because there isn't a licensed agency here that it is an impediment in this case. The process could move fairly quickly, but I could not really specify for you what the time frame in weeks might be to get through the process.

MS S. OSBORNE: I think if we had one here it would be a lot less cumbersome because - I think you know the one that I am referring to as well. That did get to be a little bit cumbersome. If we did have a licensed agency here all the parameters would be set out and we could go forward smoothly from there.

I have a question now on dialysis. I understand that there probably will not be a dialysis machine put in St. Anthony now. Is that what I understood the minister said?

MR. SMITH: No. The comment I made earlier - I guess the commitment is still there to St. Anthony but at the present time the demand is not there. It is just a matter of - and I referenced it earlier, with regards to the changing demographics. The service that would be offered there would be only to patients who were medically stable and at the present time that circumstance does not exist in St. Anthony. The commitment is still there, and I guess if and when the circumstances change in St. Anthony then that will happen.

MS S. OSBORNE: The reason I asked that question is because the woman that I referred to before who had to come in from St. Anthony to have dialysis - that was why.

MR. SMITH: I would assume in that case she probably was not a candidate, that her condition was such that she had to be done here.

MS S. OSBORNE: Okay.

I had some calls as well from parents of children who need to have assessments done. I guess they are psychological assessments because of behavior problems or whatever in the schools. I understand that the waiting list to have these assessments done can be up to a year, and I do not know that answer. I am wondering if somebody over there can help me. That seems like a long period of time if there is a child in Grade 3 or Grade 4 who is having problems. That whole year puts that child back a fair bit.

MR. SMITH: I do not know if we have anyone here who could speak to that, but we can certainly -

MR. THOMPSON: We do not have that answer here today but again, we can get back to you on that.

MS S. OSBORNE: Okay.

MR THOMPSON: You said the school system, did you mean waiting in school for somebody from Health and Community Services?

MS S. OSBORNE: Yes. I am on a school council so I get that information there. You hear of children - and it seems to be a lot more of it these days - who are acting out in the classrooms and things. There seems to be a lot more demand on psychological assessments for children in the school system now, and I understand that the waiting list is quite long. I think they go to the Janeway to have the assessment. I understand that some parents were waiting eight and nine months. They can access private psychologists but I think that is quite expensive.

That is all the information I have. I just wondered if you were aware of what exactly that waiting list is and if there is any chance - I guess I am asking the same question, that people on all of the waiting lists are asking: Are there any chances of having that remedied in the future? Because if we do not do the early intervention for these children then it does get more expensive at the end of the line, both because they do not get to finish their education and things. I guess you will be able to get that answer for me. As well, I remind you also of the guidelines for home care. I asked you for that before.

We spoke about wellness as being one of the ways that will go in the health care system. I totally agree with that. Wellness from the point of view - physical wellness in terms of the actual physical exercise. I am a bit concerned that in some schools physical education teachers are being cut. Now they are not specifically targeting physical education teachers to be cut, but in terms of some of the cuts of units or half units physical education is now being once in every six days as opposed to more often. They used to have physical education more often in the past. If the Department of Health is going in one direction and the Department of Education, unfortunately because of cutbacks, has to go in the other direction then we are certainly at cross purposes there.

MR. SMITH: I guess it is a good point because what it does underlie is the need, as we move forward on the wellness piece, to work closely with other government departments and agencies as well. Because in addition to the issue that the hon. member raises, you also know that we will, in large part, be dependent on education to deliver (inaudible) through their health programs and whatever, to get out there; and certainly in terms of trying to educate our students on the need for proper nutrition, proper lifestyles and things of that nature. We are, in fact, working closely with the other departments. Obviously, we have to in order to move forward on this wellness piece.

MS S. OSBORNE: Again, on the wellness piece, I commend the government for last year on the smoking bylaw that was brought in, but I also understand - and I would not want to say it too loudly out of here - that there are not enough people doing the enforcement. That is unfortunate because once people understand that the smoke cops, as they are referred to, are not around then they will break the law no matter how much you speak to them. They are still going to break the law. I don't want to say this too loud outside of here, that there are not a lot of them, but that is, I understand, one of the problems, so it might be worthwhile to have another couple of inspectors, or at least make random raids, so to speak, so that the restaurants, or whoever is breaking the law, would be a bit more on guard if there could be just a little bit more enforcement from time to time. Then they would never know - like the liquor inspector - when you were coming.

MR. SMITH: The deputy just whispered to me, when you were raising that issue, that the non-smokers are pretty good smoke cops as well, because these are the ones generally who are really vigilant. These are the ones who normally raise the alarms and raise the issues. I know in my capacity as MHA - as I am sure most members of this House probably have - I have actually had calls from constituents on that very issue saying - especially Bingo halls, for some reason, tend to be the focus of that sort of thing. I have had two or three calls within the last little while with regard to that, prior to coming to the department.

MS S. OSBORNE: I get calls on that as well. The Curling Club on Bonaventure Avenue is a place that I used to like to go, but then it got too smokey. Every now and again when I think it is safe to go in, I will drift back in. They are getting a bit better. They also know that I am a little bit vigilant as well, but if an inspector were to, for instance, walk in there and say, "I am here to inspect, just to make sure that the smoking bylaws are being maintained", that would keep them on guard all the time. Because I keep saying to them: If you get slapped with a $1,000 fine, then you will make sure that the patrons stay on the non-smoking side, or the smokers stay out of the non-smoking side.

MR. MERCER: On a point of order, Madam Chair.

MADAM CHAIR: The hon. the Member for Humber East.

MR. MERCER: We are now four hours and ten minutes into the Estimates of the Department of Health and Community Services. I have not heard a question on Estimates in the last hour or so. I would say that we are out of the Estimates. We are now into the realm of policy, and my questions certainly were in the realm of policy, and I can continue on to that for several more hours if that is the need. If this Committee wishes to sit, we have to make a decision. The House opens in twenty minutes. The Pages do have work to do. I, as Deputy Speaker, have to be prepared for the House at 1:30 p.m. We do have a life. We do have other things to do in constituency matters, so I would ask the members to my right, what is their intent? Do we conclude these Estimates this morning, or is it their wish to come back later this afternoon, tomorrow, next week or next month? Whatever, I do not really care, I just need to know.

In six years in this House of Assembly, six years to be sitting here in Estimates going through every detail of policy and statements which could easily be information obtained from ministers outside of the House - that is where I get most of my information, not in once-a-year Estimates. We have to make a decision. This Committee can either filibuster at this for another two or three hours - I have no problem with that - but tell us now what they plan to do. We have the people's business to conduct in about twenty minutes.

MADAM CHAIR: Deputy Chair.

MR. MANNING: I concur with my colleagues here. They have several questions yet and time is of the essence, as the Member for Humber East just stated, so all I can see us doing at the present time is adjourning. I will meet with the Chair afterwards and we will have to set a time to sit, I guess, to finish up the details.

I make a motion to adjourn.

MADAM CHAIR: The hon. the Member for Humber East.

MR. MERCER: May I also request the Chair to bring the matter up with our House Leader so that he may confer with my friends to the right, their House Leader, to come to an agreement as to whether we are conducting a filibuster on these Estimates or not. If we are, that is fine; let's roll up our sleeves and bring in the tents and have a good old time of it. But, if we are planning to do the Estimates and get them done, let's get an agreement between the two House Leaders and proceed.

MADAM CHAIR: The hon. the Member for St. John's West.

MS S. OSBORNE: No, that is fine. I just (inaudible).

MADAM CHAIR: Well, there is certainly a motion on the floor and I have heard the comments from Committee members. I will certainly take this up with the Government House Leader asking him to, in turn, speak to the Opposition House Leader. I agree that we have substantially had questions on the Estimates. I think that most areas of the Estimates have been covered; however, it is my understanding that the Opposition members still have some questions that are directly pertinent to the Estimates. Can I ask the Committee how long they think they will need to clue up the Estimates?

MR. MANNING: Madam Chair, I did not get into that with the members. The Member for St. John's West tells me she has several questions, and the Member for Trinity North, so the answer is that we will have to discuss that later.

MADAM CHAIR: It is my understanding there is no need to entertain a motion. As long as there are still questions that are directly pertinent to the Estimates of the department, we will continue on with the Committee.

At this time I would like to ask for a motion to adopt the minutes of the last meeting, please.

On motion, minutes adopted as circulated.

MADAM CHAIR: I would just like to remind Committee members that we will convene at 7 o'clock this evening to do the Estimates for the Department of Education.

To the minister and his officials, I want to thank you for your time today. I sincerely apologize that we have not been able to significantly cover all of the aspects of your department within the time frame allocated, but I will certainly be in contact with you, Minister, in rescheduling another time that will be appropriate and convenient for all people.

I would like to thank the Deputy Clerk and the Clerk this morning for their indulgence, and all of the Committee, as well as the minister and his officials.

I ask for a motion to adjourn, please.

On motion, the Committee adjourned.