Manitoba Hansard — Sitting 49B (35th Legislature, 3rd Session)

35-3-49b

Manitoba — Debates (Hansard)

MG-8048 Th ir d Session -T hirty-Fi fth Legislatu r e of the Legislative Assembly of Manitoba DEBATES and PROCEEDINGS (HANSARD) 39-40 Elizabeth II Published under the authority of The Honourable Denis C. Rocan Speaker VOL. XLI No. 498 • 8 p.m., TU ES DAY , AP RIL 21, 1992 Printed by the Offi ce of the Queens Printer. Province of Manitoba ISSN 0542-5492

MANITO BA LEGIS LATI VE ASSEM BLY Th irty-Fift h Legislatu r e Members, Constituencies and Political Affiliation NAME ALCOCK, Reg ASHTON, Steve BARRE TT, Becky CARSTAI RS, 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 GILLESHAM MER, Harold, Hon. HARPER, Elijah HELWER, Edward R.

HICKES, George LAMOUREUX, Kevin LATHLIN, Oscar LAURENDEAU, Marcel MALOWAY, Jim MANNESS, Clayton, Hon. MART INDALE, Doug McALPINE, Gerry McCRAE, James, Hon. MciNTOSH, Linda, Hon. MITCHELSON, Bonnie, Hon. NEUFELD, Harold 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. STORI E, Jerry SVEINSON, Ben VODRE Y, Rosemary, Hon. WASYL YCIA-LEIS, Judy WOWCHUK, Rosann CONSTITUENCY Osborne Thompson Wellington River Heights Radisson The Maples Kildonan Portage Ia 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 Inkster The Pas St. Norbert Elmwood 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 Liberal NDP NDP Liberal NDP Liberal NDP PC PC PC PC NDP NDP PC PC PC Liberal PC PC NDP NDP PC PC NDP Liberal PC NDP PC NDP Liberal NDP PC NDP PC NDP PC PC PC PC PC PC PC NDP PC NDP PC PC PC PC NDP PC NDP PC PC NDP NDP

24 13 LEGIS LATI VE ASSEM BLY OF MANITO BA Tues day, Ap rll 21, 1992 The House met at 8 p.m. COMM ITTEE OF SU PPLY (Con cur ren t Se ctions ) HEAL TH Mr. Deputy Chairperson (Marcel Laurendeau): Good evening. Will the Comm ittee of Supply please come to order. The comm ittee will be resuming consideration of the Estimates of the Department of Health. When the committee last sat, it had been considering Item 1. (

c) Evaluation and Audit Secretariat: (1 ) Salaries. Mr. Nell Gaudry (St. Bon iface): Mr. Deputy Chairperson, this afternoon I received a letter from one of my constituents and a copy went, I believe, to the Minister of Health (Mr. Orchard). We will put some of the comments on the record. His letter says: I am writing this letter to you to raise what I believe to be a deficiency in the public health care system in this province. The case involves my fathe r, currently 75 years old. He is in need of a hip transplant and is currently on the waiting list for surgery at the Health Sciences Centre.

The surgery had been originally scheduled for September after about a two-year wait, but with the recent delay, I understand resulting from lack of fu nding , the surge ry has been dela yed to December. To be fair, the gentleman called me this afternoon, and he has been given a date of October 7. I understand that the principal criterion defining emergency versus elective surgery in this sense then is the issue of mobility. Simply, if the person is im mobilized by the hip, they go to the A list, if you will. To be truthfu l, my father is technically mobile.

However, there is a quality issue that, in my opinion, should be considered. For example, my fa ther is an Anglican priest and has been forced to curtail many of his activities, performing services for only a certain period. He can endure the pain of standing on his feet for only a short period. He has done most of his ministry to seniors, both those shut in and not, performing a valuable service unpaid to society. He is unable to do this as frequen tly. It continue s: I could continue the litany of examples, but I trust that my point is made. Because he is technically mobile, he is on the 8 list.

Here, in my opinion, are two ironies to the situation. First, I have a 92-year-old grandmother in a nursing home, virtually a vegetable, who would be operated on tomorrow if she were to break a hip. A productive member of society has to wait. A second irony is that the cost will be the same for the operation if it is done now or later, so why delay it? Finally, while I would prefer the operation being performed locally, there are other options available out of province which our medicare system will not fund, so my father and those like him continue to rely on expensive, potentially damaging medications and wait.

I am concerned with cost constraint and cost control. I pay substantial taxes- •

(2005) Mr. Deputy Chairperson: Order, please. Can I ask you to pull up the mike? The answer is not very clear. Mr. Gaudry: I am concerned with cost constraint and cost control. I pay substantial taxes and laud the efforts to keep them reasonable. However, I also concern myself with where the money is being spent. I certainly advocate spending the dollars where they make a difference to society. I fail to see where delaying so-called elective surgery provides any net gain to society where the individual conce rned is a productive memb er putting something back into that society. One final note about my dad.

He does not complain, he endures. He happens to be a veteran and saw so much suffering in the war that he feels lucky that he is not worse off. I believe that many examples such as my dad are out there. My request is simply this. Change the priorities from taki ng care of the budget to taking care of the people. My dad will probably not live another ten years, but society owes it to him and to those like him to make those years the best they can be. I am looking for special treatment for my dad, you bet. He and those like him deserve it. The inevitable response from the offi cialdom will undoubtedly be,

24 14 LEGISLATIVE ASSEMBLY OF MAN ITOBA April 21 , 19 92 sure, but who is going to pay for it? Most of us, myself included, who watch our loved ones suffer the humiliation, the personal embarrassment and anxiety needlessly, would pay more taxes if it would make the difference . I hope that you can help make the diffe rence. Would the minister comment on the process fo r this kind of request from constituents who request on behalf of their parents? Hon. Donald Orchard (Minister of Health) : Mr.

Deputy Chairperson, that is not an unusual letter the Minister of Health gets in the province of Manitoba today, five years ago; that a Minister of Health gets anywhere in Canada, today, five years ago, the difference being that it is getting probably more commonplace that these letters land on ministers' desks. Let me give you the dilemma. I have every sympathy with the individual for whom you are bringing that case forward .

Ten years ago, maybe I am wrong in my years, but there was a time when medicare came in that this individual would not have had a service which could be accessible under any program to help alleviate the suffering from joint deterioration, hip and knee. That is one of the absolute quandaries that ministries of Health are facing in this province and across Canada, because we have an insured system which has brought, as a new procedure which we will pay for under the health plan, such technological innovations as joint replacement.

It was not there, I do not believe, as an original insured service 20, 25 years ago when the system came in. It was, quite fran kly, probably not considered. * (201 0) This is joint replacement, hips and knees, today. We are going to be f aced over the next decade-and this gets us into the issue of pharmaceuticals. There is another area where there are going to be very na rrowed and poten tially effective pharmaceuticals coming on the market. I do not have the prices in front of me. I thought we might get in this debate when we reached the Pharmacare line.

This new generation of pharmaceuticals is several tens, if not several hundred dollars, per dose. Under an insured health care system, once they are there, there is an automatic expectation that they should be made available to those to whom the process, the pharmaceutical, the procedure is prescribed. That is why, right across Canada and, indeed, North America, we are faced with an incredible dilemma of costs in our health care system. Take the compassion aside. Take the obvious desire that this family has, this individual has, to have their mobility reinstated. That is very, very natural.

The difficulty that it puts the system of health care provision is that reinstating that mobility is now proposed in terms of medical need. It is no doubt going to alleviate suffering, increase mobility, increase quality of life. Many procedures will do that, all of which are going to be demanded of the taxpayers. I have ofte n said, the changing technology and the basic miracle medicine that we can now practise in North America and Western worlds will continue to drive our costs, so that we truly will not be able to afford a publicly-funded, universally acceptable health care syst em.

I do not think I am stating something that is alarmist; I think I am making a statement of fact. In this particular case, the family say, well, raise the taxes, and I mean, they are sincere, because they would believe that would be appropriate if that is what would be required to cover the cost of this operation. But, boy, I will tell you, one of the messages we get when we detach ourselves from the individual circumstances across this nation and this province, no exception, is that the citizens across this country are saying, we are already being taxed at too high a rate.

We cannot deficit finance the system, because that also is a significant challenge and problem that all of us acknowledge. We cannot continue to deficit finance current consumption. I mean, all it is is a tax on our children and grandchildren. So it is one of those dilemmas. The way we manage it is we provide budgetary allocation which will allow a maintenance of program at a minimum and, hopefully, some expansion annually in terms of the program . That does not allow access to the system as quickly as a number of individuals who are prescribed the procedure are able to access the system.

I mean, there are significant waiting lists in both hips and knees. * (2015 ) There is some inconsistency in that waiting list that we found out when we took a look atthe process at Health Sciences Centre with them undertaking their annual budget and more dollars within the nine months of the 12 -month funding year. Some doctors have significantly higher procedure waiting

April 21 , 19 92 LEGISLATIVE ASSEM BLY OF MAN ITOBA 24 15 lists and, hence, longer waiting times. Although the suggestion is made from time to time that maybe your constituent here ought to seek a reference to another physician, hopefu lly to access the system quicker with a physician who is not as busy as possibly the one he has been referred to, but that is a partial solution, because all the other physicians are under the same constraint of accessing operating time.

I guess, I have to indicate to my honourable friend that amongst the many demands on the system that are made for elective surgeries and for funding of any numb er of very worthy and worthwhile programs, we have in general terms placed more money at the disposal of those programs over the last few years. There have always been requests for a greater level of funding, and that will never go away. That will be here as long as we have a publicly funded health care system. It has been traditional for 20 years; it will continue.

It is part of the resource allocation decisions that we are asking physicians to try and come around the issue on behalf of their patients because this government, and I speak apolitically here, does not have the unlim ited funding ability to provide the surgical capacity to deliver all of the knee and hip surgeries that are certainly being recommended across the province. Mr. Gaudry: Could the mini ster tell me who establishes the priorities for the surgery, for example, at the Health Sciences Centre? Mr. Orchard: I am going by what I understand to be the system.

We allocate a global budget figure to the Health Sciences Centre. From that, they will divide that budget amongst the many program areas that they have over at the Health Sciences Centre, part of which is an orthopedic surgery program which involves knee and hip replacement. The orthopedic

section will receive an allotment of, I believe first off, surgical theatre time, access to the surgical theatres and, of course, part of the global budget. That process is undertaken by senior management coming around the global budget issue and making the allocation as they best can, given the clear indication that there has not been, nor will there probably ever be, an infinite budget which they can access, so that they, the prof essionals, in terms of management and physicians, try to make the best allocation resources decisions that they can around the global budget that is provided to the faci lity. Mr.

Gaudry: For example, this man had been on a waiting list for two years, and then he was given a date of December. Now in the last week he has been given a date of October 7. Is this because they are doing more surgery lately, or is this that he has been established as a greater priority than he was the other time? Mr. Orchard: I cannot answer that, but I would suspect that the December date, the individual may well have been part of the decision process which said they would suspend knee and hip operations for the last three months of the year, although December is the fourth month.

About the end of November they had utilized their bud getary allocation decided on the first of the year on knees and hips, and they ran into the end of December actually with over-budget allocations, allocations beyond what was originally budgeted at the start of the fiscal year. •

(2020) I cannot indicate whether that clearly is the reason, and if I have a letter in the office I will try to make that determination, but I would suspect that this individual's surgery no doubt was cancelled in December because of last year's circumstances of doing the program and more in nine months versus 12.

The rescheduling, and this one I am more clear on, would have been made by the physicians in terms of a prioritization of the patient load that, I believe, seven surgeons or eight-it is somewhere in that number of orthopedic surgeons doing hips and knees at the Health Sciences Centre- they would make an effort to prioritize their patient waiting list to make sure that the most urgent needs are cared for first, or are served first, and they have developed their internal assessments so that there is some hope for consistency in that approach at the Health Sciences Centre.

I might add to my honourable friend that that is one of the issues that we are asking Dr. David Naylor and the head of surgery-am I using the right terminology at Health Sciences Centre and St. Boniface ?-th e vice-presidents of medical at Health Sciences Centre and St. Boniface ; and Dr. MacKenzie at Victoria General Hospital to come together along with assistance from Dennis Roch, out of this area of the department to try and develop some consistency around selection of appropriate candidates for the surgery and prioritization along the waiting list between fac ilities so that there is some consistency.

24 16 LEGISLATIVE ASSEM BLY OF MAN ITOBA April 21 , 19 92 Another thing that we find is that sometimes the waiting list can be not necessarily accurately reflective of the waiting because, for instance, when we investigated cardiac by-pass surgery a couple of years back, we found that even though there were only two hospitals offering the program, we found common patients on both hospital waiting lists and that may well exist here too. Mr. Gaudry: Yes, I thank the minister for his answer, and I will give him a copy of the letter so he knows which one we are talking about.

Changi ng-not gears, because I will go too fas t--the minister knows very well that we have met several LPNs in the last six weeks to eight weeks and met some again last week from St. Bonifa ce. Their concern was the fact that, to me there are rumours that they want to close down the LPNs in St. Boniface and do away with them. Can the minister indicate what is going to happen with the LPN, firstly for my own St. Boniface Hospital? Mr. Orchard: I guess we could go over this ground for the fifth time in these Estimates and about the tenth time in the House, but that is all right. I have all kinds of time.

The issue came up at St. Boniface because of a discussion in, I believe, late November 19 91 at the board level at St. Bonif ace, where consideration was given to curtailing enrollment in the licensed practical nursing course as offered at St. Boniface . I believe memb ers from the MALPN were either at the meeting or were informed of that meeting. That led to a significant concern over the issue, a press co nfe rence by the associatio n in mid-December. I answered at that time that I was aware that the issue was being discussed at St.

Boniface Hospital at the board level, but they had not asked for direction from government or approval from government even though government is not necessarily the final decision-maker there. Subsequent to that discussion and some, I think, requests for informati on, et cetera, the issue did not conclude with the closure of the school of LPN nursing, and they will be accepting graduates for the foreseeable future.

Now, there is no-1 will try to be as direct as I can-c ommitment for permanent operation of the school, but plans for the closure of the school for the interim time have been defe rred, and students are being accepted into the program . *

(2025) Mr. Gaudry: I will ask one more question, because my associate here has asked me if I was taking over. Mr. Deputy Chairperson, to the minister, has the minister arranged a meeting with the LPNs in the near future? Mr. Orchard: When that question did not come up this afterno on, I provided an answer without being asked. I indicated that I am attempting to set up-1 wanted to have a meeting as soon after their Thursday general meeting of the membership back about three and a half, four weeks ago. My time

schedule has simply not allowed me to get together, because we have been in Estimates and I was away for that week. Yes, I want to meet as soon as possible. As a matter of fact, my appointments-my secretary and I discussed it again and she is attempting to fit the

schedule in the very near futu re. Mr.Gaudry: One final comment. Yes, the fact that in the last couple of days the honourable member, well, the of ficial Leader ofthe Opposition (Mr. Doer), has been waving the flag to me that there is going to be a layoff of some 500 em ployees in St. Boniface. I was wondering if the minister maybe can indicate to me where those 500 jobs are going to be affected in St. Boniface in the health care services? Mr. Orchard: You have a rumour that I have not heard. Mr.

Gaudry: I just wanted to put it on the record, because I do not think anybody wants to see 500 jobs lost in the health care, and I think the minister hims elf, and all my other colleagues in the Legislature. I thank the minister for his reply. Mr. Deputy Chairperson: Item 1. (

c) Evaluation and Audit Secretariat: (1 ) Salaries. Mr. Guizar Cheema (The Maples): Mr. Deputy Chairperson, I do have a few questions. I was sort of worried there the member for St. Boniface was really taking over. Everybody wants to be a Health critic, and I would love him to have this portfolio. Can the mi nis ter ask his staff to get this in fo rma tion ready for the Health Ser vi ces Commission Estimates? Discussion on the waiting lists in various hospitals of the various surgical procedures, because that has been an issue that comes up many times.

Each and every person has his own waiting list and each and every person who is affected by the delay in surgery has a number of other reasons to ask for. I think it will be worthwhile to have the full discussion on how the waiting lists

April 21 , 19 92 LEGISLATIVE ASSEMBLY OF MAN ITOBA 241 7 are taking place, and if there is any co-ordination and how this system can be improved. I think it will require some modification to the staff. My question on the issue of the nursing education, that part of this evaluation branch is to provide support to the minister's Council on Nursing Education. During the last week's debate in the nurses' union, it was clear that they wanted to know where the nursing profession is going.

Even though I did not get any particular sense from the floor also whether which direction they wanted us to ask him questions, because it was probably not very clearly defined in my own mind, I just want to ask the minister: What is this government's policy in terms of the nursing education, whether the minister's own policy direction is to go along with to have the BN by the year 2000, or is there a different approach by the Minister of Health? *

(2030) Mr. Orchard: The nursing education issue is one which is a very complex one. There is a whole dynamic of requirements that are impacting on the system. Move to community care-that is why we are moving for instance with the registered psychiatric nurses towards a new curriculum in both the two-year and the four-year baccalaureate program, because we see in mental health and we have the lead time and the window of opportunity to craft an educational course which is reflective of the move towards community-based care.

I do not think there is any question that that will require a differently trained nurse in psychiatric nursing, and the association has taken up the goal and the challenge and has been working with government for over two years, probably two and a half years, to try to get some sense around the educational programs for psychiatric nursing. We had to agree to disagree about this time last year, budget time, with the consolidation of Selkirk school into Brandon, but it was done with the overview that we work on an enhanced education system for psychiatric nursing in Brandon, both diploma and baccalaureate.

I think, although I would not be so naive as to say everybody is 1 00 percent happy today, there is considerably less concern about the future of psychiatric nursing today than ther e was a year ago with the consolidation of the schools, because the rumours abounded then as they did in '84-85 when the Portage School of Psychiatric Nursing was closed that government had the psychiatric nursing profession in their sights and were going to remove them from the health care system. Well, I think we have clearly indicated that that is the exact opposite of the agenda of the government in terms of psychiatric nursing.

I will try to deal with the nursing issue in general, and generalities are alii can offer, I think to maybe try to get some sense of where we are heading. When I came into government in '88, amongst many issues there was the overriding issue of a report which was endorsed by MARN as our professional body for registered nursing in Manitoba, acceding to BN entry to practise, year 2000, and the regular and constant request of government, both the previous government and of course myself as the new minister as to whether we were going to adopt that goal of entry to practise BN, year 2000.

I was unable and am still unable to endorse that as a goal for registered nursing. However, what we have done in the past four years is set up what is a process which I do not think necessarily was there in the past to try and bring as much professional expertise around the training program as possible so that we develop curriculum, training program and capacity to meet future needs. The key question is: What are the future needs? I mean, what kind of trained nursing professional do we need five years out, 1 0 years out in the Manitoba health care system?

The best guess that we are trying to put to paper is the survey that we launched in January, which we hope will indicate what kind of care professionals are needed according to the facilities assessment of health care five years out or the managers of the facilities assessment five years out, so that we can then commence planning with the respective asso ciations the appropriate curriculums, No. 1 , and the appropriate graduate or enrollment capacity, so that we can take that cyclical up and down out of nursing recruitment.

That is not a perfect process, but it is really the only process that I know of that can maybe give us some clear direction on where nursing as a profession ought to set its goals in terms of curriculum and graduate capacity. One thing I want to avoid, and I started alluding to it before the break at five o'clock. I think there are a lot of people who are now questioning, asking the very direct question: What happened to the shortage of nursing? As we sat in Estimates two years ago, there was no question that we were being told almost weekly, if not daily, that there is a

241 8 LEGI SLATIVE ASSEMBLY OF MANI TOBA April 21 , 19 92 shortage of nursing, that they are leaving the province, that conditions for nursing are terrible. Part of it, I will admit, was build-up to the contract negotiations, and that is fair. I mean, that is the kind of dynamic that we will always have. You are not going to avoid that. What we did do in June, I think of '90, was we launched in co-operation with MARN an advertising campaign on television to try to encourage individuals into the nursing profession.

Within two or three months of the new contract coming in, all of a sudden we did not have a nursing shortage in the province of Manitoba. I think probably, without exception, vacancies that were there before the new contract was signed are no longer vacant. Thompson, I understand, had some recruitment problems, and they do not have recruitment problems now. What is happening-and this is a very real problem.

I have had phone calls from concerned parents who have daughters or sons that are in the nursing programs, and they are questioning, you know, where did the job opportunities go, because we understand new graduates are not facing a buoyant job market, and I think that is right. It is not only the fact that maybe the shortage was overstated two years ago, but I think economic conditions has a lot to do with it. More nurses are coming back into the labour pool. Maybe the spouse has been laid off or is unemployed or between jobs.

The sheer financial pressure of families are bringing, I think, maybe more nurses into the work force, and secondly, those that are already in the work force are taking more hours of work or as many hours of work as they can. Clearly, the shortage is no longer there. Now let us speculate. Would there be a shortage, if the economy was booming and there were lots of job opportunities in the private sector? I think you might see, as has happened in the past, nurses opt for careers outside of nursing- real estate, whatever-because they are skilled people.

But right now we do not have a shortage of nursing that I have been informed of in the province of Manitoba. I think there are applicants for jobs, vacancies on a pretty regular basis, but that is quite a different contrast to two years ago. If at all possible, and I say if at all possible, I would like to be able to develop some sense of two, three, four and five years out as to what our needs are going to be and the market survey demonstrating what our training needs are going to be.

If government is going to have a role in providing the training and if the professional associations are going to have a role in terms of encouraging people to take nursing as a career option and train for it, there has to be some attachment to employment and the needs of the system.

The system is not going to perfectly Identify those needs, but we are certainly hoping the survey gives us a good, decent indicator so that we can use that information in our planning of educational capacity, and, indeed, depending on what the survey says, it may well guide us in terms of the type of professional training that is needed, whether there will be the emphasis by the system in one area or another on BN versus diploma versus LPN versus nurse's aide. Mr. Cheema: Mr. Deputy Chairperson, in his opening statement, the minister made a remark on the mix of services and the mix of health care providers.

Can the minister tell us now how the role of nurses will fit into the new community-based program, because some changes have to be made? More specifically, is the province thinking of having the role of RN as a nurse practitioner? Alberta has made those recommendations and they are saying probably within two to three years, they may have a specific definition of nurse practitioner.

To do that, as I understand, our Canada Health Act or the regulation under the act does not really allow that so far, because they think that the health care provider who is going to be paid on a fee-for-services has to be a physician or in a similar category. So there may be some changes that have to be made. I just want to ask the minister, what are his government's views on the role of nurse practitioner in Manitoba in the future? •

(2040) Mr. Orchard: I want to tell my honourable friend that I had heard the terminology but, I have to be very blunt, I have never had a reasonable explanation of what a nurse practitioner was and what their role was until, as luck would have it, I am at Agape Table this fall and while I am there, an individual, a woman, came over to me, introduced herself as a nurse practitioner.

She had trained as a nurse practitioner out of Ontario, and apparently the professional designation no longer exists in Ontario, I think is what she indicated, and she no longer had a professional role which utilized her training skills as a nurse practitioner. Basically a very interesting conversation, and this individual made the case that the nurse practitioner

April 21 , 19 92 LEGISLATIVE ASSEM BLY OF MAN ITOBA 24 19 as she was trained would offer a significant amount of pre-patient scree ning for instance in the physician's office, and considerably enhance the ability for quality patient flow through the office because they were doing certain things.

Now, that intrigued me, and although there are many issues on the go, this one has not been specifically fast-tracked or identified, but I have made enquiries within the ministry as to whether the nurse practitioner role should be investigated, similar to nurse-anesthetist, because nurse-anesthetists practice just to the south of us here in the United States. I think in a reformed health care system offering more community care, I do not think there is any question that the nursing profession will pick up a much larger role. I do not think that is even questioned.

The one thing that we do not know, and this is always the classic $64 question, is what sort of training standards various care providers ought to have in providing those community-based services, because I just want to remind my honourable friend that one of the very interesting recommendations coming out of the British Columbia Royal Commission on Health Care was their observation that one of the greatest concerns or one of the greater concerns-! will not say greatest-they could foresee in the health care system and its affordability and its ability to deliver services is the overprofessionalization of care giving.

That clearly sends a pretty direct message, I think, to all of us that, as we move toward, say, community-based care that we do not insist on, for all cases, an unaffordable professional trained individual. That is going to require quite a little bit of discussion and insight into how we staff and how we deliver care in the community. That being said, I see a fairly insignificant enhanced role for the nursing profession in community care. (Mr. Gerry McAlpine, Acting Deputy Chairperson, in the Chair) Mr. Cheema: I have a few other questions, but I have to make a phone call, a very urgent one. If the member for St.

Johns (Ms. Wasylycia-Leis) would like to ask a couple of questions, I will be back in two minutes if it is possible. Would that be okay? An Honourable Member: Sure. Mr. Cheema: Otherwise, I do not want to lose the floor. An Honourable Member: No, go ahead. Ms. Judy Wasylycla-Lels (St. Johns): I am never short of questions. I would be happy to ask a few questions at this point and also take the opportunity to indicate to you that we are hoping to move through some lines this evening so we can get to some of the major areas of public concern and controversy.

Let me go back to an area that we touched on this afternoon and ask if the minister has had time to review the Urban Hospital Council working group that is working on staff mix and ask him how that fits into the MALPN study and all other reviews and endeavours in this whole area of nursing, education and staff mix in our facilities. Mr. Orchard: My staff inform me that they were unable to put together that information, but we will have it for Thursday. So if that would be acceptable to my honourable friend, we can have that sort of discussion even if we have to revert back temporarily. Ms.

Wasylycla-Lels: Since we are dealing with this whole area of evaluation, I am wondering if the minister can give us an indication of the impact and the evaluative process that would have been undertaken presumably with respect to the recent fairly sizable increase in personal care home rates. Mr. Orchard : You mean the per diem? [interjection] We went through the calculation as has been done since 197 4 or whatever to establish the per diem.

The per diem is established to leave something in the neighbourhood of, give or take, depending on the days, the length of the month, because it varies between a 28-day month and a 31-day month, approximately $110, $115 above the pension. You start from the basic starting point; then you set your per diems based on sole source of income being pensions. That is the way it has always been done, leaving the individual with somewhere in the neighbourhood of, for average figures, $115 maybe $120 per month for personal needs. Ms. Wasy lycla -Le ls: I appreciate that explanation.

What accounts for the fact that such a significant increase occurred in one period of time? Is it the fact that there was no regular increase on a year -to-year basis or that there was a change on the pension side to account for the jump from roughly $20.50 a day to $25.25 a day? Mr. Orchard: April 1, 1992, the rate is $24.90-do we have the

schedule that goes back? That represents 35 cents a day. It has not been $20 as

2420 LEGISLATIVE ASSEMBLY OF MANIT OBA April 21 , 19 92 a per diem probably since maybe '85 or '86. The increase has been quarterly now for about seven years, I think. It used to be adjusted on an annual basis, but now the process when I came into government in May of '88 was that it was adjusted on a quarterly basis. That had been the process for three or four years prior to that on the criteria of allowing so much minimum disposable income. •

(2050) There has not been an increase overnight from $20 to $25. Here are residential charges in effect since July 1 973. They started at $4.50 in July of '73, and now 20 years later are $26.30. To give you an exam ple: They have increased by 25 cents quarterly to 35 cents quarterly in the last little while. The last time it was $20 would have been in November of '88, actually August of ·� 1990. Ms. Wasylycla-Lels: Perhaps it is just my own confusion around this issue. I am certainly not trying to raise an issue here that the minister has to worry about in terms of a hidden agenda.

All I am trying to do is understand the current Order-in Council, which set the rates in the beginning of May of 1992 at $25.25 a day, and then going up some 35 cents a quarter. My question is basi ca lly, prior to this Order-i n-Council and the increase for May of 1992, the last increase by Order-in-Council was February 1989, where it went up to $20.50 a day. Mr. Orchard: There would have been an Order in-Council circa this time last year to set the rates.

I have brought in one Order-in-Council per year, and we try to bring in that Order-in-Council so that it is passed, I believe, by March 31, so that there is a month of notice time until the eff ective rate increase, I believe, on May 1 of each year, and then thereafter every three months there is a quarterly increase reflecting one month af ter there is a quarterly increase in the pension. That is the circumstance that has been-as I say, that was the process that was in place when we came in to governmen t in 1988 of quarterly increases reflec ting.

That was brought in shortly after the federal government changed the pension to a quarterly increase. I think that goes back seven or eight or so years ago. Mr. Cheema: Mr. Acting Deputy Chairperson, the issue of the RNs, I would like the minister to look into the issue of nurse practitioners from Alberta. The proposal has been made to the Minister of Health in Alberta, and it is my understanding that the role of a nurse practitioner in Alberta might take two or three years for them to have really a nurse practitioner as a practising part of the health care team in Alberta.

There is one more issue there: whether the nurse practitioner is going to be paid fee-for-service per patient, or are they going to be on a salary basis? I think that is where the Canada Health Act comes in . There may be some changes that have to be made or some kind of amendment, or the regulation has to be changed in terms of are they going to be paid fee-for-serv ice, and specifi cally when we are going to have a mix of services. You do not want to add on services. You are going to have the role of nurse practitioner, a very specific one, and especially in a community clinic setting.

They will be screening patients and doing a specific job, so that job should not be added on, as has been in the past. You release a patient, and the three health care providers who were serving the patient in the hospital, they are doing the same thing in the community. That does not really save any money in the long run, so I think those things have to be qualified and make sure that their role is specifi ed, and I would like the minister to look into the issue from Alberta because they have done substantial research and work on the issue. Mr.

Orchard: Yes, we will try to get some details from Alberta that maybe we can share later on in the Estimates process. I will stand corrected if I am in error here, but I do not think that the Canada Health Act is an issue here, because I think anyone who is consideri ng-let me put it this way. With the discussion I had at Agape Table with a nurse practitioner, that individual, when employed as a nurse practitioner in Ontario, was in a salaried position. There was no fee-for-service connotation at all to the discussion I had, and I have never heard that broached bef ore.

I would never give consideration to nurse pract itioner s coming in to the syste m as a fee-for- service potential arrangement. It would be under the basis of a salaried position, like for instance, in most of our community clinics-no, I should not say this, but a goodly number of our community clinics have salaried positions even, let alone the other care prof essionals that they have there. I do not think that is an issue; however, I will see whether it is. I will try to seek advice on that.

April 21, 19 92 LEGISLATIVE ASSEM BLY OF MANITOBA 2421 Mr. Cheema: When the system is changing and if those things are not taken into account at the beginning, those things become an issue in the long run. I think that is why it is so important to have a clear idea on the role of nurse practitioner and how that role will fit into our system because, as the minister has said, and many people are asking, there even has to be compensation changes for the physicians. (Mr.

Deputy Chairperson in the Chair) So if we are going to have add-on services on what we are already paying, then it is not worth it, so it has to be a specific role, a defined role, and should be a substitute to some extent, not an add-on cost to the system . When the system is in the community care, those roles have to be explored and a very essential one it has to be because, when so many patients are going to come to the community, their visits to the physician probably are going to increase if we do not have another alternate midway system put in place.

I think that is why it is so essential to look into that aspect from the beginning, so that you do not end up in a system where you are paying three times the normal stay in the hospital, the same thing, as many people have said, when you release a patient into the commun ity who would need 24-hour high-care services, so basically it is costing the same money as it would cost in the hospital, because all those services were never me ant to be a total replacement. They were supp osed to be a substitute for some of the services.

I just want the minister to realize that is a practical problem that has to be taken into consideration. Mr. Orchard: That in a way is reflective of the discussion we are into in terms of midwifery, because that can be a valuable replacement service and I have stated, I think quite clearly, that my consideration of midwifery as a professional discipline of choice for women is that it be made available, not as an add-on cost, but as a replacement cost to the system.

The same kind of criteria would apply to consideration of nurse practitioner, or for that matter any other new prof essional discipline that might come into the system. They have to replace a regime of service in a more economic fa shion. That is the only way that I think we can have some sense of ensuring that the patient receives care and that the taxpayer is not unduly burdened.

That is always tough because when you get into these kinds of discussions, there is always someone on the higher level of tier delivery in training who believes that their opportunity to provide services and earn income are being compromised by the additional skills being offered by nurse practitioners, or BNs versus RNs versus LPNs versus-and I mean it is right through that whole spectrum of training turf protection. * (21 00) Mr. Cheema: The reason is that the ma ny individuals and the many organizations are really worried.

They are saying, well, each and every person is talking about community care, and when you do not define it properly and you do not have the system put in place where each and every group has a specific role and at lesser cost. Otherwise, we will end up in a major problem and we may end up spending the same amount of money. So I think those things are a very real concern. You want a different system, you wanted a system which more efficient, that will cost less, but the roles have to be defined from the beginning. Otherwise it may take another five years to change what we have started now.

So I just want the minister to know. Many health economists are saying that is a real possibility. That is why people are not jumping right away. Let us start the community care without doing all the research, without putting everything in place, making sure that the health care provider who will fit into the program will have the training, they have a future in the long run, and have something to fall back on.

So I think that those are the very real and major concerns because it could cause ministries to fall very easily if you have 200 patients released in that community, and 200 of them are seeing a physician every day, and it is costing more than would have cost in the hospital in the long run. So I think those things have to be taken into account. My next question is in terms of midwif ery. The minister has made some comment about the issue of midwifery. Can the minister give us an update where we are in Manitoba at this stage? Mr. Orchard: Mr.

Deputy Chairperson, as we dig out the status on midwifery, I want to just indicate to my honourable friend that community care and community-based services have a wide range of interpr etation and understanding. There is no question that in some individual circumstances the provision of care in the community for independent living is probably more costly than an institutional

2422 LEGISLATIVE ASSEMBLY OF MAN ITOBA April 21 , 19 92 care regime. We have made the choice in some cases that this is an initiative we are going to take because there is a quality-of-life factor there that cannot be replicated in the institution, and recognize that these are costs that are probably higher than institutionalization would be. Those are exceptional cases.

I think where you will see the movement of patient from our high-cost institution to lower-cost institution in community, I think you will find that there is an assessed need of the patient that is very adequately met in the commu nity and, in fact, that the admission to hospital or the occupancy of an institutional bed in an acute care hospital or otherwise is inappropriate. There is more cost-effective care delivery in the communi ty which , as well as being more cost effective, is also very much superior care and more desirable to the individual. Now, midwif ery, let me just flip down to the bottom line.

Right now, the working group that was struck in June of last year has fou r subcommittees formed. They are pr act ice, curricu lum, legal and consultation. Currently the working group is identifying and exploring key issues pertinent to the introduction of midwifery in Manitoba and consultation is occurring with experts in the field from Ontario and Alberta.

Discussions are underway between the chair of the Manitoba working group and key individuals in Ontario and Alberta and health and welfare Canada to explore the possibility of a national workshop to address issues of shared im portance such as portability of midwifery qualifications. We are hoping that the working group in the subcommittees will be receiving their input from the key stakeholders as well as the public and will be submitting a report to me in fall of '92 as to whether we imp lement and, if so, how we implement and what sort of process they would recommend to us. Mr. Cheema: Mr.

Deputy Chairperson, after the report in the fall, when can we expect the legislation to be brought forward after the consultation to make sure that midwifery becomes a legalized practice of health care profe ssionals in Manitoba? Mr. Orchard: Mr.

Deputy Chairperson, I cannot give my honourable friend that kind of indication because I do not know what sort of recommen dations the report is going to make to me but, as I indicated to my honourable friend earlier on, one of the preconditions I put on this is that it become not an add-on to the cost of the system, but rather a replacement of service which has all of the regular attachments to it of assuring safe and quality care delivery so that I simply am unable this evening to prejudge what sort of recommendations we would make.

I will say this to my honourable fri end, that the reason we are proceeding with a working group is with the obvious desire to bring in midwifery as a care option in the province of Manitoba that we think has an opportunity to contain costs in the system and provide a birthing method of choice that a number of women in the province of Manitoba have expressed an interest in and the desire to have available to them. I share that desire. Mr. Cheema: Mr. Deputy Chairperson, one of the functions under this secretariat is to draft a new health discipline legislation.

Can the minister tell us, are we going to receive during this session The Mental Health Act II, the community component which was supposed to be coming forward , because when we are changing the system as the minister would see it, there is going to be a need to have a community mental health regulation put in place to make sure that the reform becomes effective in the community. Mr. Orchard: No, Mr. Deputy Chairperson, we are not anywhere close to having that sort of legislation.

I have to say to my honourable friend that the pressures on my staff over at the Mental Health Division are such in terms of advan cing the mental health reform process that I think they are putting modest effort only into the consultation and meeting process on

part II amendmen ts that we discussed last year. Mr. Cheema: Mr. Deputy Chairperson, can the minister tell us if he is bringing any other legislation during this session in terms of the health care profess ionals, not only physicians, but the other health care providers? So many of them have expres sed their intentions that some of the regulations are very old, that some of them may need some amendment s and some of these changes. We are hoping the minister will bring such a legislation so that those concerns can be heard and the changes can be made.

Without real change in health care delivery in terms of the health care providers, it will be diff icult to get the best possible care eventually, because when we are changing so many things, you have to make sure that the health care prof essionals are also along the same line. * (21 1 0)

April 21 , 19 92 LEGISLATIVE ASSEMBLY OF MANITOBA 2423 Mr. Orchard: Mr. Deputy Chairperson, it is my in tention to advance amendm ents to the professi onal acts of dentistry, optometry, this year, and hopefu lly they will be introduced very shortly.

I just indicate to my honourable friend that the pattern for amendm ent was the pharmacy profess ional act that we passed last year, a process involving a more effective disciplinary screening process and then the option. of the public hearing process and of course often increase in fines because they are out of step, but basically the path laid down with the successful pharmacy legislation will be emulated as closely as possible if not identically in both dentists and optometrists, in terms of their profes sional act.

Then my honourable friend is aware of the minor amendment that we are making to The Denturists Act to remove me as the person responsible for advancing complaints against individual memb ers. Mr. Cheema: Mr. Deputy Chairperson, a final question on this

section is can the minister tell us if there is any internal audit going on in any of the major branches within the department? Mr. Orchard: You are asking for something other than the normal audit process that they go through, like whether we have any special audits ongoing. I will have to seek advice on that. For this fiscal year, we propose major audits for mental health, environmental health, a registration system, administration and finance, continuing care and personal care home panelling. Those are the five areas that we are proposing major audits on. Mr. Cheema: Mr. Deputy Chairperson, a final question.

As a politician you always say "final," but it is never the final one. Can the minister tell us what is the complement in terms of the affi rmative action at the senior level within the Department of Health, in terms of how many visible minorities, how many women's groups, and how many aboriginal people have reached the middle management or the higher management levels in the Department of Health? Mr. Orchard: I will give you a

summary of target group representation as of March 19 92, and bear in mind that in some of these areas the designation is by choice of the individual. If an individual chooses not to be in one of the categories, they are not; 76.8 percent of our total employee complement is female, 4.6 percent is native, 3.1 percent disabled, and 3.5 percent visible minority. Mr. Cheema: Mr. Deputy Chairperson, are we meeting the target set by the Department of Health in all those areas? Mr. Orchard: I guess, yes and no, not that I am wanting to make ligh t of the issue. We are significantly over the long-range target.

I do not know how we have a long-range target of women, 50 percent, in the ministry, but that is what it is, or I gu ess that is across gove rnmen t. We are significantly above that, but we are below by approximately one-half on native. We are better than one-half way there for visible minorities, and we are slightly under the half in terms of physically disabled. Ms. Wasylycla-Lels: A few more in this area-l am still confused, I must say, about the personal care home rate increase.

The Order-in-Council that was passed on April 8, 19 92, refers to amendments to regulation 506/88R, and that regulation brings us up to date to February 1, 19 89, at $20.50 a day. Mr. Orchard: Mr. Deputy Chairperson, I do not know why my honourable friend would not have access to the regulation that would have been passed effective for the '91 -92 fiscal year. (Mr. McAlpine, Acting Deputy Chairperson, in the Chair) There has been regulation passed each year. This year the rate is 35 cents per quarter.

Last year it was 55 cents per quarter because all residents received a GST rebate which we factored in to leave disposable income roughly at the-w ell, it ranges, depending on the month, from a low of just under $10 0 to over, well, one month $1 75, but that is an exception. The average is closer to $120. It works out to a yearly average of $1 18 projected for this year. It was $141 last year; it was $1 30 the year before ; it was $128 the year before ; it was $122 the year before that; it was $1 20 the year before that, $1 33 before that.

Last year was exceptional in that even with a 55-cent quarterly increase versus anywhere from 25 to 35 that it has been over the last few years, the average disposable income last year went up, even with the 55 cents which was reflective of leaving that kind of average income in the individual's pocket. The decision was made for policy reasons that we would increase the per diem reflecti ng the GST rebate, the argument being quite frankly the same as it has always been-1 do not think it has changed significantly-t hat all the individuals' shelter, food , pharmaceuticals, and all their needs are covered,

2424 LEGISLATIVE ASSEMBLY OF MANIT OBA April 21 , 19 92 and the per diem is only approximately, maybe-it would not be a 20 percent offset of the total costs, somewhere between 15 and 20 percent of the total offset of costs. There is obviously an Order-in-Council missing in my honourable frien d's files, because the Order-in-Council last year reflected 55 cents per quarter. I believe, if I am not mistaken, the first triggering of that, because of sheer timing and getting Treasury Board approvals and whatnot, I think, was June 1 instead of May 1. It was one month delayed last year. Ms.

Wasylycla-Lels: I appreciate the patience in correcting my information. I had simply looked at the regulation listed on the coveri ng page of the Order-in-Council indicating 506/SSR being the most recent regulation. I will ask the minister afterwards, and perhaps we can clarify that. • (21 20) Mr. Orchard: Mr.

Acting Deputy Chairperson, that covering letter, I think, has to be incorrect because I have passed that Order-in-Council every year about this time of the year to make the new regulations, in fact, and always accompanied by a letter to the personal care home facilities indicating what the new per diem rates will be, because this is a source of income to the personal care home program. I do not know why that would say 88 because I know I have passed one each year, ma ybe not at exactly the same time but at approximately this time of the year.

We will try to straighten that out for Thursday as to what was the reason for that reference in the covering department. I never noticed it when I brought it in. Ms. Wasylycla-Lels : Jus t a cou ple of ot her questions. Based on the role of this branch in terms of analysis and evaluation, can the minister indicate what the increase in supplies is expected to be for health care facilities this coming year? Mr. Orchard : I do not know whether we have an estim ate-can I provide that in formation on Thursday?-because I think clearly there is going to be a difference between the estimate and what we are funding.

I do not think we are going to be in a position to fund the complete supply increase, I think that is fair to say, but I will try to provide firm information on Thursday. Ms. Wasylycla-Lels: The minister references a concern that I have raised in the past and obviously is part of my question now, and that is with the roughly 5 percent increase that the minister says is going to hospitals.

It does get back to my question and ties into what analysis has been done by this branch in terms of impact, how hospitals will handle a 5 percent increase if one accepts what the minister said previously, that out of that must come pay equity adjustment, and I am still waiting for the minister's figures on that. Out of that mu st also come the regular adjustments for incremen ts, reclassifications, adjustments, benefits and so on, as well as, of course, any negotiated settlement, not to mention the increase to cover inflation vis-a-vis supplies and hospital equipmen t.

So all of those figures are important in this whole exercise, and we look forward to the minister's information because, as it now stands, it would appear that in fact the government has not moved much from its position of zero percent for wage increases as a basic guideline when one considers all those different factors. Could the minister indicate how soon we could expect to get some of that information and be able to have some understanding of just how serious the situation will be with respect to our health care facilities? Mr.

Orchard: My honourable friend wanted a projection on supply costs, and I am going to try to get that for her, but I did it at the risk of getting my honourable friend back on the process of let us deal with hospital budgets tonight and the next request being the exact dollar that we are providing every hospital. Clearly the roughly $53-million increase to the hospital line is representative of approximately a 5 percent budgetary increase on the hospital line. I mean, that is irrefutable. You cannot get away from the mathematics of that.

It is, as I have indicated to my honourable friend, not what the hospitals requested. They want more. We are unable to provide them more, but for relative comparison, approximately 5 percent more to be allocated across the board for all purposes in the hospital system of Manitoba, be it increments, be it pay equity, be it supplies, be it salary increases, be it on and on and on. Approximately 5 percent of the disp osal of the hospital li ne is a sign ificant improvement over, for instance, Ontario, which has provided a 1 percent increase this year, and I mean it is real, and Saskatchewan who has given a

April 21 , 19 92 LEG ISLATIVE ASSEMBLY OF MAN ITOBA 2425 preliminary indication of about 2.6 percent less in the hospital budget. Now , Ontari o and Saskatchewan are not magically devoid of the increments, the supply costs, the salary negotiations, the operating costs because they are in Saskatchewan or because they are in Ontario. Ontario has pay equity, which has been significantly underfunded by decision of the government. They have provided approximately $24 million or $25 million to the entire hospital system in Ontario as a contribution towards pay equity.

We have been significantly more generous in our base line funding so that, when it comes to a relative comparison, I will put our funding this year and past years, our funding commitment to our hospital system, in comparison with anybody else, but clearly, from the standpoint of monies available, we are asking hospitals to provide us with options as to how they can provide patient care with limited budget dollars. We do not have unlimited money to put in. We do not have $106 million additional to put into hospitals; we only have $53 million. That is going to mean some management choices.

We have talked about those management choices in Estimates before, and some of the policy directions that I think are to be explored will be explored in terms of managing our hospital system. I think one of the issues that came up last week at Seven Oaks Hospital was a management decision that did not compromise the volume or the quality of patient care, but it achieved a significant saving to their budget. Those are the kinds of management initiatives that the ministry has gone thr ough. We col lap sed Health Se rvices Commission into the ministry of Health into one operating ministry of Health.

That led to 55 fewer staff at the end of the exercise-tough decisions. There were people we knew, people I knew personally, some of them. Those are never easy decisions, but I will say to you today, it did not compromise our ability to manage the health care system as the ministry of Health. I believe similar decisions can be made in our funded institutions without compromising patient care, and that is what we are asking to do because we cannot afford operating budgets which have buil t-in savings that can be achieved without compromising the patients' access to quality care. Ms.

Wasylycla-Lels: With respect to this overall branch, is this the part of the department that is responsible for the consolid ation of all of the numerous, too numer ous to mention, studies that are out and about as a result of this government's initiative? Mr.Orchard: In large part, yes, but not exclusively. • (21 30) Ms.

Wasylycla-Lels: Could the minister explain, with all these studies out in the field-and obviously it is getting difficult to keep track of them since the minister has some trouble recalling even some of the studies he rel eased in his own pres s conference-why at this point the minister would even be considering a parallel body to the Urban Hospital Council and even considering establishing a rural hospital council, as he indicated at his last press conference on this matter? Mr. Orchard: I guess I would have to ask the simple question: Why not?

I think there is some sense that only the big boys-the old boys' club, as my honourable friend calls them-get to provide advice around the issues. There are many ma nager s and boar d memb er s who have expressed the concern to me: What are we? Are we chopped liver because we are not Winnipeg or Brandon? They want to be in on the process of decision making. We agree. It is taking a little longer to set the process up, because we are talking about a more diversely spread out group.

It is relatively easy to get together the CEOs of our Winnipeg hospitals and the CEO of the Brandon General Hospital; but, if you start talking about a rural hospital council, each facility is not going to have representation. It is going to go by region and hopefu lly with the balance of representation from the region. It is into the discussion that we talked about earlier on today. We have to have a forum of discussion around delivery and care issues which go beyond the narrowed focus of the individual facility in rural Manitoba, be it long-term care, be it acute care hospital.

There has to be a greater integration with our regional services in those communities. It has to be a greater opportunity for co-operation between commu nities, so that regions of the province can advance plans for care delivery which provide a wider spectrum of services to their citizens closer to home. That will mean, in some cases, moving those services from the city of Winnipeg to rural Manitoba and to northern Manitoba. To come around that issue, and clearly that has been recommended by many people, there is a process

2426 LEGISLATIVE ASSEMBLY OF MAN ITOBA April 21 , 19 92 by which-and we went through some of the steps of it earlier today of making that happen. Now it is not going to happen very directly if every single institution zealously guards its role without consideration of change, of dynamics, of reform in the health care system. It is so very easy for a Minister of Health to say no to any given individual institution for a request which is beyond the guidelines for the area because in making decisions there are always guidelines, if you will, that the ministry establishes for various service provisions.

It is easy for a Minister of Health to say, no, I am sorry, as an individual community, you do not qualify. It makes the job an awful lot tougher if several commu nities get together and present us with a shared-communi ty plan, and that is where we are trying to have the com muni ties move in co-operation. We think there is a great opportunity for success in that process. A counterpart to the Urban Hospital Council can be very, very instrumental in bringing the leaders together in a decision-making forum-the leaders from ru ral and northern Manitoba in a decision-making forum. Ms.

Wasylycla-Lels: A counterpart to the Urban Hospital Council for rural Manitoba does not appear to be consistent at all with the interim report of the rural task force report. I will certainly be interested to see the final report, to know whether or not that is a recommendation of the rural task force, part of the Advisory Network. (Mr. Deputy Chairperson in the Chair) I will also be interested to know when we get to the line on Lotteries-funded programs, how an urban administered initiatives fund-I forget the exact name-will benefit rural Manitoba.

The mini ster knows I have raised that before, and I am anxious to hear some comments on that. Let me ask a couple of final general questions on this area. It seems that after every year that we go through Estimates there is a change in this branch in terms of people who are heading it up. The minister has gone through a lot of heads at this, branch. Last year we asked about some of those individuals. I will ask it again since we obviously have gone through another change in four years.

If I am not mistaken, the minister has gone through David Pascoe, John Wade, Kathleen Scherer, Connie Becker and now the new head is Denis Roch. I am just wondering what accounts for this rapid turnover. Also commensur ate, or consistent with that question, what has really been accomplished by this branch, in concrete terms? Mr. Orchard: New leadership. Ms. Wasylycla-Lels: Well, thank you. I would really like to thank the minister for that very enlightening answer. I do not think the minister has taken it very seriously, but it is a serious question.

In essence this branch basically comes close to $1 million a year, and I think it is only appropriate for us to ask what have we for the $1 million that is spent annually on evaluation and policy work. Mr. Orchard: As I indicated earlier, some of the areas in which we want to undertake a major audit were outlined earlier. The audit function is rather important to assure that the aims and goals of the mi nistry are being achieved with the budget allocation that is there.

We call on this group to do evaluation of outside agencies from time to time, where we have requests for additional funding and where they have the ability to provide that kind of evaluation they do. The reason for the combination though, of internal audit and evaluation with the policy group, is to have th at link age between policy dir ec tion and understanding of outcome or the various programs that we have funded.

You can do a monetary audit and evaluation to assure yourself that line X in the ministry, which was supposed to spend $637,00(h$499,000 of it for salaries and $1 38,000 of it for supplies-you can have an evaluation which puts on an accountant's hat and says, yes, they spent this much money on salaries and they were under budget in terms of their supply line as allocated; therefore everything is alright.

Well, yes, from a purely accounting standpoint they have maintained the integrity of the budget process and the expenditure process, but by combining evaluation, as in the policy research area, we can then make the determination that in fact the goals of that funding have been achieved in part or in whole and can suggest improvements or changes that can happen. So it is more than simply a clin ical num ber-crunch fu nction . It is numb er-crunch with an evaluation as to the outcome.

April 21 , 19 92 LEGISLATIVE ASSEM BLY OF MAN ITOBA 2427 Now that is new. It is going to take us some time to mature the process so that it works well, but that is sort of the intended marriage of purpose that we are attempting to achieve here. * (21 40) Ms. Wasylycla-Lels: There is one area I had overlooked that I would like to raise briefly, and that is the qu estion of legislation. Under Activity Identification, the question of health discipline legislation is referenced. I would like to know specifically on the timetable with respect to the whole

schedule for legislation pertaining to dental auxiliaries and the whole list of professional associations that we have talked about in the past, as well as to know what is the full list of legislation for the Health department we can expect for this Session. Mr. Orchard: The dental auxiliaries are not part of any legislative package.

As I have indicated to them for the last couple of years, we are awaiting-! am even going to get I believe it is the Law Reform Commission report on how we might best handle a signi ficant numb er of de ma nds in terms of professional legislation which, not that I want to categorize, but which fall outside of those who al ready ha ve it, lik e physicians, den tists, optometrists, pharmacists, so that there will be no legislative initiatives in terms of dental auxiliaries. The denturists' modest amendment is before the House.

I will be bringing forward legislation which changes the professional acts of dentists and optometrists to essentially emu late the pharmacists' act that was provided last time around. There are amendments to the Manitoba Health Services Commission, and the bill had not gone to print as of discussion with you last week, where I sought your advice, because the legislation, as originally envisioned, was to deal with the changed reporting structure from the amalgamation of commission and ministry of Health.

The legislation is, I think, going to print either later this week or the first part of next week and will incorporate, in one bill rather than two bills, the amendments which deal with the amalgamation of the ministry but also will deal with the issue of disclosure, of physicians being asked for return of billings or improperly billed services as decided by the Medical Review Committee. That will be probably the largest bill, the most com prehensive bill -big in siz e but not necessarily-principally only a couple of principles in there, changes essentially-well, it accommodates the reform.

Now, we are bringing in some amendments to The Mental Health Act which will give us compliance as mandated by the Supreme Court decision out of the Ontario case . Those will be not la rge amendm ents but neve rthe less essential amendments, and we are trying to ready ourselves for a couple of others. In the case that I do not succeed, I would use the ministerial discretion in not sharing those with you because then that would create an expectation that we may not be able to deliver on.

I am always sensitive to not doing that, and particularly I am sensitive to some of the timetables that as legislators we have imposed upon ourselves, in that we do not present, as has happened in the past, and I will not point any accusatory fingers, but there has been a complaint in the pastthat too much legislation comes in toward the end of the session and does not get reasonable discussion. We are attempting to avoid that, and I am hopeful that the amendments that I have referenced to my honourable friend are printed and maybe even before the House before the end of this month.

I know that they will be the kind of thing that my honour able frien d will, even sigh t unseen, recommend to her caucus and achieve speedy and quick passage, so we can better the delivery of health care in the province of Manitoba. Mr. Deputy Chairperson: Item 1. (

c) Evaluation and Audit Secretariat: (1 ) Salaries $804,1 00-pass;

(2) Other Expenditures $1 37 ,900-pass. Item 1. (

d) Finance and Admin istration:

(1) Salaries $2,399,700-pass;

(2) Other Expenditures $1 ,628,400-pass. Item 1. (

e) Huma n Resources: (1 ) Salaries $983,300-pass;

(2) Other Expenditures $89,300- pass. Item 1. (

f) Health Information Systems: (1 ) Salaries $3,705,400. Ms. Wasylycla-Lels: Mr. Deputy Chairperson, I would like to ask just a question or two on the status of the Health Advisory Network interim report on Health Information Systems, or whatever it is called. First of all, could the minister indicate when we might expect to see the final report, and secondly if he has a plan of action to begin to address some of the concerns outlined in that report?

2428 LEGISLATIVE ASSEMBLY OF MANI TOBA April 21 , 19 92 Mr. Orchard: We have very, very significant discussions around how we take the recommendations in that report and develop them into a workable solution for information systems across the health care system. I think there is a re asonably legi tim ate observation that solutions to date have not allowed the achiev emen t of that. I want to tell my honourable friend that this is an area that I am genuinely troubled with.

Because, for lack of better terminology, I find that in the past, okay-1 do not think what I am going to say is necessarily the case today-but I think in the past there was a lack of sort of the honest broker, if that is the appropriate phraseology, to provide advice to government on how to implem ent and what to implement in terms of information systems. I make that observation because I can recall very clearly one of the major accounting firms, I was at a reception when I was in opposition.

I was invited to a reception that they were holding, and they were kicking off a new consulting arm of their accounting business. This new consulting arm was to provide impartial advice on information systems to any and sundry potential clients including government. I thought that was an excellent move at the time because, without wanting to find fault with any of the major suppliers, because I understand the marketplace and their drive to attach sales of hardware and equipment to information systems. I mean, there is a dual motive there.

If you sell the information system and it can attach your product line, you are a double winner. That seemed to be the nature of information system development in the '80s. Now there is the advent of open architecture and a number of-and again I am out of my league in terms of the technol ogy-but ther e is open architecture and open communic ation systems which are not proprietary to a given supplier of hardware and software. That has led to a generation of new advisers who can provide systems solutions which are not necessarily tied to the acquisition of equipment.

It is along that line of advice that we are trying to place the advice and the observations by the task force, which I have to say was composed of some quite prom inen t individuals and kn owl edgeable individuals.

I am trying to take that report and background it on the open architecture and the new ability to commun icate between platforms and try to craft a workable policy across the health care system because, boy, let me tell you, this whole area frightens me. * (21 50) I mean, you can end up with literally tens of millions of dollars spent, and my experience has been, unfortunately, that the goals of achievement are seldom met, and you end up with systems which have created deficits in the various institutions.

Of course, there is the finger pointing of the agreement with Unisys that cost them versus, you know, unpredictability in terms of their implementation. I am giving a very long answer, but this is a very complex area, and I openly admit to my honourable friend that I am out of my league in understanding what to do here.

I am very much guided by the advice of the task force, and we are actively seeking the kind of independent planning advice which is not attached to a proprietary sales organization, and we believe that we have potentially that kind of expert advice available to us and are in the process of actively pursuing the initiative of information systems in government or in the health care field with these individuals. I know that is a long answer to my honourable friend, but that is about as briefly as I can put the issue. Ms.

Wasylycla-Lels: I think we certainly recognize the complexity of this whole area and the difficulties to find easy solutions or quick solutions to the problem-{interjection] and economical solutions, I certainly would concur with that. I also concur that there were serious problems before that were never addressed, before this minister's time, before this government.

They were not addressed by the previous NDP government, but this minister has had four years, and yet we see very little sign of things changing or improving or some attempt to get a handle on the fact that hospitals all continue to do their own thing. I am wondering, why has there been such a delay in terms of getting something going in this regard? Why has there been no movement specifically on what I believe to be the case in just about every other province, and that is the establishment of MIS guidelines? Mr.

Orchard: Before we fall off this congenial atmosphere that we have been cultivating diligently all day today, I want to point out to my honourable friend that I think that when I came into government, I had approximately three or three-plus years and

April 21, 19 92 LEGISLATIVE ASSEMBLY OF MAN ITOBA 2429 twent y-plus mill ion doll ars to spend on an agreement that I inherited. That took up roughly three of the last four years or two and a half of them , for sure. In the interim period of time, recognizing that the inherited process was not necessarily going to lead to the best solution or the most usable solution across the system, we established the task force on Health Information Systems and engaged, if you will, independent expertise within the province of Manitoba to provide us with some guidance. That was done. I am in possession of the report.

From that report, we are internally, and with engaging what expertise as I have indicated to my honourable friend earlier this evening in my previous answer, obtaining expertise on how we can move. For instance, MIS guidelines, yes, those are part of the recommendations and are going to be part of the end goal.

A very interesting piece of information that I have recently acquired from a source-1 consider it to be North American in its understanding, i.e., a significant presence in the U.S. system-they are of the belief that the MIS project at Misericordia is a part of and, I am informed, is considered to be a very good information base in terms of health information systems.

That view came from an expert that I recently had the opportun ity to undertake discussions with whose predominant expertise has been the U.S. system where information systems are much more mature, but not in the applicable form to the Canadian system because appreciate that their information systems are very much a financial information system so that they can account for every aspirin of an inpatient service.

I mean, that is where a significant amount of their accounting and information system resources are placed, but the observation was made by this individual who now is un der taking a presenc e in the Canadian marketplace that the MIS guidelines are pretty reasonable guidelines. That, to me, was a piece of information that came from what I consider to be that sort of outside observer without vested inte rest that is very valuable to guiding us on where we go, and maybe takes us where we do not have to reinvent the wheel, as always we tend to do when we embark on these information systems.

We always reinvent the wheel, it seems. Ms.

Wasylycla-Lels: Let me just pursue for a momen t just specifically the MIS gu idelines, because on that the interim task force report is very clear and very definitive, indicating that the MIS guidelin es appear to be a sou nd basis for management of health care Manitoba, that they can be implemented through existing health information syste ms, com put er ized or manual, tha t implemen tation is modular, department first, then global so that the implemen tation cost may be spread over several years and so on and so forth, ending up with a recommendation that the Health Services Commission approved the MIS guidelines for implementation across all Manitoba health care institutions.

What is the drawback in terms of not moving on that immediately, or why has there been this delay? I am not an expert. Just on the basis of this report and what little I know aboutthe area, I am wondering why the directive has not gone out and the work has not begun on the establishment of MIS guidelines across all health care facilities in Manitoba. Mr. Orchard: Well, no particular reason except that is all part of the process that we are embarked upon. I indicated to my honourable friend that we are moving not as quickly as a lot would like to see possibly, but there is a saying that haste makes waste.

I can always remember advice from that venerable bastion of slow pace, the former member for Ste. Rose, on his Main Street Manitoba Program, where he constantly cautioned opposition members urging him to announce the guidelines on the Main Street Manitoba Program that he was moving cautiously.

There is a heck of a lot more investment and more potential for mistakes in moving too rapidly without a system-wide goal on information systems, so that we are taking a reasonable amount of time, some would say an unacceptably long amount of time, in the hopes that when we develop the guidelines and the plans they will meet the future needs of the system and will be as applicable as believed by the Health Information task force, and will have the ability to be implemented within finite resources available for the appropriate outcomes that we hope to achieve. Mr.

Deputy Chairperson: The hour being ten o'clock, what is the will of the committee? Mr. Orchard: We better pass a bunch more. Mr. Deputy Chairperson: We will continue for a while.

2430 LEGISLATIVE ASSEMBLY OF MAN ITOBA April 21 , 19 92 Ms. Wasylycla-Lels: I am wondering what, and I know this will probably be restructuring accounts for this, but I would like to know specifically what is the roughly $3-million expenditure under total Other Expenditures that has been added from last year's Estimates for this line. (Mr. McAlpine, Acting Deputy Chairperson, in the Chair) *

(2200) Mr. Orchard: Last year, under the reorganization, what was shown in this area was the staffing costs. The costs of computer time, et cetera, were left within the comm ission budget. This year the increase reflects the total accounting under this line of not only staffing costs as was there last year, but computer costs of in excess of $3 million. It is a simple transfer of the costs of computing time from the commission where it appeared in as part of the administration budget, I would presume, at the commission line directly over to here.

It is a lateral move of existing spending with only whatever increase-there is no increase on that line even. It is just simply a lateral move from administration line under the commission over to this line. Only staff were moved last year, now the computer time and costs are moved as well. Mr. Cheema: Mr. Acting Deputy Chairperson, can the minister tell us about us this system in terms of different hospitals which the previous administration put in the system?

I think that they made a major mistake in terms of having a system in each and every hospital with no co-ordination, and now they are trying to solve the problem and spend a lot of money. Now we have nowhere to go. So basically, now, what kinds of things are being put in place to make sure we do not end up in a similar situation, and how much actually is it costing each and every hospital? That would be interesting to find out because services, if we can not utilize from the hospitals, what is the use of having a central communication when the system does not co-ordinate within each of the hospitals? Mr.

Orchard: I guess my honourable friend has identified part of the problem that comes with the agreement ofthe NDP. I mean there is a lot of finger pointing going on around that agreement. I simply do not, as much as I used to, relish in that; I mean, that was my forte. I loved to beat up on the NDP whenever they appeared to make a mistake and whatnot, but I am not into that now because what we have to do now is make our current investment of over $30-million work to the best advantage of the system.

Now, some of the ina bili ty to develop a system-wide approach has been identified, and there are various reasons for that, all of which are historical and really not germane to guiding us on how we approach the solution for information systems as presented by the Health Advisory Network Task Force Report. I am exceptionally cautious in terms of finding fault with the supplier. Unisys is a valued supplier in Manitoba and a valued industrial presence in the province of Manitoba. They will continue to have an equal opportunity to provide additional services and/or equipment to our health care system.

They are moving towards open architecture in other areas of development. Where we are trying to move is to take the report of the Health Advisory Network which I believe has some pretty significant and good recommendations. I mean, our senior people have looked at the task force report, and I do not think I have significant difficulties with any of the recommendations that are there.

Now, having said that, our next obligation is to attempt to focus sort of the best intellectual power we can put around the issue to develop that system for the future, which has the ability to commun icate, as we all would like to see, but more importantly, which is based on-how do I word this? -is based on a system of information which has a utility to the Province of Manitoba as the funder in understanding what we do in the system and how it affects patient care, outcome of patient care, general improvement of health status, which I can see is an absolutely essential component of future information systems so that the information is not merely just stacks of paper with numbers and statistics, etcetera, but that there is a usable analysis from those that can guide us as senior administration for the health care system in gene ral and can guide individual managers of our facilities in making appropriate funding and program decisions based on outcome. (Mr.

Deputy Chairperson in the Chair) I think that there is an opportunity to use the Centre for Health Policy and Evaluation in terms of assi sti ng us in developing the informa tion development which would lead to their ability to analyze and give us a real outcome analysis of what we do. That ability is not perfectly there right now-1 do not think it is there in any system necessarily-so that we are moving cautiously. I think the goals that

Apri1 21, 19 92 LEGISLATIVE ASSEMBLY OF MAN ITOBA 2431 we have are not dissimilar to my honourable friend's goals or indeed the goals as set out by the members of the task force. We will get there, and as I have openly admitted, we are probably not going to get there as quickly as some would like us to be, but in this case, I think we will make in the long run the best decisions with the prudent and consu ltative approach we are taking. Mr. Cheema: Mr.

Deputy Chairperson, can the minister tell us, do we have a system where, for exa m ple, the Man itoba Health Services Commission, if they would like to have access to any information at any given hospital in terms of the patient occupancy rate and on a day-to-day basis, and monitor each and every hospitals in terms of user of the facility so that the information can be provided and some directions can be given? Those things are going to be very important in the future when you are going to rechannel some of the patients from an institution to another institution.

Also, when the commu nity component is going to come, those things are going to be very essential because basically the control has to be at one place where the changes can be made, and I think the technology is going to come. I am aware that the Health Services Commission do have information for their own use and all the practical purposes and where the Health Policy Centre is going to drive all the information. I am just asking if there is a system which does commun icate within the commu nity hospitals? Mr.

Orchard: No, we can not access a terminal in the commission and pull up information from a hospital in Winnipeg in terms of occupancy rate, but each hospital does have that information, and it is readily available by direct contact of our staff with their counterparts in the various hospitals. Where we are deficient in our information capacity, like the occupancy rate, the length of stay, those sorts of admissions, discharges, those sorts of statistics are readily available.

What we do not have for quick and easy comparison is program costs so that we have the opportunity, for instance, to compare the cost of the gall bladder procedure in hospital A versus hospital B versus hospital C with accurate sophistication. I think that is a needed goal in terms of our health care system . I will make the case, and I do not think I am wrong, that a hospital, for instance, in my area, Carmen or Winkler or Morden, I believe, will undertake a number of surgical procedures at a lower cost than at Victoria, Grace or Seven Oaks who will undertake the same procedure at a lower cost than St.

Boniface or Health Sciences Centre. Without having that kind of quite definitive information, we cannot make the comple te program reform allocation of funding. We can get a pretty good handle on it In terms of moving the cost with the patient, but we do not have an accurate comparison so we can go directly at the individual hospital's budget so that we are assured that we are not compromising other areas of the hospital or whatever when we say this is what should be able to be moved with the patient. We will eventually have that kind of sophistication, but we do not have right now, no question. [inte�ection) *

(2210) Mr.C heema: Mr. Deputy Chairperson, the minister responsible for Urban Affairs (Mr. Ernst) will really be the best person for anything but not a good physician. That I can tell-[inte�ection) Exactly. Can the minister tell us, about 16 or 18 months ago, there was a conference in Manitoba arranged by the Health Services Commission, and a lot of noise was made. The question was raised inside the House by, I think, Mr. Doer; his question was smart card. Such a terrible thing was coming in, and now each and every province is taking a good look at the whole system.

In fact, Ontario is going implement some of the smart card systems in terms of information data which will facilit ate some of the process of application was access to the services. Now, can the minister tell us where are we in Manitoba in terms of the smart card coming into action in our health care delivery? Is the government serious to im plement such a system, or are they still considering? What are the reasons why they have not made up their mind? Mr. Orchard: Let us get right down to business.

Yes, the plastic card technology, a year and a half or so ago when we hosted the national conference, I do recall vividly those cries of concern by the Leader of the opposition party. I cannot even remember whether it got him a headline at the time, but that really does not matter now. [interjection] No, no, I mean I always mention this to my honourable friend the member for Concordia (Mr. Doer) because he is a headline hunter, there is no question about it. At any rate, we were advised, basically, by the findings of that conference, and this advice went to

2432 LEGISLATIVE ASSEMBLY OF MANITOBA April 21 , 19 92 all provinces that in terms of implemen tation of the plastic card technology, smart card or any variation of it, because there are a number of them, that we move with some caution because it is very much an emer ging tech no logy field. Ther e are advancements almost monthly. But I will say to my honourable friend that I recognize an opportunity here, and I will share sort of a vision of the future. I will put a caution on it because it has a big price tag.

I would dearly like to see Manitoba lead the way-and we have not got our minds around the issue-in terms of bringing in pl astic card technolo gy across the system: physicians' offices, any other professional offices and pharmacies which routinely provide services which are billable to the health care system, so that we can develop a system which allows the plastic card as an identifier of an individual requiring care. Let me just use this specific example: Dr. A will know that patient C had seen a physician at a walk-in clinic six hours before and had this series of tests done.

That would automatically lead the second physician to be asking very appropriate questions of the patient as to what, et cetera. That is one example of better patient care that can emanate from it. There is the issue of confidentiality. I think there is sufficient technological sophistication to our systems, and I will use the example: Everyday, I think that our banking systems in Canada probably handle more individual transactions on a daily basis than we ever would in terms of sheer volume of information and number of times that the system is accessed.

They have a security system which bars access to the system according to need-to-know. I have not heard of a time when that security system in the bank has com prom ised the confidentiality around the individual's banking records. If there is one thing that is almost as confidential as your health records, it is your financial records. So I am confident that the ability to technically handle the information volume, to technically protect the confidentiality aspect, exists. The difficulty is, and I will be very direct with my honourable friend, finding the capital dollars to implement.

To assure oneself of that, in the operation of the system, it is going to make our whole health care system more effective in its care delivery. Those are sort of the unknowns to date. But I will tell you, I can see some tremendous advantages with the expertise we have in the Centre for Health Policy and Evaluation and their ability to analyze the data that we currently have been coll ecting at the Manitoba Health Ser vices Commis sion. I mean, they have made some marvelous analyses of that data to guide us in an informed and scientific way into policy decisions.

With an information system that goes across the health care system, with appropriate information collected, I can see ourselves being a very excellent research laboratory for the world, in terms of how publicly funded health care systems can work to improve and enhance health care services and to give some definitive answers as to what the effectiveness of new programs are, because they could be almost instantly tracked and monitored. So, to me, there are a significant number of advantages.

If I had my way-and I do not, very obviously-! would be rushing rather rapidly into a province-wide system, not the pilot project as recommended by the experts. But I am guided by an abundance of caution, and we are moving diligently in trying to see where the new technology has a role in the Manitoba health care system. Mr. Cheema: Mr. Deputy Chairperson, I think all these areas are worth exploring because you do not want to be left behind when every other province is going to do it eventually.

When the information age is changing and so much analysis is going to be required, so many things are going to depend upon this kind of very new techniques-as long as patient confidentiality is kept in the highest priority. I do not think anybody would like to see that taken away, it does not matter who is in power. Even the people who are designing their own records, they are concerned. As long as the issue is kept in mind, it is worth exploring because it has a tremendous advantage of access.

While duplication of services have the-1 think eventually when we look into the issue of services delivery from the physician or hospital offices, eventually things are going to come when the system will have to be in a way that some patient responsibility has to be involved in the health care delivery. Then I think the issue is going to come. I would like to discuss that in detail that you have to have areas where a specific number of physicians will be assigned to a specific number of patients. That is a possibility and that is happening in Great Britain and in other countries, as well as in the industrialized

Apri1 21 , 19 92 LEGISLATIVE ASSEMBLY OF MAN ITOBA 2433 nations. Some people would say you are going to restrict the patient. That is not true, because the patient will still have a choice of two or three or four or five physicians. There I think those techniques are going to be very, very useful because you are working within a group of systems and how the information can be exchanged at a very rapid rate, and the issue of the compensation package of the physician can be evolved through the whole process in a very meaningful way.

The other issue which we raised, the issue of patients signing those when they are visiting a doctor, that can also be implem ented through the same thing, simply giving your code to each and every person, or say, when you are the present in a certain office , you have to punch those codes, and specific patients will be assigned a specific number. •

(2220) So there will be far less chance of any duplication of services, possible abuse by the patients or by people who do not have cards and they may be using somebody else's number, and that is happening. It is diffic ult to detect because when somebody comes into your office, you do not want their driver's licence at the same time, but eventually it is going to come, that you have to have two pieces of 10 to identify yourself, and if you are a minor, then you r fa mily or som eb ody will have some identification.

It may not be a problem in a family practice or a community clinic of fice, but it could be a problem in walk-in clinics. It could be a problem in major hospitals, and that is coming. Eventually, people are going to look at that issue. That is not to restrict services, but to use services more effec tively, more efficiently and to make sure that services are given to the people who are supposed to get them, not somebody else. I think that is the issue. The issue of technology, a smart card, is going to be the futur e. Ther e is no qu estion there.

Somebody who says that, you know, it will be not acceptable simply is probably living in another age or on another planet. It has to be part of the new system, and I think the exploration must be made. The initial cost is going to be there, but that is with anything you start. Eventually, the paperwork is going to be saved, so much of the storage space. So many things are going to be saved by having that kind of technology, especially when the system, which is publicly funded and publicly owned, will have more control with these kinds of things, rather than the individual office setting up the things.

Then the issue of offi ce protocols, the issue of referral s, the issue of testing, the issue of having access to Pharmacare, the issue of comparing the national debt, all those things will become very easy. I think that is the one problem the minister should also discuss with his provincial counterparts, as long as they can also have the implemen tation of those programs at the same level. It is going to come. It is a matter of time. I just want the minister to know that. These are very, very real issues, very practical ones, and it is just a matter of time as to when they will come in. Mr. Orchard: Mr.

Deputy Chairperson, I do not have any argument with what my honourable friend has put on the record because I think that the future he describes is going to be with us, and I know that he shares the common concern and caution that has been given to us by the experts, of making every effort to assure that confidentiality is maintained in the system. I believe that can be done. The example I used in terms of banking transactions, I mean, they operate a multitude of branches. You take a look at the number of branches that are operating in the province of Manitoba.

That is more individual outlets than we will ever have in terms of health care, in my humble opinion. So I think that can be achieved.

One of the issues that my deputy reminds me is being discussed at the provincial level, because every province, like Manitoba, is approaching the issue, and one of the things that the deputies have identified as an issue for resolution is the conjoint development between provinces, because if we want to share patient information or have an individual who may be going across Canada, it might be well advised to have the opportunity for a physician to understand the individual's condition when out of province, so that they do not prescribe improper information or whatever.

So there is that aspect, but that really takes you into quite a sophistication, and we are probably, even with mature information systems, going to rely on the phone call to our central-a B.C. physician phoning our central area, if he has any concerns. Mr. Deputy Chair person : Item 1. (

f) Health Information Systems:

(1) Salaries $3,705,400- pass;

(2) Other Expenditures $3,491 ,400-pass .

2434 LEG ISLATIVE ASSEM BLY OF MANIT OBA April 21, 19 92 2. He althy Pub lic Policy Prog ram s (

a) Administration: (1 ) Salaries $961, 000. Ms. Wasylycla-Lels: Mr. Deputy Chairperson, first of all, a general question on the whole area of Healt hy Public Policy-1 notice somewhat a discrepancy between the chart as presented at the beginning of our Estimates book and the actual description on page 29. I am wondering where aboriginal health falls as delineated on the chart, and where are the resources allocated for aboriginal health? Mr. Orchard: That initiative is still part of Healthy Public Policy. Ms.

Wasylycla-Lels: The reason for my question was that I do not see a reference to aboriginal health issues or resources allocated for that area in the descriptive part on page 29, or in any of the breakdowns of this whole

section which is not consistent with the chart, which clearly, at the top of the list, reference is made to aboriginal health care. Mr. Orchard: Mr. Deputy Chairperson, let us separate program from reorganizational direction. Under Healthy Public Policy, aboriginal health is one of the initiatives that we feel can be appropriately accommodated under Healthy Public Policy and under that ADM responsibility.

In establishing aboriginal health, which will be essentially a new in itia tive, we have un de rtaken a series of consultation with the aboriginal community, and from that consultation, have some direction around the program. We will be moving hopefully by mid-year to active recruitment of an individual to assume the leadership role within the Healthy Public Policy division for aboriginal health. Ms. Wasylycla-Lels: Could the minister indicate where in this whole

section such an individual would fall? Would there be a separate

section on aboriginal health, or would such a person be reporting to the ADM? *

(2230) Mr. Orchard: We have an SY available for the position, and what is under current discussion is the reporting structure-the sense being right now that the reporting mechanism will be directly to the ADM, because it is envisioned that the aboriginal health position will cross the department. It will not be an issue narrowed only to consideration under Healthy Public Policy. I mean, there are issues in acute care, long-term care, et cetera. So that the current thinking, unless it changes, is that there would be probably a direct reporting relationship of the individual when hired to the ADM. Ms.

Wasylycla-Lels: Could the minister give us some idea about the type of person he is looking for in terms of filling that position and that, of course, ties into the general policy directions or vision with respect to this whole area? Mr. Orchard: Mr. Deputy Chairperson, naturally, we ar e looki ng for an in dividua l who has understanding of health services, the delivery, et cetera. Obviously, what is needed is an individual who would have credibility in the community they are working with.

We are, I guess it is fair to say, rather interested in the applic ations to the position when it is advertised because, as we sit here tonight, we think there will be a great deal of interest in that position. Ms. Wasylycla-Lels: In terms of the overall mi ssion state me nt of the dep artm ent, the department references the goal of improving and promoting the health status of Manitobans and to reduce inequalities in health status. Could the minister give us his definition of what those inequalities are or his description of that statement? Mr.

Orchard: I think the most succinct description that I can give is the emerging evidence that even in a publicly funded health care system, with no barriers to access, there is a pretty clear correlation between access to that system and socioeconomic status. I do not think it is any secret, but the aboriginal commu nity tends to have, in many instances, a lowered health status than other Manitobans. Certainly, in terms of infant mortality and a number of other key indicators, they are significantly at a disadvantage compared to, for instance, the middle-income, non-native Manitobans.

That has been a historic relationship. There are gradients that have been well researched in other countries that we think probably are applicable to the Canadian circumstance and the Man itoba circumstance, those gradi ents involving the health status as it relates to the economic and the income gradients of individuals. What we are embarking upon with the Canadian Institute for Advanced Research is the population health study which, with permission from Stats Canada achieved, and with utiliz ation of the analytical capability of the Centre for Health Policy

April 21 , 19 92 LEG ISLATIVE ASSEMBLY OF MAN ITOBA 2435 and Evaluation on our health statistics, we hope to be able to establish and verify that relationship, in the Manitoba context, of socioeconomic status and health status and access of the health care system. We think we will find some interesting correlations which we suspect but will be able to definitively identify with scientific analysis and research.

That leads us to the next step in terms of the then creation of public policy which would be targeted, rather than across the board, but targeted in terms of health promotion or specific educational programs or specific policy initiatives of support at those groups which are shown to be disadvantaged in terms of their access to and service from the health care system as currently structured.

I want to point out to my honourable friend that when I start getting a greater understanding of this relationship of income and health status, I get more and more concerned about the viability of the Canadian and North American economy, because there is absolutely little question that probably our greatest public policy initiative to improve the general health status of Manitobans and Canadians lies in our ability to have a vibrant and growing economy which is providing the kind of meaningful and rewarding and monetarily rewarding jobs that a growing economy can provide.

That would probably be one of the best health policies we could ever implement. More and more research is pointing to the direct linkage of the health of the nation's economy to the health of their citizens. When we get into these debates about resources and dedication of resources to our social program underpinning, those are all very laudable public undertakings that governments of many political stripes have attempted to assure are in place and are effe ctively delivering service.

The challenge that we have is that the funding of those programs does not undercut the ability of the economy to continue growing, continue making investment and creating new jobs, and maintaining our competitive position in the global marketplace. That is the delicate balance I think that the whole debate nationally is going on right now, for instance, around health care. We could, I think, clearly dedicate 50 percent of the provincial resource to the provision of health care and still find a number of people who would say that is not enough.

In doing so, we would probably have to remove entire departments of government which are providing services to underpin the growth and the economy. If one were to be an outside and casual observer to such a proposed direction of government spending, one might call that-what is it? -penn y-wise and pound-fo olish, or whatever, that we are cutting off our nose to spite our fa ce.

Some of the direction that we are attempting to ma ke strong link ages with is in te rms of socioeconomic status and health status, because we think there is an op por tuni ty with the understanding of that relationship to very much focus the government programs and initiatives to assure that we underpin those target groups which we feel today are inappropriately accessing the health care system. Ms. Wasylycla-Lels: The minister has certainly touched on an area of broad debate. I do not know if we have the luxury of time or energy at this late point in the evening to get into it.

But I think it is worthy of a short response since, in fact , there are many who question whether or not this government does unde rstand the li nkage betwe en socioeconomic status and health status and question the wisdom of a government that has basically maintained a hands-off approach in terms of the economy and has done little in terms of actively addressing the growing unempl oyment situation, unprecedented poverty levels, increasing numbers of people being added to the welfare rolls, more and more people turning to food banks, more and more young people out on the streets turning to prostitution, to drugs, to suicide, to a whole host of very difficult life choices. *

(2240) There is clearly, we acknowledge, a linkage between the economic situation in a society and the health status of its citizens. We question whether or not this government understands that linkage by its hand s- off approach to economic activity, economic development, job creation, preservation of important social programs and supports that help fam ilies make it through these very difficult times.

Certainly, when it comes to aboriginal people who, as the minister has acknowledged, face some of the worst living and working conditions of any group in our society, there is a very clear correlation between their economic status and ill health. I am wondering where the minister intends on beginning to address tha t whole issue of socioeconomic status of our aboriginal people and the linkages with their health needs.

2436 LEGISLATIVE ASSEMBLY OF MAN ITOBA April 21 , 19 92 The minister talks of one person and hiring an individual to begin to address this whole issue and this whole policy area. Where is the minister beginning that focus? Is it with respect to aboriginal people in our urban centres? Is it with respect to aboriginal people on reserves? Is it all of our aboriginal community? What will the be the priority, what will the focus of this min ister and this government in beginning to address this most difficult area? Mr. Orchard: The process we are currently on.

But let me just take the gloves off just a wee little moment here, because we were having quite a nice evening before my honourable friend ventured into grounds where people of her political persuasion ought not to be. I want to tell my honourable friend that the solution of Howard Pawley and the NDP around job creation and solving the unem ployment problem of the last recession was to create the Jobs Fund. The Jobs Fund spent $200 million a year. There is a little anecdote that I will share with my honourable friend, parti cularly with the two newcomers that are here, one from the Liberals, one from the NDP.

Go back to Hansard, the first year that the Jobs Fund was created, and read an exchange over several days between the Minister of Natural Resources then, AI Mackling, and the then member for La Verendrye, Bob Banman, because here are the circumstances of the phoney Jobs Fund. The Jobs Fund was created. All ministries had to allocate money to it from within their budget. In Natural Resou rces, they had commenced a tree-planting program in the eastern region of Mani toba , a reforesta tion progr am , ver y enviro nmen tally friendly.

It was emp loying a number of people with a budget of, I do not know, several hundred thousand dollars, probably close to a million. All of a sudden, after being on the job about three weeks, every one of these people got a layoff notice. They were raising this issue with their MLA, Bob Banman. Well, you know what happened to them? They were laid off because the Jobs Fund had demanded of the Minister of Natural Resources, AI Mackling, some budget from within his allocation. Where did he get it?

He got his budget by laying off and cancelling the reforestation program, laying off those people so the money could go to the Jobs Fund to hire people to paint fences, to mow grass and pound up these green and white Jobs Fund signs all across the province. It was the phoniest sham I have ever gotten into, but that was the NDP solution to unem ployment in the province of Manitoba in 198 2-83. The only thing that I want to ask my honourable friend is, where are the jobs from the Jobs Fund today? They invested $200 million a year and more for several years. Where are the permanent jobs?

Where is the depth and strength in Manitoba's economy that the Jobs Fund, this proactive Howard Pawley-New Democratic Party government left a legacy for in Manitoba? Where are the jobs today? I will tell you where they are. They are in the annals of the history books because none of them exists today. There is not a single job from the Jobs Fund that exists today. The fences have all been painted, the grass has all been mowed and regrown, the Jobs Fund signs, if you can find some, are faded and gone. We have no permanent legacy of underpinning in the Manitoba economy.

What we do have is a legacy of debt where every single year for every year the $200-million Jobs Fund was in place, I now have $20 million pulled out of my Health budget every year because of the Jobs Fund of the NDP. That is the interest on the debt created by the $200 mill ion Jobs Fund. Every year, we pay $20 million out of my Health budget. It has robbed health care in Manitoba, that good old Jobs Fund that Howard Pawley and the NDP put together. So when my honourable friend comes to me and lectures me about having no idea of how to stimulate the economy, I say, I do not need your advice.

That is a failed philosophy of every NDP government that has ever tried to do anything in Canada, a failed philosophy. They have invested money in building airplanes and making Chinese food to canning beans. It has got everything to do with health care. My honourable friend the member for Burrows (Mr. Martindale) says, what has this got to do with health care? As I have indicated time and time again, the best health policy we can get into is a secure and stable job and creation of new wealth in the province of Manitoba and the nation of Canada. (

a) It is the only way we are going to sustain the tax base to pay for our social services including health care; and (

b) employed people access the health care system a lot less frequently. That has everything to do with health care, and if my

April 21 , 19 92 LEG ISLATIVE ASSEMBLY OF MAN ITOBA 2437 honourable friend does not understand that, maybe he should start talking to some experts who do. Now, you want to talk about what you do to make the link between a job and health status? You know what you do? You create an environment where the creation of wealth is a welcome initiative by those who are best at it in the private sector.

You create a taxation environment, not by raising tax af ter tax after tax that the NDP did during the Howard Pawley years, but rather, freez ing, lowering and elim inating taxes wherever you can, which we have done for five consecutive budgets. You do not rack up massive deficit afte r massive deficit. You try to control that through the control of expenditures within government, which we have done, because deficits simply add to the interest bill that detracts from economic development policy, health care policy, and any other initiative of government.

You fundamentally put an attitude out where you make the busine ss co mmu nity aware of the marvellous opportunities in terms of personnel, investment climate, taxation regime, understanding of the future, market positioning in the world and international market, the kind of skilled people we have, the absenteeism rate, the power, the hydro, the cheap electricity rates, all of those advantages, by harnessing the natural resources through an information campaign in the private sector which is ongoing right now, and above all, an attitude wherein government demonstrates clearly that it un der stands the needs of the in vestment community, the wealth creation community, so that we let people who are adept, skillful and very good at creating wealth, know that Manitoba is a good place to be.

Jobs Fund, phooey! Mr. Cheema: Mr. Deputy Ch air person, it is certainly a stimulating dose for tonight's sleep. I just wanted to put some comments on the record in terms of the issue of poverty, and the connection of poverty with illness and the prevention of illness and many diseases. I think it is not a secret that homelessness itself has become a disease in some parts of this country. There was a study that came out of Toronto and I can provide copies to the members of this committee, and I think I gave some to some members already.

It clearly correlates the connection between poverty and the many illnesses, starting with teenage pregnancy, drug abuse, alcohol abuse, family violence, and sexually transmitted diseases. Those things are coming up and the argument has been made in that

article that all those things, they are not only eating the health care services, they are also eating our economy in many other ways because it goes into social services, it goes

Document details

Collection	Manitoba — Debates (Hansard)
Citation	35-3-49b
Type	hansard
Volume / chapter	35th 3rd hansardpdf 49b.pdf
Language	en
Format	pdf
Source	PROVINCIAL
Identifier	8289256e4979cab577a825fd2d252645ef54658e

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