Manitoba Hansard — 17 June 1991 (Sitting 66B, 35th Legislature, 2nd Session)

35-2-66b

Manitoba — Debates (Hansard)

MG-8048 second Session - Thirty-Fifth Legislature of the Legislative Assembly of Manitoba DEBATES and PROCEEDINGS (HANSARD) 40 Elizabeth II Published under the authority of The H onourable Denis C. Rocan Speaker VOL. XL No. 66B. 8 p.m., MONDAY, JUNE 17, 1991 Printed by the Office of the Queens Printsr. Province of Manitoba ISSN 0542-5492

MANITOBA LEGISLATIVE ASSEMBLY Thirty-Fifth Legislature LIB - Liberal; ND - New Democrat; PC - Progressive Conservative NAME ALCOCK, Reg ASHTON, Steve BARRETT, Becky CARR, James CARSTAIRS, Sharon CERILLI, Marianne CHEEMA, Guizar CHOMIAK, Dave CONNERY, Edward CUMMINGS, Glen, Hon. DACQUAY, Louise DERKACH, Leonard, Hon. DEWAR, Gregory DOER, Gary DOWNEY, James, Hon. DRIEDGER, Albert, Hon. DUCHARME, Gerry, Hon. EDWARDS, Paul ENNS, Harry, Hon. ERNST, Jim, Hon. EVANS, Clif EVANS, Leonard S. FILMON, Gary, Hon. FINDLAY, Glen, Hon. FRIESEN, Jean GAUDRY, Neil GILLESHAMMER, Harold, Hon. HARPER, Elijah HELWER, Edward R.

HICKES, George LAMOUREUX, Kevin LATHLIN, Oscar LAURENDEAU, Marcel MALOWAY, Jim MANNESS, Clayton, Hon. MARTINDALE, Doug McALPINE, Gerry McCRAE, James, Hon. MclNTOSH, Linda, Hon. MITCHELSON, Bonnie, Hon. NEUFELD, Harold, Hon. ORCHARD, Donald, Hon. PENNER, Jack PLOHMAN, John PRAZNIK, Darren, Hon. REID, Daryl REIMER, Jack RENDER, Shirley ROCAN, Denis, Hon. ROSE, Bob SANTOS, Conrad STEFANSON, Eric, Hon. STORIE, Jerry SVEINSON, Ben VODREY, Rosemary WASYL YCIA-LEIS, Judy WOWCHUK, Rosann CONSTITUENCY Osborne Thompson Wellington Crescentwood River Heights Radisson The Maples Kildonan Portage la Prairie Ste.

Rose Seine River Roblin-Russell Selkirk Concordia Arthur-Virden Steinbach Riel St. James Lakeside Charleswood Interlake Brandon East Tuxedo Springfield Wolseley St. Boniface Minnedosa Rupertsland Gimli Point Douglas lnkster The Pas St. Norbert Elm wood Morris Burrows Sturgeon Creek Brandon West Assiniboia River East Rossmere Pembina Emerson Dauphin Lac du Bonnet Transcona Niakwa St. Vital Gladstone Turtle Mountain Broadway Kirkfield Park Flin Flon La Verendrye Fort Garry St. Johns Swan River PARTY.

LIB ND ND LIB LIB ND LIB ND PC PC PC PC ND ND PC PC PC LIB PC PC ND ND PC PC ND LIB PC ND PC ND LIB ND PC ND PC ND PC PC PC PC PC PC PC ND PC ND PC PC PC PC ND PC ND PC PC ND ND

3447 LEGISLATIVE ASSEMBLY OF MANITOBA Monday, June 17, 1991 The House met at 8 p.m. CONCURRENT COMMITTEES OF SUPPLY SUPPLY-HEAL TH Mr. Deputy Chairman (Marcel Laurendeau): For this evening, this

section of the Committee of Sup ply, meeting in Room 255, will resu me consideration of the Estimates of the Department of Health. When the committee last sat it had been considering item 1. (

b) Executive Support: Salaries $499,700, on page 83 of the Estimates book. Shall the item pass? Ms.Judy Wasylycla-Lels(St.Johns): Mr. Deputy Chairperson, just on a few items, as follow up from this afternoon. On the question of deinsurance, the minister has indicated that he is following a policy of deinsuring those services which are not medically required or cosmetic. I am just wondering--we have talked about this briefly, but I am wondering if we could have a further discussion on how reversal of sterilization fits into that.

When is the wish to have sterilization reversed and the desire to have a child considered nonmedical or cosmetic? Hon. Donald Orchard (Minister of Health): The procedure of sterilization, be it vasectomy or be it tubal ligation, is an insured service. The reversal of it has been, and we have elected to deinsure it as an elective service which the individual so choosing would then have the responsibility for covering the cost of the operation. Ms.

Wasylycla-Lels: Earlier when we discussed this and raised the situation where family situations change, where people may have a change in their family, in other words through breakup or through death and they wish to rethink an earlier decision, is that still considered something that is within the criteria that the minister is applying to this service? Mr. Orchard: Right now it is. My honourable friend the member for The Maples (Mr. Cheema) madethe suggestion about changing family circumstances and I indicated I would attempt to vet his concerns and see whether they could be accommodated.

To date, I do not have any indication as to whether they can or cannot. Ms. Wasylycla-Lels: I appreciate the minister's comments. That is certainly a change from when I first raised this issue in the House many, many weeks ago, but it seems that in trying to reopen this question and address it from the point of view of life circumstances, one ends up making a judgment call. Would it not be better off just to leave this as an insured service on the understanding and the knowledge that when people make those kinds of decisions, they are making it for a good reason based on their best judgment? Mr.

Orchard: That is why the ste rili zati on procedures are covered under medicare. Ms. Wasylycla-Lels: The minister still has not explained then why the reversal of sterilization will now not be covered under medicare. Mr. Orchard: Because, Mr. Deputy Chairman, that is deemed a nonmedical service, and if for change in lifestyle other than the impact that the member for the Maples brought up Thursday of last week where, say, you had an accidental death of the spouse, I am willing to look at that circumstance to see whether the regulation can be crafted so as to reflect that.

The other circu mstances are lifestyle changes. Ms. Wasylycla-Lels: Could the minister tell us what data he has or studies to indicate numbers of people who seek reversal of sterilization and what kind of numbers we are talking about, what kind of dollars we are talking about and under what circumstances people make that request? Mr. Orchard: Mr. Deputy Chairman, when we get to the medical services line, I will attempt to have that kind of information available. Ms. Wasylycla-Lels: I am wondering if the minister could give us a clarification on the question of deinsurance of varicose veins.

Could he just fill me in again in terms of under what circumstances varicose vein removal would not be considered insured under medicare? *

(2005) 3448 LEGISLATIVE ASSEMBLY OF MANITOBA June 17 , 19 91 Mr. Orchard: Mr. Deputy Chairman, varicose veins -in many circu mstances, the surg ical treatment of varicose veins is not related to any specific medical condition, but is primarily for cosmetic purposes. Consequently, the surgical treatment of varicose veins will only be an insured benefit when it is determined by a physician that the procedure is medically required. Ms. Wasylycla-Lels: Did the minister say in "most" circums tances varicose vein surgery is not medically required? Mr.

Orchard: The in dication I gi ve to my honourable friend is the same as I indicated to her Thursday last week, Tuesday last week, in "many" cases. Ms. Wasylycla-Lels: I mean I am not an expert on this area, but I just happened-and I am sure the minister saw this as well, an

article in the latest Medical Post, which has a quite shocking

article in terms of varicose veins and some very graphic pictures of the serious nature of varicose veins. I would be happy to share this with the minister, and clearly in terms of this article, varicose vein removal is usually associated with-is usually based on medical grounds. It is usually medically required. Mr. Orchard: Mr. Deputy Chairman, as I have indicated to my honourable friend, should that case be made, it is still an insured service. I might remind my honourable friend, The Medical Post is a newspaper for physicians, written for physicians by physicians. Ms. Wasylycla-Lels: Mr.

Deputy Chairperson, I am wondering if it would not-is the minister not just looking at adding more cost to the system if he goes down this path of deinsuring certain services, but then putting in place certain qualifiers that require a certain amount of paperwork and a certain amount of scruti ny in order to make judgments and decisions? It would seem to me going this route cannot be achieving any savings for our health care system. Mr. Orchard: Mr.

Deputy Chairman, am I hearing from my honourable friend the New Democratic Party Health critic that she wants to provide surgical services for which there is no demonstrated medical need and have the taxpayers of Manitoba and Canada pay for that? Is that a change in position for the New Democrats? Ms. Wasylycla-Lels: Mr.

Deputy Chairperson, I think the onus is on the minister to demonstrate what medical evidence he has to suggest that such services as reversal of sterilization and removal of varicose veins, as well as psychoanalysis, and we can go on with the list-the onus is on the minister to provide the medical basis for showing that these are not medically required services, and he so far to date has not given us a shred of medical evidence to give us the basis for making those kinds of decisions. Mr. Orchard: Mr.

Deputy Chairman, I suppose my honourable friend, if this were five or six years ago, would make the same case on tonsillectomies. She would be defending the system which removed tonsils from the youth of Manitoba at higher than the rate in Saskatchewan and Ontario because that would be deinsuring, or whatever terminology she would put around it. My honourable friend, in terms of varicose veins, I have read the policy. It is the onus on the service deliverer-the physician-to demonstrate that the removal of varicose veins is not a cosmetic procedure , but in fact a me dically requir ed procedure.

I do not think that is too great a task to ask of the physician to assure that what the physician does is a medically necessary treatment, with medical outcome improved health status. A (201 0) Surely my honourable friend is not saying that we ought to be in the process of providing revenue generation procedures with no medical need, because I am not coming from there. That is why the tonsillectomy issue comes immediately to mind.

My honourable friend is saying that children in Manitoba should still have their tonsils taken out surgically when there was obviously limited medical need for some of those procedures, because miraculously, when the fact was pointed out the procedure rate went down. Is my honourable friend wanting the taxpayers of Manitoba, on behalf of the New Democratic Party, to pay for nonmedical, surgical procedures, because that is what we are deinsuring? If my honourable friend wants to reinstate them, fine; we disagree on policy. I believe our policy will be the one that Manitobans will agree to. The cosmetic payment

schedule that the NOP want to protect, I would be glad to argue that on any platform, public or otherwise, with my honourable friend, since that now appears to be the New

June 17 , 19 91 LEGISLATIVE ASSEMBLY OF MANITOBA 3449 Democratic Party policy that they will have cosmetic surgery procedures paid for by the taxpayers of Manitoba. Ms. Wasylycla-Lels: Interesting how the minister likes to twist things around to suit his point of view and his argument. I think he actually does not help his argument when he refers to the question of the removal of tonsils. The minister, the government, did not proceed to deinsure tonsil surgery, removal of tonsils, from medicare.

The minister and the government found ways to ensure that the removal of tonsils was not done on a frivolous basis, just as that kind of thinking and that kind of action is done in other areas and is needed for other areas, such as the question of the high rate of cesareans in our population and whether or not that has been used on a far too extensive basis because of the fee schedule. So there are ways to deal with those kinds of situations.

The question we are dealing with here is the wisdom of deinsuring a service, which does lead us then into a direction of a two-tiered system of judgment calls, of people having access based on their income, and so on and so forth. I guess we do not need to pursue this any further, except to leave on the record that we do not believe that deinsuring a service that appears to have been done to date and the minister has provided no evidence to the contrary for medically required reasons. If I could perhaps, unless the minister wanted to respond to any of that, I wanted to go on to a new question. Mr. Orchard: Mr.

Deputy Chairman, when my honourable friend mentions judgment calls, whose judgment call is she referring to? What we are doing with varicose veins is putting the onus on the surgeon to remove those varicose veins and charge the medicare system only when it is medically required. When it is a cosmetic procedure we are saying we are not going to pay for that process. Now, the tonsillectomy was wide open. There were no checks, balances or otherwise until we pointed out the statistic that you are performing them above the averages in other provinces. That came down. • (201 5) My honourable friend would say, basis her

article in The Medical Post for the physicians of Canada, that all varicose veins are rem oved for medical reasons. I suggest to my honourable friend that is not factual. All are paid for right now, whether they are medical or cosmetic. We are saying simply we will pay for the medical requirements, but not the cosmetic. The onus is on the practitioner to assure us that those proced ures are done in his professional judgment, trained judgmentfor medical reasons, not cosmetic. I do not think that is an imposition on the system of two-tiered or otherwise.

It is simply assuring that the taxpayers pay for medica lly requir ed ser vice del ive ry amid st burgeoning demands on a limited funded health care system, something that I think makes good public policy. My honourable friend, obviously on behalf of the New Democrats, does not agree. I respect that. That is what this House is about. Ms. Wasylycla-Lels: Well, good public policy is based on proper evaluation and scientific evidence and to date the minister refuses to give us the data for these decisions.

The only way his position can even be considered half seriously is if he would tell us the number of people who have varicose veins removed for cosmetic reasons. I referred to that

article because it reinforced my belief, and I am no expert in this area, that people do not go to the extent of operations to have varicose veins removed very often just because it looks nice. I think usually people go through that kind of surgery because it is medically required and causing pain and other complications. So with the absence of any data, we are having a hard time understanding the basis for these decisions. Mr. Orchard: I will repeat for my honourable friend again, that in the instances where they are for relief of pain or other medical reasons, they will be paid for under the health plan.

I do not think my honourable friend says that is wrong. Mr. Guizar Cheema (The Maples): Mr. Deputy Chairperson, I think the minister has, on Thursday and Friday and this afternoon, said a few things on the record in the question period and I would like him to clarify those things. First of all, the issue of psychoanalysis which has not been resolved yet. I think that needs to be clarified because as the minister knows, and I know, and the member for St. Johns (Ms. Wasylycia-Leis) knows, there was never a separate part and everybody admits it. There was not a separate part under the billing system.

It was a part of the

3450 LEGISLATIVE ASSEMBLY OF MANITOBA June 17 , 19 91 psychotherapy and some physicians are billing from that point of view. So psychoanalysis by definition is intensive psychotherapy. By the minister's argument, that is not the right approach or it is the long psychotherapy-w hen you are doing it for a long time it may not have a real outcome and those statements have been put on the record. I do not think some of them-they are not valid statements and I am sure in the question period when you are in the heat of exchange you put things which are not correct.

I would like the minister to clarify and correct the record that psychoanalysis is a part of psychotherapy. Mr. Orchard: Mr. Deputy Chairman, I suppose we could rehash this issue time and time again. I do not know what more clarification I can provide to my honourable friend, but again this evening we contacted a psychiatrist who provides information and my honourable friend is correc t.

Psychoanalysis is billed as psychotherapy but it is, in most cases, a di stinct process from psychotherapy, hence identifiable, and it brings to qu estion the trea tmen t regime that some psychoanalysis billing that process only, or nearly exclusively, under psychotherapy and the value that has in the context of a constrained system of funding the mental health system. Now, what we are doing, Mr. Deputy Chairman, is working with both the psychiatric association and the MMA.

At one time, in terms of discussions we had, although we do not have anything in writing because that is not the way we operate, with those professional groups there was consensus around the issue that some service delivery regimes were not necessarily the best use of scarce resources. It is those areas that we are attempting to come to grips with because, as my honourable friend has indicated, psychoanalysis is not an insured service.

It is a part of a regime that has been billed under psychotherapy and it is billed by a relatively few practitioners in the province of Manitoba who are providing services to a relatively small number of individuals, clients that they have, or patients that they have. Mr. Deputy Chairman, I do not know-my honourable friend can ask questions and I will attempt to answer the questions that he asks. Mr. Cheema: Mr. Deputy Chairperson, at least we agree on one aspect, that the psychoanalysis was being billed as a part of psychotherapy and was never a separate part of the billing system. I am saying- •

(2020) An Honourable Member: That is what we have said from Day One. Mr. Cheema: That makes my point, when you have a small number of patients who are being billed for psychoanalysis and still getting the help. Can the minister tell us what evidence he has to back up his statement that this form of treatment is not viable treatment, is not a part of the treatment process? Even though we know that a small number of patients are being put on that kind of treatment, but still it is a form of treatment. Can he tell us why would he deinsure such a service which is not costly? It is very cost efficient.

We would end up getting more patients in the hospital system, which is very expensive. One patient per day in a hospital for one year will cost more than what you are going to save. I think it does not make any sense. We are trying to convince you that is the wrong approach. We can still agree to disagree, but I just want to make my point very clear that cutting services to a small number of patients in all the categories which you have done so far out of five is a very small population.

That is why it could be acceptable now, but eventually more services will be deinsured and that is one way of getting away with deinsuring more services. Ministers should realize that. There are another 56 MLAs in this House, and everyone is certainly not going to follow the directions of what the minister is telling us. Certainly, opposition is not going to follow all the arguments, but from a philosophical point of view, if he wants to make an argumentto deinsure services, that is up to him. We want to make it clear that the direction they are taking is not acceptable.

I will see what the minister has to say about this. Mr. Orchard: My honourable friend makes some assumptions. They are assumptions that I cannot make, and I do not know whether they are accurate or not. My honourable friend translates the service that is provided to these patients by a small group of psychiatrists as saying that they, by having those services, prevent admission to psychiatric facilities. I do not know whether that is right or wrong. I do not think my honourable friend knows whether that is right or wrong. One thing that I do know is that I am told--

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3451 Mr. Cheema: I will give you some articles to read. Mr. Orchard: Okay. My honourable friend is going to-- Mr. Cheema: This minister should contact people who are providing services. Ask the service providers. Do not ask the other groups or some special person you have designated to give your point of view. I thin k you should back your statements up with scientific evidence.

When this has been done all through the world, all through North America-the only province we know that does not insure the services is B.C., because in British Columbia they asked for opting because it became very-th ey started charging people who were able to afford, so it was easier for them to take it out. So physicians wanted the service to be out so they both were happy. ' In Manitoba it is not the case. We simply want you to realize that this is the wrong approach, and what would have happened that people still could bill under psychotherapy. So what are you going to do then?

It depends on the physician and the patient, and if the patient is getting helpful treatment and the physician is happy with that treatment, which has all the scientific basis, why would you refuse it when it is a very, very-less than 1 percent of the total Mental Health budget? Mr. Orchard: Mr. Deputy Chairman, is my honourable friend saying that the psychiatric community is unanimous in its endorsation that psychoanalysis ought to be an insured service in Manitoba? If that is what he is saying, that is �ertainly not the information that I have.

That is why 1t has never been an insured service in the province of Manitoba. *

(2025) Mr. Cheema: Mr. Deputy Chairperson, we can spend a few hours on this and we will not solve anything. I just wanted to make clear on the record that, while the minister had made those statements, we gave him a chance, he corrected himself, now he is going backwards again. I do not think we are going anywhere.

Can the minister tell then, what is the policy of this administration about the private clinics, because it comes under the Executive Support staff and what direction his department has for the- there are two eye clinics in Winnipeg, and those clinics' patients can pay a thousand dollars and get their surgeries done, and others who do not have money have to go to the U.S.A. That will make another point. How are you going to attract somebody when you do not have services for your own patients? My question is: Where is your party's stand on the private clinics in Manitoba? Mr. Orchard: Mr.

Deputy Chairman, we have allowed to operate the private clinics that were in existence when we came into government in May of 19 88. All of the not-for-admission, private clinics, for instance in Brandon and in Winnipeg for ophthalmology, were in place, as were some plastic surgery clinics, as were some private dental clinics for surgical removal of impacted wisdoms, et cetera, were all in place in May of 19 88 when we came into office. There has been no new private clinic open since we came into government.

I suppose part of the reason could be that, for instance, in ophthalmology yearly, and again I will provide the information for my honourable friend when we get to the medical line in the Estimates, we have done more procedures in ophthalmology each year on an outpatient basis than the previous year. My honourable friend's criticism and alarmism would be appropriate if we had not done more procedures, but nearly any procedure my honourable friend wants to bring up as an example, we have done more of them than the previous year, not less.

Subsequently, I think it is fair to say that there has not been the demand there was prior to 19 88 to set up private clinics, because all of them were in existence when we came into office in 19 88. The majority of them were started up during the Pawley years, and we have allowed them to continue to operate. Mr. Cheema: Mr. Deputy Chairperson, can the minister tell us, will his administration approve more private clinics in the future? Mr. Orchard: Mr. Deputy Chairman, I cannot answer a hypothetical question. None have been asked for ap proval. Every one of those circumstances would be weighed on its own merit.

We have not had any requests for the creation of private clinics since we came into government. I think, in part, the answer is that we have increased the number of, for instance, lens replacements in ophthalmology, cataract surgery and a number of other procedures. I might ask my honourable friend to be a little bit cautious when he brings up the waiting list, for

3452 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 1991 instance, as an example. He might wish to contact the College of Physicians and Surgeons regarding their concerns about the pattern of practice of one of the ophthalmologists who has operated a private clinic in Brandon, because I am told-and I am not a medical doctor-that there is a period of time of sort of natural growth in a cataract which ought to take place before surgery is there. You can tell people, and who knows-if a physician is telling you, you should go in tomorrow, naturally you want to go in tomorrow. That is not necessarily always the case.

I think that may have been something to do with the College of Physicians and Surgeo ns' discussions around the clinic in Brandon, that there was maybe some evidence of possible undue haste in terms of putting customers or patients through the process. •

(2030) Mr. Cheema: Mr. Deputy Chairperson, that is one of the reasons why I am asking the minister the question. I think it is very important to maintain the quality of care, whether it is in the private clinics or in the hospital. When you are going for the profit areas-physi cians can charge under the heading of facility fee which is not illegal, because if they were charging extra fees, then they could be penalized. The minister knows full well the college has the authority to regulate those clinics.

If they are falling within the regulations and, you know, that is possible, they can still bill for the surgical procedure as they are billin g for the Heal th Services Commission. What they are basically doing is billing $800 to the patient and the rest to the Manitoba Health Services Commission, so we are subsidizing those clinics. In an actual sense, we are subsidizing those clinics because they are still making money, because if somebody can pay $800, they can get the surgery done. I think it is very important to make sure the equality assurance is maintained and the quality care is maintained.

That is why the inspections of such clinics-and that is a responsibility of the college, but I still think the minister should be aware those things can happen, so that people do not have to go through unnecessary surgical procedure if they do not have to. When a patient goes to a physician, the physician says you need a treatment. It becomes difficult to question that person, and you go on the medical advice. Still it is the responsibility of the Minister of Health (Mr. Orchard) to make sure that there is some kind of mechanism to put in place, and we want him to be very, very careful.

If we can relieve some of the pressures, then-I might add here that they have done it in one of the hospitals, Seven Oaks outpatient clinics. That maybe will be able to relieve some of the pressures, but that kind of expansion is required in some of the other hospitals. I will let the member for St. Johns (Ms. Wasylycia-Leis) ask the next question. Mr. Orchar d: Mr. Dep uty Chairma n , my honourable friend makes some very good points. It is the college that sets the standards of practice, assures the quality of practice. The government is not su bsidizing those priva te clinics.

The government is only paying, for instance, in cataract surgery, the surgical fee. If that is where the profit is derived from, then every physician receiving the same fee within the hospital-funded system is making the same kind of "profits," in my honourable friend's words. My honourable friend brings the very important issue to light of no one-the patient seldom questions the physician on the medical opinion rendered.

That is why, for instance, in the issue we just finished dealing with at length, is it wrong to insure only medically required removal of varicose veins, and put the onus on the physician to not under take at taxpayers' expense cosmetic procedures? I think that is an exercise putting responsibility back onto the decision maker who makes the decision to recommend to the patient that surgery. If they err, there are checks and balances that we have at our disposal with the College of Phys ician s and Surgeons, the peer review mechanism which is part of Bill 4.

I hope that my honourable friend will speak to Bill 4 and pass that as quickly as possible, and that, in terms of the operation of private clinics and physicians' offices, my honourable friend also realizes that there is the opportunity in Bill 4 for the first time in the province of Manitoba for the payer-n amely, government on behalf of the taxpayers-to assure themselves that they are receiving all that they are being billed for, to avoid some of the problems that we have encountered in the past.

In June of 19 88, one of the first issues I had to deal with was improper billing by one of the major laboratories in the city of Winnipeg. We are attempting to intercede on that by having the ability

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3453 to ask for records to prove that they have indeed, when billing government and the taxpayers for procedures, delivered them, and that is part of Bill 4. I do not think that is improper. I think that is a good mechanism by which we can protect the taxpayers' investment in the health care system. Ms. Wasylycla-Lels: Mr. Deputy Chairperson, just back very briefly to psychoanalysis for a moment. Since this afternoon, has the minister had time to look at his

schedule and find a time for a meeting with Citizens for Quality Mental Health Care in the very near future? Mr. Orchard: We are attempting to do that. Ms. Wasylycla-Lels: Can the minister give us any time frame in terms of meeting with this group? Mr. Orchard: No, I cannot give you any time frame of that. I will be in contact with the group. I think they are the ones who asked for the meeting, not you. Ms. Wasylycla-Lels: Mr. Deputy Chairperson, I would like to just ask a couple of questions on the question of what data the minister has in terms of making this decision.

As I know, as I believe, others have noted how he backs up his statement that psychoanalysis may not have a real outcome for the positive benefit of the individual. Does the minister have any data that he could share with us? Mr. Orchard: Mr. Deputy Chairman, that issue has been one that has been discussed for some time. I know my honourable friend is going to be angry with me, but sobeit; that is the nature of Estimates.

Today, when she stepped out of the room for a brief few minutes, I thought that her Leader when he was taking the time to explain his election campaign commitments of 19 88, where he talked about psychiatrists and their relative salary scales in the institutions-I thought maybe that Mr. Doer might take the opportunity this afternoon to explain the nature behind his statements of April 8, 19 88, in Brandon, during the 19 88 election campaign, wherein Mr.

Doer said yesterday that hospital patients suffering from the most serious mental illness have less access to psychiatric services than well- to-do neurotics in Tuxedo. I do not know what my honourable friend was refe rring to-Mr. Doer-when he made that statement. He studiously avoided explaining it. Even though on Tuesday and Thursday of last week, he said he would. Maybe my honourable friend can shed light on that policy of the NOP from 19 88. Ms. Wasylycla-Lels: Is it not interesting, Mr.

Deputy Chairman, how the minister usually has a couple of set examples, pet ideas that he keeps throwing back into our discussion. It does not matter if we have heard it now for the last several sets of Estimates, he does not hesitate to put all those same old anecdotal stories on the record. The issue here is it is this Minister of Health (Mr. Orchard), no one else, who has made a decision to deinsure a service. That is what we are talking about, that is why we have been questioning this issue now for several days.

It is not someone else's actions on the line here, it is this minister's decision and he has refused to give us any evidence to back up his statements. Today in the House, when I asked the minister if he could tell us how many people with suicidal or homicidal tendencies would be denied access to psyc hoanal ysis services because of this deinsurance or move towards user fees in this area, he said he know of no one.

Well, if the minister is able to make such definitive categorical statements when asked on a specific area of this matter, then surely he must have some evidence, some data to back up those statements that he could share with members of this committee to enlighten us as to the wisdom and reasons behind his decision. Mr. Orchard: Mr. Deputy Chairman, this is not an old issue that I quoted back to my honourable friend, this is a very new issue. Ms. Wasylycla-Lels: That you have been using for the last several days. Mr. Orchard: That I used on Tuesday Ms. Wasylycla-Lels: And Thursday- Mr.

Orchard: -and I expected an explanation on Thursday and, of course, no explanation follows and I wondered if the Health critic for the NDP might want to, you know, sort of provide the outline of what her Leader meant when her Leader said that, because I do not know what well-to-do neurotics in Tuxedo have to do with the NDP's health policy. However, Mr. Deputy Chairman, when my honourable friend posed the question or made the statement-I do not know which it was-in the Question Period today regarding the issue that suicidal or even homicidal people would be left

3454 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 1991 without adequate treatment, when that statement appeared in the news, I think last week, by members of the medical community, I had my department ask whether in fact that would be the case and it was indicated to me that this is not the case, that most of the individuals who are receiving psychoanalysis do not have those homicidal or suicidal tendencies. •

(2040) Ms. Wasylycla-Lels: So the minister is saying he made a decision without the benefit of any evidence, any data, any scientific findings. This is simply something pulled out of the air because, as he is now saying, when a particular situation is put to him he has checked it out and come up with an answer. But surely to goodness one makes decisions in the first place based upon certain evidence, evaluation, research.

Yet the minister will not share any such information with us and we are only left to believe that this service, along with the other four or five services that this government is deinsuring, is occurring in the absence of any scientific medicine or any reasons to suggest that they are not medically required. Mr. Orchard: Mr. Deputy Chairman, I would not conclude that if I were my honourable friend. When the decision was made, the very issue revolved around psychoanalysis and the appropriateness of the resource being focused there and the necessity, et cetera.

There was never any indication that individuals who were receiving psychoanalysis were dangerously homicidal, as was alleged in the media last week.

Since that information was never brought to my attention in arriving at the decision to work with the MMA and the psychiatric association around the issue of billing-not deinsurance, as my honourable friend still persists in saying, but the billing of psychoanalysis under psychotherapy, which is what is happening-when that issue was never drawn to my attention, then all of a sudden members of the medical community are making that allegation, naturally I asked to have that statement checked as to whether it was accurate or whether it was an anecdotal reaction in the heat of the moment which may not accurately reflect the service delivery and the individuals to whom that service was being provided.

I am indicating to my honourable friend that upon posing that question, since it was never brought up as an issue around the discussion of psychoanalysis, it was then asked as to whether the statement was correct, and I am given to believe that is not an accurate statement as to the type of individual who is receiving psychoanalysis. It is not, as my honourable friend is wanting to paint, that we had not no information, et cetera. There was no correct information that these individuals receiving psychoanalysis were homicidal. Ms. Wasylycla-Lels: Mr.

Deputy Chairperson, let us be clear that it was the minister himself who said at our last sitting of Estimates on Thursday, when asked what services were being deinsured, and I li sted off a number of the m, he added psychoanalysis. So it is the minister himself who has put on record that psychoanalysis is being deinsured.

Secondly, let the record be clear that the minister has clearly stated in the past-a nd he is now trying to blur the issue- that no research or data had been collected or studies done upon which the decision to include this item on the list of deinsu red ser vices in the last bu dget announcement was made. It is clearly, as he himself said, something that is now being studied. The minister has said he is now consulting with the MMA and the psychiatrists' association of Manitoba. He did not consult with them first and then make his decision.

He made his decision and is now consulting and has no evidence to share with us for making this decision. I would like to ask him if he has had a chance to consider the very serious letter from Mrs. Sylvia Topper, a copy of which we all received today, expressing her concern about the move on the part of this government not to provide psychoanalysis as billable under the medicare system.

She makes a very good point, and I will quote from her letter: As a psychotherapist in private practice living in Winnipeg for almost 21 years and trained in psychotherapy with a psychoanalyt ical base, I have been continuously aware of the need in the province for additional psychoanalytic resources. Most psychotherapy is founded on the principles and theor y of psychoanalysis. Psychoanalysts, therefore, promote recognized standards of practice for psychotherapy in general.

Without the presence of analysts and their internationally accepted credentials, psychotherapy within this province will further deteriorate. Given that we are not talking about a very si gnificant bud get item for the present administration, there must be more to this issue than

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3455 the question of savings incurred as a result of deinsurance of psychoanalysis. ls the minister saying he is prepared to deal with and take responsibility for the logical outcome of this kind of a move, which is to probably cause our two psychoanalysts here in the province of Manitoba now to reconsider whether this is the best place to live and practise?

It seems to me that if we pride ourselves on having a quality health care system and we are looking at mental health reform and we are trying to provide a continuum of service, then it is an embarrassment for this province to be without psychoanalytical capacity whatsoever. I would think, notwithstanding the questions of savin gs, which are obviously very small, notwithstanding the questions of the minister's own views about psychoanalysis, is this minister prepared to take responsibility for one part of that continuum of service to be missing in the province of Manitoba?

Would not this Minister of Health agree that we should be doing everything possible to provide the full range of service and attracting such specialists to Manitoba and maintaining the small level of service we now have in this area? Mr. Orchard: Mr. Deputy Chairman, I think we can meet the best of both worlds. We can even accede to remedy the issue that Mr. Doer raised in Brandon in 19 88. Those two individuals need not leave the province of Manitoba.

Their services would be welcome at Brandon Mental Health Centre, Selkirk Mental Health Centre, just absolutely welcome, and we can serve both needs, patients in acute need in those two institutions, which we have had difficulty recruiting and retaining psychiatrists to. There is absolutely no reason why they ought to consider leaving the province. You know, I simply indicate that instead of providing services to approximately 10 0 people, those three could probably provide services to up to 400 or 500 people, maybe even more in Brandon and Selkirk. Mr. Cheema: Mr.

Deputy Chairperson, I do not want to interfere between the Minister of Health and the member for St. Johns. It is almost becoming a soap opera. The minister answered the question in terms of, you know, twist the whole thing and said, let us get this to the individual and ship them somewhere else. I think the issue is more important than that. It is the issue of what services are being provided, what is the definition of what we are discussing and whether that service is a necessity and that has been proven that service is a necessity. The psychoanalysis part of psychotherapy is an important issue.

Let us not joke around with the issue and get people to move from here to Selkirk or Brandon because we just want to spend 10 minutes talking about the same thing. I think it is about time that Mr. Orchard should say, well, that is fine, that is my policy and that is opposition policy and let us move to another source of questioning now. Ms. Wasylycla-Lels: I would be quite happy to move on. We are not, certainly, going to persuade the minister at this point.

He has made some decisions without the basis of good research and evaluation that he likes to talk about in other circumstances and he will not apply it in this case. I would like to know, and with respect to the Urban Hospital Council, what interface there is with the community health clinic side? •

(2050) Mr. Orchard: The interface, I suppose, would be through Regional Services in terms of having our regional director on the Urban Hospital Council. Ms. Wasylycla-Lels: With respect to the one working group that has to do with a specifically called location of community health within hospitals, are community health clinic people being consulted or included in that working group. Mr. Orchard: In which working group? Ms. Wasylycla-Lels: Location of communi ty health within hospitals. Mr. Orchard: I cannot answer that. We will try to answer that for you. Ms.

Wasylycla-Lels: I think we have clearly here a set of studies that, the topics of which have come out of either the minister's or deputy minister's office or the hospitals themselves. Could the minister indicate where the whole issue and theme of community health is being addressed in terms of this overall health reform agenda? Mr. Orchard: I am sorry. I missed the question. Ms. Wasylycla-Lels: This set of working groups under the Urban Hospital Council is clearly pertaining to the issues and concerns of hospitals and co-ordination at the institutional level.

Could the minister indicate where, in terms of all of these different areas of study and task forces, the focus for community health is being discussed in terms of necessary health care reform?

3456 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 1991 Mr. Orchard: Is my honourable friend suggesting yet another study? (Mrs. Rosemary Vodrey, Acting Chairman, in the Chair) Ms. Wasylycla-Lels: Madam Acting Chairperson, no, I am suggesting that we are having a hard time finding our way through this maze of studies to see a clear path toward community-based, preventative, promotion-orient ed healt h care ref orm. My question is: Is the focus all on one end of the equation, or is there another whole range of efforts being carried out with respect to community-based health care? Mr.

Orchard: Madam Acting Chairman, I am not sure I followed my honourable friend's question with clarity, but the Urban Hospital Council is just that. My honourable friend might recall that when she was decrying government for her verbiage of a $1 9 million cutback amidst increased funding, that that is when the Urban Hospital Council was formed to come around budgetary issues within the urban hospital. Part of that is linked to some specific areas within the Urban Hospital Council in terms of greater interface with the community. That is why we have our regional director there.

Continuing Care has a role, a potential role, in terms of early discharge, the early postpartum program and a number of other initiatives. That initiative does not stand alone. For instance, with the Health Services Development Fund, one of the projects that we have approved is the St. Boniface Hospital outpatient clinic program, one that my honourable friend the member for The Maples (Mr. Cheema) makes no hesitation, he said, that is a good one.

He is right, but that one is to bring a different level of service in a noninstitutional setting, in other words moving away from the institution and closer to the community. That is not part of the Urban Hospital Council. Ms. Wasylycla-Lels: That was not my question. Mr. Orchard: Well, what was your question? Ms. Wasylycla-Lels: My question was, I realize the Urban Hospital Council is considering a number of issues from the hospitals' perspective, particularly in the context of this government's request to ask hospitals to cut back $1 9 million from their base. We know from whence this document comes.

The minister has also touted this Urban Hospital Council to be unique in Canada, in terms of innovative policy directions, vis-a-vis health care reform. Madam Acting Chairperson, we know that any serious health care reform initiative must look seriously at community-based health care. I am asking where, in terms of all of these studies that are going on all over the place and the different pockets of activity, is the locus, the focal point, for developing community-based health care reform? Mr.

Orchard: I kind of knew that is where my honourable friend was wanting an answer, and that was what I was about to give her, but then, when she thought I was not giving her the answer, I thought I did not understand the question, but in reality I understood the question and I am going to continue giving her my answer. Madam Acting Chairman, let me deal with several issues-right off the top, community-based health care.

These build upon initiatives that we have already taken, like the crisis stabilization unit at the Salvation Army-I think my honourable friend supports that-l ike the acute crisis team, a number of initiatives in mental health. Now, with the Manitoba Hea lth Services Development Fund, that is one separate area of government. The freestanding outpatient centre at St. Boniface Hospital, that is to bring services into the community. I think that is what my honourable friend wants to know, what we are doing to achieve that. Well, that is one.

Let my explain -(in terjection)- Yes, it is, it is very much part of the question. She wants to move away from these high cost institutions and hospitals and towards a community-based provision of service. The freestanding outpatient centre that St. Boniface is studying will not operate without community support. So it is moving care to the community, which my honourable friend wants. That is one of those evil Health Services Development Fund projects for which we have signed a contract on deliverables, but it is operating and it is ongoing.

We are funding, under the Manitoba Health Services Devel opment Fu nd, Westman Rural Health Improvement Study, acronym, WISH. That is to take a look at the whole integration of health care service delivery in the Westman region, from the hospital, Brandon General, through our smaller community hospitals, through personal care homes, through home care, through public health, through community initiatives. -( interjection)- These are actually projects that are underway to bring services to the community, and that is what my

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3457 honourable friend asked. Is that not what you asked? Mr. Cheema: Madam Acting Chairperson, I think the minister is probably not answering the question of the member for St. Johns. The list has been distributed; we know the list was there August 3, 19 90. Mr. Orchard: Madam Acting Chairman, I am a little confused here. First of all, the member for St. Johns, on behalf of the NOP, asks a question. Then the member forThe Maples, the Liberal Health critic, says, well, you know, she did not really ask that question. She asked something else.

Maybe we should get the member for St. Johns to ask what she asked. Ms. Wasylycla-Lels: Madam Acting Chairperson, I would be happy to. It is just that I get a little tired of jumping in after every time the minister opens his mouth to try to get him back on the question. It is very frustrating, and it is sometimes not worth the effort of jumping in every time. I have gone on dozens of points of order in the few hours we have already been at Estimates.

I was asking the minister for not his usual presentation of these projects initiated, these announcements he likes to repeat time and time again, I was simply asking him for the overall plan in terms of the community side of things. We have the hospital side of things. I was asking about the community side. I am wondering if he intends the advisory network to provide that focal point, or if it is some other group. Is it the Centre for Health Policy and Evaluation?

I will not pursue that if the minister is not interested in that. * (21 00) I would like to ask him about-I found it quit e interesting in the shift from the original list of 48 groups to the now 26 working groups, that a number of the areas that are now out of the picture. I want the minister to know I am not calling for further studies lest he try to distort my comments from that point of view. Simply, I did note that some of the areas which are always part of overviews and studies and research on health care reform have been taken off the list, where there are possibly real savings.

I found it interesting, particularly the question of the review of hospital management levels was no longer on the list. The ques tion of doctors' remuneration was not on the list and a number of others. I am just wondering, is there some other place-does the minister have some other process going on to deal with those questions because, certainly, any health care reform cannot avoid the question of remuneration for doctors? Any savings in terms of our urban hospitals cannot avoid the question of levels at the management side of things. I am wondering how those issues are being addressed. Mr.

Orchard: Madam Acting Chairman, you see my honourable friend gets angry with me for repeating my answers, but my honourable friend is repeating questions. I mean, I explained this afte rnoon. I exp lained Thu rsday about the opportunity to get a Dr. Ginsburg up to do fee

schedule reform and factors around the volume issues. That is the forum, the opportunity to discuss the issues around physician remuneration in the province of Manitoba. I have said that, at least, on three different occasions to my honourable friend. She has asked again, so I will say again, when we negotiated with the MMA, one of the proposals we made was that we enter into a study around fee

schedule reform. The second issue was that we enter into a study to find out the factors driving the volume of services billed by the physicians of Manitoba. We intend to undertake both of those issues. The individual who we have a great deal of confidence in being able to undertake those studies at no cost to either party is a Dr. Ginsburg who is the pre-eminent, I am led to believe, expert studying methods of physician remuneration in the U.S. system and has more knowledge to contribute on the issue than probably any other individual. That is how we are getting around that issue.

Is that adequate to deal with that issue? I want to make sure, because if it takes more information, I will give it to my honourable friend. It must be all right. In terms of the management issue in hospitals, each hospital has to come to grips with their management complement. What we have done in terms of our departmental decisions is the majority of our layoffs within the ministry of Health have been middle management, management, management support individuals. We believe that example is one that the hospitals ought to take seriously.

They can do that internally with their own decision making, within their own respective budgets, because you cannot make the case that the management structure within an institution and any changes to it

3458 LEGISLATIVE ASSEM BLY CF MAN ITOBA June 17, 1991 have an impact on the system and should be studied in a collective manner. In other words, it is still an individual hospitals issue to investigate. Ms. Wasylycla-Lels: Can the minister tell us what directions have gone to each hospital in terms of their own exercises they are involved in on an individual basis in terms of cost reductions?

We have had the example of the Seven Oaks Hospital and the number of areas it is pursuing for achieving savings, one raised in the House in terms of the question of regrouping of personal care home beds within the hospital, which has caused some problems in terms of worries about patient care and certainly the question of job security for nurses.

What directions have the minister or the deputy minister sent-said it is okay to each hospital to carry on with their own cost-reduction measures, regardless of this Urban Hospital Council, which the minister has said has been put in place to address the $1 9-million cutback? One day he says it is-you know, when presented with examples, the minister says, do not worry, the Urban Hospital Council will be looking at all these issues and nothing will be done on an individual, ad hoe basis.

The next day, when asked about specific measures taken, the minister says, oh, that is se parate and apart from the Urban Council authority. So which is it? Is there any direction going from the minister? Is it a free-for-all, or is there any co-ordination going on with respect to savings in the short term? Mr. Orchard: The direction given to each hospital is that they must operate without a deficit. That is an instruction that was given to hospitals in 19 87 by the previous government. My honourable friend was around the cabinet table when that cabinet decision was made. We have continued with that policy.

Within that framework, the hospital management are given their management abilities. My honourable friend is trying to make the case that somehow the reorganization of long- term care patients within Seven Oaks Hospital is a decision that affects other urban hospitals. I say to her, that is not so. That is an issue which is within the management purview of Seven Oaks Hospital. It does not compromise patient care, as my honourable friend alleges. It has every opportunity to improve patient care.

As I have indicated to my honourable friend in the House and will indicate to her tonight, it is the same process that Victoria Hospital has just gone through and decided to expedite as a policy. Instead of having panelled patients scattered throughout the various surgical, medical wards and other wards within their respective facilities, they have made the management decisions that they will bring them together and place them in dedicated wards for panelled long-term care patients.

In that way they can change the staffing mix to approach the staffing which is available to those individuals at the personal care home level where they will be placed as personal care home beds become available. That means that the service that they will receive will be very much akin, and the program they receive will be very much akin, to the personal care home system to where they are going to be moved. That contrasts rather significantly to the current situation where they are scattered throughout the various wards in the hospital.

I am not reflecting upon those caregivers in those respective wards, but I think it is a pretty obvious conclusion that if you have the competing interest of a long-term panel led patient who needs the occasional talk, some bathing needs, food needs and assistance to walk, that patient in terms of the demands of other patients on the ward may well receive less than optimum care. That is not a reflection of the individual that is providing the care, that is a reality of a busy hospital ward.

We think and we agree with the management when they think that it is appropriate to put those individuals in a dedicated wing of the hospital and staff and program and deliver services appropriately, so patient care is not going to be compromised. In fact, I have every expectation it will be improved. What is at issue was the issue my honourable friend brought up about three weeks ago where she asked these questions and not once did my honourable friend mention quality patient care. She mentioned protection of union jobs.

Unfortunately, in this change around there will be-by the time it is implemented at Seven Oaks, I cannot speak for Victoria because I do not have knowledge-the prospect of some layoffs of nursing staff and hirings of nursing aide staff to fill the care gaps. That means that there will be possibly fewer nursing jobs. I think it is something like 1 percent of the SYs at Seven Oaks are affected. * (21 10 )

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3459 You know the reason why I described it as a win-win was that the patients win and the budget of the hospital is reduced. How can you go wrong with that? If patients receive better care and you are able to contain your cost within your hospital, is that not responsible to both the taxpayer and the patient who are often one and the same? I do not find anything particularly objectionable to that kind of a management decision at Seven Oaks. I reiterate, that is made without having an impact on other parts of the system.

I will go back and I will explain again to my honourable friend the reason behind the Urban Hospital Council. Approximately a year and a half ago when one of the major hospitals was going to face a deficit, mid-year, one of the proposals they made to the Manitoba Health Services Commission to come in on budget was to cur tail their che mother apy progr am.

Tha t would have contained their budgetary deficit and probably they would have come in on a balanced budget, but all of a sudden you have patie nts needing chemotherapy who simply would have been served in other hospitals at a cost to their budget, so you did not resolve the problem, you merely transferred it.

That is what the Urban Hospital Council is to come around in terms of the larger issues, so that decisions made within individual institutions do not simply transfer the budgetary and program problem to another hospital, that they make decisions which are good for the system , good for the patient and still stay within their budgetary goals. There are two agendas out there. There has always been the one agenda of the hospitals making their management decisions internally within their own budget, bearing in mind the no-deficit policy of some five years.

Today, which is new, unique and the first in Canada is the urban hospital concept where the system-wide issues are dealt with not in isolation by individual facilities, but rather together in the Urban Hospital Council environment where decisions which have an im pact potentially on other institutions are known at the table and will not be made causing a simple transfer of the problem and not resolving the issue. I think that makes for one of the most progressive planning opportunities in acute health care service delivery in Canada.

That is why I am rather dismayed that my honourable friend would want to try and destroy the credibility behind that process, where the CEOs of our major institutions are getting together to try and be partners with government in difficult decision making. It is the first time they have had the opportunity in 20 years. They welcome it, and I welcome it. It is not going to make the decisions any easier, but it is certainly going to make the process much more understandable and much more civilized, and much better-managed decisions will emanate from it.

There are two groups of people who will benefit, that is the patient and the taxpayers, and often they are one and the same. Ms. Wasylycla-lels: I will just have a couple more and pass it over to the member for The Maples. I just want to point out to the minister that it was the minister who first made the link between the Seven Oaks cost reduction exercises and the Urban Hospital Council.

When I first asked this issue on May 10 when we learned of the exercise that was underway, the minister's only response at that time was, do not worry, everything is being looked after, everything is being co-ordinated through the Urban Hospital Council. Then when the actual cut was introduced and staff were told of their pending layoffs, the minister then disassociated himself from those earlier comments and said each hospital must make their own decision. My concern is that all of these decisions have larger consequences and require some policy direction on the part of the minister.

I have not seen enough evidence to suggest that this is a win-win for patients. I do not know on what basis one can say the patients will get better care with a much lower ratio of professional nursing staff to patients. I do not know how one can say that this does not take us down a rather dangerous path in terms of a personal care home within a hospital as a longer-te rm solution to a serious problem. I think there are many unanswered questions. The minister likes to talk about his use of studies in terms of follow-up activity.

We have a major study done by his Health Advisory Network on Extended Treatment Bed Review. Nowhere in this report is there a recommendation for the creation of personal care homes within hospitals. Nowhere is there a recommendation for justifying or maintaining the serious level of personal care home beds we have now within hospitals. In fact, that study points out the need for action to be taken promptly to

3460 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 1991 reduce the number of personal care home beds within hospitals. So my question is still as I asked originally: Is there no overall policy direction from this minister in this department, in this government, on issues like these which, in the absence of such direction and policy attention, hospitals are making individual de cisions that are going to have long-term consequences for patients and for an overall co-ordinated reform system? Mr.

Orchard: One migh t in li stenin g to my honourabl e friend's com ment s come to the conclusion that panelled patients in acute care hospitals is a new phenomenon. Surely my-oh, my honourable friend just said no. Well, that is correct, it is not. For approximately, well, I do not know, I guess 15 years or more there has always been the use of hospital capacity to varying degrees within the institutions of temporary placement of panelled patients. Once they are panelled, there are obvious constraints as to how they can be kept living independently in the community through home care, although some of it is done.

So a number of them get placed in hospitals as an interim measure pending availability of a bed in a personal care home. That process of waiting can vary quite significantly, and it is not always varying because of a straight lack of personal care home beds, because some individuals wish to wait until they can be placed in the personal care home of their choosing. That has exacerbated the waiting time for placement in certain personal care homes. My honourable friend makes mention that the Extended Treatment Bed task force does not make mention of this policy or this initiative being appropriate within hospitals.

I dare say it did not mention it, nor was it designed to investigate that. They were designed to examine first of all extended treatment beds which were rehabi litative and chronic care beds in the hospital system of Winnipeg. They indicated shortly into their mandate they could not undertake that, narrowed a focus, and they asked if they could also study the issue around personal care home beds and we agreed. That report came in and, yes, it identified that we needed personal care home capacity. We knew that.

I knew that from the day I walked into the office and, to my chagrin, found out that the capital program for construction of personal care home beds had been frozen by the previous administration. Now, you know my honourable friends laugh, but that is a fact. You take a look at how long it took us in Winnipeg to start cutting the ribbon on newly completed personal care home beds, and you will note that without fail they were all commissioned for construction since May of 19 88 because there was not any in the works. •

(2120) Now, we have attempted to resolve that in part or in whole by a series of initiatives. I have dealt with some of them earlier on today. There is the temporary beds, the commissioning of the 88 beds at Deer Lodge. A commission of 60 temporary beds for personal care home use. There is the construction ongoing of 60 beds at Concordia Hospital. There is the redevelopmen t plan at Municipals and of course the personal care home construction proposal calls for the northeast quadrant of the city. So that all forms part of a very, very deliberately co-ordinated plan to try to resolve this problem.

This problem that is not new. This problem that has been around for at least a decade if not close to two decades. Within the context of how the individual hospitals manage their long-term panelled patients, within their facilities. You know, I quite frankly have to say to you that I think this initiative should have been done several years ago.

If there are those kinds of savings and improved patient care possible, it is pretty clear that we have not effectively been spending the budget over the last several years if they can achieve those kinds of savings by making this very basic reorganization within their bed capacities. In fact, I believe, and I stand corrected, is not Victoria actually opening some of the beds, or adding beds, to the number that they will have service? (Mr.

Marcel Laurendeau, Deputy Chairman, in the Chair) Those, coincidentally, are beds that were mandated closed in 19 87 for budgetary reasons by the NOP, and Victoria Hospital by reorganizing this delivery of service is in fact going to be able to recommission beds closed by the NOP. Now, again I do not think my honourable frien d would necessarily disagree with that unless she believes that when NDPs close beds that is somehow better and ought to remain.

June 17 , 19 91 LEGISLATIVE ASSEMBLY OF MANITOBA 3461 Mr. Cheema: Mr. Deputy Chairperson, I have heard with interest the minister's comment to the member for St. Johns (Ms. Wasylycia-Leis) , and I think the issue is more complex than what the minister has put forward. I mean no doubt we are going to save money, but are we going to have the same kind of quality care? That remains to be seen. We cannot make a judgment within five days of what has happened at Seven Oaks or at a given hospital, that we will have the same kind of care.

That means that previously those patients were not getting care, No. 1 ; and No. 2, as the minister has said, that means we have been wasting money. I think those issues have got to be resolved, and I do not think anybody has the answers right now; nobody has. Even the minister does not have the answer, because I do not think we will know the impact on the patient care. Putting them on one floor, or in one section, as the minister has said, and some hospitals are doing it very effectively as long as the physical space is concerned. Whether that could translate into patient quality care, that remains to be seen.

I think there are a number of issues surrounding the whole restructuring of the hospital beds. The first issue is the use of R.N.s. I mean if we are going to cut the use of R.N. services that means a part of the hospital will become basically a personal care home with registered nurses, R.N.s. Secondly, you are going to use the nurses aide, as the minister has said . That means definitely the chances for impairment of quality care. Also, from time to time all those panelled patients do change. I mean there is not any single category that this patient will remain in Level I, Ill, or IV.

It changes dramatically, and at times they get into acute problems. So I think those issues are still not resolved, and it will take some time to find out whether we are in a win-win situation, or we are just having one experiment in one or the other hospital. I want to ask the minister then , we have concentrated for so many hours on urban hospitals and we have not even touched base on the rural hospitals.

What will be the impact, or what specific areas of study is the minister looking at in terms of Brandon General Hospital, Dauphin, Swan River, Thompson--some of the major hospitals in the rural communities, and how they will fit into the minister's present policy of reorganization? Mr. Orchard: Mr. Deputy Chairman, only one of the hospitals my honourable friend mentioned, whose CEO is a member on the Urban Hospital Council is Brandon.

Dauphin, Swan River, Thompson are not, and again, though the gen eral parameters of no-deficit budget are in place with all hospitals whether they are urban Brandon or in the balance of Manitoba, rural and north, their program goals are to operate efficiently. You could take the goals for Health and Health Care and those are the objectives that our rural hospitals are asked to manage their budget and their patient service deliveries around. Mr.Cheema: Mr.

Deputy Chairperson, the minister is saying that the policy will be the same for both the urban as well as the rural hospital as far as the budgetary conditions are concerned. Mr. Orchard: As far as which conditions? Mr. Cheema: Budgetary conditions. Mr. Orchard: Well, all hospitals regardless of whether they are urban or rural or northern are mandated to operate without deficits. Mr.

Cheema: Can the minister tell us if he is aware of the physician management program in various hospitals, especially I know at a couple of hospitals which have initiated physician managem en t programs for early discharge of patients and making sure they are part of the team? That is being done in one of the hospitals and very effectively, I think. In fact, that may be playing a very crucial role in terms of encouraging physicians to discharge their patients early, so that the patient beds can be free, and that seems to be the general trend that most of the hospitals are moving into.

Certainly I think that is a very positive step. The physicians themselves have taken responsibility, showing that they are also concerned about the rising costs. I just want the minister to know that is being done also. Mr. Orchard: Mr. Deputy Chairman, I think that all of those initiatives have been contributing to that trend line which has made our utilization of acute care beds much more effective. Every time you shorten the average length of stay, you in effect add capacity to your acute-care side of your hospital system.

That is why it has been said by a number of observers, we have adequate acute-care beds serving the people of Manitoba. We have had this discussion in past years' Estimates, but every time, and I do not think there is a single exception that I can think of, at least in my time of planning, for instance, rural health care. I do not think there has been a single reconstruction of a rural hospital for which the bed complement has

3462 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 1991 not decreased and decreased quite significantly. Carman, for instance, constructed in 19 81 -8 2; I believe Carman was a 36-bed facility, somewhere in the high 30s, and they are now a 30-bed facility. Minnedosa has reduced bed count; Virden had. Manitou Hospital, for instance, we put a swing facility in there as we did in a couple of other communities.

Benito, wherein we replaced up to 14 acute-care beds with six to eight, juxtaposed to public health offices, physician clinics, diagnostic rooms and personal care, so that it is under one roof under one nursing station, et cetera. In each case we have reduced the number of acute treatment beds and that has been achieved through the co-operative efforts of many in the health care system, not the least of which are physicians, wherein they have participated willingly and in most cases with early discharge programs.

I would venture to say that it would absolutely shock anybody to wake up today after a 15 -year sleep and find out how quickly, for instance, by-pass surgery patients are up and walking. It is within 24 hours, and they are often discharged within a week to 10 days. Before, that took a substantial length of time in hospital. All of that has decreased the demand for sheer numbers of acute-care beds in the system. * (21 30) Mr. Cheema: Mr. De puty Ch air person , the member for St. Johns (Ms. Wasylycia-Leis) was asking a question on the issue of community health within the hospitals.

Can the minister tell us what specific plans they have, other than outpatient clinics, to locate the community clinics within the community hospitals? Mr. Orchard: That is a topic that the Urban Hospital Council is attempting to come to grips with. They have not developed any action plan or any recommendations to date; but, again, I repeat for my honourable friend, the reason why we have our regional director on the Urban Hospital Council is because she is the individual who co-ordinates, for instance, continuing care services.

Continuing care services are probably the leading community-based service which will allow early discharge of patients, whether they be mothers with newborns or post-surgical individuals or chronically ill elderly, who have been rehabilitated with a short stay in the hospital and need assistance to get adjusted back into the independent lifestyle of the home.

If I can answer my honourable friend in a long way, the interface with Community Health through regional services and the institutions offers to us the greatest potential of success at bringing more programs from the acute-care hospitals to the commu ni ty and to remo ve the ex cessive dependence on our acute-care hospitals to deliver care which could more appropriately be carried out in a fashion delivering equal quality and often lowered cost in the individual's own home in the community. Mr. Cheema: Mr. Deputy Chairman, I just wanted to pursue that with a few comments on the record about this proposal.

I think it is a very interesting phenomenon in terms of having community care located within the hospital, so that all of the elements can be put together. Patients, before they are discharged home, they know the service they will be provided, and then we can avoid the duplication of services which are, you know- there is a consultation done for Social Services, for example, when in the hospital, and then somebody else sees them outside the hospital. That could be done very easily. Also, it would be helpful to develop a program along to help the emergency rooms which is very effective.

Some of the patients could be seen in these inside community clinics, and community clinics where you have a physical space in some hospital that could be reused is a very important concept and it could work very well. I do not think there will be much opposition from any particular

section of health care providers, because the physician will still have the services. You have a community health worker; a community mental health worker; you have an outpatient clinic, for example, in any given hospital; so that could be a very good correlation with all the services. I think eventually that may be one way of taking the load off the hospitals too, and also making sure that some of the scarce resources are used.

I am sure that some of the established group of the practices may have some hesitation, but I am sure from the health care dollar spending that is probably a very good proposal and could fulfil! the community clinic concept, especially with your mental health reforms. The overburden of some of the emergency rooms can be relieved, specifically if you have a hospital where you have teaching programs. That could be a very good asset for medical students and medical graduates, to get some

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3463 experience in the community clinics which have been available in one or two hospitals but, I think, could be made more effective. We just want you to know that I think it is a concept that has been there in many, many jurisdictions, but as we say always, we have to dwell on where it is best for here in Manitoba. I think it could be probably, ultimately, we will end up having that kind of community clinic within the hospital system.

That way you are not threatening the other health care providers, but still providing the same care and asking them to participate in the system. I think that will also take care of further factors which are eventually going to come into play, the overhead expenses and from a physician's point of view, from a nurse's point of view, everybody else. If we put everyone els e under one roof, giving one a community clinic in each and every corner of the city, that will also help to take some of the pressures off, from the financial point of view, from walk-in clinics also.

I think people would rather go to a community clinic where they know that they can get all the services. I think those clinics could also have the use of so-called, you know, various physician extenders. As the minister has said, if the United States is the most vulner able heal th care industry where probably every third or fourth doctor, I stand to be corrected on this, has been sued for one or the other reasons, and there they have been making use of some of the nurse practitioners.

Some of the physiotherapists are making a good contribution and some of the physician extenders are being used in O/Rs where you do not need a physician to assist some of the services. I am sure some of the orthopedic surgeons would love that. That will help them to relieve some of the pressures, and I think there are only one or two states, I can provide the name of the states to the minister, where physician extenders are being used for O/R purposes, for special purposes, and this has been a very, very effective way of taking care of some of the medical needs.

I just want the minister to know that I think this probably will end up eventually to be one of the community clinics set up within the hospital system. Where you would have control, quality assurance can be maintained, because it is no secret thatwhen you are working in a group you always try to give the best care because you know somebody is watching over your shoulder and you have to prove your worth. That is a very, very effective way.

That is why most jurisdictions are asking physicians to work in groups because I think that is sort of a peer review almost every day, and that helps the tax dollars and I think quality care in the long run. Mr. Deput y Cha irm an: Appropriation 1. (

b) Executive Support: (1 ) Salaries $499,700. Mr. Orchard: Mr. Deputy Chairman, I thank the honourable friend from The Maples for his thoughts. Let me tell you that back in, I do not know, '88 or '89 I had the opportunity to-it is not quite the same as what my honourable friend is talking about, but I had the opportunity to visit a free standing outpatient clinic. It unde rtook many of the professional disciplines' work out of there, as my honourable friend has indicated. You had physicians doing not-for-ad mission surgery. You had, of course, nursing staff complement there.

You had physio and occupational therapy, pharmacy, so that basically it was a very interesting facility in that a pati ent coming in, for instance , for a not-for-a dmission surgical procedure would go through an orientation the day before to have explained what would happen, and the patient was actually walked through the system and explained how the day would go and what sort of services would be provided postdischarge from the facility. The next da y they woul d even arrang e transportation service if the individual could not arrange their own so that they had someone to bring them in and to take them home.

The one thing that intrigued me about the whole issue was their me thod of profes sional reimbursement. The American system, in a lot of ways, probably has the appearance of higher salaries and schedules for everyone. What they did here was quite unique. They followed, and I will deal with physicians here for instance, they had a fee schedule, I guess, which was comparable for the city they were in. The physician was paid a competitive fee

schedule but because the physician used the clinic for their office, the overhead was cover ed by the fac ility. There were varying deductibles that they would take off the fee schedules, so in fact if my memory serves me correct, the physician ended up with about 38 percent of the original fee schedule. The balance was built in to pay various overheads that were covered. The physician did not have to worry about billing, a pretty big issue in the U.S. system.

3464 LEGIS LATIVE ASSEMBL Y OF MAN ITOBA June 17, 1991 Should we pursue this issue here, I think my honourable friend can see some interesting discussions that have to accompany any such establishment in our care-delivery system in Manitoba, because the commonly guesstimated figures is that our fee

schedule reflects a 40 percent contrib ution to the physician's overhead for maintenance of office, et cetera, et cetera. * (21 40) Now if we are going to, for instance, have a community health clinic and maybe enhance its role so that you do NFA surgery and maybe some other procedures like that, if you undertake something-if you try to organize service delivery in that regard, then clearly if the taxpayers are putting the facility up, the capital cost of the facility and providing most of the staffing cost, then we would have to approach the physician reimbursement, as an example, from a different standpoint because otherwise we might have a pure add-on to the system without any cost-effective reflection in terms of the budget.

I simply say to my honourable friend that in a way, not completely, but in a way the St. Boniface Hospital Outpatient Centre Feasibility Study is trying to investigate a lot of what my honourable friend has put on the record tonight. I thank him for his contribution. Mr. Cheema: Mr. Deputy Chairperson, I think I just want to expand on a few things. It is very important that in campaigns all those promises are made and when the campaign is over we do not discuss those things.

It is very important to put that on the record that this concept could be rearranged according to Manitoba standards and Manitoba's ability to pay, and ability of taxpayers, and also above all to maintain the quality care which is very important. I think everyone would know that this is in a hospital setting, or in a larger peer group, and if you are working in an environment where you have to justify whatever you are doing it makes more sense and that has been proven effective.

Of course, in some areas as the He alth Main te nance Organization, it is called the HMO organization, some has been done in Ontario too but I think that is maybe a different concept that could be changed to some extent to make sure that the tax dollars are being used in the best possible way. Of course, when the new physicians are coming, each one's expectations are different, but the reality of the whole financial affair has to be taken into account. That is why I said that when the issue of the fee

schedule by the consultant is going to be discussed, I think that should be one of the topics, to see how some physicians or health care providers, not only physicians but the R.N.s and physios and everyone else would fit into a system that will justify the tax dollar but make sure that the community clinic concept is provided. I am sure some physicians would love to- some health care professionals would love to go into a system where you do not have to take 45 to 48 percent for expenses. Everyone outside the health care area will think physicians are making a killing and that may not be absolutely right.

You have to understand the total expenses they have to pay and some of the overhead and so many other obligations they have . They work as one of the major employers in the city as well. I think that should be taken into account. I do not want to go away from my original topic; I think I went a little bit away, but I think it is extremely important that we should have a community clinic concept to redefine now properly. We have four years and you know that is our Manitoba model, and it will fit one corner and let us try it.

It will not be very difficult to evaluate it because you have a certain group of patients could be taken right away. That is not something you have to wait for years to do. It could be done in collaboration with the centre for study or in collaboration with one of the hospitals. Day hospitals is a very good example. That is almost-not the same model but on a similar line-that model is functioning in some of the hospitals, how the patient would come. That does not fit the acute care need.

We have to find a community clinic concept that should be made in Manitoba and make sure we have at least some area where the patients feel confident and they know that they are going to get the best service and also the taxpayers would know that their tax dollars are being spent in the best possible way. Mr. Orchard: Mr.

Deputy Chairman, in the concept my honourable friend is talking about, too, there is, as I see it, the opportunity for-I am looking for the right kind of language so my honourable friend understands what I am trying to say-b ut the opportunity for multidisciplinary patient evaluation so that maybe not always, for instance, the physician has to deal with every patient, that nursing can take a sizable portion of the patient's needs, take care of those without accessing the physician.

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3465 That is very similar to the concept that goes back to the fall of 19 88 in terms of mental health reform. The entry point to the system of mental health services, and I know this is an unfair generalization but is intended to be via the physician or psychiatrist, particul arly the psychiatrist. That has been observed as being a possibly very ineffective use of highly skilled resource

whereas the case is made that a number of people had the opportunity to access service from a multidisciplinary team may, in fact, receive the intervention that they need and that would be most effective, for instance, from a registered psychiatric nurse or a mental health worker or a social worker. So what my honourable friend is talking about is that concept, I think, transposed to the hospital setting in terms of medical needs ratherthan mental health needs. Mr. Cheema: Mr.

Deputy Chairperson, I think the new conce pt has to be based not only on volume- oriented health care, it has to be on the multidisciplinary approach, as the minister has said and also on quality care within the hospital or joining the hospital in a community clinic concept. There, the question is going to come, how the financial incentives can be given to health care providers who take care of a

section of a community, so they are responsible in a way that they would encourage more prevention and a healthy lifestyle, so that time can be given to that. If the system is volume oriented--you know some of the aspects, and that is a reality of life. We know it, and whether the health care provider would admit it or not, that is the situation in some cases. As long as we are moving away from the volume-oriented system, I think eventually things can improve in terms of spending in health care and definitely quality care can be maintained.

It is an interesting phenomenon, but it still has to be developed, and it will have problems initially, but eventually I think things will work out in this regard. Mr. Orchard: I thank my honourable friend for his comments. Ms. Wasylycla-Lels: Mr. Deputy Chairperson, let me just further pursue this whole discussion on community clinics and tie that back to where we started off with Esti mates, and tha t is the reorganization of the department. The minister said this would be a good place to keep raising issues pertaining to the reorganization.

One of the things that the minister has repeated, vis-a-vis this restructuring, is the whole question of integrating institutional and community-based care. I am wondering precisely where that shows up in thi s reorganiz ation, wha t speci fi cal ly this reorganization achieves in terms of integrating community and institutional care. Mr.

Orchard: Well, again you know we did get into this-many of the examples I am going to give to my honourable friend are examples I provided to her last week, but I am fully prepared to discuss them again so that-let us deal first with Provincial Mental Health Services. • (21 50) We are attempting very much to have an integration of services in mental health under one responsibility, one reporting responsibility within the former system. I guess I best describe it that way rather than anything else.

Formerly, the system was organized around-for instance, the mental health workers in Regional Services would report to the then ADM of Regional Services. The mental health centres were a responsibility of the Assistant Deputy Minister of Mental Health Services. The Eden Mental Health Centre was a responsibility of the Rural Facilities co-ordinator at the Manitoba Health Services Commission, and the acute care psychiatric beds at our ma jor hospitals were the responsibil ity, reporting, I guess, directly to Mr. DeCock at the commission.

The attempt has been made to bring all of those service lines of delivery under one ADM. Now, when one takes a look at Continuing Care Programs, what we are attempting there is to focus program del ivery, which ranges from community-based programming such as continuing care or support services for seniors right in to integrate it with the institutional-based care of the personal care home services. That is where you see, under one ADM, the range of programs from chronic care personal care homes to home care rehab and support services.

We are attempting that integration from institution through to community-based services and services provided in one's home. We think that kind of an integration allows us to better plan our utilization of resources. It allows us to have the opportunity to more readily identify overlaps of service and gaps of service and replace one with the other.

3466 LEGISLATIVE ASSEM BLY OF MANITOBA June 17, 1991 Under the former system-and it is not a criticism of those involved in it because this was the natural tendency-you tended to have less rather than more communication between funding lines in the budget. This system brings those like-purpose funding lines together under the administration of one assistant deputy minister, with the opportunity for one ADM to make program and planning decisions and funding decisions from community through to institution.

That is an example of how we are integrating our program and service delivery to reflect a greater marriage and integr ation of community and institutional services. Ms. Wasylycla-Lels: I am wondering where the minister's thinking is at generally in terms of local community control and ownership. Mr. Orchard: Of what? Ms. Wasylycla-Lels: In the health area. Mr.

Orchard: Personal care homes throughout rural areas are generally sponsored by a community group, and they have a responsibility to bring a contribution of serviced land into the construction project, and then a board operates the institution, again, within the constraints of no-deficit budget. I am not sure I understand my honourable friend's question. I do not think that is what she was asking. Ms. Wasylycla-Lels: The minister may recall, at the outset of this set of questions, I was referring or picking up from the member for The Maples' (Mr. Ch eema ) commen ts, generally, in terms of community clinics.

I was specifically interested, first of all, in how the discussion around integrating institutional and community-based care dealt with that issue of community clinics, where the minister sees that whole area going. Part and parcel of this, of course, is local community control and ownership, involvement in a community's particular health needs. I asked that simply to know the minister's gener al policy direction. I would like to ask him about the whole que stion of district health development, since I understand there has been a moratorium placed on that.

I am wondering, given this focus, in terms of integration of institutional community-based care, why a moratorium has been placed on district health development. Mr. Orchard: Mr. Deputy Chairman, community health districts still have an opportunity to attempt to combine the initiatives or the service, the lines from a number of communities and bring them together. There is nothing preventing communities from doing that, and we are open to those kinds of proposals.

Since coming in, I believe- well, I am not sure, I cannot give my honourable friend numbers, but I know that we passed at lea st a couple of Orders-in-Council bringing district health services into the purview on the plan of the community. So that issue is one of ongoing planning. That is the whole objective behind the Westman rural health improvement study or the Westman Integrated Strategy for Health, the acronym WISH is they are looking at the Westman region. I started to explain that before supper, and I will not get into it again in the interest of time.

My honourable friend me nti ons a pret ty interesting topic, because she is wanting to know what involvement we are trying to achieve or attain orgetfrom individuals in, particularly, rural Manitoba in terms of their involvement with their health care system. At every opportunity that I have spoken to MHO and other rural organizations around the topic of heal th , I have emp hasized commu nity empowerment, individual empowerment, of taking control of their own issue. I made a speech about, I guess, a year and a half or so ago to Canadian Public Health Association who was in Winnipeg for their national convention.

I will paraphrase what I indicated to them. Over the past 20 years I think it is fair to say that individuals, because of the promise of a fully funded "free medicare system," have tended to vest over to that system responsibility for a lot of issues around their personal health status. We have developed the opinion that the system is there to fix me if I need it, and therefore we have taken maybe less due care and caution of issues around one's own personal health status. We have tended to neglect certain areas of exercise or diet or stress management or any number of other issues.

It has been a subconscious thing, I think, because we have come to rely on the health care system as always going to be there and always going to be able to provide the reparative restorative services that we may from time to time need. That is substantially different from the original vision of our medicare sys tem. Our medicare system was, I think, designed to prevent traumatic illness episodes, either illness or accident, from basically taking all the family's resources to provide

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3467 care to the individual, and it has moved into a much more universal program providing all sorts of support when one believes one needs it. Now that has also contributed to the cost drive. I can recall an opening of Estimates, I think it was 19 86 or maybe it was 19 85, where the then Minister of Health, Mr. Desjar dins, put together a slide presentation-I did not know that was a slide projector up there or a screen-to open Estimates, pointing out how we could not continue on this expenditure curve for very long because it was going to bankrupt the system. •

(2200) What I have been attempting to do at every time is to point out to individuals the necessity to take responsibility as much as possible for their own personal health status. I think that only makes good sense. If I can follow up on it, I know my honourable friend will be interested in answering further questions.

It fits into the whole genesis of this government of Healthy Public Policy where we are moving the issue of health beyond the formal spending within the health care system to beyond that to such issues as income, the economy, jobs, the environment, housing and a whole series of issues that are non-health related but very much major de terminan ts in the he alth status of individuals. There is a saying that good health adds years to your life and life to your years. I think nothing can say it better than that. Mr. Deputy Chairman: The hour being ten o'clock, what is the will of the committee?

Some Honourable Members: Sit. Mr. Depu ty Chair man: Sit. We will continue sitting. Ms. Wasylycla-Lels: Mr. Deputy Chairman, I cer tainly apprecia ted the mi nister's stated commitment to community empowerment and community-based services. However, my question still remains. I do not believe I have had an answer, and that is the current state of district health development. Where is it at? Are applications for approval under the provisions of The District Health and Social Services Act moving along? Mr. Orchard: Mr.

Deputy Chairman, as I indicated a couple of answers ago, where communities wish to investigate with the department the health district concept, we will provide them planning assistance, et cetera. Ms. Wasylycla-Lels: How many district health projects, for want of a better word, have bee n--h ow many are there? How many district health projects are there now approved under this legislation, and are there others in the works? Is there activity going on with respect to this area?

I know the minister has referred to the Westman Integrated Strategy for Health in terms of its study or its look at the question of providing a full range of services under health care and new models of delivery. Could the minister give us some idea of where things are at with respect to district health development? Mr. Orchard: I do not have the appropriate staff here to indicate how many. Ms. Wasylycla-Lels: Okay, I will come back to that. Mr. Orchard: If my honourable friend would ask that when we get to basically the commission line, I can provide her with that kind of information. Ms.

Wasylycla-Lels: I will raise these issues again at the appropriate time. I would like to go back to the line by line for this part of our Estimates when we first asked the question about the deputy minister's salary. When I raised this issue in last Estimates, I asked the minister what the deputy minister's salary was at that time, and asked him, although it was covered under MHSC, if it was the difference between $21 8,700 and $1 43,1 00, and the minister said yes. That would have meant the deputy minister's salary one year ago was $75,600.

However, it shows up as an actual for that fiscal year of $88,300, with an increase for '92, bringing his salary to $92,100. My first question is: Was there actually a jump in the last fiscal year from $75,600 to $88,300, or was the minister just-perhaps the minister had inadvertently given me inaccurate information in the last set of Estimates. (Mr. Gerry McAlpine, Acting Chairman, in the Chair) Mr. Orchard: I did not inadvertently do any such inadvertent thing.

I do not know the date when this process took place, but within the last year and a half or so, or-I do not know, is it about a year ago that Executive Council did the-about a year ago, Executive Council did a review of the deputy ministers, and the review came around such varying and dive rse factors as siz e of budget, the responsibility, et cetera, and put the various deputy

3468 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 1991 ministers into about, what- four rating categories or five, was it-I do not know, a number of rating categories. My deputy minister, because of the size of the department, size of the budget, complexity of the issues, the number of varyi ng and different programs that he is involved with, went into the highest rating group for deputy ministers. Other things such as length of service and other aspects also helped place deputies in various things. My de puty went to the top- Senior Officer 6 or 7?-Senior Officer 7 category, I think.

However, if it is 6 or 7, it was the highest category that was there. Tha t was not where he wa s positi oned -(int erjection)- Senior Officer 8? Senior Officer 8--a nd commensurate with that was an increase in the deputy's salary. From last year to this year, I believe, that reflects an increment which is available to all civil service, unless they have reached the maximum of their increment steps. Ms. Wasylycla-Lels: Can I ju st get some clarification that the deputy minister's salary has gone from $75,600 to $92, 10 0 in the space of one year?

I do not know what increase that is, but it is cer tainly a signific ant jump. I am jus t wondering-first of all, am I accurate? Mr. Orchard: You are accurate, if you see that it went from $88,300 for fiscal '90-91 to $92, 10 0 for fiscal '91 -92, and that is because of the increment that the deputy is-we ll, entitled to under the Civil Service Agreement. I will have you know I did sign that increment for him because I think he has done a lot of very, very significant work in the past year. Ms. Wasylycla-Lels: Mr.

Acting Chairperson, wi thout making any jud gme nts ab out the competence or capabilities of the deputy minister, it is still quite hard to justify that kind of an increase when at the same time this minister is part of a government that has chosen to implement a wage freeze for the lowest-paid members of our health care system, and imposed zero percent on health care workers, aides and attendants, who are also finding themselves with increased workloads and increased pressures and economic needs.

I just wonder how the minister can rationalize on the one hand that kind of incredible increase to the salary of his deputy minister and support his government's decision to freeze those at the lowest end of the health care system. Mr. Orchard: Mr. Acting Chairman, is my honourable friend suggesting that we ought to deny as a matter of contract the increments that are available to civil servants, because that reflects the change in this year's salary over last year. Is my honourable friend saying that the New Democrats would not only freeze the salary as we proposed, but also freeze the increments?

Because that is what she is suggesting. I have indicated that I gave my honourable deputy the increment this year. He is not going to get an increase, zero percent is what he is going to get, but he is getting the increment, as 40 percent of civil servants are getting. Is my honourable friend suggesting we ought not to give the increment to 40 percent of the Civil Service? Is that the NDP policy now? * (221 0) Ms. Wasylycla-Lels: I think for the benefit of the Minister of Labour (Mr. Praznik), he may have missed the point that in the space of one year we have seen a salary go from $75,600 to $92, 1 00.

We are not talking simply about an increment based on the general pattern across the Civil Service. We are dealing with a very significant jump in salary at the very same time that this government has chosen to by-pass free collective bargaining, override it, and impose its wage freeze, zero percent, on hospital workers, who are now at the lowest end of the pay scale, and who are having increasing difficulty making en ds me et and meeting all of their responsibilities.

My question to the minister is: How can he one day support that, we believe it is about over a 20 percent increase for his deputy minister, and a zero percent for the lowest paid in our health care system? Mr. Orchard: Mr. Acting Chairman, if other members of the Civil Service within the last year and a half have been reclassified, they have received an increase. My deputy year over year is receiving his increment. I find my honourable friend's position starting to shape up that the NDP want to deny increments.

Because that is the only increase my deputy is going to receive this year over last year, an increment that he and approximately 40 percent of the Civil Service are going to get. Is my honourable friend now saying the NDP want to deny the increments to 40 percent of the public service?

June 17, 1991 LEGISLATIVE ASSEMBLY OF MANITOBA 3469 Ms. Wasylycla-Lels: Perhaps the Minister of Health (Mr. Orchard) would like to tell us what increment health care workers, those at the bottom end of the wage scale are going to see as a result of this government's generosity? Mr. Orchard: Forty percent of them throughout the service, whether they be my deputy minister or an AY3 elsewhere in the system, if they qualify and have performed their duties appropriately they will receive an increment.

That increment is in the neighbourhood of 3.6 percent regardless of whether you are the lowest paid or the highest paid. That is what it amounts to. Again, is my honourable friend stating new New Democratic policy that they would deny those increments? I think I want to know that and I think those civil servants want to know that. Is that what you are saying? Ms. Wasylycla-Lels: Mr.

Acting Chairperson, is the minister saying that he is prepared to, on the one hand, defend with all his might this kind of an increase at the highest end of his department and provide no more than a zero perce nt-zero percent-a freeze on the hospital workers of this province, some 8,000 workers who are traditionally covered through the collective bargaining process which has been bypassed by this government? That is the issue we are dealing with, not the question of increments, but the question of this government's policy when it comes to health care workers throughout Manitoba. Let me go on to another question.

Could the minister tell us who the five individuals under the Professional and Technical category are? Mr. Orchard: Mr. Acting Chairman, you know my honourable friend wants to make her perverse little case without fact. When I go to correct her I know she will not accept it, but I want the record to show that increments will not be denied anyone who qualifies for increments.

Now, if my honourable friend is saying that we ought not to provide increments, then let her state that case because my deputy minister is getting a zero percent salary increase, just as it has been mandated by the legislation and applicable to all of the other professional staff that I have with me here tonight for Estimates. If they qualify for an increment, they will get the increment as do 40 percent of the Civil Seniice. Let my honourable friend not try in her meandering way to say that this increase is anything but zero percent, because it is zero percent on the salary. The increase reflects an increment.

Does my honourable friend understand that difference? If she does, then will she answer the question: Are you going to deny the increments to 40 percent of the Manitoba government employees who are taking zero percent on the salary? Are you going to deny their increments and are you going to deny increments to the hospital service workers? Ms. Wasylycla-Lels: Could the minister tell us what the approximate 8,000 health care workers covered by Bill 70 are going to get this year? Mr. Orchard: Where they qualify, the same as the Civil Service, they will get an increment.

Their salaries will be a zero percent increase as the salaries for MGEA are, but my honourable friend is still leaving the impression that the New Democrats would cancel the increments and I regret that. Mr. Cheema: Mr. Acting Chairperson, I will just have one question with regard to the salary. I just want the minister to clarify what was the basic salary in 19 88 and '89 and last year in '90-91 , and if this figure $75,600 was correct and now we have $92,000. I just want the clarification that it does not reflect on the deputy minister's capabilities.

I think we are just talking about the process and when the deputy minister is here, and any member of staff, when we are going to ask questions in no way is that a reflection on their capabilities. We are just asking basic questions. I just wanted clarification on that one point. Mr. Orchard: Mr. Acting Chairman, I cannot indicate what the salary was in '88-89 or '89-90, but as I indicated to my honourable friend from St. Johns, there are two things that have happened in the last year and a half.

First of all, a reclassification, and any time you have reclassification within the Civil Service, your salaries go up to reflect the equivalent positioning in the new classification. That is one aspect but what is reflected this year is simply the increment. I cannot give you off the top of my head what the salary flow has been, but we will get that for you before we pass, or even if we pass this line of Estimates, we will get it to you as soon as we can. Mr. Cheema: Mr. Acting Chairperson, just one comment. In my opening remarks, I made a

3470 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 1991 statement and that statement in no way should be undermined by any of the questioning, what we are doing here in terms of either the deputy minister or any of the minister's-any ADM in the minister's office. If we ask questions, they should please not be taken in a negative way. Mr. Orchard: I did not take any offence. *

(2220) Ms. Wasylycla-Lels: Mr. Acting Chairperson, could the minister give us the names of the five professional technical positions? Mr. Orchard: You want individuals' names for that? Ms. Wasylycla-Lels: Yes. Mr. Orchard: Okay, we will attempt to provide that to you. The re is Special Assis tant Ca therine Evenson-that is my staff; Executive Assistant Alan Hiebert. Ther e is the French Language co-ordinator, Lise Lacombe, and two of the five positions are vacant. One is the special adviser position to the minister, and the other is the senior nursing adviser which we have not recruited into yet. Ms.

Wasylycla-Lels: Yes, I just wanted to pursue what happened to Dr. Larry Wiser who was a consultant to the deputy minister, particularly involved in the MacDiarmid Report. Mr. Orchard: Dr. Wiser was on a one-year contract with government, and when the one-year contract was over and his duties performed, the contract expired. Ms. Wasylycla-Lels: Could the minister tell us what his one-year duties were? Mt. Orchard: One of his major roles was on the Technical Advis ory Comm ittee with the federal-provinical committees. Ms. Wasylycla-Lels: Mr.

Acting Chairperson, I understand he was also responsible for following up the MacDiarmid Report, something that both our Family Services critic and myself as the Health services critic are quite anxious to hear about. Let me just ask generally, where is the MacDiarmid Report? Mr. Orchard: Mr. Acting Chairman, I received the MacDiarmid Report some time ago, and we had a committee on implementation review some of the recommendations in the MacDiarmid Report. I received that a little while ago, a couple, three weeks ago or months ago. I am not too sure of the exact ti me.

We are working through some of the suggestions and recommendations because, as one can appreciate, some of them have financial costs attached. Ms. Wasylycla-Lels: We have a prime example of the minister setting up a committee to study a study or study another committee or to have the study of a study of a study, and in the meantime people of Manitoba, particularly those concerned about therapy services, are concerned about government action in this area. Could the minister tell us when we might expect to see a plan of action based on the MacDiarmid Report? Mr. Orchard: Mr.

Ac ting Ch air man, is my honourable friend saying that the announcement of about a year ago in terms of increasing the number of students in the faculty was not a reaction to the MacDiarmid Report and was not action taken? Has my honourable friend conveniently forgotten about that because that was good news?

That is part of the action taken, and as we develop budget, we will undertake further initiatives as the taxpayers of Manitoba can afford them or as recom men dati ons are made wh ere we can reallocate, reprioritize dollars within the health care system to refocus them on the issue of rehabilitative care, something that we are striving to do through a number of these initiatives and studies which hopefully will point the way to reallocating our health care budget to get more effective utilization and more effective improvement of health status from them. Ms. Wasylycla-Lels: Mr.

Acting Chairperson, once again the minister just chooses to avoid the question, which is some sense from this minister when we might expect to see an overall plan of action from a report that has been in the works for a long time, now being studied by another committee. I think it is certainly not too much to expect the minister to just give us some sense of his overall intentions with respect to that particular report. However, it is clear that we will not get any more answers with that if we try to pursue it. Back to the primary function that he said Dr.

Larry Wiser was performing, is he being replaced by anyone, or how is that function now being carried out? Mr. Orchard: Well, that was to provide input to federal-provincial committees. Ms. Wasylycla-Lels: Pardon me?

June 17, 1991 LEGISL ATIVE ASSEMBLY OF MAN ITOBA 3471 Mr. Orchard: That was to provide input to federal-provincial committees on technology. Ms. Wasylycla-Lels: My question was, who is replacing him in terms of that role? Mr. Orchard: We have not replaced Dr. Wiser. Ms. Wasylycla-Lels: The minister is saying Dr. Larry Wiser is still on contract doing that work? Mr. Orchard: I said we have not replaced Dr. Wiser. Ms. Wasylycla-Lels: Sorry, I think we are just having some hearing problems here. It must be part of the day and the focus. Do you have a question on this line? Mr. Cheema: Mr.

Acting Chairperson, I have been asking the same question for the last four times, and I am going to ask him again. Have they settled with Mr. Kaufman? Mr. Orchard: You know, it is with a great deal of regret that I have to revisit this issue of my honourable NOP friends, but fortunately, at least I think this is fortunately, we have asked probably well over a year ago that we wanted a reply back from Mr. Kaufman's legal counsel, so that we could begin to settle the issue. It has been a year now and we have not received any communication back from Mr.

Kaufman's legal counsel, so I simply say that we are sort of in limbo land awaiting a reply, and no indication of what the settlement might be can be proffered tonight. That is not our doing. I mean, we asked over a year ago for a position from Mr. Kaufman's legal counsel and simply have not received it. Again, you know, I simply reiterate, as I have done the last couple of Estimates, that this sort of points out that really a government, regardless of how long it thinks it is going to be in power, ought not to sign no-cut contracts with senior people. I mean, that ties the management hands of future governments.

It even ties the management hands of the existing government if for some reason the individual does not perform according to style. The NOP, under Howard Pawley, had the habit of writing these no-cut contracts. They did it for Mr. Kaufman. They did it for some people in the Manitoba Energy Authority. There were Volvos involved and all kinds of fancy cars. There were golf course green fees in Montreal for the CEO of Manfor, compliments of the NOP, Howard Pawley and the NOP. I mean, that kind of obscene abuse of the taxpayers' dollars is not part of what Manitobans want to have as public policy. Mr. Cheema: Mr.

Acting Chairperson, my question has been the same, and the minister's answer has not changed either. I think there is a very Important lesson from this to be learned. Hopefully, I think everyone should learn from this bad experience. As the minister said, fortunately, that issue would be resolved in the best interest of taxpayers, but still, I think it was under a lot of stress that people were expecting something could happen if that person did not secure another position in another province, so maybe that Is, fortunately, good for the people of Manitoba.

My question is to the minister again that the member for St. Johns has asked about. There are a couple of positions still not filled. One of them is special adviser, and the minister has said that person was on the federal-provincial technical committee. That was his role. Can the minister maybe redefine or elaborate on that particular point? Mr. Orchard: No, Mr. Acting Chairman, the one contract that was a one-year contract was Dr. Wiser. He is a special adviser to the deputy minister. The position that I indicated, which was one of five that my honourable friend for St.

Johns inquired about, was my SA's position, my EA's position, Lise Lacom be, the Fre nch Language Se rvices co-ordinator. The vacant position is my special adviser. That position has been vacant now, oh, I guess, for a year and a half. Mr. Cheema: I do not think you need any-you know your staff. Mr. Orchard: No, I know, but that position has been vacant for about a year and a half. There is one other vacancy in the staff complement of five, which we intend to use to fill the position of nurse adviser that my honourable friend might have recalled the discussion around on Tuesday last.

The special adviser, Wiser, was to the deputy minister, not to me. *

(2230) Mr. Cheema: Mr. Acting Chairperson, in the minister's executive support, has the minister ever thought of having a person with a health economy background advising the minister on the day-to-day operations and developing of policies which will be more economically oriented? Can the minister give

3472 LEGISLATIVE ASSEMBLY OF MANITOBA June 17, 19 91 some indication whether that will be a good suggestion? Mr. Orchard: Mr. Acting Chairman, we attempt to hire and recruit those kinds of individuals, but not attached directly to my office. Quite frankly, the salary ranges of my political staff, if you will, do not allow generally to recruit that kind of expertise. We have recruited that kind of expertise into our Policy and Secretariat. As well, if I can be so direct as to bring up the Centre for Health Policy and Evaluation again, a num

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Collection	Manitoba — Debates (Hansard)
Citation	35-2-66b
Type	hansard
Volume / chapter	35th 2nd hansardpdf 66b.pdf
Language	en
Format	pdf
Source	PROVINCIAL
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