April 3, 1995

SOCIAL SERVICES ESTIMATES

COMMITTEE

Pursuant to Standing Order 87, Gerald Smith, MHA

Port au Port substitutes for Percy Barrett, MHA Bellevue.

The Committee met at 9:00 a.m. in the Colonial

Building.

MR. CHAIRMAN (Oldford): Order, please!

This is the Social Services Estimates Committee

responsible for social policy review. Today we are here to look at the Estimates

for the Department of Health. We will begin by introducing the Committee,

starting on my right with the Vice-Chairman. Members, I ask you to identify

yourselves. If you are substituting for another member, please identify the

member for whom you are substituting.

MR. HODDER: Harvey Hodder, the Member for

Waterford - Kenmount.

MR. CAREEN: Nick Careen, the Member for

Placentia.

MR. LANGDON: Oliver Langdon, the Member for

Fortune - Hermitage.

MS. COWAN: Patt Cowan, the Member for

Conception Bay South.

MR. SMITH: Gerald Smith, the Member for Port au

Port. Today I am sitting in for Percy Barrett.

MR. CHAIRMAN: My name is Doug Oldford, the

Member for Trinity North, and I am the chairperson.

I will ask the minister to introduce his staff in a

few minutes, but first of all, I wanted to say to you that the recording

technician is not familiar with either the members of the Committee or the

witnesses, so he has asked me to have members and witnesses identify themselves

when they either ask a question or respond. I want you to stick to that because

he is not our regular recorder. Jack Oates, in the House of Assembly, would at

least know the members of the Committee. Please stick to those rules.

I now call upon the minister to introduce his

staff. The minister will have ten minutes for an opening statement and then I

will have the Clerk call the first subhead. We will begin the questioning with

Mr. Hodder, the Vice-Chairman. Having said that, I now call on the minister to

introduce his officials and then we will allow him a ten-minute opening

statement. Mr. Minister.

MR. L. MATTHEWS: Thank you, Mr. Chairman.

I am pleased, this morning, to introduce my

officials, who are here for the Estimates hearing. On my near right is Deputy

Minister, Dr. Robert Williams; seated next to him is the best looking one of the

group that I brought this morning, Mrs. Joan Dawe, Assistant Deputy Minister,

Community Health branch; on my far right is Roy Manuel, Director of Hospital

Services, on my left, Chris Hart, Assistant Deputy Minister, Finance and

Administration branch, and Gerry White, Assistant Deputy Minister for Policy,

Planning and Drug Programs; sitting over there on the far side is John Downton,

Director of Drug Program and Services; at the north end, Max Osmond, Director of

Financial and Operational Services, and Kent Decker, Director of Institutional

Financial Services. With an A-team like I have with me this morning, I don't

anticipate that you will go away with any unanswered questions or any concerns

that will not have been adequately addressed.

MR. CHAIRMAN: Is that an A-team or an `H-team'?

MR. L. MATTHEWS: It is an A-team, Mr. Chairman.

`Chairperson', you prefer to be called, I note.

I feel comfortable with the people who are making

up the Committee because I have the ultimate in friends on my right and I think

I have some very good friends on my left. The Member for Placentia will be happy

because he is going to get a new nursing home this year finished. The Member for

Waterford - Kenmount is my own personal MHA, so I have every confidence that he

will be -

SOME HON. MEMBERS: Hear, hear!

MR. L. MATTHEWS: I have every confidence that

he will be gracious toward my staff and myself.

The Department of Health, as you would be aware, of

course, is responsible basically for the delivery of all health care services

within the Province of Newfoundland and Labrador. That covers a wide gamut of

institutional and outside institutional activities that we engage in on a daily

basis. We are responsible, of course, for all of the acute care hospitals. We

are responsible for the long-term care facilities which are sometimes otherwise

known as nursing homes. We have responsibility for the governance and the

licensing, and that sort of thing, of the personal care homes that operate in

the Province. In addition to that, we administer extensively through our Public

Health Units, involved in the community-based services into the schools and into

the communities by and large. They are involved quite heavily not only in

prevention and education, immunization and public awareness-type activities, but

they are also involved to some extent in the delivery of services to individuals

at the community level that tie in with the Enriched Needs Program that up until

this year, of course, was part of the mandate responsibility of Social Services.

In addition to that, we have full responsibility

for the road ambulance and medical air services in the Province. We also have

responsibility, of course, for the operation of the Medicare Commission and all

that entails. On top of that, we are the only Province in Canada that has direct

responsibility for the medical school that we have in our Province. Every other

medical school in Canada falls under the responsibility and jurisdiction of the

Department of Education or some other similar department. We are, at the moment,

the only Province that maintains direct control of our medical school under the

Department of Health.

Last year was a fairly active and busy year in the

Department of Health. I went into the ministry about mid-year and the main

activity that was ongoing at that particular time, of course, was trying to

finalize the restructuring for administration and governance purposes of the new

regional health care boards and the new community health care boards. I am happy

to report that we have now concluded appointing all of these boards. All but

three of them, as I reckon - three or four at the most - are up and running in

that they have taken, officially, charge of their new mandate, and the

governance in the new and expanded region that they have been given jurisdiction

for. The other three or four boards that are not quite up-and-running but are

active and getting organized, I anticipate will be on stream by June 1, and that

will have us completely reorganized on both the community health care side and

the institutional side for governance purposes. That activity is really only the

beginning of the new and expanded role that these boards will be expected to

play in the delivery of health care. I won't say any more about that; you may

want to talk about it as we go through the proceedings this morning.

The 1995-'96 year will be an interesting year in

the department. There are a number of things on the go that we will be directing

our attention to. One of the things that we have been able to move forward on in

this year's budget, the estimates that you have before you, is the continuation

of the implementation of pay equity within the health care sector. We have to

this year reflect upon the recommendations of the PRAG committee, which reported

late last year. That was a committee which essentially looked at the

availability of physician resources in the Province, the mix that we have, the

mix that we should have, the areas in which they should be deployed in terms of

giving us good coverage across the Province, and a lot of recommendations as to

how we can achieve both the numbers and the mix and the deployment on a basis

that will meet the health care needs of the Province.

We have been able to accomplish outside of the

budget recently a package that seeks to address some of the inequities and some

of the concerns of rural physicians in Newfoundland. Now, this was not a

budgetary initiative. It was not covered in the budget, it was an initiative

that I have been setting my mind to for the last three or four months, since I

have been over in the department, and it coincidentally happens to have been

approved by government within the last two weeks. We are pleased that we could

achieve what we have in terms of the package for rural physicians.

One of the concerns I have had since I have been in

the department and one which I have spent some time dealing with and dwelling on

is the extent to which our medical school should be playing a role in providing

physicians and physician resources for the Province. I have had a number of

meetings with the outgoing Dean of the medical school, Dr. David Hawkins. I have

had some casual discussions with Dr. Art May at the University. I have spent

some time over at the medical school and in forums and events relating to the

medical school and it is my own personal view and feeling to some extent, that

we are not yet achieving, through the medical school, the provision of physician

resources in the Province that we should be. We are not much different, in terms

of retention of our own students than most other provinces are but that, in

itself, does not satisfy me completely because I believe that the medical

school, in the first instance, was brought into existence to help meet the needs

of Newfoundland and it is my view that we need to revisit that concept if we are

going to achieve what we need.

There will be a new Dean at the medical school we

think within the next month or two because Dr. Hawkins, who is the present Dean,

will be moving out of the Province. He has accepted a position elsewhere. I look

forward to having some further dialogue and discussion with the people over

there, with a view to seeing what we can do to get - if it takes this change in

mind set and direction, so that rural students, rural Newfoundland would become

again a matter of more urgent consideration in their admissions policy and in

their overall operation over there.

We will continue this year to work with the new

health care boards that are on stream and we will continue to work with the new

community boards that we have brought into existence. You may be aware that one

of the significant new programs that Health will be responsible for, for the

first time this year, will be the delivery of the home care and enriched needs

programs. Now, these programs, up until the end of fiscal '95 which was March

31, were the responsibility of the Department of Social Services. Government

took a decision in the budgetary process that the delivery of these programs and

responsibility for their further development and delivery would rest with, in

the future, the Department of Health, and this will be a significant new

activity in our department this year. We are in the process now, on a very fast

track basis, attempting to gear up, if you will, staff up, so that we can take

responsibility for those programs and get on with the job of delivering them

within our mandate.

I think that is about all that I need to say except

that also this year, for the first time, we are introducing two other programs

on the prevention side or the preventive side. One is a hepatitis B immunization

program which we will be initiating in the Grade 4 classroom stream this year.

It is the first time that this program will have been run and we think that is

significant in terms of prevention. We, of course, have a new strategy,

developed last year, that is directed toward the whole very serious AIDS

situation in the Province. It has a number of elements including education,

information and not the least in importance also is attempting to deal with the

families and the individuals who find themselves in a circumstance of having to

deal with this unfortunate disease or sickness. The other thing that we will be

doing this year for the first time is going with a fluoride mouthwash or mouth

rinse program in Grades I to VI in our schools. This is a continuing part of our

initiative in health to try to bring some additional preventative activities to

the dental side of health care delivery. We believe that it will have long-term

effects in the reduction of tooth decay and the other things that happen in the

mouths of children whose teeth are not looked after properly otherwise.

I think I should probably stop there. I believe my

ten minutes is up by my clock, not by the one up there. That hasn't moved since

I've come. We could have a long day if we go by that one. I think that is about

the extent of my time and so I will stop there and thank you for your attention.

We will move on at the direction of the Chair.

MR. CHAIRMAN: Thank you, Mr. Minister.

We now go to Mr. Hodder.

MR. HODDER: Thank you, Mr. Chairman.

I'm not sure whether I will take up the ten

minutes, but every time I say that I generally run out of time.

I would first of all like to apologize for the

critic for the Department of Health, Loyola Sullivan, who, I'm sure we all

understand, has other matters that he is considering these days. He has decided

that he will not appear at either the House of Assembly or during these

sessions, since he does not want to use the House or these public sessions for a

forum in which he might be perceived as using these types of settings at this

particular time, given the leadership contest that is on within our party.

I do have some issues that I wanted to bring

forward. Some of them I am pleased to be able to support. I think I should start

where the minister left off, and that is the initiatives that have been taken in

terms of preventative medicine. Because all of the research that we have

available to us tells us that a healthy public policy is the only way in which

we are going to do anything long term. When the minister spoke of the

initiatives in the Grade IV classroom hepatitis-B and the initiatives that are

taken in dental care, these are positive actions. They should be supported by

all members, they should be supported by the public. My only concern is that

there are many other issues that we should be identifying and letting the people

know what we really mean by a healthy public policy. Though it is in the jargon

of the health care professionals, it certainly needs definition, it needs

communication.

I would be pleased to support further initiatives

on the area. For example, we should be doing a lot more to promote safety and

something simple. It was brought up in the House last spring - the issue of

bicycle helmets is something the Department of Health should be aggressively

supporting. The idea of having roller blades and children getting hurt with no

pads, no helmets, no protective equipment. The cost of one child being treated

at the Janeway with a serious injury is far more than a good sound promotion

policy. I looked at some commentary on that just a little while ago and I would

recommend to the minister that he develop some kind of video, some kind of

policy, talk to the children in the language they understand, namely cartoons.

It is certainly a worthwhile initiative. I think it is something the Department

of Health - regardless of what the Department of Works, Services and

Transportation might be saying about it, this is a health issue. It is good

dollars spent.

Going along with that concern as well, I think we

have to see connections between every other department and the Department of

Health. I compliment the department. It has been the leader in the government in

terms of having its legislation reviewed by all different divisions of the

government and in terms of initiatives. That certainly is a positive step

forward. In some ways, this department is further ahead than some other

departments of government. I compliment them for that. However, we all know that

if you don't have good roads you are not going to have a good healthy public

policy. Even just painting the sides of the highway with the white lines saves

people from getting hurt. They know where they are in the fog. We have lots of

fog in Newfoundland.

Certainly, I want to say to the officials and to

the minister, you are going in the right direction. However, we are still

spending too few dollars in preventative medicine. There are still too few

dollars. We often look at the people who are already ill; and while that makes

good public press, in the long term - I'm not saying we shouldn't attend to

those needs, not at all - we save public dollars, keep people healthier, if we

make them more aware of the things they do.

In that connection, I totally support the

initiatives in terms of the anti-smoking legislation, you know, healthy places

to eat. In fact, I've written several of the national chains when I've gone to

restaurants and found that you can get into a smoking

section a lot faster than

you get into a non-smoking section. I've written several national chains

complaining that non-smokers shouldn't have to wait longer than smokers.

However, my colleague here doesn't necessarily agree with that. It is easy for

me, I have never smoked, therefore I don't want to sound too sanctimonious; but

I don't have these difficulties.

I would like to talk about AIDS education, and

probably the minister can make some notes and we can chit-chat back and forth

about it. Yesterday's paper again had the

article about Conception Bay North.

There is a certain amount of stigmatization occurring. While it may be based on

fact, if you talk to some of the students in the schools in CBN you will find

that there is a great deal of negativity occurring there. On the other hand, I

was talking to some people in Conception Bay North just last week. They had a

public information session to which only four people turned up. That is part of

the problem. We still have the - it is not that the teenagers don't know. We

haven't bridged the gap between knowledge and preventative actions. I don't know

how we can do that but it certainly is a factor in that particular part of the

Province. Yesterday, of course, we had the blood bank, and the recruitment

policy there was carried in the paper as well.

The minister mentioned the transfer of the

responsibility for personal care homes from Social Services to the Department of

Health, the $20 million assigned to that. We would like to have the minister

give some further commentary on how that is going to happen and give assurances

that there will not be a reduction in care, and that this will be occurring with

minimal disruption, that there will not be anxieties to staffing, there will not

be any, shall we say, significant change to delivery of services, and the fact,

of course, we would like to see improvement in services.

In terms of the care, I have to bring to the

minister's attention the cutbacks that have occurred in some of the nursing

homes, and in particular the effect it is having in some of the more acute

facilities like the Miller Centre. Last week it was brought to my attention the

low number of nurses, or care givers assigned, particularly in the evenings.

Stories of seniors who are lying in bed for hours in very, very distressful

conditions, wet and that kind of thing. I had a story told to me last week which

is shocking and when it was investigated by the family the people in charge

blamed it on cutbacks. I think we have to look at and make more rational the

assignment of staff to certain of these centres.

The homes for ex-psychiatric patients which is a

category here. It is a connection between your department and the Department of

Social Services. We believe in the program, however, we have to have a greater

co-ordination between justice, between health, and between social services.

There has to be an assurance given to the public that we are on top of that kind

of thing, and while incidents will happen - we do not want an incident to

happen, period - but when they happen we should be assured that we as a

government, or we in the sense of all of us in that sense, the government has to

be assured that there are programs in place to assure the people who live in

those neighbourhoods that these types of homes are not a threat to the quality

of the neighbourhood.

It does not take much to make the gap between,

shall we say, an acceptable home in a neighbourhood and one that is not

acceptable. From my years in municipal government I can tell you that there is a

very fine line and everything goes well until something happens, then you

suddenly have it played in the media and you tend to have a lot of unexplained

things because after awhile you can do all the explaining you want and people

will not accept the rationale, in other words. We need to look at that.

The special needs assistance for residents who are

required to travel out of Province for transplants. I see there is an allocation

here for that, and that is an area where I think we should look at having some

better guidelines.

It grieves me that we have to have people who have

been approved for transplants and then we have to rely on community agencies to

try to do fund-raising, to try to help out, to try to ease the financial

burdens. There is some provision here, but if you look at the total amount there

are no great big dollars in terms of the need.

That is not to say that people should not have to

have some responsibility for these costs, but at the same time we have to be

aware of the fact that families are suffering, the patient himself or herself is

suffering, and often the additional pain is brought on by the lack of finances.

Mr. Chairman, I will leave it at that. I do have

some other areas I will get to in the subheads.

MR. CHAIRMAN: I want to remind you that our ten

minutes includes questions and answers in response, but we will consider yours

to be an opening statement on your side. We will go to Mr. Smith for

questioning. Maybe throughout the morning you will have an opportunity to

respond to some of Mr. Hodder's concerns. Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman.

MR. CHAIRMAN: You have ten minutes, including

questions and responses.

MR. SMITH: Thank you, I'm sure that will be

adequate. Mr. Minister, maybe if you could just elaborate a little more. You

referenced in your opening remarks this fluoride mouth rinse program that the

department is initiating. What is that going to involve? You mentioned the

grades, so I assume it is going to be administered in the school. By whom and

when will this be taking place?

MR. L. MATTHEWS: It will be administered in the

schools in the first instance, the introduction of it, by our public health

units with the public health nurses. It is essentially something that used to be

done, I guess, in the dentist's office. You would go in and you could have a

fluoride treatment type of thing. The concept is to get it into the schools so

that every child will benefit from the fluoride mouth wash so that it is not

restricted in terms of benefit to just children who would otherwise go to a

dentist. Every child will get the opportunity to have fluoride mouthwash

administered to them every year from Grades I to VI. It is really a preventative

type of program. It is not designed to cure anything or correct anything. It is

basically designed to be a preventative agency. That will be commencing this

September and throughout this school year and on into the future school years.

My Deputy Minister reminds me that it has already

started actually in Central Newfoundland this year as a sort of pilot project

type thing.

MR. SMITH: What is the cost of that program?

MR. L. MATTHEWS: The cost of the program - I'm

not sure what the exact cost is, probably - Mrs. Dawe?

MRS. DAWE: (Inaudible).

MR. L. MATTHEWS: She says about $375,000 for

the Province. The program is sort of developed in conjunction with the

assistance that we give through the dental program in our budget. You will

notice that in the Estimates the dental program was reduced. It was one of the

few things that was reduced in our Estimates, and I would tell you that up

front, from last year's budget, from $5.7 million to $5.2 million. We believe

that shifting resources in this area - which is something that the dentists

endorse, by the way, and the dental association agrees with - is an appropriate

thing to do. They didn't say: Do that and reduce the budget that you are going

to spend on dental care, but they certainly appreciate the appropriateness of

the fluoride mouthwash program. It is one of the many initiatives that are

ongoing in terms of prevention within the schools. It is just an add-on to many

of the other things that we are doing, really.

MR. SMITH: Thank you, Mr. Minister. The other

thing I had under subhead 3.3.03 relates to the dental services and you just

referenced the fact that there is a reduction there in the amount that is

budgeted this year. How will that translate?

MR. L. MATTHEWS: How will it translate into

services that will be affected?

MR. SMITH: Yes.

MR. L. MATTHEWS: The child dental program is a

program that covers a number of things. It covers things like two dental visits

a year per child up to the age of twelve, I think it is. It covers fillings and

cleaning, that sort of thing, up to a certain cost. What is covered by the

program doesn't necessarily cover what the dentist wants to charge. Sometimes

the dentists, of course, because they are not covered under Medicare, they can

top up the billing, but basically it provides for a basic program of prevention

and maintenance for children up to age twelve. The fact that we have reduced it

by $500,000 this year is really the emphasizing of what we do in the surgery,

and trying to bring the prevention aspect of it back so that all kids get the

benefit of it right back to the classroom. So that part of the program that

might be delivered in the dentist's office may change this year because we are

doing it in the schools, and if there are any other minor adjustments that have

to be made in terms of coverage, then we will work that out, as has always been

done with the Dental Association. The Dental Association is very much involved

in the development and the composition of what is covered under that particular

program.

MR. SMITH: Under subhead 3.2.02, Indigents, in

terms of the prescription drugs, I note there is budgeted a significant

increase, and I would assume that this reflects an anticipated increase in the

caseload for the Department of Social Services this year?

MR. L. MATTHEWS: 3.2.02?

MR. SMITH: Yes. Last year you budgeted $32.5

million, the revised was $33 million, and this year you are budgeting

$34,745,000. I am asking if this -

MR. L. MATTHEWS: It is a 6 per cent increase

over last year. What page is that on in your estimates?

MR. SMITH: I am sorry, page 232.

I guess my question is: Does that reflect an

increase, or an anticipated increase, in the cost of the drugs themselves, or is

that anticipating an increase in demand in terms of if it would mean -

MR. L. MATTHEWS: It is a provision for an

anticipated increase in utilization. That is basically why that increase exists

in the vote. As I say, that is the basis on which the estimates were developed,

and we anticipate a higher level of usage for the program.

I guess we have an aging population, a population

that is getting older. Not only that, people live longer on average as time goes

on, so that translates into higher percentages of our budget being spent on the

maintenance of seniors as opposed to (inaudible).

MR. SMITH: But this particular subhead relates

to support to indigents, so does that -

MR. L. MATTHEWS: Oh, yes, under social

services.

MR. SMITH: Yes.

MR. L. MATTHEWS: Yes, and the same thing there.

Social services were expecting provincially, I think, an increase in workload.

We have already had an increase this year, and the projection is that the

caseload for social services will continue to increase this year as a result of

all of the not so good things that are happening out there with people coming

off TAGS and all that sort of thing, so it is a provision for that anticipated

utilization in the program.

MR. SMITH: Okay, thank you, Mr. Minister, that

was my question on that.

Section 3.4.02 the Road Ambulance Program, I notice

that the department has budgeted a slight increase -

AN HON. MEMBER: (Inaudible).

MR. SMITH: My question there is a general

question. Having had some experience in working with establishing an ambulance

service in my own area of the Province where I live, the fund-raising end of it

and also trying to maintain the service after, my question is, in terms right

now of looking at the provincial perspective, how adequate is the level of

ambulance service that we are providing within the Province right now?

MR. L. MATTHEWS: The Road Ambulance Program is

one that has undergone a complete review in the last year. In less than the last

month actually, Assistant Deputy Minister Hart has presented me with a report on

a number of aspects of the road ambulance program. What we are doing is really

looking at things like standards, we are looking at things like coverage, we are

looking at things like cost effectiveness and all of these sorts of things have

been revisited in the road ambulance program. We have some gaps in certain areas

in terms of service, we are trying to adjust these.

We don't feel that generally the levels of training

for attendants on ambulances is as high as it should be so we have some

recommendations going forward to government to try and enhance training levels

from Attendants I and Attendants II up to EMA Is to EMA IIs which are really

medical assistants. This is the highest level of training provided for ambulance

attendants in the country really. We have some of these now at the Health

Sciences and some of the other areas but in terms of maintaining the Road

Ambulance Service, at the moment we feel that - the department and I have met

just recently with the independent road ambulance operators - there is really no

serious gaps in terms of service. They would all like to get a little extra for

what they do like everybody else who does anything in the health care system or

any other part of government these days but we feel the funding that is in place

is sufficient to provide.

You are talking about I guess the community base

services because there are really three types of operators for ambulances in the

Province; one is the hospital base, the second one is the private operators and

the third one is the community based services. Where a community based service

gets into trouble because of not being able to fully fund their operation they

come to us and we deal with them on an individual basis and if we have to render

additional assistance to them to get them through, we do that. So we are more

than sympathetic, we are responsive to the community based services. In

particular, knowing that they are operating in an area where there is not always

a lot of utilization but yet they want to ensure that a service is available for

whenever it is needed.

MR. CHAIRMAN: Thank you, Mr. Minister. Mr.

Smith your time is up. We will have to go to Mr. Careen.

MR. SMITH: Mr. Chairman, if I could? I have

just one other question, by leave if I could, and I won't ask any more questions

this morning because that would exhaust what I have here and -

MR. CHAIRMAN: Is that okay?

AN HON. MEMBER: (Inaudible).

MR. SMITH: - because it is in keeping with this

one.

MR. CHAIRMAN: Sure, alright.

MR. SMITH: It relates again to the community

based services. When you are talking about the standard of service and that sort

of thing like that, I appreciate that the community based service, from my own

experience, is run by volunteers. Now one of the big problems with that program

is being able to avail of the necessary training. I was involved in the

beginning and I did the Level I training myself.

The department did show some flexibility at that

time but later we did have to put some pressure on in terms of making it

available in the evenings because people who are doing this as a volunteer still

have to make a living. Now, in order to do the Level 11, which is a little more

intensive, these people have to somehow get time off from their work and go away

for an extended period of time to do the training. Keeping in mind we are

talking volunteers, and at the present time and into the foreseeable future, I

do not see anyway that this government or any future governments will be able to

put in place fully funded service in all of the rural areas of the Province, so

I am wondering in line with that, is your department, and are the officials

within your department looking at some ways where they can be a little more

innovative in how they deliver this training?

I think we all share the concern that, even if it

is a volunteer service, I like to think that if I am picked up by an ambulance

at some time there will be somebody there who will know something about what

they are doing. We are all coming from the same perspective on that but you can

appreciate the situation, if you are talking volunteers it is a bit different.

These are people who do other things during the daytime and really the only time

they would be available for training would be in the evening. I think it is

something that has to be addressed because from my own experience it is not - I

cannot say for today, but it certainly was not within the last few years

adequately addressed.

I am just wondering where, in terms of your

department, where the thinking is now with regards to that?

MR. L. MATTHEWS: Well, we contract out for the

most part the training to St. John's Ambulance. I guess your specific question

was regarding the flexibility of training, the availability of it?

MR. SMITH: Yes.

MR. L. MATTHEWS: I do not know if that has ever

been discussed, the problem in terms of when the training is available. It is

more the levels of training that should be available and the levels to which we

want to build up to. We have in this report that was just developed a concept of

what level all of these ambulance attendants should be trained up to, and we are

proposing a slightly lower level of training for community based services, given

the fact they are volunteers, and also given the fact that community based

services for the most part have a mandate to operate within their own local

area.

Their mandate is really to take a person to the

nearest health care clinic or hospital that is appropriate, and then if there is

a transfer to be done once the patient is stabilized from that setting, the

transfer gets done at the direction of the health care clinic or the hospital on

further.

MR. SMITH: But at the same time we are talking

about an emergency service. A lot of these people who are being picked up are

people who have been involved in accidents and it is a crucial period of time.

For instance in my own situation, just transport alone, can be anywhere from

forty-five minutes to one hour and fifteen minutes. Now, that is kind of a

crucial period of time which means that those people who are first there can

make the difference in that person surviving or not, so in terms of the broad

question, as to the level of care that is provided, and accepting as a given,

that if we are to have any service at all in these areas it has to be provided

by volunteers, and we do not have the resources to go out and fully fund it.

Right now you cannot entice private operators to

come in because it is just not worthwhile for them, but to me it is key that we

be concerned about that level of training. I am not active with the committee

now in my community, other than the fact that I talk to them on a regular basis,

but I was on the understanding that they had been advised that the minimum now

will be Level 11. Is that correct?

MR. L. MATTHEWS: There are a whole new series

of levels of training that we are proposing to government, and this is a report

that was just developed in the last week or two. Now, Mr. Hart our Assistant

Deputy is involved in this program and is going to comment on what we are trying

to build up to in terms of levels of training.

MR. HART: Christopher Hart, ADM in Finance and

Administration, and I am also responsible for the Road Ambulance Program which

is somewhat outside the normal realm of finance, however, I have taken it on

with some great interest.

As the minister has mentioned we have over the last

year or so, really - it has been a fairly major initiative - we've looked at

implementing standards for the Road Ambulance Program. Initially what we had

thought was that there should be one uniform standard, but we had the same

concerns that you had. At the end of the day we realized that to implement a

similar standard for volunteers as for the private operators, you would be

imposing an impractical, I guess, and unrealistic regimen on them.

What we decided through this, in order to get our

standards in place, that we would accept a somewhat lower level of standard for

the community operators in recognition of the fact that they were as you said

volunteers, and as Mr. Matthews pointed out, that they are the first line of

getting to the patient. Their major responsibility is for getting the patient to

the nearest medical services where they can be properly administered medically.

As a result of that we've cut back somewhat the

standards but at the same time we've recognized that we want, eventually, to get

to the highest possible standards. One of the things we've done is with the

private operators we've said that the training standard is an EMA. For the

community-based, we are saying it is an attendant II level. Which is somewhat

less, but at the same time we are saying that for each community service we are

asking that there be one person trained at an EMA level - just one - so that one

person in that community then would be there to give in-house training sessions,

that sort of a thing. We are trying to build it up in that respect.

The other side, when you get down to the actual

training, we also recognize that it is difficult for these volunteers to take

the time and to take a week or two or whatever it takes to get up to that level.

What we are looking at - we haven't worked out the details of that - but we are

fully aware that we are going to be looking at other ways of delivering that

outside of the traditional methods, through the St. John Ambulance and that sort

of thing. The Health Sciences does a lot of EMA training for us. What we are

looking at is, is there some way we can bring the training to the communities?

We will be entering into discussions I guess with the Department of Education

and Training to see if we can get some involvement through the colleges system

and that sort of thing.

It is not carved in stone exactly how we are going

to do it but we are very flexible on it. We do recognize the problems inherent

with the volunteers, and we also recognize the valuable service that they

provide. We are working towards that end.

MR. SMITH: That would be my final comment with

regards to that. That the department and all of us be cognizant at all times of

the very valuable service that these volunteers are providing in terms of that

particular aspect of health care in the Province.

MR. HART: The other thing I should mention is

that just last summer, because of some of the ongoing problems that we have, we

supported a development of an association for the community operators. I'm

pleased to say that is now in effect and has been since last June. We are now

actively meeting with them as well as the private operators and dealing with

issues specific to them.

One of the other major issues with the community or

volunteer operators is that of funding. A lot of them are funded at levels, as

Mr. Matthews pointed out, that sometimes makes it difficult, because they are

not in a high-volume area, and relying on the funding coming from the department

is not always enough to make them viable. We have addressed concerns in the past

but we have just received a proposal from the community operators as a means of

providing a funding on a different basis. We are studying that and we are going

to try to come up with some better way of funding them within available

resources. Because we always have to be cognizant of our financial

considerations and that sort of thing.

MR. L. MATTHEWS: Thanks, Chris. The other

thing, just to clue that one up, I guess, is that if we can use distance

education we are open to that concept. What we are working toward - in the

context of the regionalization of the health care system and the new health care

boards that are put in place, it is my view that really the operation of

ambulances are an extension of the work of the emergency departments of

hospitals, to a large extent, and part of the concept of trying to bring higher

standards to the business and a better rationalization of resources to the

service is consistent with our thinking that eventually, probably the operation

of ambulances generally should be moved out as a responsibility also of the new

health care boards.

Right now, as you know, we have the three levels,

the three operators. We have the hospitals who operate the services, we have the

community-based people, and we have the private ambulance operators, and they

are not always completely in sync in terms of the way they think and their

mandate for operating. So that is the long-range view, that these ambulance

services should, once we get them up to snuff, if you like, in terms of training

levels and rationalization of services, put them under the new health care

boards that have an expanded mandate.

Thank you.

MR. SMITH: Thank you, Mr. Minister. Thank you,

Mr. Chairman.

MR. CHAIRMAN: Mr. Careen.

MR. CAREEN: Good morning. Just a little bit on

the ambulance bit, it is always nice to be exploring things like efficiency. It

is not your department, but we still have to maintain good roads for those

ambulances to drive over. The way everything is going, with $15 million less

going into road construction this year, the ambulance drivers and the poor

patients are going to have a rough ride. Anyway, that is another story.

Minister, last year two - three - psychiatrists

left this Province to relocate elsewhere in North America. I think there is

another man, a senior fellow, who is part-time, and we are given to believe that

two out of every five Canadians, or three out of five Canadians, see a

psychiatrist some time in their lives. Have you bridged that gap since those

people have left? Do we have new people in?

MR. L. MATTHEWS: In psychiatric services?

MR. CAREEN: Yes, Sir.

MR. L. MATTHEWS: Psychiatrists.

MR. CAREEN: Yes.

MR. L. MATTHEWS: Well, there is always a

movement of doctors in and out of the Province, and around the Province, and

specialists are usually harder to attract and retain because of our ability,

number one, to pay them what they might get somewhere else, and secondly, I

suppose, because geographically we are not located in the most favourable or

enticing spot in the world.

In the urban centres, for the most part,

particularly the St. John's area here, we have what we deem to be more than an

adequate supply of psychiatric services, psychiatric doctors and that sort of

thing. For a long time there has been some difficulty on the West Coast, the

Corner Brook area, in retaining psychiatrists. Since December, they have been

able to attract -

whereas they only had one, I think, for the last year or two,

I think they have at least two new psychiatrists on staff there now, and

probably a third one heading, so they have significantly improved what they have

been able to do on the West Coast. Now, that is not to say that they have enough

based on population and need, but outside of the shortage that we have - I think

it is fair to say still a shortage of being able to provide what we would deem

adequate services for children at the Janeway. Outside of that situation we have

a pretty fair supply of psychiatrists.

Now PRAG recommends that we need seventy or

seventy-five psychiatrists in the Province. At the moment we have how many -

forty?

AN OFFICIAL: (Inaudible).

MR. L. MATTHEWS: The officials point out to me

that we did go down, and as a result of that we put some money into the

psychiatrists' salary budget last year. It was $115,000 last year and there is

an extra $280,000 going into the incentive package for psychiatrists this year.

So, while we have certain urban areas where we have pretty good coverage,

overall you are right, we do have some shortages and we are addressing them in

terms of the financial incentives we are offering. Now, financial incentives

will help, but this kind of money will not overnight attract enough resources to

give us the full coverage that we need.

We have shortages in the area of specialists, not

only in psychiatry but in some other areas. General practitioners - we have

enough GPs in the Province if only we could get them spread out properly, but in

terms of specialists we do have some inadequacies of service in certain areas of

the Province.

MR. CAREEN: Specialists are very important. I

mean, a doctor is very important. Health is a wealth. I was concerned because

all of us here have friends or relatives who have sometime in their lives needed

a psychiatrist. If someone has a broken arm or that kind of thing, you can help

him along a bit, but if it is something with the head where you have to try to

kick start him in the morning - I am very concerned about the shortage of that

type of speciality.

The incident you mentioned at the Janeway, that was

another thing, too. I am not going to the nth degree of what you were saying

about PRAG, that these fellows said there should be seventy-five, and that is

utopia and all this kind of stuff, I am just talking about a measure to spread

it around. Is the Janeway still short?

MR. L. MATTHEWS: We still have some

difficulties there in terms of providing services quickly. I am going to ask my

deputy to speak to that because he is a little more familiar, having worked over

the years to try to bring that up to a proper level.

DR. WILLIAMS: The area of psychiatry and the

area of medical oncology are the two areas of the Province in which we are most

short of specialists. There is a worldwide shortage of medical oncologists and

there is a shortage of psychiatrists. I think the number of oncology cases is

increasing as the population ages and there are only certain centres that train

oncologists. We may not be training enough to keep up with the demand over time.

An oncologist is a person who treats cancer, who specializes in cancer,

chemotherapy, this type of thing.

MR. L. MATTHEWS: On a medical basis rather than

a radiation basis.

DR. WILLIAMS: There are radiation oncologists

and medical oncologists. There are two groups of oncologists. One treats people

with radiotherapy and the other treats people with chemotherapy, so they have to

have a detailed knowledge. You usually have to train as an internist and then go

on and sub-specialize in medical oncology, so there is a shortage and they are

difficult to recruit.

The other area is psychiatry. In rural Canada, for

instance, in Ontario, in the golden triangle, I guess, probably between Windsor

and Kingston, in that area, there seems to be enough psychiatrists, but in

places like Sudbury, which are large places but they are a little bit outside

the area, they have shortages of psychiatrists and they have to bring them over

from Ireland and England. That is my experience when talking with Ontario. We

have a shortage of psychiatrists in Newfoundland. We put in an incentive package

last year in an attempt to recruit psychiatrists. We want to maintain a viable

training program here at Memorial University for psychiatrists. We increased the

intake into that program from twelve to sixteen some four or five years ago. So

we are able to -we have a normal stream going through and on an average, trained

four psychiatrist a year. We have a reasonably good bursary system where we give

psychiatrists a grant of $12,500 a year, I am told, and in return they will

practice in Newfoundland, and that has been somewhat successful.

As the minister pointed out, we are enhancing the

salary scale for psychiatrists in terms of a bonus - if they stay for a year

they will get a bonus on scale. Also, for the people who serve a psychiatrist,

we are making some adjustments to these scales in an attempt to make it more

competitive with other parts of Canada. But we did have a shortage. We were

concerned with the number of psychiatrists, we went from thirty-three down to

twenty-nine last year. We were worried about our maintaining the viability of a

training program at Memorial, so we put these measures in place. I understand,

second-hand, from talking with the person who is acting Chair of psychiatry at

Memorial that he has identified three or four new people for the program. We

have added another child psychiatrist at the Janeway. We are now up to four at

the Janeway. So we are making some progress but that area is difficult and as

well, the medical and oncology areas are difficult. Other areas have a problem

with radiation oncologists but so far we haven't had that problem. We have five

radiation oncologists in the Province but we are looking for medical

oncologists.

MR. L. MATTHEWS: We have Newfoundland Cancer

Foundation Treatment, they have a medical oncologist on the way - have they not

identified one?

DR. WILLIAMS: They are interviewing people and

we are hoping that it is going to bear some fruit.

MR. CAREEN: Minister, in your opening

statements, you mentioned approaching MUN Faculty of Medicine, trying to make it

more attractive - you were on a number of weeks ago trying to make it more

attractive to -

MR. CHAIRMAN: Could you speak louder, please?

MR. CAREEN: That is the first time I have ever

been told to speak louder. It's Monday morning.

A number of weeks ago you mentioned in your opening

remarks about trying to make it more attractive to Newfoundland medical students

to stay here. We were hoping we would see here a bunch of Newfoundlanders and I

still hear some of them say, `I'd sooner stay home on one meal a day than be on

the mainland for three.' How is it working so far?

MR. L. MATTHEWS: Well, that must apply to

everybody except the medical graduates from MUN, because they seem like they

want to go elsewhere. I guess the bottom line is that as of March 1, this year

we had in rural Newfoundland - when we say rural Newfoundland it is rural, and I

guess, rural, rural or out there where doctors have to work on salary because

fee for service wouldn't render them any meaningful level of income. We have

about 130-odd locations out there like that. We have twenty-seven vacancies as

of March 1, but the thing that disturbed me when I found it out - it was only

about a month or less than a month ago that I became really aware of it - was

that eighty-eight of these positions are still being filled by foreign medical

graduates, by doctors who have come in here and don't even have full licensure

in Newfoundland because they haven't met the requirements of CMA and the NLMA in

terms of being fully licensed. We had, I think it was eighty-eight locations out

of 112 positions filled that were being filled by provisionally licensed

doctors. Now that is not to say that these doctors are not good people - a lot

of them are - it is just that they have not gone through Canadian medical

schools, so they haven't completed examinations for full licensure, but the

bottom line, that tells us, at least it seems to tell me, that despite

twenty-odd years, or however long we have had a medical school at MUN, that we

really haven't done the job in providing to ourselves doctors to meet our own

needs.

Now there is a lot of discussion; I had extensive

talks with Dr. Hawkins one morning about the admissions policy at MUN Medical

School, should we be taking in more rural students? How can we guarantee that

students who say they will go to rural Newfoundland will, in fact, go there when

they graduate?

Another thing that is a little bothersome, I think,

is that we make available second, third and fourth year bursaries - ten at the

moment - to students at MUN. These bursaries are worth $12,500 a year. Last year

we could only give away seven. Kids will not take them because attached to the

bursary is simply a year for year service. If you take it for a year, you go to

rural Newfoundland for a year, so if you take $37,500 over three years, you

would be expected to spend three years in rural Newfoundland, and the kids will

not take the bursary, so they have their minds made up right at the outset that

they are not going back to rural Newfoundland to practice, or that they are not

going to rural Newfoundland if they are not from rural Newfoundland. I say go

back; that is those who come from rural areas, and those who come from urban and

other centres are less inclined.

My comments initially were in the context of - I

view it as being a concern, because if our medical school is not meeting our

needs, and if we have to depend on Cape Town and Johannesburg medical schools to

meet our needs, I am wondering if we should not be funding these universities

and getting our doctors from there, and if our own kids want to go and become

doctors so they can flirt off to the U.S. or somewhere else, well let them go

get a medical education as best they can elsewhere, or at least pay the fair

market value for their education.

We provide ourselves with teachers in excess. We

have provided ourselves with nurses, more than we need at the moment. We don't

have a law school; we have lots of lawyers on Duckworth Street. We have an

engineering school and we have lots of engineers, but doctors we are having

difficulties with, so I guess my concept is that as soon as a new dean goes in

place over there, I want to have some meaningful discussions with the medical

school to say: Now, how are we going to use this facility to meet our physician

resource needs? If we cannot get it done, then we will look at whether or not we

need a medical school, or whether or not we need to keep it under the Department

of Health. I will tell you, they are not very anxious to go over around Memorial

University to have to fight for their funding over there. If we cannot get the

job done on the basis that it should be done, then I am prepared to make what

they would consider, I guess, drastic recommendations to government, but I think

recommendations that government would be very receptive of, because I have had

some preliminary talks with my colleagues in Cabinet about this issue. It is a

serious one, and I am intending to address it.

MR. CAREEN: Thank you.

Carrying on with that just for a second, this might

be a ludicrous statement, and I have made them before in my life, but I share

the worries, you can't expect to tie everybody down but, holy God, we were

raised here. There must be some kind of an attachment somewhere.

We have a lot of nurses and the majority of them

are women. That is not being patronizing or anything; it is just a straight

fact. We have some very, very qualified nurses, across this Province. Some of

them have taken extra training in different roles or whatever they do. Is there

any way it can be looked at - it doesn't cost anything to have a look - how some

of these people could be given opportunities to start in at second year or third

year or the fourth year of a medical school? And they will go back because their

homes are back in rural Newfoundland, for them to take the step instead of

continuing on as nurses.

MR. L. MATTHEWS: You are talking about -

MR. CAREEN: Yes, get them to become doctors.

MR. L. MATTHEWS: You are talking about changing

the entrance requirements to medical school so that people who normally wouldn't

qualify could get in because they have other medical training in their

background?

MR. CAREEN: Yes. I'm just wondering if there is

some way we could tackle some of this stuff that is going on. Now, I never

talked to Patt about it, she is a nurse, but I would just like to have it thrown

across here.

WITNESS: She is a teacher.

MR. CAREEN: Teacher, is she?

MS. COWAN: I'm a teacher.

MR. L. MATTHEWS: Doctor Williams, I don't know

how many people we would send to a psychiatrist on the admissions committee at

M.U.N. if we tried to do something like that.

MR. CAREEN: I know. It seems difficult to

change, Minister, but -

MR. L. MATTHEWS: You know about M.U.N., they

have this mind-set about academic freedom and so on?

MR. CAREEN: Yes.

MR. L. MATTHEWS: Just to give you an example.

You might be interested to know that the New Brunswick government always funded

ten spots up at the medical school. We held ten spots for it and it paid $13,700

a year for these spots. Well, this year, right out of the blue about a month ago

it said: Budgetary considerations, we are not funding any more spots for our

students at M.U.N., we are going to send them to Dal. So we had ten spots left

up there on the open market. Or, ten spots left that we thought were for M.U.N.

The dean of the medical school, said: I want to put these on the open market and

sell them down in the States for $30,000 a crack. I said: Go for it, we will

support you. Then the admissions committee over there comes back and it says: We

believe we have some responsibility to the students in New Brunswick because

they have airline tickets bought and they are coming over for interviews next

week. I said: With the greatest of respect, if any government has a

responsibility to those kids it is their own government who pulled the seats

out.

All hell almost broke loose because I sort of

suggested that they should have less flexibility in considering students from

New Brunswick as a group. I said: Throw them in with the Canadian stream.

Because we allow six seats for Canadians outside of New Brunswick. I said: Put

the New Brunswick students in with the rest of the Canadians and if they get in

on that basis, fine, we will admit them. Otherwise, don't give any special

consideration to New Brunswick kids, I'm sorry. Give them to our own kids if you

have to.

When you talk about doing something like you are

saying, Nick, take a nurse with a Bachelor of Nursing and give her special

admission rights to M.U.N. I can only imagine, Doctor, what you would hear in

the first instance.

DR. WILLIAMS: They are very protective about

the admissions committee functions over there. Basically I think they have a

hands-off policy on that. That was a decision that he as dean would not get

involved in, or could not get involved in. It is supposed to be a pure process,

I guess, the admission process, as far as that goes.

WITNESS: In addition of course you've got the

Board of Regents and then you've got the Senate. You never hear tell of the

Senate. Memorial has its Senate -

WITNESSES: (Inaudible).

MR. CHAIRMAN: Order, please!

WITNESS: Okay.

MR. CHAIRMAN: Mr. Hodder is out of turn. Ms.

Cowan.

MS. COWAN: (Inaudible) to my left here is just

chomping at the bit so I'm letting him go first.

MR. LANGDON: Thank you, Patt. To follow up on

the rural thing, rural Newfoundland. I have a particular interest in that. I was

talking to someone connected to the paediatrician in Grand Falls. I don't know

his name but I understand that he is leaving. He just can't cope with the fact

of being on call seven days a week, twenty-four hours a day, one paediatrician

for the central area.

I have a son-in-law who will be a fully qualified

paediatrician next year, from Grand Falls, and could go back to Grand Falls and

it has nothing to do with money at all. He said I am not prepared and sacrifice

going back to Grand Falls to be on call seven days a week, twenty-four hours a

day. He said I am just not prepared to do that. However, if there were two or

three of us where I could be guaranteed one in four days off or one in five off

and three nights a week or four nights a week, then I would consider it but I am

not prepared to consider seven days a week, twenty-four hours a day.

I think that in itself is something that the

department could look at because it is the work hours that many of the people

have to put up with and it is the same thing in many of the rural areas. We have

two doctors in the area, Dr. Sidhu in Hermitage and Dr. Parsons. Dr. Parsons is

a South African who is leaving and going back to South Africa again and I have

talked to Dr. Williams about this before. The dollars are good and obviously the

incentive that the minister put in it is an added incentive but I think the most

important thing for a lot of these people out there is the time element, the

fact that you are on call twenty-four hours a day, seven days a week and I am

not sure if any of us or any other profession would want to be involved in that.

So I think that is a major problem and I am wondering -

MS. COWAN: (Inaudible).

MR. LANGDON: We are, well okay. We are a

different breed I guess but anyhow, have you looked at that?

MR. L. MATTHEWS: Yes, there are two big issues

that come to the fore in terms of rural physicians - physicians generally but I

guess rural physicians - number one is remuneration and number two is lifestyle.

I had lots of discussions with my deputy about this because he went to rural

Newfoundland twenty-five years ago and he knows what the doctors were prepared

to do back then as students when they went out and basically he tells me that

they did not know any better so they worked seven days and seven nights a week

but now it is not the same. Doctors are not prepared, young physicians are not

prepared to go out and give that level of commitment because it is a different

generation, a different mind set, different expectations and they want back-up

people to be able to work with them. They want to have a reasonable lifestyle

outside of their profession and they want to be paid well for what they do and

why not if they can get - I think in Manitoba they start them anywhere from

$90,000 to $120,000 a year - if they can go and get a job at that level? We

start them in the $60,000 to $90,000 range. So we are way behind the eight ball

in dollars and cents. We will never be able to make it up purely on the

economics but we are trying. The incentive package that we introduced last week

I think is going to be a good first step. There is also provision in that by the

way, Oliver, to recognize extra workload.

So to some extent that package includes recognition

of extra workloads such as that. For instance, if there are five doctors that

should be in a location and there are only three there for an extended period of

time we will take some of the salary allocation and - well they do that now,

they split some of the salary allocations up but we will give some extra money

to compensate for extra workload but, as you say, that is not the total answer

because people are not going to work seven days and seven nights a week in

perpetuity. Do you want to add anything to that Deputy?

DR. WILLIAMS: Yes, probably the Connaigre

Peninsula illustrates a problem that we have in a large part of Newfoundland, in

the rural parts of the Province. For instance, in Mose Ambrose and Hermitage we

always had one physician practices there and we increased the practices to two

physician practices some years ago recognizing that maybe the population could

not justify two people - justify maybe more than one but not two - in terms of

the volume of work, but just to give people a better lifestyle. Even then it is

more than they can take.

Maybe we have to look at some creative solutions in

terms of moving the physician population to Harbour Breton and increasing it

from three in Harbour Breton to probably five, six, or seven doctors in Harbour

Breton and then they would outreach to Hermitage and Mose Ambrose, and do call

in Harbour Breton; so they would be doing one night in five or six and have

outreach clinics. But that creates some inequities as well because the people in

doctor, so you trade off one for the other.

You probably would get more stability in terms of

your physician population in that kind of an environment, but there is the

question of whether the people in those communities of Hermitage and Mose

Ambrose would be prepared on weekends and at night to drive to the hospital at

Harbour Breton to get seen. Certainly, I suspect they would have less of a

turnover of doctors because there is a better lifestyle. They are working in a

group, there is more collegiality, they are working harder when they are working

but they are working less often. So that is the kind of trade-off you have to

make.

Sometimes you think you can do something for

somebody by having, say, two doctors in Mose Ambrose, but then they are working

every second night and that, over time, wears people down as well. So those

issues, as well as in some of the speciality areas, in some of our district

hospitals we might have enough work to justify two specialists but, over time,

one or two is not too conducive either. In this type of thing where there are

small populations, you may not be able to justify any more than two on an

economic basis. Certainly, on a fee for service basis, two probably wouldn't

make it, so we usually have those positions as salary positions. That trade-off,

in terms of population and geography, makes it difficult sometimes to have an

adequate number of staff and a reasonable lifestyle for physicians.

MR. LANGDON: But with two, it is better than

one.

DR. WILLIAMS: With two, it is better than one.

MR. LANGDON: It is the same problem. People

have come to me with the ENT specialist in Grand Falls. The man is backed up

about six or eight months and there is just one of them out there. Again, we had

one there from our own area, from Belleoram, as you know, Dr. Savoury and he

left. Basically, it is the same thing, you just get tired out, you just get worn

out from being on continually, and I think that is a problem that has to be

addressed by the Department of Health.

MR. L. MATTHEWS: We have been recruiting quite

actively for ENT in Grand Falls. I am aware that they are backed up there and I

thought they had a good prospect of bringing in somebody.

DR. WILLIAMS: Yes, they had, from South Africa,

but the person wouldn't come because he would have to be on a salary.

MR. LANGDON: So they do need ENT.

DR. WILLIAMS: There is one ENT in Gander and

one in Grand Falls, and then two in Grand Falls as well.

MR. L. MATTHEWS: I had some people complaining

because they had to go to Corner Brook for ENT services but I am not sure it is

much better there.

MR. LANGDON: Another question I have to

follow-up, I think, on what Gerald said earlier on the ambulance service. I am

glad the department is taking it upon themselves to look at a new funding

arrangement, for want of a better word, for the community health people. Because

in the area that I serve again, in the Connaigre Peninsula, there are three

ambulances, all community-based, and more often than not, they are coming to the

department when they have overdrafts, and I must say, the department has been

very helpful in that and have addressed the needs a number of times.

Only this past week, the ambulance board for the

Hermitage area canvassed the different houses. In Seal Cove, one of the people

knocked on my door. I think it is $20.00 a year that we give to help run the

ambulance in that area, and they are having a difficult time in making ends

meets. Basically, I guess, it all comes back because there is a different

arrangement, a different formula for community-based versus the privately owned

operators. That is being addressed and obviously it will take away a lot of the

stress from the private ambulance people in the area I serve, and others as

well.

You were saying, you are taking over some of the

nursing care and so on from Social Services, which you now do. Can you go into a

little more detail and tell me some of the people who are in this group that

Social Services did care for, versus what you have now?

MR. L. MATTHEWS: Yes. The programs that we are

taking over really cover three groups of clientele, if you like. There is the

mentally disabled and the physically disabled, and there is the seniors, the

enriched needs program. These are the three basic groups that were being funded

under the programs that we are taking over.

In terms of the budget split, I would say, of the

budget last year at least 40 per cent of it was directed towards seniors, the

enriched needs, if you like, homemaker services and the like. The other 60 per

cent of that budget was dedicated toward the mentally and physically challenged

who have been de-institutionalized for the most part and who are now being

supported in the community with a broad range of services that they need to

exist, and to have a better lifestyle, as well as better services in the

community.

MR. LANGDON: Who in your department is

responsible for that?

MR. L. MATTHEWS: Assistant Deputy Minister,

Joan Dawe, is directly responsible for developing the policies that we will be

following and implementing in health and getting the staff up and running. She

has all the answers, Oliver, that you would ever need, and she has only been in

charge two days.

MR. LANGDON: I will make an appointment over

the next week or so to -

MR. L. MATTHEWS: Yes. Now, as I said, she has

some staff working with her who are involved in that, but it falls in her shop

primarily, these new programs, from Health purposes. They are not new programs

for government, but they are new in terms of coming over into Health.

MR. LANGDON: In the department.

MR. CHAIRMAN: Thank you, Mr. Langdon.

We are going to take a ten-minute coffee break,

then we will come back with Mr. Hodder.

Recess

MR. CHAIRMAN: Order, please!

Ms. Cowan, Mr. Hodder has decided that we would have

you go first with your two short questions; we will get two short answers, and

then we will go with Mr. Hodder.

MS. COWAN: I demand equal time. I have just a few

questions. I could go on forever because I've had so much personal experience

with the health system in the last few years.

I like Nick's idea about that upgrading thing. Now, I

know all about academic freedom and the ivory tower and all that kind of thing,

but just something that crossed my mind, and it is more of an idea than it is a

question: Is there some way that anyone who had finished a nursing degree could

upgrade and then go into a medical program? That just sort of crossed my mind.

It is not really a question. I don't know whether you would think the same sort

of academic snootiness would prohibit that, but it is a thought.

MR. L. MATTHEWS: There is no difficulty at the

moment at M.U.N. in the medical school in terms of attracting students who are

applying for admission. A lot of students year after year don't get in. It is

not a case of not having enough people applying. I guess, from a provincial

Department of Health point of view, trying to meet our own needs with doctors,

what I would like to see them be able to achieve is an admissions policy such

that they would give some weight and consideration to the question of where

people are prepared to practice once they get out; and having gotten that

commitment, some ability to be able to, for want of a better word, enforce that

commitment.

Because some kids now who take the bursaries - they

don't all get taken up, but some who take them - the three-year bursary is

$37,500; at the end of their third or fourth year they get these offers from

down in the States and places like that. They get hospitals and clinics coming

up, buying out their bursaries, saying: We will pay that off for you. That

relives them of their legal obligation, and certainly a moral obligation doesn't

count for very much.

MS. COWAN: No.

MR. L. MATTHEWS: It is pretty difficult to even

enforce a commitment up front. That is where it is. It is not a matter of not

enough people applying; it is a matter of the choices they make at the end of

the day. As to whether or not we could ever get to a circumstance where you can

consider criteria other than purely academic - like historical service in

nursing or something like that - that is a question that I can't answer, and I

don't think you could get a ready answer at M.U.N. Well, you would. I guess they

would say: We wouldn't consider it.

MS. COWAN: You can be allowed sometimes to upgrade

to get into arts courses and things, so it just struck me that it was a

possibility.

MR. L. MATTHEWS: Nurses can go on to the

baccalaureate program at M.U.N. for their B.N. Now, in the nursing profession we

have a new collaborative curriculum coming into existence in 1996, so that when

we amalgamate the three schools of nursing in St. John's - the General, St.

Clare's and the Grace - there will be just one school of nursing, one

curriculum. That curriculum will have a couple of exit points. They can exit

with an R.N. or they can go on to the university level and exit with a B.N.

Whether or not something could be developed to further enhance that, such as

they could go on to medical school, I think is a whole new area, Patt, that

really we are getting into discussing.

MS. COWAN: I don't want to harp too much on this

because we have talked a lot about it this morning, but just one thing before

you close Memorial's medical school.

MR. L. MATTHEWS: Lest you misunderstand me, we are

not in the mind-set of closing the medical school.

MS. COWAN: My colleague, here, from Bay St. George

and I were talking, with our background in education. Is there any possibility -

and I would think there is a great possibility - that the lack of science

courses and other courses that would lead kids to choose medical school are not

being offered in rural Newfoundland, and therefore the kids just don't have the

qualifications to get into the medical school.

MR. L. MATTHEWS: That might be, but to the credit

of the medical school - because they are doing some good things over there -

they have been running for a number of years, and I attended part, last year, of

what they call a rural Med Quest program. It is a Med Quest program where they

go out and encourage - schools identify likely, good candidates for admission to

medical school eventually, and they encourage - they go out and sell the whole

concept of getting into medicine such that kids in rural Newfoundland in

particular are given an exposure to a mind-set that they can qualify and do well

in medical school if they wish to choose that career path. The Med Quest program

is a very impressive program -

MS. COWAN: Yes, it is.

MR. L. MATTHEWS: - and a very good initiative. I

will have to say that in defence of and to the credit of the medical school over

there.

They are making good efforts to get rural kids in. We

just want to have some way that we can get them in and keep them in Newfoundland

after they graduate.

MS. COWAN: Yes. It is the education system I'm

questioning now, the high school system. Are they providing the proper courses

in rural Newfoundland that would enable a young person to get in.

The other thing that I am very interested in - and I

guess from the experience we have had in the Children's Interest Committee, and

it was referred to by one of the two gentlemen there on the other side - is that

the Department of Health seems to be sort of on the cutting edge of change. It

is something we found all across Canada actually when we did a little bit of a

fact-finding trip there a while ago. So I commend all of your officials,

Minister, for the fact that they do keep on the cutting edge. That doesn't mean

we are not going to have some recommendations when it comes to things to do with

children, but it is very good to see such a progressive department.

Having said that I want to turn to breast cancer.

Because I don't suppose there is anybody in this room who hasn't in one way or

another had their lives touched by breast cancer, and for women it is something

that we live with with a constant fear. It is almost the same as being very

cautious about when you go out at night and that kind of thing for fear of rape.

Breast cancer is something that is a real concern I would think to all of us. In

the Canadian Living magazine - and I'm not sure that I'm quoting it

correctly or if it was right, but it certainly was frightening - that one in

eight women will get breast cancer in Canada and that the number is dropping.

That the statistics may show that it will be seven, or something. Anyway, it is

getting worse instead of getting better.

I know we make a lot of fuss about things like, you

know, these machines that you take around from place to place, but research

shows that they really don't change anything. I know that we do something here

in the Province and I just wondered if you could enlighten me, and perhaps tell

me, Minister, we must be plugged into national networks and so on in that

particular area.

MR. L. MATTHEWS: I guess I can ask Mrs. Dawe to

speaks to it in a minute. Last year, in 1994 as a result of the ad hoc committee

report on breast cancer the government put $700,000 into a three-year pilot

project, if you like, to address the whole issue of breast cancer and to do

something new or enhance things in terms of trying to deal with the problem. It

used to be the biggest killer in women up until recently, breast cancer. Now it

has dropped off to second place of course and lung cancer has taken over,

believe it or not, as being the biggest killer for women. I thought you might be

interested in knowing that.

The initiatives that we are doing provincially involve

basically breast health education for public and health professionals, involves

the teaching of breast examination in women over fifteen years of age, it

involves a bi-annual, I guess, or every two year examination, screening by

mammogram of women between the ages of fifty to sixty-nine.

MS. COWAN: (Inaudible) they are required?

MR. L. MATTHEWS: No, these are the things that the

initiative is encouraging and trying to promote. Joan, probably you can speak

more fully to where we are with that project specifically and to breast cancer

in general for Patt.

MRS. DAWE: I'm chairing the implementation

committee to deal with the report on the breast screening project. On that

committee we have representatives from the health system broadly: community

health, institutions, the medical association, the nursing association, consumer

reps, Cancer Foundation, Cancer Society, and on they go. We've brought together

quite a group of people to deal with the implementation of that report. That

actually started in November. Just two weeks ago we finalized the budget

requirements to start the implementation of the four components that the

minister had mentioned. Mammography is just one component and we want to start

well back with education prevention initiatives.

We've selected as of last week - and it is not public

yet but the decision has been made by the committee - that the two pilot sites

for mammography will be here in St. John's through the Grace Hospital and in

Central through James Paton in Gander. They will be the pilot sites for

mammography. Then we will use through the public health nursing system nurses

for the education of the public, of women, and other professionals, so there

will be much more, I guess, information flowing within the next month as we

finalize other components of the decision. That is a significant initiative.

The budget requirements were over $700,000 for the

first year and $600,000 for each of the next two years. It is a three year pilot

project with the intent then that a provincial project will be phased in after

we complete the implementation of the pilot.

MS. COWAN: So this is largely an education

project. We could not afford, I would think as a Province, research. We probably

feed into some central (inaudible).

MS. DAWE: On the committee where we have

representation from the Cancer Society, the Cancer Foundation and the University

these are our links with our national bodies to ensure that we have the latest

information in terms of research, treatment and education. So we certainly do

not need to duplicate efforts there. It is a matter now of using the

information, the research and getting on with the implementation of programs

that are relevant, starting with prevention and then moving along the line to

the mammography.

MS. COWAN: Just in passing, in something else that

we were discussing, I met one of the women involved and she was just so

enthusiastic and ever since then I have been sort of anxious to find out some of

the details of it.

Just in my closing, either comment or question, I am

not a great believer in the over use of specialists. I think that we have that

problem here in this Province and also the over use of emergency for things that

could be attended by a family doctor. I don't know if there is anything that can

be done to educate people. I talked to friends who have said for example: Oh, I

just love my family doctor. She sends me to a specialist right away. Well what

the heck is she trained for, unless you have something really, really serious. I

know with my thyroid for example, I was going to a doctor and waiting six hours

to see a specialist at the hospital which I felt I did not have time to do. So I

said this is crazy, we now know what is wrong with me. Why isn't a GP monitoring

it who can then contact the specialist if we run into trouble?

So it seems to me that there is something wrong in our

thinking that, gee you just got to have millions of specialists and we all have

to be rushing to them. Is there anything that can be done about that? The same

as people having a sore on their big toe for two months and then finally going

to emergency with it at midnight on a Friday or something, these kinds of

things. They are big users, I would think, of the money in the health care

system.

MR. L. MATTHEWS: Well the system is to a large

extent, like you say, physician driven in terms of not only referring on to

specialists but the ordering up of examinations, tests and procedures, all that

sort of thing. That is an area where the medical profession basically has to

take significant responsibility in ownership because they are the ones who are

on the front lines and they know to what extent they may be over-subscribing for

speciality services or for procedures. So to a large extent that is in their

shop and they are not unaware of the view of government, especially these days,

that they have to take responsibility to curtail the unnecessary use of their

procedures. Having said that of course, when it comes to your health it is a

pretty fine line and a pretty difficult thing to say to somebody that in my

opinion - especially us being laymen, all except Dr. Bob I suppose here this

morning - that was an inappropriate prescription or that was an inappropriate

ordering up of tests and that sort of thing.

MS. COWAN: Well maybe it was an inappropriate

statement for me to make.

MR. L. MATTHEWS: I would not go that far, Patt,

but I mean your observation is valid to the extent that that is how you feel. So

I am not sure that there is much more that can be done about it then for all of

us to use our good common sense. Now as far as people going to emergency at 12

o'clock in the night when they could have gone at 12 o'clock in the day, I don't

know if it makes much difference or not, probably they should have gone to their

family doctor. Education is the thing that will change the way, not only that

doctors practice medicine but the way that we as clients subscribe to using

medical services. That is the bottom line.

MS. COWAN: I do notice some younger doctors having

these signs in their office that come from the Medical Association, sort of

suggesting that you not overuse the medical system. I cannot remember the quote

exactly but I was quite impressed by this. I do not see it in older doctors

offices but it would seem to me it is a slight indication that there is some

responsibility being taken there. Maybe those are just prejudices of mine.

MR. L. MATTHEWS: New Brunswick is doing a pilot in

one of their Moncton hospitals, and I think they are one of the first or few

doing it. They have people phone in to a nurse or somebody to get advice as to

whether they should go to emergency, whether they should go to a doctor, or

whether they do not need to go anywhere. That is a fairly innovative thing and

we are going to be watching to see what the results of their experiment is in

trying to cut down some of the things you were talking about.

MR. CHAIRMAN: Thank you, Mr. Minister.

MR. L. MATTHEWS: My assistant deputy tells me we

have Dr. Drover now so that is our early answer to that type of thing.

MR. CHAIRMAN: Mr. Hodder.

MR. HODDER: Well, of course, that would be

consistent with your doing away with the Ombudsman, would it not? The Premier

said that you could call your MHA and do all this kind of thing, so now we can

call Dr. Drover to enquire as to whether we have need of services.

MS. COWAN: Now, be nice.

MR. HODDER: Be nice. I shall, but there is some

instinct there somewhere.

Your health care boards - all appointed?

MR. L. MATTHEWS: Yes.

MR. HODDER: The question is on their operations

and the publics right to know and have access to information. This is a board of

governance that governs wide areas. Will the operations of these boards and

their meetings that go with it, will they be public forums whereby people can

witness the boards operating?

MR. L. MATTHEWS: I was just checking that with my

deputy, because I know in the case of school boards, and I sat on a school board

myself as a trustee for eight years, all school board meetings are public

meetings unless they are designated as private meetings or privileged meetings.

The deputy tells me that under the Health Act meetings of health boards are not

public meetings unless they are designated as public meetings, so I guess they

are not automatically public forums are they?

DR. WILLIAMS: It has not been the trend in the

health system in Newfoundland to have any board meetings public meetings. What

some boards do is have an annual meeting where they present an annual report and

members of the public are invited to come along, receive the annual report and

ask any questions they wish to ask, but there have not been up to this stage

anyway. I do not know if there is anything in the act that prevents it. I think

it has just been policy.

MR. L. MATTHEWS: It is a good point, Mr. Hodder.

Probably it is something that should be considered in terms of whether or not

all meetings of health or trustees should or should not be public meetings.

MR. HODDER: I come from the point of view that at

these meetings you are not talking about client/patient confidentiality, you are

talking about governance and if you are going to have a good system of

governance therefore the pubic has to perceive that they have access to

information and there has to be a certain level of accountability. I do not see

a system, with regards to whether it is through government or through the party

I am part of, I cannot see anybody in the Confederation Building being publicly

accountable on a day to day, or monthly basis for something that is happening in

Corner Brook, Grand Falls, or Clarenville.

I do believe that there is going to be a sense of

ownership generated at the regional level. There has to be a system set up

whereby people have to feel that they have a right to have access to, have

information from, and carry it in the local press, so I come from the point of

view that says that all operations of the regional boards, if we are going to

give it a chance to work then the department has to make sure that they operate

in a public forum. Then people will feel they are part of it; they won't be an

imposed kind of thing.

The other thing is again the freedom of information on

certain issues. We had incidents a little while ago involving a child in

Conception Bay South who was given wrong - well, there was a very fundamental

error made.

It bothers me that the Newfoundland Medical

Association can operate almost in a very private manner investigating errors

that are made, and we know there are errors made from time to time, and we have

to accept the fact that there are going to be errors made. I am asking the

minister, is there going to be some way in which there can be greater public

awareness of, an accountability to the public, for this kind of thing, other

than waiting until something comes up in court?

MR. L. MATTHEWS: Well, all professional bodies

basically have the mandate and the responsibility to police themselves. I am

thinking of the legal profession, the engineering profession, the medical

profession, and others. They all basically have the same system of policing

themselves and monitoring their activities as amongst their members. For the

most part, as best I can judge from any experience I have had in the seven or

eight months that I have been Minister of Health, things do get addressed

appropriately through the NLMA and through the procedures they have in place.

That is not to say that people are not going to end up with civil suits in the

courts; they will, and they have that right, and thank goodness they do, but I

am not aware that there is any great public outcry to change the way that

complaints for perceived malpractice or inappropriate prescriptions or that sort

of thing is handled. There is no group coming forward as saying how medical

complaints or doctor complaints and hospital complaints are being handled is not

working appropriately.

MR. HODDER: It bothers me that when something goes

wrong, the first place we hear it from is CBC. Automatically you have somebody

who is going to call into the media, you have the child on TV, and this kind of

thing. It seems to me that people feel that if something goes wrong they don't

have ready access of redress through the channels, so they have to make a public

cause before the system moves.

MR. L. MATTHEWS: Most people, when they have a

difficulty, if they went to a hospital, say they didn't get admitted, or the

diagnosis was inappropriate, or the treatment was inappropriate when they were

in, or that sort of thing, in the first instance we direct them, if they come to

us, back to the hospital itself, because the hospital board in the first

instance, and now the new regional boards, have a responsibility to see that

things are done properly in their area, but there are procedures beyond that to

the medical board -

AN HON. MEMBER: The pharmacy board.

MR. L. MATTHEWS: The pharmacy board, the medical

board, and these procedures, like any other profession, are working, I think, as

best I can judge, as well as they would in any other profession, whether it was

the legal profession or anything else.

If you have any suggestions as to how things could be

done differently or better I would be glad to hear them.

MR. HODDER: It is possible in Newfoundland - I

mentioned this last year and Dr. Bob Williams will remember it - it deals with

doctors who lose privileges at hospitals. A doctor who loses privileges at a

hospital of course, doesn't have to admit people, he can still carry on his

clinic. It is possible in Newfoundland -obviously it is changed now - for a

doctor who has lost privileges at a hospital to decide that he doesn't need to

use a hospital. He can get away from that. In St. John's he can make a choice.

If he has lost the privileges at St. Clare's he can move people around. That is

possible. Losing privileges in itself doesn't mean that the doctor has been

penalized.

Is there some way in which we could try to address

that issue? Again, we know that doctors lose privileges for a whole variety of

reasons, and they are not always, shall we say, something dramatic. It is just a

matter of failing to write up your charts consistently, which is an essential

patient service, but it can result in your losing your privileges after the

appropriate procedure is in place. There is nothing that says that a doctor

can't continue to practice medicine.

MR. L. MATTHEWS: Dr. Williams?

DR. WILLIAMS: A doctor can lose, as you say,

privileges at a hospital for a variety of reasons. They mightn't be dealing with

the actual conduct of their practice in the sense, there mightn't be malpractice

issues or poor practice issues. They might be, as you say, (inaudible).

MR. HODDER: (Inaudible) poor practice issues but

not malpractice.

DR. WILLIAMS: They didn't complete their charts

properly on time or on schedule. In St. John's now of course where they have one

health care board they can't just pitch at another hospital because they will

have privileges with that board. It would be certainly devastating for a surgeon

to lose privileges at a hospital or an intern to lose privileges at a hospital,

because it would be really difficult for them to function in terms of economic

realities.

You have in Ontario many psychiatrists practising

outside a hospital environment. That is a tendency that is coming into vogue in

terms of that profession because in many instances they don't need hospitals.

The more difficult patients are just sent to the hospital and they are operating

an office practice. If certainly a physician loses privileges for a clinical

issue then I'm sure that issue is followed up with the medical board, and they

might in fact lose their licence for a period of time, depending on the issue.

They have the right to fine a physician, hold a hearing. The person making a

complaint can appear at the hearing and make the complaint. It is done

consistently across that profession and the pharmacy profession and in other

professions. There is a mechanism through the professional governing bodies

where physicians or pharmacists or that can lose their licence. When we get

complaints at the department that are dealing with professional issues such as

that we have the complainant referred directly to the appropriate board; then we

follow up to make sure that we get a copy of the board's response and tell the

complainant if we get it in writing, and if they are not satisfied to let us

know. There is usually that mechanism in place.

As well, in the PRAG report that we talked about

earlier - the minister talked about the Physician Resource Advisory Group is

making a recommendation - I think it is recommendation 14 - that physicians

should be required to maintain privileges at hospitals and required to do their

fair share to make sure the hospital functions adequately.

AN OFFICIAL: Exactly.

DR. WILLIAMS: Sitting on peer review committees in

the hospital, sitting on quality assurance committees, sitting on credentialing

committee, sitting on tissue audit committees, and doing their call in the

emergency department. The PRAG recommendation 14 deals with that requirement,

and if physicians do not fulfil those requirements then there is going to be a

financial penalty if that recommendation is carried forward. We know in some

rural areas for instance that some physicians run on a fee-for-service basis,

and others on a fee-for-services or salary. Some physicians will not even cover

the emergency department or do obstetrics in some of these smaller communities

to the detriment of the other physicians who are doing it. So that

recommendation will hopefully deal with that.

MR. HODDER: The Burin Peninsula Hospital is a

prime example of where doctors deliberately will not accept hospital privileges.

DR. WILLIAMS: Yes, that's right.

MR. HODDER: Some of the people up there with the

most lucrative practices - practices that begin at 6:00 a.m. and get the people

on their way to work and while that is good, there are doctors who do open

clinics at 5:30 a.m. on the Burin Peninsula and these doctors refuse to accept

hospital privileges. They do not see themselves as part of a macro kind of

health care system. What I am saying is that where doctors deliberately choose

that route they are not contributing in the global sense. So therefore we have

to say to these doctors if you want to do that you are not going to get the same

revenue per patient as doctors who do do it. So we have to have sanctions in

there that make it possible for their total system to operate.

I will get back to my other point that I started with,

is it still possible for a doctor who had been denied privileges, say as a GP,

to decide that he does not need that anymore and he can now go out and set

himself up as an eye specialist?

DR. WILLIAMS: Well I think a GP -

MR. HODDER: Not as an ophthalmologist but an

optometrist.

DR. WILLIAMS: It is possible for a physician to

bill the vision assessment. It used to be possible but I think we removed that

from the MCP payment

schedule so that they don't get recompense for a vision

assessment. We had some physicians years ago who thought optometry was a

lucrative field. They would do a course in optometry, refractions and then do

general practice but also do a fair number of refractions. Well we removed that

component from the MCP billing schedule.

MR. HODDER: So that has been removed in recent

months?

DR. WILLIAMS: Yes, that was removed a few years

ago. They do not get paid by MCP for doing refractive services. The other point

that you -

MR. HODDER: But with their limited training - my

point is that if you are going to go into a school to study optometry or

whatever, it is a four to five year course. You have a general practitioner who

decides that, for whatever reason, he does not want to carry on a general

practice or job anymore, is situated in one of the more urban areas and that

person then decides well there is good money here in the eyeglass business - I

call it - and so decides now I did a course in that area or whatever which is

basically a month course, if that. I mean you went through the system, you know

how much time you spent at each component, very limited. Then suddenly this

person is set up as equal to the person who has had four or five years training

in that area alone. That is still possible in Newfoundland isn't it?

DR. WILLIAMS: It is still possible I guess, not

only in Newfoundland but anywhere that somebody can go in to do refractions.

They have a medical knowledge of the eye, the needs of the eye and then they

take a course in doing refractions which, with the equipment that they have

today with computers, it is not as hard as it used to be, in a sense. So they

can do refractions, yes. We do not pay for them. We have not had any complaints,

that I can remember, from a member of the general public since I have been at

the department who says that they have not gotten quality service or have

complained about that kind of service but, personally speaking, I am not in

favour of that, no.

MR. HODDER: I brought it up last year and just

briefly again, I think it is an area that we need to address in terms of our

total health care and mandate, fetal alcohol syndrome, latest research, have we

done research on that particular syndrome in Newfoundland,

and what is its status?

MR. L. MATTHEWS: One of the deputies will answer

the question, but there is more and more evidence that there is a link between

alcohol and deficiencies and deformities and that sort of thing. The effects it

has on newborns, I'm not sure where we are in terms of research in Newfoundland

as isolated from national or international research. Is that what you are

asking?

MR. HODDER: I'm just wondering if we are

participating in the national research. Obviously we wouldn't have the capacity

here to do our own independent research.

MRS. DAWE: That is correct. Our director of drug

dependency services within our division participates and is currently in with

our counterparts across the country on fetal alcohol syndrome. I don't have the

ready information. I will be happy to share that with you, but it is a current

activity of our division, yes.

MR. HODDER: Because it is -

MR. L. MATTHEWS: Getting back to your former

question though, Harvey. If we made it a requirement that a physician has to

have an attachment to a hospital board in order to get a billing number for MCP,

that would move us a long way toward addressing situations like you are aware of

in Marystown, on the Burin Peninsula. Because if every doctor had to have a

billing number, before they got it they had to have a relationship with a

hospital board, then they would have some responsibility to do certain things in

order to maintain that billing number. Like covering the emergency for a period

of time or being involved in some of the other activities that the Deputy

Minister mentioned.

That is a significant recommendation of the PRAG

report and it is probably not one that the medical profession will want to buy

into right away. Because all of the recommendations there that have impacts on

practice and that sort of thing, the NLMA - they don't all think alike all the

time over there, let me tell you.

MR. HODDER: Not likely.

MR. L. MATTHEWS: No. If they were a union they

would be the most fragmented union in the world. That is my view.

MR. HODDER: It is connected to keeping doctors in

those hospitals. You might need a recruitment, and then when the doctor gets

there he or she finds that they are working diligently, long hours, no breaks,

find themselves not having the quality of life, and get very frustrated that a

high proportion or a certain proportion of their activities on a daily basis is

really looking after someone else's patients. That is the bottom line. You've

got a group of doctors who are operating on the basis: I will send you to the

hospital, but when you get there someone else will look after you because I just

don't have time to do that.

MR. L. MATTHEWS: Especially on the weekends or in

the nighttime.

MR. HODDER: Yes.

DR. WILLIAMS: You are well-versed in that issue on

the Burin Peninsula. It applies in a number of other areas. When I worked on the

Burin Peninsula it applied there as well. That was quite a number of years ago

but we did have a similar problem there with a number of physicians in

Marystown. We were working at the cottage hospital in Burin and on weekends and

nights we would often get people dropping down from Marystown and Creston,

places like that, because their doctors weren't available.

MR. HODDER: That is right.

DR. WILLIAMS: Yes.

MR. HODDER: But it happens all across the

Province.

DR. WILLIAMS: Yes, it wears you down. This

recommendation number 14 I think will deal with that in a major way, and there

will be a major financial penalty for these physicians who do not participate in

those activities. I think a physician has a responsibility to society and to

their patients. They have to cooperate to make sure that is done.

MR. HODDER: It happens here in St. John's as well.

DR. WILLIAMS: Yes it does.

MR. CHAIRMAN: Excuse me. We will go to Mr. Careen

for some questioning.

MR. CAREEN: Thank you, Mr. Chairman. Minister, the

grants to hospitals, and long-term care facilities, and the health clinics are

down this year compared to what was budgeted last year or revised last year.

MR. L. MATTHEWS: The grants to -

MR. CAREEN: Yes. Page 236.

MR. L. MATTHEWS: Yes.

MR. CAREEN: Are we going to see reduced health

care services in those areas by such reductions?

MR. L. MATTHEWS: We are not going to see

reductions. There is only a slight reduction there, as you can see, and

basically we anticipate that as a result of the restructuring, just by the

adjustments that will make in some of the middle management positions, it will

create a fair degree of savings in terms of dollars and cents, but in terms of

the reductions here you will see that it is very, very little on a percentage

basis. You are talking about the figure that goes from $573 million down to $569

million, about $4,000 on a $573 million budget.

MR. CAREEN: No, there is one there, grants for

hospitals, which last year was $423 million.

MR. L. MATTHEWS: Okay, just that one, 4.2.01.10.

MR. CAREEN: Last year it was $423 million; and $82

million to $81 million, and $34 million to $33 million.

MR. L. MATTHEWS: Yes.

MR. CAREEN: Well, Sir, we have seen that in middle

management positions.

MR. L. MATTHEWS: For the most part there will be

more than that saved. Basically, the Department of Health - we were able this

year in the Budget to hold the same Budget in dollars and cents as we did last

year, and we were fortunate to be able to achieve that because a lot of

departments didn't have that success. I think it goes beyond the department. I

think it speaks to the whole issue of government's commitment to do whatever it

has to do to the maximum extent possible to provide appropriate health care, but

certainly the reorganization of boards and the restructuring is going to cause

some savings, not at the point of delivery, or not at the bedside, if you like,

or not in the emergency department, but by eliminating a lot of departments that

are unnecessary to keep at the staffing levels they have now.

MR. CAREEN: This leads me to the parochial

question of which I touched based with you on Friday. When they formed the

regional health board of Placentia, Carbonear, Whitbourne, New Perlican, there

was fair representation on it. Every existing board had people picked off the

board, or other people to represent them - nothing wrong. Now, I mean, it is

true that the board members themselves will have to bring their own expertise to

the table, and hopefully they all have that kind of stuff; but the community

health board, that I brought up the other day in the House, that

is where I have a bit of trouble.

Now, in the Act you can go to a maximum of fifteen,

and when that fifteen is attained you have them stretching from Topsail in the

east right to Port Blandford in the west, two on the Burin Peninsula, the

Bonavista and Clarenville area is covered, and up to Port Blandford. There is a

woman over in Riverhead, St. Mary's, someone in Whitbourne, then there are six

in the Trinity-Conception area. Now, on the eastern side of Placentia Bay there

is not one person, and this seems short-sighted - I don't know what happened. I

was told that the public health board (inaudible) sent in names. I was told that

the hospital board in Placentia recommended a name. Our facility in Placentia,

the Lions Manor, which has seventy-five beds - and there are six not being used

now because they are building onto the hospital there - covers the Cape Shore

area and part of St. Mary's Bay North, Long Harbour and then you go right up to

the other end of the district and there is no one there at all. I am wondering

if there is any kind of accommodation that can be made to cover that shortfall,

like a person might be on the regional institutional board who could change

places with somebody else. You have to have someone to be able to hone in to,

and under the legislative law you cannot put sixteen because fifteen is there.

I was talking to Ms. Simms on Friday - she seems like

a nice lady to talk to - she is on the regional health board, and she is Chair

of the community-based board. Is that usual practice?

MR. L. MATTHEWS: Yes, I can explain that to you.

MR. CAREEN: So you have a continuity.

MR. L. MATTHEWS: There is a cross representative

from all institutional boards to the community health care boards. As Ms. Dawe

said, it is for purposes of cross representation so that one board, at least,

has somebody on each that knows what the other is doing. Because these boards

are going to have to work together pretty closely, and the community health care

boards are new creatures as opposed to the institutional boards really being a

consolidation of existing hospital and long-term care boards, but to your

question that you asked in the House Friday, or whenever it was, and back to

that one, the concept was to put equitable representation on the boards for

every geographic region. Now, the area that you just described is pretty big.

You go Trinity - Conception Bay, Placentia Bay, and you are up to Trinity -

Bonavista Bay, and you only have fifteen slots to fill.

The only answer I can give you is that I would hope

the area you are describing generally in Placentia Bay, on a per population

basis, if you took the 50,000 or 60,000 people in that region - because that is

about what it works out to, well, a little more than that on the community

health care boards, that's what, on average, the institutional boards work out

to - if you took the people serviced by that board, and took the fifteen

trustees and divided up on a population basis, you may find out that in the area

you are describing you may have pretty equitable representation, but if you

don't, and it is clearly an anomaly of under-representation, I think you are

doing the right thing by bringing it to my attention, and you would probably

want to bring it more formally, and write to me and say: Look, this is an

inequity, as I perceive it, and as soon as you can address it, please give

consideration to an appointment from my area to this community health care

board. That is the only remedy for it.

MR. CAREEN: You have already told those people who

wrote to you that as soon as there is a vacancy -

MR. L. MATTHEWS: Yes, because these new boards are

covering such large geographic regions, there have been a couple of other areas

where people have felt, on a geographic basis, well, we are under-represented.

The people in the Bonavista Peninsula feel they should have three rather than

two representatives on the institutional board.

Again, you have eighteen people whom you can put on

the board. You have all of these big geographic areas to cover off, and as best

they can, I think, the boards are appointed to reflect fairness and balance, but

if there is an anomaly or an inequity that exists, certainly as soon as it can

be addressed I have no hesitation in dealing with it.

MR. CAREEN: Right away (inaudible) glaring at you,

and I am not saying anything against these people.

MR. L. MATTHEWS: No.

MR. CAREEN: But there are six people there in the

Carbonear, Harbour Grace area.

MR. L. MATTHEWS: On a per population basis,

though, Nick -

MR. CAREEN: Well, of that regional health board,

the largest population outside of St. John's on the Avalon is in that Conception

Bay area. I am not taking -

MR. L. MATTHEWS: I am just wondering if it is

balanced, if it is equitable. I am wondering if it is as inequitable as probably

it appears to be. I don't know, but I am prepared to look at it when we can.

MR. CAREEN: The other thing that makes it so much

more community-based, you are talking about health protection and health

promotion, and alcohol and drug dependency, all this kind of stuff. You are also

going into this community care. We are also going to have to have someone who

has a touch on reason.

Now, probably we are getting into the institutional

stuff, and you said they have to work together. We could be looking at, down the

road, are they going to be administering the single point of entry? Are they

going to be saying who goes where, and John Doe has been there and (inaudible).

MR. L. MATTHEWS: We are into that now.

MR. CAREEN: And all of a sudden there is a

resettlement program and that old fellow who lived in that community is gone to

the west, Sir. You see?

MR. L. MATTHEWS: No, they are getting into - the

single entry system is now up and running in St. John's region and it is running

in - Central Newfoundland?

MRS. DAWE: In the West (inaudible) East.

MR. L. MATTHEWS: In the West. Central East, yes,

that is the Gander to Eastport region, and it will happen in the other regions

eventually.

MS. DAWE: Yes, and it will happen in the West

Central very shortly.

MR. L. MATTHEWS: If you want to comment further on

his particular area, Joan.

MS. DAWE: Thank you, Minister. The Eastern

Community Health Board, while appointed, hasn't officially assumed its

responsibility yet, so it hasn't become operational. One of the very first

things that will happen as it becomes operational is to get ready to put the

infrastructure in for the continuing care for single entry system, as you

referred, but that is a few months down the road yet.

MR. L. MATTHEWS: So as soon as these boards take

over their mandate officially then the single entry system is a given, new

concept in terms of admissions policies.

MR. CAREEN: You might be able to have a look at it

yet.

MR. L. MATTHEWS: The board?

MR. CAREEN: Yes.

MR. L. MATTHEWS: No, the board has been appointed,

it is just a question of formalizing their mandate by dropping a Minute-in-

Council for a certain date.

MR. CAREEN: I can go back to the original

statement I made, that if a person is on the regional health board, there is no

reason why he couldn't change places with someone else on a regional health

board. Wouldn't that be possible?

MR. L. MATTHEWS: Well, I suppose you could.

MR. CAREEN: You could fill a gap.

MR. L. MATTHEWS: We could look at asking somebody

to step down from this board and go over to this board.

MR. CAREEN: A changeover.

MR. L. MATTHEWS: It would have to be for very

extenuating circumstances to consider that. Because the other board is up and -

no. (Inaudible) board?

MR. CAREEN: (Inaudible) started April 1.

DR. WILLIAMS: (Inaudible) board, no. April 1, yes.

MR. L. MATTHEWS: April 1, yes, it is up and

running now.

MR. CAREEN: (Inaudible) just started.

MR. L. MATTHEWS: Yes, there were two or three who

took their mandate officially April 1: St. John's Health Care Corp. and that

board, yes.

MR. CAREEN: Another thing, too: How closely does

your department work with Environment? I will go on to this. I've heard it in

different parts of the Province, but living out in the Placentia area you hear

it more pronounced. We had high industry down in Albright and Wilson and we had

the Americans there for over fifty years - high incidence of cancers. It must

because of this, the statements there, or it must be because of that. My friend

over there and I, he is from the West Coast - the Americans had a large presence

out in Stephenville. Gerald and I spoke about it on our drive on Friday, we

spoke about it before, incidences of cancer that seem to be out of proportion. I

don't know if they are out of proportion or if it is because we live so close to

people -

MR. L. MATTHEWS: That you think that is the case.

MR. CAREEN: Yes. I don't know if it is addressed.

The Federal Government did a survey in Argentia last year to see if there is any

environmental damage. It proved there was. There is mercury down there and PCBs

and other stuff. And they have another grant out now to find out the extent of

the damage that is in Argentia.

MR. L. MATTHEWS: Deputy Minister, you can speak to

the studies that he is referring to.

DR. WILLIAMS: We co-operated I think it was about

two or three years ago with the Department of Environment on a health study in

the Long Harbour - Placentia area where we had the health research unit - Dr.

Roy West and Dr. Sharon Buehler - do an assessment of the incidence of cancer in

that catchment area. They concluded that there wasn't any undue increase in the

incidence of cancer. There was some borderline incidence of brain cancer

probably worth watching, and have another look at it in a few years time.

They did a review at that time - independent. We

funded the study. We co-operated with Environment, but they are independent of

the department. They did this study. Environment - obviously, now you are saying

they are doing some studies in terms of the chemicals and this type of thing out

in the area. I don't know if we are involved in detail with those studies at

this time, Joan.

MR. CAREEN: Joan, may I interrupt you for one

second before you go on? The interesting thing about Argentia that we all should

be mindful of and we all forget, is that thousands of people came in from other

parts of Newfoundland and parts of Conception Bay to work in Argentia. It is not

only the people that would be there now and it is the same as Pepperrell, the

same as Stephenville or Goose Bay.

DR. WILLIAMS: They did a population study. They

did not do an occupational study, it was a population study.

MS. DAWE: Just to answer your question about our

relationship with the Department of Environment, indeed our environmental health

inspectors, public health inspectors work extremely closely with the staff of

the Department of Environment. Just to get back to reference that - and a

comment that was made by Mr. Hodder earlier this morning - where the environment

is an important determinant of health it brings the two departments very, very

closely in a working relationship. I could certainly check and see what the

latest involvement is with the study that you have referred to but it is very

much a given that through environmental health it is a very close association

and there is lots of documentation here on that.

MR. CAREEN: Thank you. One more thing, Mr.

Chairman, lots of times I let my old heart fool my old head but most times I

come out on my feet.

There last fall, minister, when I approached you on

some occasions to keep me informed because you called me from the House or I

called you. During the blackout there was a problem up at a home in Dunville,

public home, the people were without heat one Thursday night a little after

midnight until 1 o'clock Monday morning or so when it came back on. A report was

done by a person from your department who checked out one side of it and then

after that they did come out eventually when a bit of a furor was started. They

did come out and met in Placentia with some of these people - relatives of these

people who were up there - the committee met in December and they met again in

January, they were looking for more information. A Mr. Caddigan is the chairman

of that board and he was in court when I called. We all know that open heaters

are not allowed but that was a dire emergency. We all know that to put in

special kinds of generators is going to cost a hell of a lot of money. There

were some areas that did not have any problems at all. Some of them had some

problems but is there anything that you came across that closely touched what

happened out our way?

MR. L. MATTHEWS: I don't know the number but given

the geography of Conception, Trinity Bay, St. John's and your area, there was a

tremendous number of personal care homes, hospitals and all that were affected

with power outages during the sleet storm. I think, as I said to you when you

call