ISSN 0542-5492 Fifth Session - Thirty-First Legislature of the Legislative Assembly of Manitoba DEBATES and PROCEEDINGS 30 Elizabeth 11 Published under the authority of The Honourable Harry E. Graham Speaker VOL. XXIX No. 438 - 8:00 p.m., MONDA V, 23 MARCH, 1981 Office of the Queen's Printer for the Province of Manitoba

MANITOBA LEGISLATIVE ASSEMBLY Thirty - First Legislature Members, Constituencies and Political Affiliation Name ADAM, A. R. (Pete) ANDERSON,Bob BANMAN, Hon. Robert (Bob) BARROW, Tom SLAKE, David BOSTROM, Harvey BOYCE, J. R. (Bud) BROWN, Arnold CHERNIACK, Q.C., Saul CORRIN, Brian COSENS, Hon. Keith A. COWAN, Jay CRAIK, Hon. Donald W. DESJARDINS, Laurent L. DOERN, Russell DOMINO, Len DOWNEY, Hon. Jim DRIEDGER, Albert EINARSON, Henry J. ENNS, Hon. Harry J. EV ANS, Leonard S. FERGUSON, James R. FILMON, Hon. Gary FOX, Peter GALBRAITH, Jim GOURLAY,Ho n. Doug GRAHAM, Hon. Harry E.

GREEN, Q.C., Sidney HANUSCHAK, Ben HYDE, Lloyd G. JENKINS, William JOHNSTON, Hon. J. Frank JORGENSON, Hon. Warner H. KOVNATS, Abe LYON, Hon. Sterling R. MacMASTER,Ho n. Ken MALINOWSKI, Donald McBRYDE, Ronald McGILL, Hon. Edward McGREGOR, Morris McKENZIE, J. Wally MERCIER, Q.C., Hon. Gerald W. J. MILLER, Saul A. MINAKER, Hon. George ORCHARD, Hon. Donald PARASIUK, Wilson PAWLEY, Q.C., Howard PRICE, Hon. Norma RANSOM, Hon. Brian SCHROEDER, Vie SHERMAN, Hon. L. R. (Bud) STEEN, Warren URUSKI, Billie USKIW, Samuel WALDING, D. James WESTBURY, June WILSON, Robert G. Constituency Ste.

Rose Springfield La Verendrye Flin Flon Minnedosa Rupertsland Winnipeg Centre Rhineland St. Johns Wellington Gimli Churchill Riel St. Boniface Elmwood St. Matthews Arthur Emerson Rock Lake Lakeside Brandon East Gladstone River Heights Kildonan Dauphin Swan River Birtle-Russell lnkster Burrows Portage la Prairie Logan Sturgeon Creek Morris Radisson Charleswood Thompson Point Douglas The Pas Brandon West Vir den Roblin Os borne Seven Oaks St. James Pembina Transcona Selkirk Assiniboia Souris-Killarney Rossmere Fort Garry Crescentwood St. George Lac du Bonnet St.

Vital Fort Rouge Wolseley Party NDP PC PC NDP PC NDP Prog. PC NDP NDP PC NDP PC NDP NDP PC PC PC PC PC NDP PC PC NDP PC PC PC Prog. Prog. PC NDP PC PC PC PC PC NDP NDP PC PC PC PC NDP PC PC NDP NDP PC PC NDP PC PC NDP NDP NDP Lib lnd

LEGISLATIVE ASSEMBLY OF MANITOBA Monday, 23 March, 1981 Time - 8:00 p.m. CONCURRENT COMMITTEES OF SUPPL V SUPPL V - HEALTH MR. CHAIRMAN, Morris McGregor (Virden): Order. We're on line 3, Hospital Program - pass - the Member for Transcona. MR. WILSON PARASIUK: I'd like to ask one qu estion about the Birch River Nu rsing Sta tion, what's happe ning there. The people in the community there are concerned that there is some move to close it or is it closed right now? I'd like to know the status of it and what the intentions are. MR. CHAIRMAN: The Honourable Minister. HON.

L.R. (Bud) SHERMAN (Fort Garry): We have not been able to obtain a doctor for Birch River, Mr. Chairman, and the community has not been able to obtain a doctor. We have service supplied to Birch River from Swan River and we have a number of instances in which people have gone out or are going· out to Swan River for medical attention, but despite the best efforts of the board and the community, we have not so far seen any success in attracting a doctor.

I don't think we've had any comment or any request or appeal on the situation in recent months that I know of. it's been very quiet and there's been no pressure from the community on that subject, but it just hasn't been possible to attract a doctor into Birch River. lt really bespeaks the problem that afflicts rural areas everywhere today, Mr. Chairman, the question of the one-doctor practice. We've almost moved beyond it and unless you can get at least two doctors to go into a community, you have grave difficulty.

No one individual doctor wants to be on call 24 hours a day, seven days a week and this certainly is a factor of the times and Birch River is in that position. I'd like to if I could - the Member for Transcona may want to ask further questions on that point or on other points - but at 4:30 I hadn't completed my reply to the Honourable Member for Elmwood. He had raised a question in general terms with respect to the supply of hospital beds in Winnipeg and in Manitoba generally. I would just like to detail very briefly for the Committee, Mr.

Chairman, the fact that indeed last year, late last summer and early last fall, there were very extensive pressures that had built up on our hospital bed supply largely as a result of acute care beds and emergency departments being under some duress and demand. I must say it was not unique to Manitoba or to Winnipeg. In meetings with my colleagues, the other Health Ministers in Winnipeg in September and in Toronto later in the fal l, it appeared to be a national condition that for lack of better explanation, can only be described as one of those cyclical things that occurs in medicine from time to time.

There was in the summer and fall of 1980 in most major urban 1999 centres across Canada, a very heavy demand on acute care beds and emergency departments. We felt because of the unique climatic problem that we face here in Winnipeg where we have a heavy volume of demand on our hospitals in the wintertime, that we couldn't dare go into the winter with that much stress and strain on our hospital bed supply.

So during the fall we had a series of meetings between officials of my office, the Health Services Comm ission, the MM A, the Ho spital Administrators in Winnipeg and Personal Care Home Administrators to put together a program that would help us get through the winter and bridge the gap between then and the coming summer when a subs tantial numb er, several hundr eds of new personal care beds will be coming on stream.

We did that and it worked out very successfully. it included the return to rural hospitals of a number of rural patients who were occupying acute care beds in Winnipeg, particularly the trans fer of patients back to Flin Flon who had been transferred into Winnipeg in the course of a strike of the Flin Flon General Hospital. We managed to free up a number of acute care beds at several hospitals in Winnipeg including Grace and Misericordia and the Municipals. We got the MacEwan Residence open at St.

Bon iface which involved an expansion from 25 beds to 56, which was an expansion of 31 beds; it meant those people could come out of acute care beds and go into the psychiatric facility where they belonged. We go t 11 6 beds open at Seven Oaks. We achieved considerable co-operat ion from the panelling process and the personal care home admissions process where we were able to shift the priorities a little bit to put more emph asis on admissions from hospitals.

We opened, through the co-opera tion of the Fred Douglas Lodge and the Presbytry in charge of Fred Douglas Lodge and Deer Lodge Hospital, a 32-bed personal care unit at Deer Lodge and we opened a 63-bed personal care unit at the Health Sciences Centre. That combination plus a couple of other minor adjustments, produced a rapid and very necessary increase in availability of acute care beds in the Winnipeg system during the winter, and the pressure has been off since approximately the new year period.

We have received comments, I personally have had comments from medical directors at various of the major general hospitals in Winnipeg since early January, commenting very favourably and positively on the turnaround in the situation.

In total, in all, the system including those personal care beds which are to come on stream during the next few months, produces an expansion in the capacity of the hospital and personal care home system in Winnipeg, of a total of 817 beds during the 18 -month period, December 31s t, 1980 to June 30th, 1982. it's an 18- month program and at the end of that 18 months, the capacity of the system will have been expanded by 817 beds. As of the end of December, Mr. Chairman, it had been expanded by 231 of those 817 beds and there have been more beds freed up in the system since that time.

So we've made good progress on the plan, on the campaign and the pressure that was being

Monday, 23 March, 1981 experienced late last summer and early last fall has definitely beem relieved. MR. CHAIRMAN: The Member for Seven Oaks. MR. SAUL A. MILLER: Thank you, Mr. Chairman. The Memb er for Transcona had to leave for a moment, but he asked me to bring this matter up to the Minister 's atten tion. it's with regard to Winnipegosis.

Apparently the problem - if I read this letter correctly, I just gla nced at it - with inadeq uate number of doctors in Winnipegosis, I belie ve they have a fairly new hospital in Winnipegosis, with an operating room and according to this a case room, as well as a lab and x-ray and they're close to opening a new nursing home in Winnipegosis as well.

I'm wondering, can the Minister tell us whether he feels that in his opinion, tha t there's sufficient medical people in Winnipegosis to be able to serve the community and these new facilities that have apparently been built there, and which will no doubt attract people to the Winnipegosis Hospital, who may have been going elsewhere, but now becaus e of the new facilities they have and the new nursing home, will of course expect to find sufficient doctors on hand in the Winnipegosis facilities?

Is the Minister satisfied that in fact, there are sufficient doctors to fulfill the function and to meet the demands of a new hospital and nursing home? MR. SHERMAN: No, Mr. Chairman, I'm not satisfied that we have sufficient at the present time. There were two doctors in Winnipegosis at one time; there's only one now and that's certainly 50 percent less than what we need. The MM A, through the Placement Bureau that has been established and funded as part of the ongoing program commitments of MHS C in the past year, is attempting to recruit another doctor for Winnipegosis. MR. CHAIRMAN: The Member for Transcona.

MR. PARASIUK: I had to leave for a second. Did the Minister answer my question on Birch River? You talked about the doctor but I believe right now it's not classified as a hospital. I believe there's a facility there which is being treated as a nursing station. Is that crrect? MR. SHERMAN: We classify it technically as a Medical Nursing Unit, but it's in effect, a smal l hospital. MR. PARASIUK: I've just heard some concerns. I was meeting with some Manitoba Association of Seniors, actually, and one of the representatives there is from Birch River and she raised this whole question with me again.

They said they had raised it in the past. They're concerned that since there hasn't been success in getting a doctor in there, they're concerned, and there's some rumour around the community that the Birch River Medical Nursing Station is going to be closed down. Could I get a clear statement from the Minister as to what the intention of the Birch River Medical Nursing Station is? MR. SHERMAN: Mr. Chairman, I was just checking with my officials and they confirm that it is closed, which is what my understanding of the situation was. lt is closed, and has been closed for approximately two years.

We have told them that we are prepared to fund it, and in fact there's provision in the Estimates for doing so, if they can obtain a doctor. MR. PARASIUK: How realistic a proposal is that, in view of the fact that a number of other places don't have doctors, and Winnipegosis which has one doctor and possibly serves a larger area, can't get the second doctor? I've heard of offers that people can't refuse but this strikes me as an offer that people, in all reality and practicality, can't accept. Are there any other alternatives? You say that if they get a do ctor, you 'll provide assistance.

Is the Placement Bu reau actively seeking a doctor on behalf of the Birch River community? MR. SHERMAN: Yes, the Placement Bureau is, Mr. Chairman, actively seeking a doctor and I know the board in the community is actively seeking a doctor. We in the government, certainly do not wish to close or see closed any rural Ma nitoba hospitals, notwithsta nding the difficulties of the day in maintaining some rural hospitals.

In general, our approach is supportive of small rural hospitals, on the grounds that the viability of the rural community in many cases depends very heavily on the maintenance of institutions like hospitals. So we are not making any declamatory decisions, or closing any doors. We are prepared to continue funding the Birch River Hospital, if a doctor can be located. When the honourable member asked me how realistic that is, I'm not sure that I can give him a very satisfactory answer.

Birch River is about 24 or 25 mi les from Swan River. it can be served and serviced by physicians from Swan River. it's in the difficult competitive position that a lot of small communities find themselves in, that professionals will very often prefer to live in a larger centre, becaus e most times their families prefer to live in a larger centre and they're prepared to take a day or two days a week and go out and serve smaller centres. So, I don't kno w how realistic it is other than can be expressed by the attitude that says, let's not close any doors at this point.

One can't predict with any accuracy what kinds of population shifts and trends are going to develop over the next few years, in fact, there seems to be at least a small ray of hope indicating that some people are be ginning to opt for life in rural Ma nitoba and smaller communities over life in major urban centres. I wouldn't say there's been any significant shift in urban ization patterns at the moment but we are not closing any doors and we can only hope that some physician will be interested enough, and intrigued enough by practice in Birch River, that he or she will be attracted to it.

But I have to go back to the point I made a few minutes ago that bigger than the challenge of rural practice is the challenge of one doctor practice, one physician practice. it's much easier to encourage practitioners to go into a two practitioner community than a one practitioner community. So, I can't say to the Honourable Member for Transcona that it's realistic. it's merely hopeful. MR. PARASIUK: One of the major reasons why I haved raised this is that in the last campaign the 2000

Monday, 23 March, 1981 present Member for Swan River made that as a type of election commitment that the Birch River Hospital would be kept open and that's why the community of Birch River keeps contacting me, as the Opposition health critic, with this issue feeling that there had been some commitment, in their minds at least anyway, on the part of the go vernment in this respe ct. I'd like to mo ve on no w to the - (I nterject ion)- Oh, my colleague raises the whole question of what about a nur se practitioner. Is there any thought being given to a nurse practitioner for a Birch River nursing station?

There is a facility there, presu mably a nu rse practitioner could fill th e function. MR. SHERMAN: Well, there certainly is an interest in obtaining a practitioner, a qualified practitioner of any particular category. Again we run into the same problem with a nur se practitioner as we would run into with a qualified M.D ., the one practitioner 24 hours a day, on call for all emergencies, seven days a week kind of environment.

Certai nly the practitioner who goes in there, if you are going to operate a hospital, has to be qualified to meet all emergencies and I think, all things being equal, an M.D. would be preferable but there is certainly no pre-set attitude that operates against the hiring of a nur se practitioner and the search is covering all categories. MR. PARASIUK: Well, we have a problem now in Birch River. There is a problem in Winnipegosis that my colleague the Member for Seven Oaks raised, where they can't get a second doctor. Has the problem been resolved in Benito?

I believe Benito has a hospital and they have been looking for a doctor. Has that problem been resolved there? MR. SHE RMAN: Mr. Chairman, I bel ieve the problem in Benito has been resolved. I can confirm that the problem in Benito has been resolved and a doctor has been obtained for Benito. MR. PARASIUK: I'm wondering, does the Minister have a list of those communities who have hospitals, that aren't staffed by a doctor or who have medical facilities like a hospital that are understaffed as is the case with Winnipegosis where the Minister says two doctors are indeed necessary but only one doctor exists?

Does the Minister have a list of what the shor ta ges are? I kno w we'v e got a Pl acement Bureau. We've had a number of problems; we have a couple of successes - can we know what the challenge is, what the problem is, what the scope of the problem is? Are we talking about 25, 30 communities with respect to hospitals? Or say only five or ten communi ties with respect to hospitals lacking a doctor or being short of a doctor and possibly in the order of 30 or 35 commun ities lacking a doctor per se in terms of how the Placement Bureau might define the challenge. What is the challenge? MR.

SHERMAN: The number would be about eight or nine communities lacking a doctor, Mr. Chairman. Certainly all communities · in Manitoba with hospitals that are opera ting, either have a physician that is on site, on staff and avai lable to deal with the req uirements of the commun ity and with 2001 emergencie s; or the y are served by visiting physicians from neighbouring commu nities. Otherwise the hospital does not operate. There are eight or nine commu nities in the province where we lack that kind of medical service.

The number in terms of those that actually lack a resident physician would possibly be greater than that, Mr. Chairman. But I can advise the Commi ttee, that among the new programs that are included in the Budget for this year which I referred to when we began consideration of these Estimates several days ago, is an Inc entive Program for physicians which is aimed at meeting this need in what we refer to as medically under-serviced areas. We also have the MMA Placement Bureau in place as I have mentioned earlier.

The Incent ive Program grows out of work that's been done by the Standing Committee on medical manpower and is designed to provide services in areas of the province that have been designated by the Minister of Health as medically un der-serviced and also to provide specialist services in selected categories of medical specialties wher e th ere is a short supply of manpower. The program consis ts of four inter related components.

One is a summer work experience for first and second year medical students; one is a program offering loans to third and fourth year medical students; one is a program known as the Rural Manitoba Residency which provides for the funding of four resident physicians over and above the 320 resident physicians that are cu rr ently appro ved in the province and they are designated as rural Manitoba residencies. The fourth component is the concept of the incentive grant for physicians commencing practice in a medically underserviced area.

It can take the form either of a guaranteed annual net professional income or an income tax free inc ent ive gr ant that's payable over a fou r-year period. These components of that Inc ent ive Program emanate from studies and considerations undertaken by the Standing Committe e on Medical Manpower over the past several months.

In those studies the Standing Committee on Medical Manpower identified the primary barriers, as it saw them to the establishment of pra ctic e in various ru ral and underserviced areas, and they included the condition of isolation from one's professional colleagues, lack of adequate or acceptable housing, lack of suitable practice facilitie s, limited social and cultural amenities, the high cost of establishing a viable practice, the high cost of living expense, the difficulty of getting temporary replacement to permit attendance at professional meetings and continuing educ ation sessions or for vacat ions, lack of consultation services and the like.

As honourable members know, we did introduce a fee differential for northern practitioners which was about 6 percent two years ago, and a year ago was raised to 10 percent, which is designed specifically to help meet and overcome those barriers to northern pract ice. This new prog ram containing the four components that I have suggested, is designed to zero in on underserviced areas in general, whether they're northern or southern or wherever they may exist in the province. We would hope for some positive results from it with the introduction of this

Monday, 23 March, 1981 new program and the funding for it in this new set of Estimates for the new fiscal year. But the problem is a real one and the shortage in rural areas remains, of the 1, 600 practitioners in Manitoba today; 75 percent of them are in the City of Winnipeg; 425 of them are in rural Manitoba. That represents the highest total in rural Manitoba in 20 years, I believe.

The number has increased from a level of around 405 to 425 in the past year but the inequities in the equation are still there and we don't think that we can meet them very successfully with anything other than an Incentive Program of this kind and we may have to reinforce and expand the incentives very substantially in the early future. MR.

PARASIUK: I'm going to ask some questions about northern doctors on behalf of my colleague, the Member for Churchill, who may be able to get back in sufficient time for him to raise them himself - if he can't then I'll be raising some questions when we come to the Medical Program - but generally in this whole area, the Minister is talking about what I'd call very traditional approaches to trying to deal with a problem that, in my estimation in a large part, has arisen because of what I'd call the traditional delivery system.

I'm surprised that the Minister will not make any mention at all of alternatives that the people have looked at and thought of with respect to trying to provide medical and health care in rural and Northern Manitoba. He has not talked at all about community health centres which provide a challenge 1 think to people in the health care field, including doctors, of a different nature. This is a challenge of a different nature, the challenge to try and put a team together and a challenge to try and meet the needs of people in remote communities.

I know that the University of Manitoba was very interested in the whole Churchill Health Centre and I know that there were dedicated people in the health care field who wanted to go to Leaf Rapids and I know that this was some of the talk relating to Gla dstone or Hamiota.

I'm just wondering whether the government continues to low profile or even dismiss the alternative of community health centres as a way of trying to meet this challenge that obviously isn't being met right now in a number of communities; a challenge that the Placement Bureau is having some difficulty meeting; a challenge that the Manitoba Health Services Commission through traditional means is having some difficulty meeting; a challenge that I think will only have a slight prospect of being ameliorated through incentives.

So I would like to get a report from the Minister as to the status of all the community health centres, especially those in rural and remote communities. MR. SHERMAN: Mr. Chairman, there's been no change in the numbers or the method of operation or the methodology of the community health centre concept since we last met to review Estimates of the Department of Health. There are 10 community health centres or community clinics in the province, Mr. Chairman, tha t numb er has remained unchanged. MR. PARASIUK: What are they? MR.

SHERMAN: There are four in Winnipeg; Mount Carmel, Nor' West Co-op, Klinic and Citizens Health 2002 Action; and six in rural Manitoba; the Vita Health Centre, Lac du Bonnet, Ch urchill, Leaf Rapids , Hamiota and Gladstone. There are no new ones and none closed.

We have in motion right now a process of amalgamation between the Health Sciences Centre and Citizens Health Action which is an objective that was mutually entered into by those two facilities, the Health Sciences Centre and Citizens Health Action, and has been appr oved by the government which really will meld the Citizens Health Action operations into the Outreach activities of the Health Sciences Centre, with an emphasis on adult day care, the day hospital concept and adult day care. But that's only in the process of being formalized at the present time, Mr.

Chairman, so at this moment there are no changes in the list from last year. The budgetary increases provided the community health centres have been consistent with those provided generally through the health facility field. We haven't detected any evidence that expansion or extension of the community health centre concept would help us meet the problem that the Member for Transcona is discussing, the problem of finding and loca ting medical profess ionals in under serviced areas, but we would certai nly be prepared to entertain any ideas, proposals or concepts that might help us overcome that challenge.

We think that the new proposals that have been forthcoming from the Standing Committee on Medical Manpower will help. The designated area idea, or the designated region idea, has apparently worked very well in rural Ontario and we're certainly hopeful that it will work here. lt certainly commends itself to us as worthy of a very intensive try. MR.

PARASIUK: I was wondering if the Minister could tell us which of these health centres have doctors, which ones do, Mount Carmel Cli nic, Nor'West Klinic, Citizens Health Action Centre, Vita, Lac du Bonnet, Chur chill, Leaf Rapids, Ha miota, Gladstone; do they all have doctors? MR. SHERMAN: Yes, Mr. Chairman. MR. PARASIUK: Are the doctors resident there, or on call, or providing a service? MR. SHERMAN: The doctors are all resident in every case, Mr. Chairman. Of course, with Mount Carmel, it would be a matter of resident somewhere in Winnipeg. MR.

PARASIUK: Well, I'm surprised then that the Minister says that he doesn't think that this is an alternative worthy of consideration. We've just had a discussion of a number of communities, and even hospitals, that are having some difficulty recruiting and keeping doctors, for a number of reasons. You know, the reasons he gives are all, in a sense, lifestyle reasons. But I believe that there are some idealistic doctors who are willing to try and develop a new team approaches to delivery of health care in situations that are difficult, where traditional means may not be the answer.

I can recall some of the discussions - I was never that involved in the whole health care area as a civil servant - but I know that in some respects some of the reasons why some of these health centres got off

Monday, 23 March, 1981 the ground was to try and meet that challenge. Despite the fact that you'v e had a government that, let's face it, at least last year and the year before, was very very much against commun ity hea lth centres.

It said so I think, when the present government was in the opposition, they were very much against the whole notion of Community Health Centres; yet, despite an attitude on the government of, at a minimum, benign neglect - some other people might call it harassment - these health centres have existed and have doctors resident in every case, and would strike me as being a valid alternative for consideraion and development and nurturing, so that we aren't locked into one system.

When the Minister occasionally has said that we have been bound by ideology, I think that this is a very clear example of the government being blin kered by ideology, no t looking at empirical evidence, which I think is interesting and supportive and provides some indication of ways in which some of these challenges can be met. -(Int erjec tion)- I'm being advised by my colleague, the former Minister of Health, that there are volunteer doctors, doing volunteer work, who are interested in this concept.

We're not saying that community health centres are the alternative; we've been saying that they are an alternative that should be looked at so that we can develop a complementary system of the delivery of health care in Manitoba, so that we have better acces sibility to health care by all residents, be they urban, urban people sometimes are remote in an urban setting and that's why I think Mount Carmel Clinic has been providing a very useful function in the past, that there are people who live in Winnipeg who are socially remote in other respects, and I think maybe that's why Klinic provided a function in the past, and still does.

Then we talk about geographical remoteness, Hamiota, Chur chi ll, Leaf Rapids, some of these communit ies in present day parlance, given some of the problems you have indicated before which were identified by the Health Manpower Committee, some of the problems of lifestyle, lack of colleagues, lack of amenities, some of these other communities would fit into that description as well. Yet there's been something that has kept the doctors operating there, and I would assume that there are other people that are part of those health care teams. I think that's the challenge of the idea. Can it work?

Is there some utility? Can there be something to be learned by society by these approaches? That's why I would have hoped that the government would be seizing the opportunity to learn from the posit ive experienc es of Mo unt Carmel, No r'W est Klinic, Citizens Health Action, Vita, Hamiota, Gladstone, Lac du Bonnet; I would think that there's opportunity for some positive experiences to be gained from, and an expansion of this program developed. Here we are, we're talking about an incentive program, in a sense trying to appeal to doctors' financial considerations.

I would think that maybe has some utility, but at the same time, although at times I've been critical of doctors when they want to go for a 39 percent yearly increase in salaries, especially given the big base that they start out from, although I'v e been criti cal of tha t aspect of a doctors' professi on, I know that there are many committe d physician s, who believe that they are 2003 serving a very useful purpose in society, who I think, if given an interesting challenge like a community health centre, would be quite willing to sacrifice a lot of amenities, would be quite willing pos sibly to sacrifice a lot in the way of income to serve humanity better.

I just don't think this government is providing that option for those types of doctors or indeed, those types of health care workers. MR. CHAIRMAN: Line 3 - pass - the Member for Transcona. MR. PARASIUK: Well, I have one other question now that I've raised the whole matter of the 39 percent increase, or 49 - people are talking about a 49 percent increase - but I will raise one other point on the ho spital side.

Is it true that the government or in a sense the Manitoba Hospitals Organi zation has said that they would not reopen any negotiations with health care workers who are at the bottom end of the income scale in the provision of health care, even though there is some thing in the agreement that says that these can be reopened if both sides agree?

But at the same time it has said that it would reopen negotiati ons with do ctor s because of the impact of the cost of living on doctors and I just want to get it clear from the Minister while we are on the hospital prog ram because I would believe that health care workers would be covered under the hospital program. MR. CHAIRMAN: The Honourable Minister. MR. SHERMAN: As far as I know, Mr.

Chairman, the Manitoba Health Organization has said that they will not reopen the two-year contract that was signed last June and was retroactive, I believe to May 1s t, with the support and service workers who are represented by CUPE and approxima tely half the health facilities in the province. There was not, of course, in that contract the same kind of reopener trigger that was contained in the cont ract having to do with the fee

schedule for the doctors. Further to that the two-year contract for the service workers provided an end rate increase of approximately 27.5 percent plus reclassification and the end rate on the fee

schedule contract was 22.3 percent, over a two­ year period, 22.3 percent. (l nterject ion)- Well, Mr. Chairman, the Member for St. Bon iface asks of what, and that is a very good question. I'm glad he raised it because I despair myself at times over the proclivity of all of us and particularly the media to use percentages as indicative of incr eases and of prev ailing conditions in the wage sector, generally.

The question is well taken; 25 percent of a dollar is only 25 cents but 25 percent of a $1 00,000 is a lot of money, so the question is one that I subscribe to and I perhaps have fallen into the same trap of using percentages in this instance. The 22.3 percent end rate for the doctors was based on an average gr oss earning of medical practitioners in Manitoba, among those billing the commission for more than $20,000 a year at that time of about $66,000 - $67,000, it's higher than that now, but I'm talking about at the time the agreement on the fee

schedule was reached, it might have been $68,000 - $69,000, today it's closer to $77,000 or $78,000. But that was what that fee

schedule was based on,

whereas in the case of the support and

Monday, 23 March, 1981 service workers there is no question that their increase was based on a much smaller base. I have to say that we do not live in, nor do es this government subs cribe to any philosophy tha t sugg ests comp lete egalitarian ism across the economy and across society.

Some persons by virtue of the time effort and expenditure that they have put in to achieving their qual ifications and by virtue of the competition for their services, are going to in any free competitive society, command and legiti mately deserve higher incomes than others who have not put in the time and the effort in achieving qual ifications of a similar nature. Now, that doesn't say that say the support and service worker s stiould not be prop erly compensated for the job they do and I said at the time that we would ensure they would be recognized for the job they do.

I think that the two-year agreement that was achieved last June did go a considerable distance in recognizing the needs and the rights of thos e service workers. I'm not suggesting there isn't a notch or two on the scale to which they should not be raised yet, but at the present time they are in the midst of a two-year contract that did attempt to address their legitimate wage requirements and MHO has indicated they are not prepared to reopen at this time, as far as I know. That's the last word that I've read from MHO. I haven't been in touch with MHO about it MR. CHAIRMAN: Is the Member from Transcona finished?

The Member from St. Boniface. MR. DESJARDINS: Mr. Chairman, there is no doubt that we also subscribe to that theory that you don't pay everybody the same, there is no doubt about that. But when I said of what, I wanted to make sure that it wasn't the same comparison. This is easy, MHO does the negotiating to a point but always they have to find out how much government is ready to pay, there's no premiums, the only money comes from the government, so we all know that.

We shouldn't hide behind that There is nothing that would prevent the Minister or the government of the day to say to the MHO, fine, if they have no money they can't do anything about it But to say well, if we're going to reopen, as the Minister said, we try to be fair with these people and we try to be fair with the doctors because I'm sure the Minister tried to be fair with the doctors, but because ther e is an inflation factor and we'r e reopening, we'll look at this thing too.

There is nothing that would stop them because if the doctors are underpaid, if they are suffering because of .5 percent increase in inflation or whatever, after getting what they receive, I'm sure that we can say the same thing about the other people. What did the Minister say the total percentage over two years for the medical pr ofession was increased? Does that take into consideration everything? Does that take into consideration the increase in northern allowance and also the money for adjustment in psychiatrists and so on because tha t -(Int erjec tion)- and the $1 million was showing up in the two years.

But it is estimated this was a result in the first year, an increase as much as 12 to 12 .3 percent in the cash flow to the doctors, so that's another factor. Now, the only point that I make - I'm glad the Minister mentioned that - at no time do I feel that somebody cleaning the floor should get the same thing as the doctor. I'm saying that they still have their family to take care of and those people don't have any other investment anywhere else and I think that we have to be fair. Any society has to be fair.

You have to recognize the people that have achieved, through work and all that, they've spent long years, but there are a lot of other factors. I'm not suggesting for a minute that the doctors are overpaid. I might, if they get a 49-percent increase over what they have now because of half of 1 percent I don't think that would be in a period of restraint, in a period that we don't look at the other people, I think it would be most unfair. Mr.

Chairman, another factor, the Minister said that if we have to look at everything and the Minister said, well, you know, they've spent time and a lot have studied and so on and that has to be taken into consideration. If you do that, let's look at everything. Their education was paid mostly by the state, by the same people who are in fact not getting an increase in some instances, who paid their share through their share of tax, taking care of the university and that costs, the Minister knows and I know that costs quite a bit of money to the state.

I don't begrudge that, in fact, I think that maybe we should hire them before they go to university with some kind of an arrangement and some kind of an agreement that they would work maybe a couple of years in the rural area, maybe certain places like other people might have to do. That might be the only solution to get the people. I want to make clear that I'm not sugge sting, not even tongue-i n-cheek, that everybody should be paid the same. Mr. Chairman, I have two other questions.

There seemed to be, in certain areas anyway, a shortage of doctors and I'm sure that the Minister could easily tell us that there is probably a surplus in the City of Winnipeg, not of every specially, but some of the doctors, there's no doubt about that. That also is an important thing when you're talking about the fees. Let's remember, I don't know of anybody else in society that generates their own revenue, I don't know of anybody else.

That's a factor; that's not a remark to mean that these people are not honest but, in the old days when there was no Medicare, a doctor would say, come and see me in six months or something. The people didn't bother going if they didn't feel good, now the doctor can say, come and see me next month; if he's not too busy, he can say, come and see me next week. Technically he can say, come and see me tomorrow and I know of instances that was done.

Again, I want to be careful that I'm not saying that this is the practice of the medical profession but that is the case, this is one of the things, you put a lot of trust, you let them police themselves and so on, so those are all factors that are important Mr. Chairman, as I say in certain areas there is a shortage of doctors, and in the last days that I was there, there was discussion and we had people working on that, the Federal Government, because Ontario was quite concerned.

They were getting doctors coming in from Pakistan to England and then because of their program they would move to Ontario and so on and then other provinces. The Immigration was fairly tough but I think the idea was that if the province would say, well, we want this 2004

Monday, 23 March, 1981 person, we need them, the points would be given and there wouldn't be any difficulty. Is that the case or do you have to wrestle and fight with the Federal Government if you want to bring a doctor in here? MR. SHERMAN: Mr . Ch airman, we can bring doctors in from other countries through Immigration if we want them and demonstrate that we need them and demonstrate their designated areas where they are required. (Interjection)- No, no. MR. DESJARDINS: There's another thing that might be a problem.

I don't know where it's at now but I know in the days when I was supposed to wish and encourage a confrontation with the doctors, it wasn't a question of money because there was a ceiling. The qu estion was very simple, there was one thing, that the MMA wanted in their contract, in their agreement, a clause that said there wouldn't be any hiring out. In other words, nobody could hire a doctor if the MM A did not agree.

Now, are they coming back for this or have they abandoned that even with the change of government and does the government intend to maybe put that in a future cont ract where if ther e would be a strike or somebody with . . . service that they could not hire a doctor without the consent of the MM A; in other words, the MMA would have a veto for any doctor that's hired by the province? MR. SHERMAN: No, Mr. Chairman, that's not a part of the written agreement and I might say that it has not come up at any time in my ministry, to my knowledge, it has not come up to me. MR.

DESJARDINS: What a difference a day or a year makes. I guess that was supposed the extent of the confrontation and I'm glad that this is the case and I'm not going to waste time on that if it's not an issue, but I can't see where a government would say, here, to people engaged in a free-enterprising . . . Then we'd say, well, you can't hire anybody else; it wouldn't make sense and it would be just like that thing that Green doesn't like about not being able to hire people, but anyway if it's not a factor, it's not a factor. That's about all I had at this point. MR. CHAIRMAN: Line 3 - the Member for Transcona. MR.

PARASIUK: I just wanted to pass my comment on the Minister's statements regard ing reopening negotiations with doctors while not reopening them with health supp ort and service workers.

The reopening trigger that the government negotiated with the doctors is tied to inflation; it's tied to the cost of living; it has nothing to do with other aspects. lt basically says if the cost of living goes up by more than 10 percent it hurts the doctors and should be taken into account and, therefore, I would assume the basis for reopening negotiations is to deal with the difficulties caused doctors because of increases in the cost of living.

Now surely the increases in the cost of living impact on people at the lower end of the income scale, at least as much and I would argue far greater, than they do upon people at the higher end of the income scale. So when the Minister says, well, you know, there are going to differences in what people make, I can agree with that, yes, there's 2005 going to be th ose differences. Percentage settlements tend to increase the differences rather than even keep the differences constant but this is situation where I think the morale of workers in the health care field will be hurt desperately.

Inflation will hurt someone; the increases in the cost of living hurt someone making $7,000 or $8,000 far more than they hurt someone making $70,000.00. We've been told that the major increases in the cost of living come from increases in food prices.

So that when the Minister says, well, the government will reopen negotiations with doctors because someone grossing $70,000 is hurt by increased food prices, I don't think it stands up that well compared to people at the lower end of the scale, many of whom are single parents who have to deal with the problem of increased food prices, a problem caused by increases in the cost of living. My colleague, the Member for St.

Boniface is so right; 10 percent of $70,000 is $7,000 which means that the next base is $77,000.00. 10 percent of $77,000 is $7,700.00. 10 percent of $7,000 is only $700, so the base for the next settlement is $7,700 .00. The increase, it's almost an exponential increase and I think that there has to be some way in which people say that increases in the cost of living will in fact be dealt with a different way. If the 10.5 or 10.7 percent increase in the cost of living is impacted on doctors, then I think it's impacted on everyone else in the health care field. I think we are setting a wrong prece dent.

We either say that a contract is a contract for two years, or if we're going to have something like a cost of living adjustment that has been called COLA by other people; if we're going to have a CO LA-type of item, then it should be in there for all health care workers if we're going to have any fairness and consistency and if we're going to have a high morale. I think that's very important in the del ivery of health care.

Right now we've got a difference, the double standard, the doctors are being treated differently from other health care workers with respect to the way in which the cost of living impacts upon them and I just don't think that's fair. MR. DESJARDINS: Mr.

Chairman, in all fairness - and I want clarification here - it might be used by the press and maybe even by the Minister, not purp osely of course, but I'd like the Minister to correct me if I'm wrong, but it's not a qu estion of reop ening the contr act. lt is tha t part of the agreement was that if there was inflation over 10 percent before last December, that the increase would be reviewed, not that the whole contract would reopen, reviewed with not necessarily a change taking pla ce. lt's just that the government had agreed to review it, but then if the government said, no, that's it, the contract is valid, it's just an honest review.

Am I right? Because that's not the same as renegotiating a contract. MR. SHERMAN: The Member for St. Boniface is correct, Mr. Chairman. The agreement was that if those conditions prevailed, the general cost increase of the second year was subject to renegotiation. MR. DESJARDINS: Renegotiation or review? MR. SHERMAN: Was subject to renegotiation, but that doesn't say that it would be negotiated upward, necessarily, but subject to renegotiation.

Monday, 23 March, 1981 MR. DESJARDINS: Well, I want to make that clear, because if there's no meeting of the minds, there's no agreement;

whereas in a review, if there's no change, you stay with what you have. I was under the impression it was a review, not renegotiation. MR. SHERMAN: Mr. Chairman, I interpret the

section the same way the Honourable Member for St. Bon iface does, but the precise wording of it is that in the event that - and here I'm not quoting direct ly - that the conditions to which the Honourable Member for St. Boniface referred took place, then - and here I am quoting directly - "The general cost increase of 8.9 percent commencing April 1s t, 19 81, is subjec t to renegotiation". I would like to just respond very briefly to the point raised by the Honourable Member for Transcona in this connection, Mr . Chairman.

The Member for Transcona makes the point that increases in the cost of living and increases in the cost of food impact just as heavily, if not more heavily, on the person making $1 0,000 a year as they do on the person making $70,000 a year and I don't dispute that for a moment, nor does the government. We are not re-examining and renegotiating that level of increase in the second year of the contract because food prices have gone up.

As a matter of fact, I don't think it matters much now what I place on the record in this connection because I'm sure the Manitoba Medical Association is fully aware of all the backg round lea ding up to the current negotiations anyway. As a matter of fact, the government gave very serious considerat ion, and I personally gave very ser ious consid era tion, to not reop ening at all , because the conditions laid down in the trigger clause were legitimately deba table. We are not reopening because of the cost of food.

We are reopening and re-examining because of the technical cost increases, the overhead and professional cost increases that doctors have encountered in the past 12 months. Just one example is the cost of x-ray film, which has escalated beyond anyone's expectations because of the unexpected and unpredictable increase in the cost of silver.

There have been instances of that kind in various areas of the practice of medicine, and because of those enormous increases in technical and operating costs, I believe and the government believes that morally we should have a look at that general cost increase which was pegged at 8.9 percent with an additional 1 percentage point for shoring up in certain specialties so it came to 9.9 percent, and see whether some reasonable upward adjustment is not called for and justified in this case.

The increase to which the Honourable Member for Transcona referred, which was the subje ct of some initial publicity and was apparently the first position emanating from some spokesmen for the MM A, is not within the realm of increases being contemplated by the government. We struck an agreement a year ago that attempted to take into account the kinds of things that were happening in the economy, but could not foresee what was happening on the technical side of the practice of medicine.

I might say that we can demons trate, I think unarguably, that 40 percent of the gross incomes of practitioners in Manitoba is devoted to the payment of overhead costs, so that when you're looking at the average gross income of pract itioners it is not what it appears to be on the surface.

When you've taken off approximately 40 percent for overhead costs, you find you rself, I think most reasonable people find themselv es as king, whether the three years of science, the four years of general medicine, the one year of internship or residency and the years of specialty training, ranging anywhere from four to seven years depending on the specially, were worth it. MR. DESJARDINS: Mr. Chairman, then if that is the case, maybe the Minister gave as an example the cost of certain supplies such as x-rays. Well, it's not every doctor that is responsible for the x-rays.

There might be some in clinics, or many of these x-ray labs or whatever you call them, the doctors send you there. But if there is anything, or the thought might be fair and then you treat people a little more the same way if you looked at the percentage of fees that has been accepted as overhead, and maybe look at that, instead of increasing the whole thing. To look at that point and then, all right, if it costs them more and they're not losing, but that'll pay for their costs, not necessarily increasing their take-home pay, if you may call it that. MR. CHAIRMAN: Line 3 - pass. Line 4 - pass. MR.

DESJARDINS: What's line 4? MR. CHAIRMAN: Medical Program. MR. DESJARDINS: I thought that's what we were at. MR. CHAIRMAN: No, we were Hospital Programs. MR. DESJARDINS: Why didn't you tell us we've been talking about doctors for the last hour. MR. CHAIRMAN: The Member for St. Bon iface. MR. DESJARDINS: Then I'll have another crack at it in the Minister's Salary. Mr. Chairman, could the Minister inform the committee, if there is any change, if the physiotherapists have approached the Minister, 1 think they wanted

an Act and then they were talking about maybe trying to have some coverage via Medicare. Is that contemplated at this time at all, or is that not? -(In terjection)- MR. SHERMAN: Mr. Chairman, that question was asked of me in the House this afternoon and I named four of the Acts that were coming, the professional legislation coming in the health field - The Medic al Act, The Pharmaceutical Act, The Respiratory Technologist and the Lab Techs. The other two are The Dieticians and the Physiotherapists. MR. DESJARDINS: Oh, the physiotherapists. Will there be any coverage under the Medicare? MR.

SHERMAN: Not additional to what is provided, outpatient services, Mr. Chairman. MR. DESJARDINS: Excuse me, that's through the hospitalization, not Medicare. That is a service given 2006

Monday, 23 March, 1981 by the ho spital and they're on salary. They requested, I think the physiotherapists, that they be covered something like chiropractors or something like that. MR. SHERMAN: Mr. Chairman, have we passed the hospitals line? That has been passed. We are now dealing with Medicare. MR. DESJARDINS: No, but my question is, is there any intent of getting them covered under Medicare so I am in order? MR. SHERMAN: Not this year, Mr. Chairman. MR. DESJARDINS: Is there an intent later on or is that still not decided? MR.

SHERMAN: It's certai nly a ho pe and an object ive for the future but, as the honourable member knows, there are a number of applications for insured programs under Medicare and we have to proceed with them as we can justify them and afford them in the Budget. So, you know, I can only say that there is no position of opposition or rejection but they can not be accommodated this year. MR. DESJARDINS: Will there be any debate before this is done in the House, of the way it's going to be done?

I have no objection of the service being provided but you know we're talking about the high cost of health care and if we put everybody, we used to have paramedical and the Minister, I think, just gave us an explanation of what he thinks of the medical profession and I agree with him and I think that we can't just bring all these people that are doing a good job in certain areas and put them on the same system as the medical profession, on fee­ for-service and that's exactly what happened to the chir opractors.

No w, I might no t make too many friends at this time but I think that maybe one of the things that could be considered, because I think it's in ... of, two different professions doing the same same. Some people believe in chiropr actors and I have no objection, I do too, especially when there is pressure and I can't see anybody else, they're the only one that could help. But the physiotherapists I think are there to answer the same need except they work under the medical profession in a different way.

What I like about them, especially in the hospital, is that they have more time to go along and explain to you what it is and I think that's a big factor. It's an education that you can then take care of yourself and a possibility, without taking anything away from the chir opractors, would say, okay, a family - I'm not saying this is an ideal way but a possibility, something that could be studied - you might say, we' ll increase the maximum coverage for chir opractors but then we'll make it a choice of the patient. Either he gets his physiotherapy services or a chir opractor's.

I don't think that normally the same person would go to both. I don't think you need both services. I'm all for letting the people make their own choice and I hope the Minister can understand what I'm sayi ng. But I can 't see people going to a chiropractor and a physiotherapist, not normally. If they could combine, let's say that even if you doub led the maximum, because I can 't see why you'd put a maximum anyway on some and not on 2007 others if they're going to be covered with Medicare.

I think that if the service is there it's while the people need them but the possibility of the suggestion, and I'm only asking the Minister and his department to study it at this time, to say all right for physiotherapist and chir opractic services, this is what you have. In other words you lump it for the insurance part. I don't know if that's feasible. MR. SHERMAN: Well, Mr. Chairman, we would certainly want to examine that kind of method, that kind of approach, very carefully before introducing such a program. I appreciate the comments from the Member for St. Bon iface.

I can tell him that on our projections a fully insured physiotherapy program would cost $2 million. Could I just say that there are other services, there are other practices, other health occupations, and I know that the Member for St. Bon iface is familiar with them, who pr ess for inclusion under the Medicare Program every year. We have added a program or two each year as the previous government did but I would want to just place on the record this one word of caution. The system that we have in Man itoba and in Canada is cert ainly admirable and is cert ainly enviable.

Envied by many other countries around the world and we want to maintain it and I think everybody around this table would concede that it is under siege and has to be protected very carefully because of costs, because of demands and because of limited revenues.

If there is any one individual threat that I would identi fy as posing perhaps the greatest potential danger to the Medicare System, as we know it, it is not the threat that is so often voiced by critics in the ongoing Medicare debate, it is the demand of service after service, health occupation after health occupation, to be included under the insured program.

Ideally one would aspire to a system of medical services that insured and covered everyt hing, but that is an abstraction that simply can't be met in pragmatic or realistic terms until an economy and a society can support such a concept and until the necessary adherence to responsi bility and requirement and accountability is met by all. by all of us in govern ment, by all of us who are consumers and by all who are practitioners. At the present time we can do so much and we want to reinforce and maintain what we've got and we can add gradually.

But I have no hesitation in saying that a major threat of the viability of the system would arise if we were to accede all these requests for inclusion of new services under the insured program. I think physiotherapy is a desirable one. There are others that are equally desirable I think and hopefully we can move to them one by one. But I put that one word of caution on the record, that desirability and practicability and affo rdability are different things.

We can't this year in the Budget and in the new program spectrum that we have announced, include insured physiotherapy services outside of the hospital out-patient environment. MR. DES JARDINS: Mr. Chairman, as far as the warning of the Minister that we have to be careful that we don't price ou rself right out of the medical program, he won't have any argument on that at all. I don't quite agree with him when he says that the main thr eat is that you bring more and mo re

Monday, 23 March, 1981 services. lt depends what services you bring, but I think it is mostly the way we bring these services. In fact covering more services might save money. Again, I'd like to make a pitch to say that it is with the high cost of providing this care I think we've got to go to para-med ical. I think we've got to go to people that have expertise in a certain field.

But the mistake that we make and that is why I agree, I'm not suggesting that we cover everybody and give him the moon, I would like to see a debate on this before because if I had a vote I would vote against the system proposed by the physiotherapists, I want them, I want that service. But I don't want people that are making now $20;000 or so, maybe a bit underpaid, maybe a lot underpaid, but I don't want the minute that you cover them that they become professional in the same way as doctors and that's what happened to the chiropractors and that's going to happen to the others.

That is what's going to kill the plan. -(Int erje ction)- The fee for service espe cially. Then it's a tem pta tion agai n, you'r e generating revenue, That's another thing and you don't take the time. If you do that you're going to miss the boat, it's going to cost you a fortuune and you're going to cut down on the standard and the services because a physiotherapist needs time.

If he's on a fee for service and if you're giving the fee somewhere like you do to these other professionals, that's what it's going to cost you, the amount $7 million or whatever you mentioned but I don't think there's any need to cost that at all. My main objective in the field of health is not to create new professions or new people and say here, that's not a make-work outfit - god knows that it costs enough money - it is the welfare of the patient. Of course they're going to ask for that but I don't think they really expect it. I think that it would be a big improvement.

If there's not enough of them in the hospital that you set up certain clinics but not private clinics, clinics of the government and pay them a salary, give them a fair salary, they should have a fair salary. What they are getting paid now is probably too low but there's a difference between $20,000 and $10 0,000.00, and that is when we lose track. When we talk, sure we give lip service to para­ medical and nurse pract itioners and so on, if we're going to pay the same as the top group, and as the Minister said they don't warrant the same kind of pay, but I don't think you need that to give the service at all.

The service might save money. If you've got instead of having to wait now, what is the choice? What are the choices? If you've got let's say a sore back, you have a choice, you go to a doctor, an orthopaedic surgeon or you go to a chiropractor, that's all you have first. Then if you go the doctors route it'll take you a while; he's going to send you to a physiotherapist and I think you've got to look at the act and you've got to release them and give them a little more consideration, always under a doctor.

You've got a sore back, you have to go and see a doctor, you have an x-ray, he sends you to a physiotherapist and in another two months you have a sore back. You shouldn't start that all over again. There's got to be leeway and if these people are well trained and they usually are, they're real good, they will work with the doctor. They might give him a phone call - what do you think - and providing it's the same thing, they could tell if a 2008 fellow's got a broken back especially if he's had an x-ray and has seen the doctor. I'm with the Minister 100 percent.

We've got a damn good plan and let's not ruin it. lt is the envy of all the world, there's no doubt about it in my mind. I wouldn't want to do anything that would jeopard ize that. Besides the people of Canada and Manitoba can't pay to have everything, that's impossible. But in this area in the long run, it would save you money because you would have certain things.

That's what we brought in the Dental Program for and it's a proven fact - and I'm not going to start that again - but it's a proven fact that for certain things these people can do better work or at least as good as somebody that has more education, that is qualified, that is an expert in more things because that's their specially. I think you can say that.

For instance, I would like to see inoculation and these things, I would like that to move in public health care and I still have my dream of having many of these things, test ing the eyes, the ears and every thing of students and keeping rec ords of inoculations and immunizations and so on in schools. I don't know if the Minister has been in the hospital but when they come with this needle I'd much sooner see at the other end of the needle a nurse than a doctor who'll jab you, who doesn't seem to be as careful in many instances as a nurse and a nurse does it all day. MR.

SHERMAN: Especially if you're the Minister of Health. MR. DESJARDINS: Especially if you're an NDP Minister of Health - then you're taking your life in your own hands. I hope that the Minister understands what I'm saying. I'm with him and I will always support him when he wants to make sure that we don't price ourself out. But I would think keep the services the way are; don't create another bunch of professionals who'll be interested in fee for service and see more and more and more patients.

A physiotherapist can't do the work in eight minutes or five minutes like a doctor or a chiropractor will do, especially if you want some kind of education. My first step if I was the Minister or if I had any advice to give to the government, I would say okay bring in physiotherapists; get together with the do ctors an dsee if th ey can relax a bit the relationship. Some do, but you don't have to go every two minutes to go and see a physiotherapist; they can take the phone and say, here this guy's back after a month and it works.

Some doctors will go ahead and then given them good salaries - people should be paid fairly - but don't put them in the $1 00,000 bracket or anything like that, like you've done to chiropractors, it's too late with the chiropractors now. There was no need for that. There's no use having para-medical people if they're all paid the same thing, isn't that right? We might as well wait until they have all their education and pay them the same thing. Those people would be paid. You have a clinic, and you say if there's not enough in the hospitals, they'll always work for the doctor.

They won't take you if you're a new patient; they'll say go and have an x-ray; they'll do that but they'll save the doctor's time and you'll save many many hours of loss of work in that area. So I'm not that far away from the Minister. I'm not suggesting

Monday, 23 March, 1981 we try all new things. In fact I'm going a little further I'm saying don't think, as you mentioned a while ago, that if you cover that it'll cost you $7 or $8 million, there's no need for that. MR. CHAIRMAN: Line 4 - Medical Program - the Member for Inkster. MR. SIDNEY GREEN: Yes, Mr. Chairman. Did somebody have the floor? -(Int erject ion)- Maybe I can move back to that item. MR. CHAIRMAN: We're going on to the Minister's Salary next for the member but we are on Medical Program. MR. GREEN: That's what I wanted to discuss, Mr. Chairman.

I wanted to ask the Minister whether he has any policy at the present time with regard to extension of the right of a person to seek advice from persons who are not medical practitioners, such as chir opractors. I know that the chiro practors are entitled to benefits or people - it really should be stated prop erly - that people who go to chiropractors are entitled to benefits the same as citizens who choose a doctor for the same work. Now are there any other areas that the Minister is considering in this respect? MR. SHERMAN: Outside of the additional insured programs that we've announced, Mr.

Chairman, that fall into specific categories with which I think the Hon ourable Member for Ink ster is familiar, the Orthopaedic Shoes Program for one, the answer would be no. MR. GREEN: Mr.

Chairman, I wonder whether this is entir ely fair and I wonder whether the Medicare Program - and probably all of us are at fault with that because we immediately consider that it's a Medicare Program, it must relate to doctors - but there are people who disseminate health services who are not medical practitioners, but who we recognize as disseminating health services or delivery health services, that they are qualifed and accepted as delivering the same type of health services as a medical doctor does, but we tell the citizen that if he choos es that person he has to pay for it himself,

whereas if he choos es a medical doctor the public pays. Now my friend, the Member for St. Bon iface said we're not discussing the private school question but we're discussing, Mr. Chairman, a situation which is probably more compelling than the private school question. -(I nterject ion)- We permit a person to choose a school and pay for part of it. My friend, the Member for St. Bon iface would say we haven't gone far enough.

But why is it that a heal th service tha t we recogniz e, th at is acce ptable, that requires the training and that is the delivery of the same service, why do we insist that we chase a patient who would prefer to go to one person who delivers the service rather than a medical doctor, we chase him to the doctor and then we have a tremendous problem - and I'm not trying to dodge this problem but I don't wish to make it mo re acute than it is - in negotiating the fees with one particular profes sion?

Now I'll go to one that I'm sure the Minister has heard from and I have heard from them and I will put 2009 that on the record that I have heard from them, but the case that they made seemed to me to be reasonable and therefore I bring it up.

The fact that I was called upon and spoken to - I was called upon by the ps ychologists - the psychologists say that they are entitled to practice the psychology; that psychology involves the delivery of health services up to a certain point; that the psych iatrist will deliver those services, be paid publicly and if I wanted to go to a psychologist instead of a psychiatrist or the Minister, we would be pushed away by the public from going to that person because if we went to the psychiatrist they would pay, if we went to the psychologist they wouldn't pay. I think that there must be other areas, Mr. Chairman.

A chiropodist is entitled to do certain things to your feet. We have

an Act. We have a limitation on the practice. They are prohibited from doing certain things but they are trained; they have to go to a school; they are delivering a service that we recognize and accept in the Province of Manitoba and we have people who prefer them. Mr. Chairman, they must prefer them because they go to them and pay their own way rather than going to a doctor and having it paid for them. So obviously some people are very much wanting to do that. I will mention, Mr.

Chairman, and I will also disclose that I represent them in a particular case, but the Minister, in answering these questions, is going to have to answer for other professions that we recognize, that require schooling, that obviously have a clientele and we say to the person, if you go to a medical doctor we' ll pay; if you go to a naturopath we won't pay. I'm not talking about a naturopath doing somet hing that only a doctor is permitted to do. We know that a naturopath cannot practice surgery and I don't think he can prescribe drugs but he can do other things that doctors do.

I suppose he can give a diet - I'm looking at Dr. Johnson hoping that he will nod or shake his head but he won't do either. They are licensed to practice; they have

an Act. The chiropodists are licensed to practise; they go to school; they have

an Act. They will remove a wart, I think they are entitled to do that. (Int erjec tion)- Wel l, Mr . Chairman, the Member for Pembina makes light of them. MR. CHAIRMAN: One member at a time. MR. GREEN: The fact is, Mr. Chairman, that I don't know what the best way is. I happen to be of the cons ervative philosophy that says that the medical people are the best people; I happen to be sort of engrai ned in that system but I don't know that.

I'm sure that if I had to have some thing like that done I'd probably go to a medical doctor but there are people who don't agree with me and they will go, spend their own money and go to a chiropodist, go to a chir opractor before we paid them. I remember the Member for St. Bonif ace was one of the strongest people on this issue. We did it for the denturists, too. We made the denturists legal because we knew that many people wanted to get their dentures made from a denturist rather than a dentist.

Now surely the Minister, especially becaus e of the negotiations that he is involved in, does not want to tie the public or himself to relying solely on this profession. I can't answer the psychologists because I didn't think of it at the time when we were discussing

Monday, 23 March, 1981 Medicare. Here's a man, he is fully trained, he cannot prescribe a drug but he can, as I understand it, engage in psychoanalysis because that is not the prescription of any drug. He cannot do certain things that a psychiatrist can do but he can do some of the things that a psychiatrist can do.

If you go to a psychiatrist for that treatment the public will pay; if you go to the psychologist for the same treatment the public will not pay. lt seems to me that we are driving people into the hands of one profession when we recognize and accept the fact that there are other professionals who can do the work. Now, why would the Minister not be looking at that, par ticularly at a time when the medical profession, for reasons which certainly they would justify to themselves and maybe could be justified to many others, are the toughest people to negotiate with?

Does the Minister think that Manitobans should have a greater freedom of choice? Because I suppose even I am not so free-thinking as to permit them to go to witch doctor and pay for that.

Whereas the person might think that's the best doctor for him, I am not suggesting that there be tha t complete licence, but profess ions tha t we recognize, professions where we know that there is a school where a person has to become qualified, that they have to go through a course. Why do we not permit the citizen the freedom of choice to go to that person and pay the same amount that we are now paying to the doctor for the delivery nf that service? I'm asking a question, Mr. Chairman. MR. SHERMAN: Mr. Chairman, the basic answer would be because the system can't afford it at the present time. There is also the qu estion of qua lifications, of dia gnostic capa bilities, and of

definitions of treat ment and diagnosis and professionalism, but the basic reason is because the system can't afford it at the present time. I agree with what the honourable member says about the clinical psychologists. They are indeed a group, a professional group, which has asked and, in fact, been asking for some time for inclusion under Medicare as an insured program. A few moments ago the Member for St. Boniface raised the case of the physiotherapists which is another such group.

We have, of course, had app roaches from the chiropodis ts and from the pedia tr ists and the Member for lnkster has referred to them. We've had appr oaches from the nutriti onists; we've had approaches from a wide range of health occupations for inclusion under the insured service spectrum. We cannot afford to include all those services under Med icare at the present time and we have proceeded as best and as responsibly as we can to add an insured program or two each year.

There are a su bstantial numb er of health professions and occupations included under Medi care now if one considers, not only the conventional specialties and disciplines of medicine but the prosthet ic and orthopedic specialists, the optometrists and the chiropractors. In the case of psychologists, clinical psychological services are covered in a hospital setting. They are an insured service inside hospitals. (lnterjection)­ Yes, what the clinical psychologists have asked for is insured coverage in their offices, that's correct.

The difference, and I think the Member for lnkster has al ready alluded to it, primarily is the training, specialty qual ifications of a psychiatrist as against a psyc hologist. Certainly a psychologist can provide therapy and does and certainly they provide a valuable service in the mental health field in our society but they cannot presc ribe dr ugs or medication where the psychiatrist, of course, can. The differentiation, at least in professional terms, has some beari ng on the app roach I think that government has to take with respect to qualifying specialties and services under the insured service spectrum.

I have not, by any means, closed the door on clinical psychology or on physiotherapy as potential future insured services under Medicare, not by any means. But, as we discussed a few moments ago, Mr. Chairman, in my opinion of all the threats that exist to Medicare, to this enviable system that we have, the biggest threat is, I might say relentless, although certainly gentlemanly pressure, from group after group, occupation after occupation for entry into the sy stem.

If one looks at the progra m spectrum and one looks at the budge t for the Manitoba Health Services Commission, some $654 million this year, and the total Health Budget as a percentage of the total provincial Budget, I think that one would fairly and reasonably have to conclude that Man itobans, through their tax dollars, through their commitment to pay for services for their fellow citizens and themselves, are paying a substantial portion of that outlay, or directing a substantial commitment and portion of that outlay to health care services, not the least of them being insured health services under Medicare.

We have to make sure that we can afford what we are going to be able to do. We have added some $2 million worth of insured programs this year. If I were to add clinical psychologists we project the initial year's full year cost of adding clinical psychology services under Medicare, at this point, at being $1.5 million; that's the projection for the first year.

No doubt, that would grow but we have tried to divide up the money that is available for new progra mming to meet a number of other needs; a number of other health needs including high-risk maternity, including intensive care nurse tr aining, including incentive programs for physicians, including the orthopedic shoes program that I referred to, including the Manitoba Health Research Council and additional funding for medical researc h. So it's a matter of making do with the dollars available and priorizing, Mr. Chairman.

I don't dispute the position that the Member for lnkster takes vis-a-vis the desirability in the long run when it's possible to add additional services like this to the spectrum but I would have to say that if we were to act hastily on these requests that come before us that we would jeopardize the Medicare system that we have in place. MR. GREEN: Mr. Chairman, I'm more sure of my grounds now than I was before the Minister answered. The Minister says that the biggest threat we have to the Medicare system, to the high-quality Medicare system in the Province of Manitoba, is the adding of such services. MR.

SHERMAN: In Canada, I would say. MR. GREEN: Mr. Chairman, I sugge st to the Minister that the biggest threat that Canada and 2010

Monday, 23 March, 1981 Manitoba have to the Medicare system is that it will provide a basic, high-level income for doctors which they will then supplement by saying that they won't work for that and work for more and which I have always said that they should have the right to do because I never tell somebody that he shou ld provide a service at the rate that I think he should get. Therefore, the freedom of a doctor to opt out I don't challenge.

If he opts out and wishes to deal with the patient directly and then doesn't involve the plan and is able to make the arrangement that the patient will get money from the plan, pay him and that there is no assignability, no involvement of the plan, he has that right.

The biggest threat that Medicare has in Canada and in the Province of Manitoba, although we have managed to have only 7 percent opted out doctors, is that there will be a larger and larger number of opting out that the so­ called "b etter doctors" will opt out, and that people will be restricted, if they want to get Med icare for the fees that the public pays, will be left with a smaller selection of doctors; that's the biggest threat. And if the member feels that what I am suggesting is a threat, I'm suggesting that exactly the opposite is the result.

There is no need at this point to say that because you will permit a chiropodist to get paid publicly the same way as a doctor doing the same thing, there is no need to assume that the person who goes to the doctor will continue to go to the doctor. He may be going to the doctor because society doesn't pay the chiropodist and therefore he should have a choice of going to the chiropodist and getting the public to pay for that service in exactly the same way as they pay the doctor. The person who is now going to the psych iatris t might have wanted to go to a psychologist.

He may have gone to a psychologist and said, I would like you to help me and the psychologist could say to him, I would like to help you but I want you to know we will have to make an arrangement for fees. Then the person says, well, doesn't Medicare pay you? He says, no, Med icare doesn't me, it pays the psychiatrist. The patient says, thank you very much, I'll go see my psychiatrist. What is happening is that you are driving citizens and preventing them freedom to choose the kind of medical services that they will get and because of that you are elevating the price which the doctor is able to demand.

Then you have a problem, because then the problem of the doctor being in the exclusive position of being able to receive these funds is in an exclusive position to demand more money. In the long run if you have a greater number of people who are able to deliver a service, then the amount of people that themselves deliver the service reduce the bargaining power of a smaller group of people.

Therefore the Minister should be looking at this suggestion, not from the point of view of increasing the draw on the medical funds but in the last analysis providing more options for the citizens to be able to get the service and to get the service at a reasonable rate and less people opting out. I've also said this, Mr. Chairman, with regard to the Minister's and the government's virtual abandonment of any effort to provide an alternative form of health care system.

I respect the fee for service system, but I don't think that it's the only syst em, and with the greatest 20 11 of respect I think that there is much argument to say that it's not the best system, not that I would refuse a doctor the right to do it. There are medical clinics in the United States, and the Kaiser Clinic is a perfect example, which is a private clinic it's not a government clinic, but who practise medicine in a different way.

The Minister, who is concerned with the integrity of a plan which will provide citizens the opportunity of obtaining medical care at social rather than individual expense, which is the key, and says that he wants to protect that and I kind of believe that he does.

I don't think that he wants to see the doctors of our province in a position where they feel so strong in their position and also so dissatisfied with their fees that they will say, fine, I'm not going to work for Medicare, I'm going to work for my patient and my patient will get what he can from the Medicare system and I will charge him again, and I'm not talking hypothetically; that's done. In Manitoba we've managed to not have it reach the proportions that it ha s reached in other provinces, but there's no guar antee that it won't.

I'm not sure what the Minister is going to be told in this current round of negotiations, but I sure remember sitting in the other committee room talking to the doctors and their lawyers and we were on the verge of a medical strike in the Province of Manitoba because of the desire of the doctors, and I believe it was a misunderst anding, to be able to be in a position to veto health policies. That's the kind of thing that can occur when you put all your eggs in one basket. Now there doesn't happen to be that many baskets now, but surely we should not be limiting the number of baskets.

Furthermore, we are actually doing a disservice to those people who say I want to go to a recognized pract itioner, a man who practises a skill, which you have licensed, which requ ires a degree or at least requires an education for the delivery of a limited type of service. That same service if I went across the street to a person with M.D . on his door, the public pays. Now I don't want to go to both of them.

Therefore I'm not certain that when you say that that it's going to increase you by $1. 5 million you're not calculating it as if some of the people who now go to M.D.'s would go to a psychologist, or some people who now have their feet treated by a doctor would go to a chiropodist, or some people who used to go to a doc tor for back tr eatments would go to a chiropractor.

Really the citizen is being short-changed, because he is being denied his freedom of choice and being dr iven to a particular discipline rather than having his choice of discipline. it's not a one-way street; it doesn't necessarily mean that it's going to be a matter of bucks. lt could be in the long run a reduction of the demands that are made in terms of the delivery of health service. I think that the plan that the former Minister of Health set up with regard to dental nurses would not have been a more costly plan. In the long run it would be a less costly plan.

The Minister is, I think wrongly - why do I think wrongly because nobody has all the answers, but he's placing his faith in one profession, nobody has all the answers. I think it's a pretty good argument on the part of the citizens that another profession may do more for him than the medical profession. Then he says up until now I've

Monday, 23 March, 1981 been paying out of my own pocket rather than going to a doctor I've been paying this man because I believe he does more for me. Who are you to say he's wrong? Or me? MR. SHERMAN: I don't disagree, Mr. Chairman, with the Honourable Member for lnkster when he says that a major threat to Medicare would occur with any substantial kind of opting out by the medical profession. I do disagree with him when he says that is the major thr eat to Med icare.

He disag rees with me when I say the major threat is the capabil ity and capacity of the people, of the revenues of the province and the country to support the system that is in place right now, and that can be jeopardized by the too rapid entry into the system of too many other occupations seeking coverage under the insured service spectrum. He disagrees with me on that. it's an honest disag reement. In any event, let us say that we can agree that mass opting out is cer tainly a major threat to Medicare.

I would ask him to consider the position that I take with respect to the other major threat, which I see at the moment as a bigger threat. Nor do I quarrel with the logic of the Honourable Member for lnkster. I think he makes his case with impressive logic. I don't think, however, that his case is based on a sound premise.

Our experience in terms of adding other insu red prog rams to the insured program spectrum has not been one which has produced a reduction either on the demands placed on the medical profes sion, the interest generally shown in the medical profession by the public or the volume of work generated by the medical profession. In fa ct, our experience ha s been qui te the opposite. I think if one looks at the occupational group s that have been added to that range of programming one clearly sees the evidence of what I am saying.

This is not to sugge st that because that has been the experience after adding chiropractors and some other health occupation groups to that spectrum there should never be any consideration given to adding other health occupation groups. But I do challenge the premise on which the Honourable Member for lnkster constructs his very logical argument.

I think it makes excellent read ing and it makes excellent argument, he was the Minister of Health once, I think experience that one has as Minister of Health even for a limited time, and heaven knows that any of us is only Minister of Health for a limited time, demonstrates quite clearly that addition of other occupations, health groups and occupations, into the system or entry by those other occupations into the system has to be approached very cautiously and carefully in the current economic context of Medicare.

We cannot for example say, well, we will displace several millions of dollars out of that $654 million He alth Services Commiss ion Budget and spend it on adding chiropodists or adding clinical psychologists because it's going to save us so many millions of dollars on the regular conventional medical services side. We can't say it because I think I can sugg est without fear of contradiction that it won't happen, it won't happen. The majority of people still turn and will in my view continue for some considerable time in the future, to turn to the conventional medical practitioner.

The system in the country, in all provinces including this one, of producing a fairly impressive crop of medical school gradua tes year after year has an impact and an effect on that Budget too. All provinces at this present time through the provincial Ministers of Health and through their Deputies are intensively studying this whole question of medical manpower supply and "oversupply". Some provinces have moved to reduce intakes in their medical schools.

Some provinces are moving to specifically recog nize a certain number of internships and residencies only for certain specialties and declaring that they shall not be filled by interns and residents of any other specialty. If they're not filled by that particular specialty, they're to lie vacant because of some of the imbalances that are building up. I don't think Man itoba can move on this kind of challenge or this range of challenges unilaterally. We can certainly do it in concert with other provinces of Canada tied in with us into our national Med icare system.

Cert ainly those are prob lems that are being addressed by the Health Ministers. Today we're looking for solutions to problems that include this prob lem of manpower supply and imbalance in supply. The result of that, in the course of these next few years and particularly in the course of this de cade, may well be that we can shift the system some degrees both along the lines of those proposed by the Member for lnkster and in some of the directions that I favour, which call for a much greater emphasis on particular specialties which have not been terribly heavily emphasized up to this time.

In the course of these efforts to shift and change the system, I believe we probably can win the attitudinal battles that have to be won where the medical profession is concerned, where the whole sense of responsibility to the people of Manitoba and the people of Canada and the taxpayers of the country are concerned, where the whole sense of respo nsibility both from the prac titioner and the consumers view vis-a-vis use and overuse of the system is concerned, but we're not there yet.

To move in the current context to add additional, fairly expensive insured prog rams, I think is dangerous and would jeopardize the funding base tha t is attained and achieved by no small effort, both in this province and our sister provinces at the present time. I close no doors and I respect the argument made by the Member for lnkster, but my experience in the brief time that I've been Minister of Health is that adding those additional occupational groups at the present time will cost me money that I haven't got and that he hasn't got.

If I start to jeopardize the system that's out there, that was put in place initially to guarantee Canadians and Manitobans that they would have an adequa te standard of conventional medical care, then I think I' m doing nobody a service. Certa inly refinement, improvement, expan sion and exte nsion, all those things are desirable, but the initial rationale for Medicare and hospitalization surely was to put in place a system that relieved Canadians of the worry of illness and the attendant bills of illness. For most Canadians tha t means conventio nal med ical services and conventional hospital services.

We'r e having a difficult and a challenging time maintaining that system, not that it's in danger of collapse. We are maintaining it and we're going to maintain it and we're going to continue to reinforce it. but I think we have to be very cautious and frugal about the 2012

Monday, 23 March, 1981 application of the available funds that we have, and the kinds of things that the Member for lnkster talks about, although desirable as long-term objectives, are ahead of their time at the moment. it's not that we haven't thought about them.

I've been through many discussions with these groups and with my officials and I appreciate the advise of the Member for lnkster and assure him it'll continue to occupy our attention and our consideration, but in 1981- 82 we are committing the avai lable revenues of Manitobans to the extent that we can .commit them and we cannot add any of these additional programs that he and I have been discussing. MR. GREEN: Mr. Chairman, I app reciate the concern and the seriousness with which the Minister has both listened to my submission and answered my questions, and I'm not going to prolong the subject.

I do say that he is looking at it from the point of view of adding occupations. I am not looking at it from the point of view of adding occupations. I didn't have in my mind, when I was arguing Medicare for years and years, that there were different people who delivered health systems and that people chose to go to different people. I didn't know, frankly that the psychologist was different than a psychiatrist or that the chiropractor was not performing the same work as a medical doctor, and therefore, it never was in my mind at the time that I was going to be making an exclusive recipient as the medical doctor.

Had it been brought to my attention more forcefully I hoped th at I would n't have been thinking as conventionally as the Minister is now putting it back to me. I'm not thinking of adding occupations to the medical service. I'm thinking of caring for the health of Canadians, who in their judgment see that health best looked after by somebody in the health field who doesn't happen to be a doctor. What we are doing is driving people into the doctor's office; we are not permitting them to choose and I believe that in the long run that will cost us money, it will not save us money.

I do agree that experience will show that when you added chiropractors, you didn't have people leaving the doctor and going to their chiropractor; that generally those people who wanted a chiropractor still went there. That was a particular skill which probably had achieved some prominence in that particular type of injury which maybe was even more highly regarded than the medical people, at least to those people who chose to, they swore by them. We had one of them in this House and I'm sure he swore by them.

So, it never was as latent to me as it is now, because I've now seen that we should have licenced other people to go into the health field and I'm not thinking of adding those people. No, that's not the point of view I have at all. I'm not thinking of that guy coming in and getting it. I'm thinking of the citizen who wants to go to somebody and is told we will pay you if you go to a doctor, but we won't pay you if you go to a psychologist. That seems unfair. MR. CHAIRMAN: The Member for Transcona. MR.

PARASIUK: I'd just like to raise one element of this in terms of experience, and the experience tends to reinforce the position put forward by the Member for St. Boniface and the Member for lnkster. The 201 3 Minister says that if we allow people to see these other people in the health care field, that somehow this will increase the expense.

Well, the point is society pays for those expenditures anyway and in Canada by going into a partially comprehensive system, because it's not quite fully comprehensive, we have been able to provide, in my estimation, a far better health care system than the United States with approximately 7 percent of gross national product being spent for health. In the United States without having that type of system they have spent 9 percent of the gross national product on health.

So, I think that if we try to im prove the comprehensive health care system that we have which is public, we'll find th at over the long run we'll get a more complimentary system. We'll get people, I think, making better choices and I think that our record in relation to the American system, which is far less comprehensive than ours, will continue to improve in terms of the percentage of gross national product that is spent on health.

I wanted to, while we're on the Medical Program, raise a couple of questions in relation to Northern Manitoba on behalf of my colleague, the Member for Churchill, who can't be present but asked me to raise some questions on his behalf. I'm wondering if I can find out how many doctors there are north of 53 and where they are located and how this compares with three years ago? MR. CHAIRMAN: The Honourable Minister. MR. SHERMAN: Mr.

Chairman, I believe the latest figures that I saw from the College of Physicians and Surgeons indicate that our position with respect to supply of physician manpower in Northern Manitoba is better than it was two and three years ago. lt has improved numerically in a small but notable way, but I'll have to get those specific figur es for the honourable member, I don't have them. MR. PARASIUK: Okay, if I could just add one other item to that for the Minister to determine, I'd like to know where the doctors are actually located as well?

The Minister indicated in prior discussion some of the things that are being done to deal with the general problem of shortages of doctors in Manitoba, in both rural and Northern Manitoba, so I think that my colleague can look at that of Ha nsard for that type of answer but if you could just submit this information with respect to northern doctors to myself, I'll pass it on to my colleague. That would be sufficient at this particular time.

While we're on the Medical Program, I'd like to ask the Minister if he has informed the chiropractors that he will not be proceed ing with the professional association legislation. lt was their understanding, and I guess because we consult the same groups my underst anding, tha t the government would be pr oceeding with a profess ional bill for the chiropractors. The Minister is now saying that they aren't. Has he formally informed them of that fact? MR. SHERMAN: Yes, Mr.

Chairman, we have informed the Manitoba Chiropractor's Association that we won't be proceeding with their legislation this Session, but we will be continuing to meet with them over the course of the next few months to resolve some of the unresolved aspects of that proposed legislation that are still in front of the two parties.

Monday, 23 March, 1981 MR. CHAIRMAN: Line 4 - pass. Resolved that there be gr anted to Her Ma jesty a sum not exceeding $654 million - the Member for Seven Oaks. MR. MILLER: Before you pass that I wonder, could the Minister inform us whether the amount shown for the year ending March 31s t, 1981 is that going to be fully expended or will there be a shortfall in the spending? MR. SHERMAN: Mr. Chairman, the Honour able Member for Seven Oaks is referring to the figure in the printed Es tima tes at $54 7 million. The appropriation vote for the year ending March 31s t, 1981, that is all spent and then some, Mr.

Chairman. There were Supplementary Estimates of about $19 million added to that. MR. CHAIRMAN: Resolved that there be granted to Her Majesty a sum not exceeding $654,049,000 for Health - pass. We turn to the Minist er's Salary, 1. (a) - the Member for Seven Oaks. MR. MILLER: To follow up, the Minister indicated there was a $19 million supplementary Estimate. Do you mean suppleme ntar y Est imate or special warrant? MR. SHERMAN: That was a special warrant, Mr. Chairman. MR. CHAIRMAN: 1. (a) - the Memb er from Transcona. MR. PARASIUK: Yes I don't want to .. MR. CHAIRMAN: 1. (a)( 1), I should ... MR.

PARASIUK: I don't want to take the time of the committee on an item, but I assume the Minister will still be getting me that information that I asked him the other evening with respect to personal care homes; which ones were private, which ones were non-pr ofit, which ones ha d submit ted aud ited financial statements? MR. SHERMAN: I have received that material early this evening, Mr. Chairman, and I'll be able to give it to the Member for Transcona without delay. MR.

PARASIUK: Well, since we've come to the Minister's Salary I'd just like to sum up with respect to the two major items which we feel are the major issues with respect to the He alth Estimates as presented. We feel that the one big issue is the wild oscillation in health care spending by the government and it would appear that the health care spending is not related to need as much as it should be, but rather to the cycle of electoral politics and we believe that this has hurt the health care system in Manitoba.

Our evidence is a shortage of nurses, a shortage of nursing home beds, acute care beds plugged up with extended care patients who should be in the nursing home beds that were frozen or cancelled. There are waiting lists for accute care beds in hospitals. There are waiting lists for elective surgery and we feel that this is a major result of the restra int that was practiced in the first two years and we note that the deficit really hasn't changed. In fact, over the last while it has gotten worse.

We have that concern and we feel that there should be a more regular type of health care spending because surely the needs of the population do not oscillate between 4 percent and 19 percent on a yearly basis in terms of what their health care needs are. The other major issue we feel is the whole issue of private profit making nursing homes. We've had an opportunity, unfortunately I would say, to get a window into the operation of one private profit making nursing home and what we see is not a good picture. We wonder whether, in fact, that's not the case generally.

Some initial survey results of health care workers and nurses indicates that there are problems in the personal home care field because of past restraint, but that these problems are magnified tremendously in private profit making institutions. We find that the evidence in other jur isdictions, in other provinces and in the United States indicates to us that when profit is the incentive for the provision of nursing home care to elderly people in personal care homes that the quality of service deteriorates and ultimately we're concerned about the quality of service.

We don't want to build in economic incentives for private entrepreneurs to decrease the quality of services in order to sque eze out more profit. We feel that the alternative of going to nonprofit community, religious and service groups is the right alternative to follow. We know that there is a waiting list and we've heard this before, a waiting list of at least 1,8 00 people waiting to get into personal care homes. That means that the demand for this type of service is strong.

We need more facilities, we also need to broaden our programs in this area generally, but certainly no one would argue that expenditure in personal care homes will lead to their being under­ utilized in the future; unlike the situation with schools where one might have argued that perhaps there was too great an expenditure in schools and we have some empty schools. Given the fact tha t our population is aging, that an increasing percentage of our population will be people in the future who are over 65, we know that these personal care homes are going to be filled up.

So, therefore, the demand is there, the need is there, and I think we are fortunate in Manitoba to have groups of a non-profit nature, community-based groups, religous gr oups, service gr oups, who recognize that this is a need and are willing to offer their services to provide that decentralized type of direction and attention required to run these non­ profit institutions, their experience to date has been excellent. I really haven't come across any non-profit personal care homes that I could say have not provided good quality care to the best of their ability within the difficulties of a restraint program.

They have been incred ibly conscientious people. Their experience has, in my estimation, been excellent. They really have nothing to gain from what they do, apart from serving humanity. In that respect, I think we should commend them for what they have done in the past, for their past experiences, and we should try and use them to the greatest extent possible. Their experience has shown that they can do the job and do it effectively. 2014

Monday, 23 March, 1981 In this connection, I think it's impossible for us to agree with the government policy that replaces old, in some instances the Minister says, condemned private, profit- making nursing home institutions, which in my estimation, may have been terri bly rundown in the past because people have been running down the facility in order to take money away from that facility, and haven't been reinvesting their profits into the quality, or upgrading, or keeping up the facility; that it's impossible for us to accept the Minister giving approvals to these corporations, and indeed adding 120 nursing home beds of a private, profit-making nature, while at the same time having turned down non-profit groups like the Selkirk Hospital Board, like Fred Douglas Lodge, like Park Manor Nursing Home.

We think this is the wrong way to go about it. We've said that many times. We will state it finally again. I don't think this is an issue that will subside during these Estimates. 1t is an issue that will be debated over and over again, because it is such a fundamental issue with respect to health care. That's the way we see this issue, and we will debate it very strongly into the future. 1t certainly won't die here. I know the Minister knows our position on this very strongly. MR. CHAIRMAN: 1. (a)( 1) - pass.

Be it resolved that there be granted to Her Majesty a sum not exceeding $570,400 for Health - pass. MR. SHERMAN: I would like to thank the Opposition very much for their comments and I would like to thank my own colleagues for the support that they have demonstrated, for hanging in there through the long sessions. Thanks very much. Thanks very much to the Chairman. MR. CHAIRMAN: Committee rise. SUPPLY - FINANCE MR. CHAIRMAN, Abe Kovnats (Radisson): This committee will come to order.

I would direct the honourable members' attention to Page 61 of the Main Estimates, Department of Finance, Resolution No. 66, Clause 6. Tax Credit Payments - pass - the Honourable Member for Lac du Bonnet. MR. SAMUEL USKIW: Mr. Chairman, at 4:30 I was trying to make the point that the government was somewhat unconvincing and perhaps insincere when it makes the statement that their Tax Credit Program was designed to assist those people in the greatest need.

I made that observation on the basis of the contrl'!.dictions that have been built in the formula itself wherein the people, who are in the greatest need , in many instances and we have shown a number of examples, are indeed penalized by that very program and that if the government was indeed intending to move in that direction, then it's obvious that if they had to make it operative or workable they would have had to have established a threshold figure below which people would not suffer a reduction of tax credit benefits. So in the absence of that kind of a commitment, Mr.

Chairman, I don't see what the government has in mind, if anything, other than perhaps some public relations period for them to recapture their image with respect to the program. 20 15 Otherwise, if they don't do something by way of commitment, I don't what they are saying to the people of Manitoba when they are saying they are going to review the anomalies, so to speak, as they have des cribed them or some of the errors or mistakes in the formula itself that has had the effect of denying people in medium to low income categories of their tax credits.

Now I think one of the other observations that should be made with respect to the whole tax credit idea, when it was first put together as a program of the New Democratic Party Government, it wasn't designed mainly on the basis of need but rather it had to reflect the escala ting costs of living for the people of Manitoba. 1t was in part an answer to resolutions in this Chamber asking that certain exemptions be allowed under The Sales Tax Act or Revenue Act or whatever because of income categories and so on. lt was sort of an answer to all of those other arguments.

That's how that particular program came into being and it recognized that the Province of Manitoba wanted to share more in the area of education financing and so the Property Tax Cr edits were introduc ed and indeed amende d periodically in order to reflect increased costs and increased mill rates at the municipal level. There was a series of amendments with respect to the amounts, with respect to both the Cost of Living Tax Credit Program and the Property Tax Credits.

I believe each year there was a change in the amount of the credit and that was in keeping with the policy of trying to adjust with the inflationary impact in our economy, and to cushion the blow at the local level, whether it's pro perty taxes or general taxa tion of the province, and so it had more to do than just trying to make it possible to respond to sort of the welfare category of people in our society. Those programs were intended to respond to all of the people in our society that were affected adversely by the inflation of our economy at the time. So, Mr.

Chairman, I don't believe that the Minister is accurate in suggesting to us tha t they have brought in corrective measures that would better reflect the original intent, because the original intent was much broader than what he has defined in the comments as I have heard him here in this debate. MR. CHAIRMAN : Cla use 6 Honourable Member for St. Johns. pass. the MR. SAUL CHERNIACK: Mr.

Chairman, I'm sorry that I was unable to be present during much of the discussion of this department's Estimates and I don't want to attempt in any way to try to come back and start debating again matters th at ha ve been reviewed, but listening to the Member for Lac du Bonnet's comments about the Pr operty Tax Credit Plan and its intent, I would say, Mr. Chairman, that I was not surpris ed dur ing the deba te when we brought in the Property Tax Credit Plan and later the Cost of Living Tax Credit Plan. I was not surprised that Conservatives opposed it. I was not surprised that they voted against it.

I was not surprised when the then Memb er for Aiel said that it was unacceptable, criticized it substantially, inasmuch as sayi ng tha t as soon as pos sible after the Conservative Government came to power, they would cancel it out. I was not surprised because I felt that the plan as it was, was inconsistent with what I conceived to be Conservative policy.

Monday, 23 March, 1981 Now the last time that I was in this House was when we were debating the Property Tax Credit Plan, when the Member for lnkster challenged the Minister to talk about the fiscal pol icy of the government. All I got out of the Minister's responses were again consistent with what I believe to be Conservative policy on the question of any attempt on redistribution of income, or on taxation on a progressive measure, or taxation on the ability to pay principal, all of which, I believe, is a matter of lip service for Conservatives, that they don't believe in it.

I don't believe that Conservatives really believe in the progressive tax system as a policy measure. I bel ieve that when, in 1977, the Cons ervative Government, the new Cons ervative Go vernment came rushing into this House and reduced taxation, that they did it, since they did it by attacking the most progressive form of taxation, that they were again spelling out their philosophic approach to taxat ion, their firm belief that leaving money in the hands of the entrepreneurs of society was the best way for the economy to develop.

The old story that came up in the United States, that what's good for General Motors is good for the United States, I believe, applie s to a very large extent to the philosophy of Conservatives. I can recognize it. I don't have to use abusive language in recognizing it. I disagree with it. I believe that's the case. One problem I've had in 18 years I think, of my being in this Chamber, Mr. Chairman, is to get a Conservative to spell out his philosophic approach on the question of wealth, the redistribution of wealth and on the taxation policy.

I'm still having that problem, although this Minister in a short space of time, did one of the clearest expositions on that side that I've heard . lt wasn't that clear, but to me it came through fairly loud and clear, that it is good to give back taxes to those who can best use it, and those who can best use it are the ones that can develop the economy under a free enterprise system. There was a long time, Mr.

Chairman, when I belie ved that if one wanted to st imula te the economy, one put money into the hands of those who would stimulate it by being consumers. lt is not only my belief, but my experience has shown to me that people in the upper brackets of income - and I don't use the term filthy rich that was referred to the last time we debated it - but those people who are wealthy are people who, to a large extent, don't spend the income that they earn, but invest it, reinvest it, in not necessarily productive ways.

When I say productive ways, I say that if you put money into the hands of the people who are spending all that they receive, they are the people who stimulate the economy. They create a demand which is then reflected in development of goods and services, which they want. In that way, it reflects on the creation of jobs,

whereas those people who are the beneficiaries of the Conservative policy of reducing taxation, or giving back taxation, are just as likely to invest their money - and I don't fault them for it in this system we have - to invest their money where they get the best return, which may well be developing a mine in the Hondur as, or wherever one does, in investing in the development of other countries where the returns will be greater. They are the people who are the entrepreneurs who look to find the investments which will give them their 2016 greatest return.

They are not consumers and if they were investors in their own province, that would be good but they are not, Mr. Chairman, to a large extent. If they buy shares, and I don't talk about multinational corporations, but any corporation that does work beyond the boundaries of Manitoba, then obviously they are investing in building the economy outside of Manitoba which isn't bad if it's within Canada. We are all Canadians as the successful Mr. Davis said just the other day that no matter what his responsibility was as he felt it to Ontario, he was a Canadian first.

So who are we Ma nitobans to begrudge the gr owth of Canada in the expectation that a prop erty equalization formula will benefit Manitobans as well? But, Mr. Chairman, it's a difference in philosophy and I think that's the important feature. We can rant and rave about management abilities; we can rant and rave about whether this Minister of Finance can do a better administrative job or not.

The fact is that with the same staff and I'm happy to know that the staff of the present Minister of Finance is much the same as the staff that served the New Democratic government which is an indication of their devotion to the job which is an indication of their dedication to serving the government for the time being. lt is als o a recog nition that they do what their government wishes them to do and in the case of this program, we are now discussing the Rebate Program.

They are carrying out and making work as well as they can a plan which is approved of and directed by this government and this Minister of Finance. What to me is hypocritical about the whole process ... MR. RANSOM: Out of order. MR. CHERNIACK: Mr. Chairman, I did not speak of any individual person as being hypocritical. If I did, the Minister of Finance might wake up and say what he said now but I want to tell him that what is hypocritical about carrying on a program which they opposed is that it is done because they know what the people think about it. That was the biggest example we had.

The shock we had on Autopac was when the aspirant for the premiership of the province under the Conservative banner stood here on this side and said, we will not upset Autopac. After all the years of attack on public enterprise, on the Autopac system and all that it stood for, the Conservative government before it was a government made it clear they would not change Autopac and that is in real contradiction I believe in their philosophies such I've been able to understand it, hard as I could and as I tried to understand it.

The Property Tax Credit plan is also, I believe, contrary to their philosphy if they have one and if I understand it correctly, Mr. Chairman. I call it hypocritical when they try to destroy the plan the way they've done this' year without discussing even the basic intent of it and the effect that it has on society. By what they are doing they will, I would think if they had enough time and I don't think they will have that much time, that they would dr aw back and attempt to undermine the program but would not dare for one moment to cancel it, to change the tax system.

I would really hope that this Minister of Finance when we deal with his salary will tell us something about his taxation policies - what he bel ieves about

Monday, 23 March, 1981 progressive taxa tion, what he belie ves about consumer taxat ion, such as sales tax, what he believes on royalty taxation, although I think I know pretty well what Conservatives do in that regard, and what they believe about a program such as the Tax Credit Plan, which has several effects, consequences, one of which is red istribution of wealth; let's face that. When you tax the upper brackets for the benefit of the lower income brackets you are redistributing wealth. (I nterject ion)- I didn' t hear what the banker had to say over there; did he want to say it more loudly?

A MEMBER: Once you've got it made it's okay to talk that way. MR. CHERNIACK: Mr . Chairman, he says once you've got it made it's okay to talk that way. Let me tell the gentleman across the way that if he is implying that I personally have done well then I have to tell him that I am pleased that working in his system I was able to work well. But I would like to think that other people who did not have the opportunities that he or I had would be able to have a greater opportunity to benefit in the growth of Manitoba. Those are the people I'm concerned with a lot more than the Member for Minnedosa is.

Those are the people I represent much more than the Member for Minnedosa does. Mr. Chairman, that is exactly the concept that we had when we set up this plan, the Tax Credit Plan, was the opportunity to assist those who were burdened by property taxation on a flat rated basis related to asses sment. We wanted to help those who were not able