April 30, 2002 SOCIAL SERVICES COMMITTEE

Pursuant to Standing Order 68, Wally Andersen, MHA for Torngat Mountains,

substitutes for Mary Hodder, MHA for Burin-Placentia West for part of the

meeting.

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

MADAM CHAIR (Ms Jones): Order, please!

Good morning, everyone. I would like to welcome you to the Social Services

Committee for the Estimates for the Department of Health and Community Services.

I welcome Minister Smith and his officials this morning.

We won't adopt the minutes of the previous evening, as they have not been

prepared yet, but will do so later this morning.

I would like to start by asking the Committee members to introduce themselves

by name and district, and then we will ask the minister to introduce his

officials.

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

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

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

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

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

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

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

MADAM CHAIR: Okay, Minister.

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

Good morning, everyone.

First of all, just to introduce the officials I have with me, I think most of

them would be known to the members opposite. Robert Thompson is the deputy

minister of the department. To my left is Donna Brewer, ADM for Finance. Bev

Clarke, who is behind me, is ADM for Policy and Planning. I think Gerry is next

to her, the ADM for Government and Community Relations. Robert had this in an

awkward order, or at least the crowd didn't sit the way that he gave me the

listing. We have Moira Hennessey, the Director of Board Services; Lynn

Vivian-Book, the Executive Director of Programs; and Jim Strong, the Director of

Financial Services.

MADAM CHAIR: Thank you, Minister.

I would just like to ask all Committee members and your officials to identify

themselves before they speak. We have only one camera, which is the one directly

in front of me, and the switching for the microphones is done in the basement of

the building. Sometimes it is very difficult for them to find out which

microphone, so just make sure that it is on before you speak. We need to have

your name in order to ensure that it is recorded properly for the House. I will

ask the Clerk to call the first head.

CLERK: Subhead 1.1.01.

MADAM CHAIR: We will have discussion on any aspect of the department

under the first head, if that is acceptable to the Committee members.

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

move to questions.

MR. SMITH: Thank you, Madam Chair.

It is a pleasure for me to have the opportunity this morning as the Minister

Responsible for Health and Community Services, just recently appointed, to bring

forward the Estimates for that particular department.

My previous work as the Minister Responsible for Human Resources and

Employment, my experience as Acting Minister of Health and Community Services

last year, and my participation in the Social Policy Committee of Cabinet and

Treasury Board have certainly made me aware of the challenges that lie ahead. I

look forward to working with all of you to lay out a vision for health for the

future. I am sure the Member for Trinity North is pleased to hear that. I look

forward to presenting to the people a Strategic Health Plan for the Province. As

I indicated in the House yesterday, we are hoping to have that later this

spring.

I look forward to working with the people on a health charter for the

Province, which I think is an interesting initiative. It is something that was

referenced in the presentation which I made to the Romanow Commission. I think

it is something I would like to have the opportunity to explore with my

colleagues and members of the House in some detail as we continue to move

forward on that particular work.

As I referenced, I recently had the privilege to present to Commissioner Roy

Romanow, the government's views on the future of health care in Canada. This

submission calls upon the federal government to increase its funding for health.

Further, it outlined the future plans for the health system in this Province, in

particular the need to focus on wellness and primary care reform. The Province

also called for the implementation of mechanisms to identify, on an ongoing

basis, the services that should be included, medically necessary, under the

Canada Health Act.

The submission by the provincial government reflects the feedback from Health

Forums 2001 and reflects the health care needs of the population. The Government

of Newfoundland and Labrador is committed to building on its current strengths

to create a better health and community services system for the future.

Some of the budget highlights from this year, as I have repeated in this

House and elsewhere in response to questions from the general public and the

media, certainly health care remains a top priority of this government and to

the residents of the Province. Those of you who have been in the House for a

number of years would know that we went through a period of time of declining

budgets, generally, when virtually all of the budgets of governments were being

reduced. I did sit through that period. Health was one budget that, in every

year, managed to grow. Some years it was very little, but there was always some

growth. That budget was not cut.

In terms of the priority, we heard time and time again in the health forum

consultations - and the Minister of Health also heard this during the pre-Budget

consultation - the importance of health care and the fact that it does remain

the number one priority for the people of this Province. Forty-five cents of

every dollar is presently spent on health and community services. The department's

budget for the fiscal year 2002-2003 approximates $1.5 billion. This includes

spending for hospitals and nursing homes, physicians and dental services, drug

subsidies, road ambulance operations, blood services, and numerous

community-based programs delivered by the four Health and Community Services and

two integrated Boards.

Our spending per person on health care in Newfoundland and Labrador is among

the highest in the country. According to the Canadian Institute for Health

Information, Newfoundland and Labrador is projected to spend $2,550 per person

on the public sector health care in 2001, up from $1,713 in 1995. This is $154

per person above the Canadian average in 2001, which the actual figure was

$2,396. Specific details of the increased investments in health care are

contained in the Budget Highlights document, the Speech and department's press

releases, and certainly today we will be pleased to answer any specific

questions which hon. members may have. However, I would just like to briefly

highlight the following:

Since 1996-1997, $462 million has been added to the department's gross

operating budget, an increase of 46 per cent. On a cumulative basis, $427

million has been added to the base budgets of boards since 1997. Since

1995-1996, over $500 million has been committed in this Province for health

related capital projects and equipment. The total value committed by this

government in 2002-2003, for capital spending to support ongoing construction of

new health facilities, renovations of existing facilities and equipment, is $52

million. New funding commitments this year include $2.7 million annually to

provide a 4 per cent increase to the rates paid to home support workers; $1.1

million provided for a wellness strategy, which would include expansion of the

breast and cervical cancer screening programs and a renewed commitment to the

provincial tobacco strategy; $1.3 million to increase rates to personal care

homes and a number of subsidies for individuals; $300,000 to increase students

admitted into the nursing program by thirty-two seats, up from the current 220

seats; and $800,000 has been provided to establish a psychiatric assessment

short-stay unit in St. John's. Of course, this is a project that has long been

advocated by a number of people in this House and certainly within this Province

as being a need.

Madam Chair, these are some of the highlights from the Budget, just some

brief comments with regard to the department itself. I am going to stop there

and we would certainly welcome any questions which the hon. members may have.

MADAM CHAIR: Thank you very much, Minister.

We will now open it up to questions and we will start with the Member for

Placentia & St. Mary's.

MR. MANNING: I open my comments with a welcome to the minister and his

staff. I certainly say, I do not envy your positions on most days.

Just to start this morning, I would like to run through some of the Estimates

and the figures that we are looking at, just some questions on those. We may get

some more questions brought forward from these. I am just going to go over some

in-line figures here.

Under Executive Support, subhead 1.2.01.01., you had a budget last year of

$822,000, which was reduced to $765,000 - I am just going to round off the

figures - and this year we have a budgeted amount of $835,000. Could you explain

the difference on that?

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

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

that.

MS BREWER: The $822,000 was the original budget for the staff complement

when the budget was prepared back in early 2001. During the year there were some

(inaudible) of staff. We had lost our Executive Director for Communications for

a period of time, and there was a vacancy in one of the ADM's secretaries, and

that position was kept vacant for a period of time.

Going into $835,100, those positions are now filled. Instead of an Executive

Director for Communications we have an Executive Director position now in the

form of Lynn Vivian-Book for the Programs side. Also, what is reflected here is

the salary increases, the 5 per cent that has been awarded to all public service

employees; plus, there was a reclassification of our medical consultant along

the lines of a recent reclassification that occurred last year for the medical

directors in the system, so that would account for the increase in that.

MR. MANNING: Under Administrative Support, 1.2.02.01, Salaries. We had a

Budget amount of $3.7 million and our Revised Budget was $4.1 million. Again,

our Estimates this year are $3.8 million. I am just wondering about the

difference in the amounts.

MS BREWER: I just asked Jim to confirm, but it is my understanding that

the salary increases are now being reflected in the Revised, or did they restate

the budget for those two?

WITNESS: (Inaudible).

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

$4.1 million?

WITNESS: (Inaudible).

MS BREWER: Okay.

There was a restatement here, the audit staff for the Medical Care

Commission. We are budgeted over in another activity and it got restated here in

the projected Revised. Then for 2002-2003, they reflected back over under the

Medical Care Commission again. So our salaries in total are correct, but there

was a brief misstatement there on the projected Revised for that activity. The

audit staff were included and they should not have been included.

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

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

there.

MR. MANNING: Just further down under Administrative Support, Purchased

Services, exactly what does that mean? There is a $50,000 increase from your

budgeted amount to your Revised.

MR. STRONG: Purchased Services would cover things like the rental costs

and general advertising costs that the department would be incurring. The costs

for 01.02. are up slightly because of a slight increase in our rental costs.

MR. MANNING: Under Board Services, 1.2.04.01, Salaries. We had a Budget

amount of $943,000 which dropped down to $692,000; a considerable amount. Why

would that be?

MS BREWER: There were a number of positions - we had a retirement last

March of our Director of Board Services. Our Director of Service Quality, Moira

Hennessey, was successful in getting that position but then the director

position, plus one of the consultant positions, have been held vacant for the

balance of the year. The increase that you will see then in the following year

basically reflects the salary increases for the staff that are on staff today.

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

MS BREWER: No, our salary plan for next year continues to assume that

those two positions will be held vacant.

MR. MANNING: Okay.

Under 1.2.05, Policy and Program Services, 05. Professional Services,

$138,000 budgeted, $204,000 revised, $148,000 this year. Why the increase?

Exactly what would those professional services be under Policy and Program

Services?

MS BREWER: Subject to Jim confirming this, I believe that is where the

money for the professional services relating to the health care forums that

Minister Bettney had last fall were charged.

MR. STRONG: That is correct.

MR. MANNING: 1.2.06, Government And Agency Relations. Again, Purchased

Services, budgeted $18,000, revised is $76,000, and then budgeted for this year

$3,500.

MS BREWER: Last year, up until - was it October, Robert? - the department

was the lead province for the federal-provincial territorial Ministers of Health

and conference of deputy ministers. So we were given extra funding that was

cost-shared with the federal government and all of the other provinces. That was

a one time expenditure that has been incurred in 2001-02 that will not occur

again in 2002-03.

MR. MANNING: Okay.

Over to Senior Citizens, 2.2.02, page 191. You haven't got the book, okay.

I guess it has to do with drug costs and GIS. Allowances and Assistance, I am

just wondering about the increase. I partly guessed why it has increased. There

must be more dollars spent on drugs and GIS. Have you seen an increase there? Is

that something that is going to continue? Because you went from $28.9 million,

we will say $29 million to $32 million, an increase of $3 million and you are at

$32.5 this year. Is that a progression of an aging population? Why the increase?

Are you expecting - you had a $3 million increase last year but you are only

increased by $500,000 this year. So I am just -

MR. THOMPSON: That is right. Every year, in recent years, we have seen a

general climb in the increase of the two drug programs. With senior citizens the

price increases come from inflation and also from substitution of new drugs into

the formulary and other drugs. Sometimes we have drugs that have less

utilization because new drugs come in. So there is a constant mix that is going

on in the program. In the upcoming year we would expect some of the same

pressures to occur but we are also going to try to institute new measures to

manage the total amount of drug costs.

If you look to the original budget last year - as you noted it was $28.9

million - there was considerable growth in-year. We are going to try to manage

with the same budget this year and balance out at the higher level that we had

as a projected Revised in the last year.

MR. MANNING: Again, would that follow true for Special Drug Programs,

2.2.03? The Budget was $600,000 last year, the Revised amount was still

$600,000, but we see an increase of $631,000 this year. Would that follow under

the same -

MR. THOMPSON: Subject to correction by Donna, this is a little bit

different than that. There are a much smaller number of recipients and it is

there for a very targeted one or two types of drugs. We think we will be much

more comfortable fitting within the allocated budget there and it is subject to

less volatility. The seniors' program operates under different pressures and

demands than the Special Drug Programs.

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

just for -

MR. THOMPSON: It is for a very designated -

MR. MANNING: Not for everybody. I mean, it is not an age - like where you

have your seniors' program. Special Drug Programs are for anybody, I guess,

who needs the service of a special drug, whatever age they are.

MS BREWER: One example would be cystic fibrosis and the other ones are

people who suffer from lack of growth hormone.

MR. MANNING: Yes, okay.

Under 2.3.01, Administration. Salaries again, we had budgeted $1.77 million,

the Revised is $1.20 million, and this year - well, I guess that is the increase

of about 5 per cent, but I am just wondering, there is almost $500,000 there

revised on Administration. Could you give some explanation on that, please?

MS BREWER: Administration, that was for the Medical Care Plan. There was

some one-time money provided in the budget that was estimated on account of

regionalization that we did not spend.

I am just going to turn to Jim for clarification on how the audit staff are

being reflected here.

MR STRONG: We were restating the audit staff, so there was a misstatement

here. When we reflected our projected revised position we overstated

Administration slightly and we understated the Administration in MCP slightly by

about $300,000.

MR. MANNING: Purchased Services again, there is a Budget amount of

$2,200, the actual Revised is $41,000; 06 under Administration.

MS BREWER: Again, that would have been one-time costs that would have

been incurred as a result of regionalization that we do not expect to occur

again in the next fiscal year. There was about $33,700 of that $41,400 that was

directly related to the regionalization; the moving of the staff from St. John's

to the Grand Falls-Windsor office.

MR. MANNING: Physicians' Services, 2.3.02.09, Allowances and

Assistance. I realize it is fee for service. The Budget amount is $5.8 million,

Revised is $5.1 million, but we are budgeting $5.8 million again this year. I

will ask both questions now at the same time. Grants and Subsidies, $57.2

million and the Revised is $53.7 million. There is a large decrease there. I am

just wondering, could someone explain what happened there exactly?

MS BREWER: On the Allowances and Assistance, those payments relate to

people who are travelling outside of Newfoundland and receive medical services

in other provinces or those eligible residents who are out of the country and

have to seek medical treatment. We cover those costs through that vote. So the

activity during the year was less than had been anticipated.

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

MS BREWER: All that is for that purpose. We think that part of the

problem may be a timing issue where the Ontario government was in a strike

situation.

MR. MANNING: Okay.

MS BREWER: We found that last month their bills have not been coming in

as quickly as possible. So, it may be a timing issue.

Grants and Subsidies; that provides for our salaried physicians. What happens

is that the salaried physicians are employees of the boards. The boards indicate

to us what positions they have approved and we fund, but through turnover - or

there has been some vacancies within the boards which has resulted in less cash

flow that was required in 2001-2002. Plus, there is also funding included there

- we cover physicians' medical malpractice insurance. The costs there were

less than had been anticipated.

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

$59 million.

MS BREWER: Yes, because the boards are in the process of recruiting and

we anticipate that there is going to be some successful recruitment in

2002-2003.

MR. MANNING: Dental Services, 2.3.03.05, Professional Services. You have

a Budget amount of $5.5 million, the Revised is $4.945 million, and this year we

are up to $5.5 million. There is $500,000 there, I am just wondering about the

difference.

MR. STRONG: The Revised is based on the level of activity in the program.

The program, basically, provides services to children under the age of twelve or

if they are over twelve, between the age of twelve and seventeen, if the

children are on income support. The level of activity for next year is based on

the forecast. As well, we are reviewing the program.

MR. MANNING: I guess there is a less amount of children partaking in the

program. Would that be...?

MR. STRONG: Yes, but what we are looking at is, we are estimating there

will be a higher take-up rate next year than in the current year.

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

Under Community Services, 3.1.01., Purchased Services, again, $5,000

budgeted, $38,000 actual with a budget this year of $63,000, if somebody were to

elaborate on that.

MR. STRONG: The reason for that increase is due to the gearing up of some

of the new projects under the ECD programs and NCB programs. The project

(inaudible) were required to engage some consulting services to do some of the

work.

MR. MANNING: Under Professional Services, there is no money budgeted but

there was $115,000 allocated under the revised, under 05., Professional

Services, under Community Services. There is none in the budget but there was

$115,000 allocated afterwards.

MS BREWER: The $115,000 would reflect two reviews that the department

commissioned during the year. One was a contract with Goss Gilroy to do a review

of certain cost drivers in the health and community services system, primarily

the home support program for seniors, and family and rehabilitative services,

and also a contract - Bev Clarke can help me here. I forget who we contracted

with, but it was to begin a review the mental health services in the community.

MS CLARKE: Through the Colleen Hanrahan shop; she has a small consulting

company and they are doing the review now.

MR. MANNING: Who is that again?

MS CLARKE: Colleen Hanrahan.

MR. MANNING: Okay.

WITNESS: (Inaudible).

MS CLARKE: Yes.

MR. MANNING: Okay.

Under 3.2.01., Health Facilities Operations, we have under 05., Professional

Services, a budgeted amount of $250,000 and the actual amount revised was

$690,000 with a budgeted amount this year of only $220,000. I am just wondering

why.

MS BREWER: Subject to Jim's concurrence, I believe that is where the

HAY operational review for the Health Care Corporation of St. John's was

charged.

MR. MANNING: What was the total amount on that? Was there a contract on

that report? Is there a specified amount for that, or is it...?

MS BREWER: I will have to get you the exact number. My recollection was

four forty or four sixty, in that range.

MR. MANNING: Under 10., Grants and Subsidies, $809,000,000, revised

$818,000,000 with a new figure this year of $834,000,000, can you just explain?

I think that covers hospital services and the operations of the hospitals. Would

that be correct?

MS BREWER: Yes, that is correct. It also would include funding for

out-of-Province hospital payments. It would include grant money for the Canadian

Blood Services. It would include some miscellaneous boards, like the Pentecostal

Senior Citizens' Homes, the Newfoundland and Labrador Centre for Health

Information, and the Newfoundland and Labrador Centre for Applied Health

Research, and also the public health labs. By and far the majority of the money

is for the ten institutional health boards.

MR. MANNING: So you are seeing an increase in the need this year. It has

increased to $834,000,000.

MS BREWER: The majority of that would have been negotiated salary

increases and there was also an occupational review that occurred last year that

you are seeing carried forward; the annualized, in fact, going into 2002/03.

MR. MANNING: On 3.3.01., Health Care Facilities and Equipment, Capital,

07., Property, Furnishings and Equipment, the budgeted amount was $13,600,000 to

a revised amount of $27,600,000 and this year you are not going to buy many

furnishings by the looks of things. You are down to $1,000,000 for this year. I

was just wondering if you could elaborate on that a bit. There was an increase

of $13 million.

MS BREWER: As announced in the actual Budget Speech, I believe it was

three years ago the government made a commitment of an allocation of $15 million

for three years. What you are seeing here is the final year, $15 million. From a

cash flow perspective, they asked us to flow $14 million in March of 2002, so

you are seeing the project revised being increased by $14 million and the $1

million that is in 2002/03 is basically the balance of that $15 million

commitment. It is the final year of that $45 million, three $15 million

commitment. They asked us to cash flow at $14 million old year, $1 million.

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

MS BREWER: Into next year.

MR. MANNING: On 3.3.02., Health Care Facilities, appropriations are for

repairs and renovations. There is, under 01., Salaries, $100,000 budgeted,

$223,000 revised and $222,000 estimated for this year. Were there new people

hired here to do some work?

MS BREWER: There was a change in budget approach this fiscal year. If you

happened to have the Estimates from last fiscal year, you would have seen a line

item amount voted in other government departments. This, in reality, is really

the money that Works, Services and Transportation spends. It is their salaried

employees, but the budgeting division of Treasury Board decided to vote the

money directly within the department because it directly relates to health care

projects verus voting it in Works, Services and doing what they call a transfer

vote into our department. Basically, this would be their projection as to their

salary and costs that they incur in terms of managing the various capital

projects such James Paton, et cetera.

MR. MANNING: Are these people paid by your department or by Works,

Services and Transportation?

MS BREWER: They will be on government's payroll and the cost will be

journalized to our department.

MR. MANNING: Just under Salaries again, Professional Services, the

budgeted amount is almost $6 million and we actually spent $1.4 million or $1.38

million. What happened there? There must have been a possible need for the $6

million but the actual amount spent was $1.86 million. I am just wondering.

MS BREWER: I am going to turn that question to Moira Hennessey because

she can give you details of the status of the capital projects last year. I

believe there are certain projects that did not proceed as quickly as had

originally been thought last year.

MS HENNESSEY: I am not sure I clearly understand the question. I wonder,

would you mind repeating it?

MR. MANNING: No problem.

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

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

MS HENNESSEY: I will have to make a good guess at this one. This is the

former Works, Services vote as well. My understanding is that with respect to

some of the Professional Services, the design fees, perhaps there would be a

decrease in that. Many times the design fees associated with projects are up

front costs that occur on the first six or nine months of planning, but I am not

as familiar with that particular vote as -

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

MS HENNESSEY: Yes, it would be.

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

MS HENNESSEY: No, not that they would be reduced but the design costs

occur up front in our capital projects. As we move further into the construction

period, the amount of money being expended on professional services would be

less because the design has been done at the start of the projects.

MR. MANNING: Okay.

Under 06., Purchased Services, under the same heading, we had a budgeted

amount of $25,450,000 and the actual was $28,938,500, almost $29 million. This

year the budget is again around $29 million. I am just wondering about the

increase there of, give or take, around $3.5 million.

MS BREWER: The numbers are going to vary from year to year based on

Works, Services assessments as to particular contracts that are going to be let.

The purchased services would be the actual construction work. For example, like

in the James Paton contract in 2001-2002, there was a higher cost. Again, I

refer more to the details on the actual fit up of some of the contracts within

the James Paton. What Works, Services would have done would have been, if there

was a cash flow decrease on another project, as you pointed out the decrease in

the professional services, they would have had the flexibility within the vote

to reallocate the dollars.

MR. MANNING: So the total vote on the bottom line has not really changed

a lot from up here; it is just the movement around inside that particular

heading, right?

MS BREWER: The way government works with the capital projects, they

approve a total capital project and then the cash flow will flow depending on

how quickly contracts are let and how long our construction session is.

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

MS BREWER: Yes.

MR. MANNING: Under 10., Grants and Subsidies, under Health Care

Facilities, I see an increase of almost $5 million; a budgeted amount last year

of $2,500,000, revised to $7,200,000, and this year it is reduced to $1,500,000.

MS BREWER: Again, as announced, in my recollection, in the Budget Speech,

government has committed $5 million for additional fire and life safety

enhancements through our various facilities throughout the Province. Again, they

cash flowed $3.5 million, they asked us to spend before March 31, and the

remaining of the $5 million is being reflected as $1.5 million in our 2002/03

Estimates, the same approach as they did with the capital equipment.

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

MS BREWER: Yes

MR. MANNING: Okay.

If I could go back to 2.4.01., Road Ambulance, just for clarification, I

guess, there are community-based ambulance services and there are private

operators and then there are the health care facilities that have some of their

own. Could you give us a breakdown of the numbers of those? How many community

services, how many privates, how many...?

MS BREWER: These are gradually changing, but at the time that we did the

development of this budget there were thirty private operations and twenty-three

community. Since that time, I understand, there have been at least two that have

switched from community to private.

MR. MANNING: How many government facilities have them? How many

government operations, like the Health Sciences, I am just wondering, elsewhere

in the Province, like the hospitals here in town?

MS BREWER: That is not reflected here in this budget. I would have to get

you that, Mr. Manning. I do not have it, unless Robert knows it.

MR. THOMPSON: I do not know it offhand. As Donna said, those budgets are

reflected in the board budgets and not in this ambulance budget. Maybe Moira

Hennessey would have a better idea as to how many facilities would have direct

ambulance service.

MS HENNESSEY: We have hospital-based ambulance services in Carbonear,

Gander, Grand Falls-Windsor, Corner Brook, and in Labrador City.

MR. MANNING: The private ambulance operator receives a subsidy per

vehicle. What would one subsidy be?

MS BREWER: It varies, depending on the operation and the number of

ambulances that they are expected to man.

MR. MANNING: Just for one ambulance, a private operator, would that be

uniform across the Province? Joe Blow in Norris Arm has an ambulance and John

has an ambulance in Bay Roberts - two private operators, one ambulance each -

would they receive the same subsidy?

MS BREWER: I am not 100 per cent sure, Mr. Manning. I know it was

negotiated and was outlined in that MOU that they negotiated with the operators,

but, just looking at the list, by far the majority seem to be getting

twenty-eight. No, sorry, that is community. Like Brigus, for example, the grant

there for Broughtons is $62,000, and there are a number of operators that are

getting $62,000, but there are others like Baie Verte regional ambulance

services - $122,206.

MR. MANNING: What I am trying to get at is: one vehicle, one operator.

With Baie Verte, would that be two vehicles?

MR. THOMPSON: Just on your first question, there are two components to a

rate for a private ambulance. One is a base or a block fund component, and then

there is a variable component -

MR. MANNING: On mileage and -

MR. THOMPSON: - on milage and other elements of the service. So, if you

have one ambulance you might have one block and then that is a set rate. Then

there are variable costs over that. If you have two ambulances, you require

maybe two blocks. Sometimes when we allocate half a block, I do not know all the

details of the structure but there is a base that is common, and the variable

component.

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

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

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

MR. MANNING: And the variables will be based on if someone travels 200

kilometres versus someone who travels six. That is where you come into the

difference on subsidy.

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

are the main elements.

MR. MANNING: Would it be possible - not this morning, I do not expect -

to get a breakdown of how those operate? Because I am sure, as some of you are

aware, I have some problems in my own district. I am trying to get around but I

just have a problem knowing exactly the guidelines and the layout of how it is

done, the subsidies and the breakdown.

Now, you are saying there is a base subsidy to private operators and then

there is a base subsidy to volunteer operators. You mentioned $62,000 - not to

nail you down on $62,000 but I am just wondering, there seems to be, across the

board, around $62,000 on private, give or take. I am not saying that is the

exact number.

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

MR. MANNING: Of several, yes.

MS BREWER - and it looks like a lot of the community operators are at

$28,000. There are a few as high as $50,000.

MR. MANNING: That would be on base?

MS BREWER: That is their block funding, yes.

MR. MANNING: I have to ask the question, because from $28,000 to $62,000

is an incredible amount of difference from community based to private. What is

the rationale for that? We depend on the volunteer sector to operate these

community services in most cases but at the same time, I mean, a vehicle is a

vehicle is a vehicle; I am just wondering.

MR. THOMPSON: That is right, it is a volunteer component. That is the

main difference. So that is a huge determinate in the cost structure of the

ambulances. You are right, as well, an ambulance is an ambulance and gasoline is

gasoline. Those components are supposed to be equalized between the two, but

volunteer labour is the main difference; and administration of course.

MR. MANNING: All these people who are operating or working on, or

volunteering their time on community based and the private, all receive the same

training? They all have to be of the same qualifications?

MR. THOMPSON: I don't know the answer to that in detail. We do have new

training requirements and we are trying to bring both community and private

ambulance operators to a new level of certification and training. I do not know,

for sure, if we have the exact same requirements of the attendants on both sets.

Does anybody have any? No? We will have to get you that answer.

MR. MANNING: Yes, okay. I know on private operators there is an onus on

them, as private operators, to have a certain level of expertise in their

ambulance service in order to receive their subsidy and in order to receive

their licence to operate. I am just wondering from a private sector, we have

twenty-three communities. I just want to ensure that the same level of service

is uniform across the Province; not necessarily who operates what but that the

individual, not the operator, more so the individual out in the community.

MR. THOMPSON: I apologize, I do not have the answer specifically. Just to

reiterate, emphasis is on bringing the level of training and certification in

all sectors up to an appropriate minimum. Whether there are any specific

differences between the two sectors, we will get you the answer to that.

MR. MANNING: I have a couple of questions now for clarification. I do not

know if it will be any clearer when I am finished because I am not too good at -

I may not have the questions clarified yet, but I am going to ask a couple of

them anyway.

In relation to policies of ambulance services; you have your health care

facilities. There is a policy at the Health Sciences. There is a policy, as the

lady mentioned, in Grand Falls-Windsor and Labrador City. Is there a uniform

policy for ambulance operators - I am more interested in the private operators

with this question - a uniform policy that I could lay my hands on or someone

could give to me to see exactly how the ambulance operator is supposed to

operate, the medical facility that they attend? Is there anything in relation to

an ambulance policy?

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

First of all, there is a memorandum of agreement that the government has with

the private and community ambulance sector and that, in itself, is a statement

of policy and have some rules and standards in it. In addition to that, there

are standards or rules related to areas of coverage in which how far an

ambulance may go within their own zone or outside their zone and under what

circumstances. There are standards related to training and certification. So

those all exist, and we can supply them to you. There may be several different

documents, not all in the one. I am not sure, but we can certainly supply them

to you.

MR. MANNING: Does each private ambulance operator have, what one would

call, a base hospital or base medical facility?

MR. THOMPSON: I am not exactly certain if they have a base facility, but

every ambulance operation does have a defined zone in which they are permitted

to operate and they will have a defined health facility to which they will

normally take patients. But, there are circumstances - I am sure because I have

heard of them - where they can operate outside their zone, depending upon the

nature of the case. So, there are - I do not know if you would call it a base

hospital but there are defined zones in which ambulances must operate.

Moira, can you add to that?

MS HENNESSEY: What the deputy minister has said is accurate. There are

also some guidelines with respect to what we call routine transfers and

emergency transfers in which ambulance services can do one role or both roles.

In a case where someone only operates one ambulance, it is pretty well localized

to emergency transfers.

MR. MANNING: I am going to cut to the chase because I have a problem in

my own district, and with all you people here I should be able to get some

answers.

I have a situation in my district on the Cape Shore, an ambulance operator,

the Cape Shore Ambulance Service, from what I understand the operator receives

one subsidy. A couple of years ago he requested some additional operations but

they said that he could not do that because he only has one subsidy, one

vehicle. He went and acquired a couple of more vehicles.

I will give you an example, I live on the Cape Shore in St. Brides's

myself. If I am travelling to Placentia tonight and for some reason or other

have an accident in my car and I call the Cape Shore Ambulance to pick me up in

Patrick's Cove and they transfer me to Placentia hospital. It might take four

or five hours to ascertain whatever is wrong me, to either transfer me to St.

John's or whatever the case may be. The Cape Shore Ambulance has returned to

St. Bride's and I have to hire another ambulance service, which is Power's

in Placentia, to take me to St. John's. Now, if I am lucky enough to roll my

car in Placentia, I would only need one ambulance.

I am sure that some of you people are aware of this situation because it has

been ongoing for a long time, and I am in the process of meeting with the

minister on it. I am just trying to find out why - I will throw this out because

this is how it came through to me. The ambulance operator on the Cape Shore has

approximately, I would say, a population now - we are lucky if we are talking

1,300 or 1,400, tops. That ambulance service is supposed to be for that area,

but Placentia is our hospital. If I am sick tomorrow in St. Bride's and I end

up out at the Placentia hospital, I either go on to Carbonear or I go on to St.

John's.

If a person is in the Placentia hospital from the Cape Shore and he wants to

- we had a situation there two weeks ago. As a matter of fact, I got off the

phone with his daughter last night where an elderly gentleman was in Placentia

hospital and needed, as far as the doctor was concerned, an ambulance service to

take that person back home. The people at the hospital insisted that the

Placentia ambulance service would take that person to Branch, this happened to

be, but the elderly gentleman who had traveled with the Cape Shore ambulance on

numerous occasions over the past several years because he is on a breathing

ventilator and was comfortable with that, but wasn't comfortable travelling

with, what he deemed to be, a stranger. Now there are no strangers to be me, all

of them, but he is up in his years. All hell broke loose and they ended up

putting him in the back seat of the car and bringing him home because he just

refused to travel that way. You know, there is something wrong somewhere. There

seems to be a major lack of communication somewhere along the line or a clear

policy.

My understanding is, from conversations I have had, that there is a policy

brought down from the board level. That is why I asked the question earlier of

the policy of the department because I would not want to be in any part of

Newfoundland or Labrador and be relegated down the line to another policy, if

there is a policy across the board here that every Newfoundlander and

Labradorian should be treated equally.

I do not know if anybody can elaborate on that or if I am making any sense on

this side of the floor this morning but, I mean, it is a -

MR. SMITH: I would like to speak to that issue because it is - well, the

hon. member and I have had a discussion on this and I have committed to meet

with this service from his area, and it is a very (inaudible) concern.

In terms of my discussions with the officials as it relates to the broader

question, I think the issue that the hon. member raises with regard to so-called

routine transfers, and not the emergency service end of it, I think there is a

concern that when the service is being involved in doing routine transfers that

the equipment is not available to be on standby to address the emergency end of

it. I think you are right in saying that - obviously in that whole area of

ambulance service there are certainly growing concerns. Personally, I have

already made a commitment to meet with the groups as soon as possible to just

talk in general terms about the delivery of service. We all recognize that they

are an important component of primary health care. We certainly have to do

everything we can to make sure we sustain the service.

You mentioned the community ambulance service. I am quite aware of the

concerns there. As a matter of fact, my own hometown, I established the

community ambulance service in my community prior to getting into politics, and

I have worked closely with them in intervening years. We have another service in

my district and they have been encountering difficulties. It is interesting, the

issue is so broad and complex because when the hon. member raises the issue as

it relates to training and training requirements of - on the community side

right now, we are trying to insist that we increase the standards because

obviously there is this whole issue of liability and we want to make sure that

the people who are being transported are being given the proper care. Also,

there is a concern for the people who provide the service.

We understand that for volunteers this is a tremendous undertaking. I served

in that myself. I trained with our own ambulance service initially, and I can

tell you, I remember the first call that we received was for a snowmobile

fatality. If you are a volunteer and you are doing a community, when you get

called out these are people you know. These are not strangers you are picking up

by the side of the road. We are well aware that it is a really challenging area.

Right now I certainly want to give this a priority with regard to the particular

issue that the hon. member raises. Certainly, when I finish, if anyone has

particulars that they can share I am sure they will, or if they cannot we will

undertake to provide them to them.

I am really interested, when we have a meeting with the service from your

area, to get that kind of perspective because I agree that we have to do

everything we can to make sure that we sustain this service. If there is the

possibility that without some accommodations being made then the service is put

at risk then we all have to be concerned because the last thing that we need is

to see services going under.

I have had a number of interventions in the short time that I have been with

the department. I have been contacted by the private ambulance operators and I

have been in constant contact with the community ambulance operators because of

the concerns in my own district. I share some of the hon. members concerns with

regards to that whole service and I would hope that as we move ahead - I think

the meeting that you have requested will be very beneficial along those lines to

hear from somebody who is providing that service, what needs to happen in order

to accommodate this individual, and if in fact the department and the system, as

it presently exists, has the capability of accommodating.

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

they can add.

MR. THOMPSON: I will just add that I believe the situation being

encountered there has to do with the roles that are assigned to different

ambulance services. Some ambulance services have a role related to emergency

transfers only and as soon as that transfer is complete they must go back and

await the next emergency. Their role does not encompass routine transfers which

would be the return of an otherwise stable individual back to their home.

The problem you raised though, with a small population area, is there going

to be enough transfers and therefore enough revenue to have a stable service? I

think that is the issue that needs to be examined, to make sure the policies we

have or the roles that are assigned are going to support a stable service

because we do not want to have rules that are built in and are going to cause

instability in an otherwise (inaudible) service. So when the meeting occurs, we

can look into that issue.

MR. MANNING: We thought long and hard to put an ambulance service on the

Cape Shore at the time. I watched my own brother lie in a ditch for three hours

waiting for an ambulance back years ago. I do not understand the financial

situation that the operator is in, only what he explained or what he wants to

tell me, I guess.

It will be a sad day to lose the ambulance service. When you look at a map

and it says fifty kilometres from St. Bride's to Placentia, it does not look

like very much. It is not very much when you are on a double highway but anybody

who has been out to the Cape Shore lately or has been - I know you have, as the

deputy minister - it is a treacherous road. My understanding is that the person

only wants to take care of the people who are in the Cape Shore area.

I look forward to the meeting and explaining it. I want to request, from

anywhere in your department, any policies that relate to the operation of the

ambulance services. I have some meat on the bones when I sit down and have some

information also. My understanding is, and I stand to be corrected, that there

are policies at a departmental level and then there are policies at a board

level. I realize that the department passes over certain amounts of money to a

board, and says: operate A, B and C. At the same time you don't want to - I

would like to have something clear on that, and only by gathering information

that -

MR. SMITH: I would offer to the hon. member as well, because I know that

it is genuine concern with regard to his area. We could certainly arrange, if he

wanted to, to meet with the director, to sit down and just have a discussion

along those lines. That way you could probably even move beyond just having some

written material, to be able to pursue those in terms of questions so you will

have a clear understanding so that when we go into our meeting - I am sure that

is where you are coming from - you will have all the information you require.

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

ambulances.

In relation to the board's responsibility, I have different situations in

my district that arise from time to time which the board makes decisions on. It

is the decision of the board whether there are going to be a certain amount of

positions - I will use Placentia hospital because it is in my district again,

where there are going to be a certain amount of LPNs - is that 100 per cent made

at the board level?

MR. SMITH: My understanding, as I have stated on occasion here in the

House, is that our role, obviously, is that we have responsibility for setting

certain standards. It is the responsibility of the department to ensure that we

have standards in place across the Province. In terms of the actual delivery, it

does fall to the boards themselves. They do generate a budget to us in which

they outline what they are planning to do, which gives us an opportunity to have

some interface at that level, but it is basically their responsibility. I think

we recognize, as we are moving forward, that one of the reasons for now wanting

to do the strategic health plan is to clearly define and layout what services

people can expect in what areas of the Province, in terms of primary, secondary

and tertiary health care.

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

MR. THOMPSON: Thank you.

Just to clarify a little. The basic principle is that we provide a global

budget and then boards make the decisions about who they will employ and what

ratios of different staff. That is the general approach. From time to time we

may work directly with all boards or subset on the standards or the ratios for

particular types of units or particular job classifications. For example, in

long-term care we may work with boards to help establish a provincial standard

for the ratio of nurses to LPNs. When we do that, it reverts back to the board

to actually define how many are in each facility or in each unit and make the

decisions regarding hiring and allocating a budget. So the final decision, the

final implementation, is at the board level.

MR. MANNING: Is there at Placentia hospital - I keep referring to

Placentia hospital because it is my district. At Placentia hospital now there

are ten beds in the hospice part of it. It is built onto the Lion's Manor

Home. Is there a review carried out at certain times? As a matter of fact, I was

in the hospital on Thursday to visit a couple of people and I was there again on

the weekend, and it seems like every time I go there it is pretty full. As a

matter of fact, there are people, at times, who are sent home. I know that

happens right across the Province and we are not looking for the perfect world

here. I am just wondering: Is there, at times, an annual review or whatever

done, on the use of the amount of beds that are there?

I talked to the people and the staff there and some people say to me: You

know, if we had four or five more beds we could do so much. There are ten beds

there now. They have been there for x number of years. Is there a departmental

review or a board review or something that is carried out, and if there is at

what time it is carried out, to see the need? I know there are extra costs

associated with that and nobody wants to hear tell of the extra costs, but I am

just wondering: How do you determine whether there is a need or not a need for

that?

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

We do not do an annual review process of the adequacy of the number of beds

in each facility. We are sure that individual boards do that. In fact, they are,

on a constant basis, looking at their occupancy rates, the needs of the

population, the global budget that they have, and then making adjustments as

necessary to try to manage within that total budget. This is the balancing act

that we ask them to make, to stay within their budget and to have high occupancy

rates, but not allow wait times or backups in emergency rooms, to have any

deterioration of the quality of service. We are asking them to go and do that

balancing all the time, because the most efficient utilization of resources is

when you have a relatively high occupancy rate with some margins for turnover

and accommodating emergency patients or surges in activity. So we ask them to do

that.

I am going to ask Moira to address, more specifically, how those reviews

might get done.

MS HENNESSEY: We do reviews, what we call staffing and operational

reviews of individual health facilities. They are usually at the request of the

individual boards. With respect to Placentia Hospital, we did do a review about

two years ago. At that point in time we did add an additional nursing assistant

to the staffing compliment. During those reviews we would look at things like

the average occupancy rate and the lengths of stay. These reviews, if they are

of a small nature, are done by your own internal staff. If it is something

really significant, like the Health Care Corporation Review, we engage external

consultants to do the work, but most times now they are at the request of the

individual boards.

MR. MANNING: If the issue is raised with me, as the MHA, I could contact

the board and ask them to conduct a review; you know, would they be interested

in conducting a review.

I have one more question. As an MHA, we deal every day with all the different

boards and committees and organizations in our districts. As a matter of fact, a

couple of weeks ago I had somebody do a review of my own. In my district, I have

318 that I know of, different organizations and committee to deal with. It gets

confusing, to say the least, and that is just in my district. We deal with

institutional boards, we deal with community health care boards, we deal with

RED boards, we deal with every board you can think of.

I am just wondering: Is there any thought given to - I know it was discussed

in the health care forum that I attended on Salmonier Line - realignment,

because for the ordinary citizen out there it has to be really, really

confusing. I know for myself it is. Our health care board really goes up to

Avondale, but our institutional board goes up to Carbonear. Then you have so

many health care boards versus so many community boards. Has the department

given any - because it was discussed at length by people who are involved in the

system at the health care forums. I am just wondering has any consensus been

reached on that, to realign, to have six health care boards and six community

boards with the same geographical regions, or to have a combination of both,

whatever the case may be? Has any thought being given to that? I know I run into

it a lot with people who really have a problem understanding exactly where their

jurisdiction is? I am talking about, as we will call them, "ordinary

people" out there, not people who are in the system.

MR. SMITH: Just a brief comment, and then I will defer it to the Deputy.

I know last year, when I was acting in the department, that was an issue that

was raised with me at that time. I, like the hon. member, have heard it from

time to time. My understanding is that it is certainly something that we are

aware of and there has been some discussion about it.

The deputy tells me that there have been no decisions. Maybe Robert can speak

in more detail on it. Is there anything else you can add, Robert?

MR. THOMPSON: Sure.

It is a subject of regular discussion and, as you said, it has come up in the

forums. We posed the question, actually, in the discussion document, about

whether there should be more board integration. The feedback from most of the

forums was that it is worthy of some consideration, for the kinds of reasons you

raised. The public, generally, does not consider it important, whether or not a

service is this structure or that structure, as long as the service is provided

and provided well.

Sometimes we encounter situations where, if an individual client needs to

transfer from the service of one board to the service of another board, they

actually have to cross an institutional boundary if not a geographic one. We

want to make sure that is as seamless as possible, that there are no barriers.

That is usually what is said by people who favour more integration.

Then there is also the issue of ensuring that the community health boards,

that their role in health promotion and community level activity, if integration

was to occur it does not get submerged or seen as a lesser priority than acute

care, emergency rooms, technology, and all the things that are so immediate and

so demanding of resources. If more integration was to ever occur, we would have

to balance off that issue.

It is an issue that was raised in the forums and no decision has yet been

made, but it is one of the issues that could emerge as a topic in the strategic

health plan.

MR. MANNING: The people that are involved in the system, the health care

professionals themselves: At the forums I attended anyway, there were some great

discussions on that and they had some major concerns.

That is it for me. Thank you for your answers. I haven't anything at the

present time, but God knows what will come up while I listen to the others ask

questions.

Thank you.

MADAM CHAIR: Thank you, Mr. Manning.

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

MS S. OSBORNE: Yes, I do.

Some of the questions I had have already been asked by my colleague. I guess

I will ask a question first on Children's Protection Services. Is there

somebody here who can answer some questions on that?

WITNESS: (Inaudible).

MS S. OSBORNE: You know, it is down, I guess, to the micro questions, but

they are questions that I have come across in dealing with constituents and

other people who have come to me, and they have caused me some concern.

The policy for interviewing a child: For instance, if a five-year-old child

is brought in for an interview because he or she is possibly in a violent

situation and the department wanted to determine that, there are no tapes done

of that interview at all. It is just the social worker and the child. There is

absolutely no taping, no video taping, no audio taping, and, in many instances,

there is no observer from the outside, and that concerns me a lot. I am not

going to say that a social worker could go in with a hypothesis, but I have seen

some situations that have concerned me. I mean, I have a four-and-half year old

granddaughter. I can ask her questions if I want answers. Do you know what I am

saying?

I am wondering: Has there been any thought given to changing the policy? I

have gotten a copy of the policy from the Director of Child Welfare in Nova

Scotia. She was amazed, actually, that here in Newfoundland we do interview

children and there is absolutely no record of the interview; just when the child

and the social worker walk out of the room, there it is. Has there been any

thought given to revising the policy, to probably have audio, video or any sort

of taping like that?

MR. SMITH: Lynn or Bev?

MS CLARKE: I haven't had that question raised before. Certainly, it is

something that we can look into further, but my understanding of one of the

reasons why there hasn't been tapes is because of the very delicate nature of

the situation with the child. Of course, if you have technology there, it is

difficult enough sometimes to get child to answer questions in these situations.

What I will say is the staff are well-trained to do that kind of interview,

but I certainly understand your concern about the record piece, and that is

something we can certainly have some further discussion about.

MS S. OSBORNE: I understand that the staff are well-trained, and over the

past couple of months I have run into situations that were very uncomfortable

for me because I did not want to challenge that, but, at the same time, I did

have feelings. You know, I was perceiving something was not right. It did work

out okay in that, when it went before the judge it did work out. As it happened,

it worked out the way I thought it would, but I was a bit worried about the

process.

I know it is quite a delicate situation, but if you bring a five-year-old

child in, or any age young child, and say: Look, there is a tape recorder here

and this is being taped, or there is somebody on the other side of the glass and

they are observing - in Nova Scotia, they have a person present in the room who

is out of the sight of the child but they are in the room. They go for best

practices and they find that that works really well. I thought I would bring it

up here as opposed to in a more public venue, because it is very delicate. I

thought that I would ask that it be looked into.

I have a copy - and I am sure that you can access it as well - of the policy

manual from Nova Scotia. It is quite different. Ours is, as one psychologist

said to me, almost Victorian; it is Archaic. I did not realize that, as I said,

until I ran into this situation a couple of months ago. It was very, very

uncomfortable, it was not a good situation.

You know, none of us are infallible. Personalities do come into play. As I

said, if a worker goes into a room with a child it can be a hypothesis, they can

have the feeling, yes, I know violence is happening in this home, or, yes, I

know violence is not happening in this home. Any of us could be subject to

asking the questions along that, no matter how well trained we are, okay. That

is one question that I have.

Another question that I have is the home care. Is there still a freeze on all

home care? What is the situation? I am asking that. I really do not know the

answer. I have not come across anything in the past couple of months since the

freeze was on, so I do not know if the freeze has been lifted with the new

Budget or not.

MR. THOMPSON: There are new criteria that were introduced for home

support services. I would not call it a freeze, but there are new criteria that

are more rigid or have higher hurdles, if you like, to ensure that home support

is being provided to certainly the most urgent cases, given the budget

constraints that we have. So those criteria are still in place. Do you need more

information on what the criteria are?

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

MR. SMITH: Sure.

MS S. OSBORNE: We have people here from institutional and community

services boards, I guess. Are you still finding that there is a backup in

hospitals because people have been medically discharged but they have no place

to go? They cannot go home because there is no home care provided. Are you

finding that to be -

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

MS HENNESSEY: With respect to the modified criteria, the hospital

discharges who are going home on home support, they are going home quickly

across the Province so we do not have a backlog in our hospitals of medically

discharged patients awaiting home support services. We continue to have a

backlog in our hospitals of medically discharged patients who may be awaiting

placements in some of our nursing homes across the Province. Oftentimes you can

have upwards of twenty in city hospitals, particularly in the hospitals in

Gander and Corner Brook.

MS S. OSBORNE: Okay.

I understand there is a policy - and some people have called me about this -

where family cannot do home care. I understand completely why that policy is.

Then I also look in a small community where probably the best person available

is family, and I also looked where family - I will just say, for instance, if my

mother were living with me but I was working outside the home, and then she

became ill and I had to give up my job to take care of her because I felt that I

would provide her the best care, can you do assessments that would determine

that, as opposed to having it black and white, no family can do it?

In many instances, a person who is a family member - and I do not subscribe,

for instance, if I were not working outside the home and my mother was looking

for me and then I started to take care of her, I do not think I should come and

ask for money to take care of her, but in terms of if I had to give up my job to

take care of her, that is a different situation. Has there been any thought

given to doing individual assessments on situations like that so that the best

possible care can be provided to the individual?

MR. SMITH: I will ask Bev Clarke.

MS CLARKE: Actually, we had reviewed our policy last year about who, in

fact, can provide home care in terms of payment, and we did revise our policy to

some extent. As you know, there are certainly concerns about having relatives

paid.

MS S. OSBORNE: Absolutely.

MS CLARKE: There are exceptional circumstances, and in our assessment of

the situation we do take into consideration if there are exceptional

circumstances. The exceptional circumstances usually are around because of the

nature of the care that the person has to receive, or because of their

disability, that the most appropriate person to provide that care is a family

member. In that case an exception is made, but those are fairly rare.

Also, in terms of family members - and certainly we can get you a copy of the

policy if you do not have it already - we have always had the concern about, if

you live in the same home and then you are employed to provide the service, so

we have certainly tried to keep that to a very limited number.

MS S. OSBORNE: As I said when I was asking the question, I understand

that if I were living in the home and not working outside the home and then were

to take care of my mother, that is one thing, but if I were working outside the

home and were to give up my job to stay home, that is another circumstance. I am

sure there are situations out there like that, where family members who are

close to the person - especially if the person is in early stages of Alzheimer's

or dementia, or something like that, the best possible person in many cases, the

ones who understand them, and the ones that the person is most comfortable with,

are family members. I would never argue with the policy that family members in

the home, that is sort of crossing the line, but family members in the home who

have to give up a paid position out in the community to stay home, if they are

willing to do that, then that is possibly another circumstance.

I had an instance, actually, a woman came down from the Great Northern

Peninsula and she had approved home care. She brought her home care worker with

her because she came in with some kidney problems, and then it was determined

that she had to remain in St. John's because there was no dialysis machine in

St. Anthony. She had to remain in St. John's and she had a granddaughter here

who was working. The woman was not used to living in St. John's; she had lived

in a small community all her life. She asked for her granddaughter to give up

her job to stay home and take care of her, but I don't think that ever got

approval.

In that instance, this patient would have been most comfortable, the

granddaughter would have been comfortable with her, and it is not like the

granddaughter did not have a job but was going to use this situation to get

money. That wasn't the situation. In instances like that, I wonder if you

could go before a panel and explain the situation and have individual

assessments done in cases like this, as we go before an appeal panel for human

resources cases, for instance. I wonder, rather than just stick to the policy,

no, not in any circumstances or in very few circumstances do we allow families

to take care of patients at home, because in many instances the family is the

best one.

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

carry on.

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

MS S. OSBORNE: Okay, I have a couple of questions here. One is on the

movement of the MCP to Grand Falls. Is anybody in St. John's working on MCP

cases in Grand Falls because the staff in Grand Falls were not able to do it?

Have there been any circumstances where there still had to be people retained

here to do the work?

MS BREWER: For a period of time, early on in the days of regionalization,

there was a backlog that had been created, and there were some staff - actually,

I believe they were some audit staff within St. John's - who provided some

assistance. Sometimes they travelled to Grand Falls-Windsor to provide the

assistance, and sometimes they stayed in their own office. As far as I am aware,

there is no staff now currently in St. John's who are providing assistance in

terms of claims to Grand Falls-Windsor. Now, the medical staff was retained in

St. John's, so some complex claims - the staff out in Grand Falls-Windsor

would have access either through phone or through video conferencing to Dr.

Blair Fleming, who assists those staff in some complex assessments and complex

claims.

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

MS BREWER: There were two individuals who were employed in St. John's,

who actually made the move to Grand Falls-Windsor.

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

MS BREWER: Yes, there were competitions.

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

What was the cost of the relocation?

MS BREWER: In 2001-2002, the department incurred directly $538,800 and

there were some costs incurred by other government departments. There were

redundancy costs paid by Treasury Board that was just over $200,000 and there

was about $25,000 spent by Works, Services and Transportation to relocate office

furniture, new signing. Forklift rental, I am not sure what that was for.

MS S. OSBORNE: The other thirty-something that was there for Purchased

Services, I guess when Mr. Manning asked the questions - that is on line 06. in

2.3.01.

MS BREWER: There was a period of time that we actually rented some space,

before our office was ready on July 3. The staff were hired anywhere from six to

eight weeks in advance, and there was rental space incurred to provide some

training for those staff.

MS S. OSBORNE: Is the cost of the staff travelling from St. John's in

the transition period factored in there, the cost of transportation and things?

MS BREWER: Yes, it would have been travel for staff; like our HR staff

would have actually done the interviewing on site in Grand Falls-Windsor.

MS S. OSBORNE: In the initial stages when some of the people in Grand

Falls were not trained enough, when some of the staff from here had to travel

back and forth, that is all factored in there, is it?

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

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

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

MS S. OSBORNE: Okay.

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

MS S. OSBORNE: Yes, I understand.

In 3.1.01.05., you said there was a Goss Gilroy report. Did Goss Gilroy do a

second report, or is that the report that was done four or five years ago that

was included in that $115,000?

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

understanding.

MS S. OSBORNE: Okay.

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

MS S. OSBORNE: So that is not the Goss Gilroy. Because in the initial

stage, first in your answer, I think you said Goss Gilroy. I wasn't sure if

they were doing another report, because they had done a report in the beginning,

I think, on the Perlin Training Centre and the Pre-Vocational Centre, and those

services that were being provided.

MS BREWER: No, this is specifically a review of the four Health and

Community Services Boards and the two integrated boards in terms of assisting us

to better understand the cost drivers, the factors influencing their budget,

particularly on the home support side.

MS S. OSBORNE: Okay.

I will turn it over to Ross now.

MR. ROSS WISEMAN: Thank you, Madam Chair.

Just to pick up on a couple of things that were raised by one of my

colleagues before we move too far down our agenda, can I go back for a moment to

the ambulance service operations? Right now there are agreements between each of

the ambulance operators that, in terms of their contractual arrangement that

expires some time in 2003, I understand - I appreciate, Minister, your comment

yesterday about having to wait and see what is in the strategic plan, so this is

not an attempt to get you to answer the question you did not answer for me

yesterday. The question around ambulance services, and there have been a number

of comparisons done by the people involved with providing ambulance services,

and discussions they have had with our office around comparison between Nova

Scotia and New Brunswick and Newfoundland. From what they are sharing with us,

the Province spends roughly $9.3 million in private ambulance services and there

is roughly a little over $3 million being spent by the government provided

services through health boards throughout the Province, in comparison to

somewhere in the range of $80 million to $90 million in Nova Scotia.

The current thinking by that group at least is that with the standards and

the recently released manual for ambulance operations, and the standards you

have in place for each service - which, by the way, I commend you for, because I

think it is important that you have baseline standards for the provision of

service, especially one when you are talking about the first responders to a

critical situation and you don't want unqualified people out there responding.

I commend you for having prepared that kind of standard document, but one of the

things that they are suggesting to us is that as a government today you are

getting good bang for the buck that you are spending - in fact, getting a pretty

good deal in their terms, and underpaying for it. So, the comparison is that if

you take the services that are provided in Nova Scotia and New Brunswick, which

are very similar to the standards that you are proposing for use in this

Province, and if you were to take those standards and implement them throughout

the Province - because what we need to be careful of is that we don't have a

two-tiered system in that you have some smaller services, which unfortunately

tend to be in more of the more remote areas which don't have access to other

kinds of health services as well - if you were to take those standards and

implement them across the Province, there would need to be a significant

infusion of money.

Can you give us some sense of whether or not, as you forecast into the year

2003, particularly because there is only twelve more months and this agreement

is going to be expiring, had you envisaged a model very similar to what is being

currently in operation in Nova Scotia and New Brunswick, for this Province?

MR. SMITH: At this point in time, as I indicated earlier, I mentioned in

response to the hon. member's question earlier, in terms of the ambulance

service generally, I guess from my perspective it is an area that I do have some

sensitivity to because of my past experience and the fact that I have had to

deal in my own district with a couple of operations who were going through

difficult times.

First of all, I guess, the present situation: The groups are operating under

an MOU that was put in place and runs until 2003, as the hon. member mentioned,

and the fact is that they were aware when they entered into this that the new

standards would be coming in.

What I have committed to the groups, and I sincerely want to do it - as a

matter of fact, I am hoping to have the possibility to meet with the community

ambulance operators representative group shortly because I learned on the

weekend that they have a meeting coming up in Gander in the next little while. I

am hoping that I will be able to, if they are willing to have me visit with them

at the time, to take advantage of the opportunity of coming together to sit with

them and to hear first-hand their concerns. Similarly, with the private

ambulance operators, I have communicated directly with them and advised them

that I am generally interested in sitting down with them and having a chat with

them. As the hon. member characterized it, and accurately so, this is a very,

very important service in the fact that these are the first responders, and

there is no question that I think, as a government and certainly as a

department, we have to be committed to try to maintain this high quality care

service.

Now I am not familiar with the situation in the other areas, but I would hope

that as I move forward with this in my meetings with the other group, I am sure

that they will, as they have done with the hon. member - and I am sure he was

probably aware in his previous work life, and was familiar with those operations

anyway - I am sure, from my meetings with them, that they will be making me

aware as to what is happening in other jurisdiction.

I guess it does provide us with the opportunity as we are moving forward, and

once the present MOU concludes, to see where in fact we can go with this. As

well, the hon. member mentioned the Strategic Health Plan which we will be

bringing out later this summer. Obviously, that is a component of it. It is a

very important service that we provide to the people of the Province, and it is

certainly something that we want to maintain and improve.

MR. ROSS WISEMAN: Minister, just as a comment, I was very surprised a

little while ago - and I mentioned this to your predecessor as well in a private

conversation - to realize that there are only a few of those ambulance services

who have malpractice insurance. Other than the public liability that they carry

on their vehicles, many of those operators don't have malpractice insurance.

It is kind of foolhardy of them, number one, to be like that but secondly, I

guess, as a public policy issue for the protection of the general public it

would be, I think, extremely important and somewhat critical to ensure there is

that level of comfort in the public, that if something were to happen that were

unfortunate, that they would have some recourse. Without having malpractice

insurance, it puts them in a very awkward position. I suspect, and I don't

know this and it is not a legal opinion, but I pose a question about whether or

not it also puts the people who issue the licence in a very precarious situation

as well for having allowed it to happen. I just throw that out as a comment.

MR. SMITH: If I could have a quick response, I was not aware of that. I

am glad to hear that it is mentioned to the deputy, and it is certainly

something I would want to pursue. It is very interesting because along those

lines - I know in the discussions in my district with the community ambulance

operators, they have been saying to me that because of the improved standards

that we are bringing in, the higher level that we are bringing in, it is

creating problems for them in terms of being able to recruit new volunteers.

What I have to argue with them and say to them is that this is, as much as

anything - there are two tiers here. They say, first of all, we have a level of

care that we have to offer to the people that we are providing the service to.

Beyond that, the service providers themselves, I mean, it is a level of

protection for them too because there is a liability thing. While we are very

appreciative of the kind of commitment these volunteers make, if something

happens, if you are out there, once you undertake to do that, it is not

sufficient to say: Well, I am going to do it. We can all envision a situation

where something happens and there is a tragedy and someone says: Well, gee,

there wasn't the proper level of care administered here.

We have to be aware of all of these issues. I find that when I am talking

with the groups in my area, I am just constantly reminding them of that. The

standards are there as much for your protection as they are for the protection

of the general public.

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

that.

MR. ROSS WISEMAN: As I said, I commend the department for developing the

standards that they have because I have had a look at them and I commend you for

having done that.

Just one other point that was raised by my colleague, that I just want to

pursue just a little bit with a couple of questions with respect to it, I won't

get into discussion around the boards. You responded to his question around the

future of boards and what you thought it might be in terms of the numbers that

exist. There is one board I just wonder what the current status is: the St. John's

Nursing Home Board. When they came together, or when that board was created, it

was a reflection of bringing together the nursing homes in St. John's. As I

understand it, and maybe you can clarify this and make some comment as to what

it does, number one, to its operation and what it does, who makes decisions and

who is spending money. The board that is in St. John's, as I understand it, is

a board that has a mandate to operate the long-term care facilities in

(inaudible) but there is still an issue around the former boards that have

stayed in place and there is a question, I understand, around the ownership of

the buildings. There is second piece, and I wonder if you could comment on it,

and that is the issue of: those former boards, in addition to owning the actual

buildings themselves - so it is a property ownership issue - what involvement do

they have in the operation? Are they in some way layered in there in that

governance issue and a part of the management?

In responding to the question, could you comment also - because I understand

each of the sites have, I don't know the title they are using - a director,

site manager, site administrator or something - I am given the impression that

there is a dual reporting relationship somehow here. Can you give me an overview

of what the current picture is in the St. John's Nursing Home Board.

MR. THOMPSON: The opening of your question seemed to indicate that there

might be question in its continuance or in its future, but that is not the

question.

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

MR. THOMPSON: Okay, (inaudible).

The St. John's, Nursing Home Board is one of the fourteen Health and

Community Services Boards in the Province. It has a unique structure, though,

different than any other. It has a Board of Directors appointed by the minister.

It has a CEO and a corporate executive team with administrative services. It

administers essentially the budget and the service delivery for the nursing

homes in St. John's, but not all of them. The Hoyles -Escasoni is an exception

because that facility is operated directly by the St. John's Nursing Home

Board. The other facilities which were previously, I think, in the main

denominationally operated, continue to have what we call owner boards in place.

They have a role, which I will describe, but from the department's point of

view there is one board that we deal with and that is the St. John's Nursing

Home Board; one board to whom we give a budget and we hold accountable for the

service delivery in all of those nursing homes. In turn, they administer all of

the services and they operate to the extent possible as a single service

delivery organization.

The St. John's Nursing Home Board has a Memorandum of Understanding with

each of the owner boards that remain in place; for example, the owner board for

St. Patrick's Mercy Home, or for Saint Luke's and so forth. Those agreements

do specify that the owner boards continue to own the property, so there has been

no transfer of ownership of the property as in comparison to the Grace Hospital

where the ownership was transferred. The owner boards, each of them have two

representative, I believe, on the St. John's Nursing Home Board itself, so

there is cross-representation on those boards.

You are right, that there is a site manager in each case that has a dual

reporting relationship. Hoyles-Escasoni, as I said before, is direct, and there

is no intervening board, but each site manager has a responsibility to their

owner board because that owner board does own the facility. The owner board is

not responsible for the operation, that is for the budget, for the staffing, for

the issues related to human resource policies, financial policies, placement in

individual rooms or beds and so forth; that is all corporate. That site manager

also reports to the CEO of the St. John's Nursing Home Board on all of those

operational matters, so it is a unique structure. There is a burden or

co-ordination involved there, as you can appreciate, but it does work and it

delivers a good service.

MR. ROSS WISEMAN: The burden that you talked about is probably the one

that is probably more problematic, I suspect, and somewhat handicaps the board

in what it might do because it has to go through that layer of bureaucracy to

vet things through in terms of what it might or might not want to do because

there is the ownership issue.

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

MR. ROSS WISEMAN: Just to, if I could, Madam Chair - and I apologize if I

bounce around in terms of the layout of the Estimates - I would like to talk a

little bit about services and programs. Maybe I can try to structure it in a

fashion that falls under some kind of reasonable semblance in the Estimates.

Let's talk a little bit about board operations found on pages194-195. Can

you share with us the mechanism for funding of health boards in the budgetary

process for a moment? Let me preface my question by making the comment - and I

guess it was raised in the House yesterday - the Budget came down six weeks ago

and here we are today, and unless the letter went out yesterday or today or

something, boards are out there today not knowing what their allocation is for

this year. I guess, Minister, the question becomes one of how, if you are

looking at board-operated health services and facilities in the Province, and

their fiscal year runs from April 1 to March 31, the expectation is that they

have a balanced budget, and they submit to you well in advance of the budget

date their plans for next year, both fiscally and from a program perspective,

the difficulties that may present to them in terms of what they want to do, and

there is a lead time to implement their strategies and a lead time they need to

be able to more forward, what would be the problem with having the boards have

their budget allocation coinciding with the announcement of the Budget in this

House? When the Budget comes down in this House, and the Estimates that we are

talking about here today, that is the amount that has been voted to the

Department of Health and Community Services. You are not going to get any more,

or no less, so that is the amount you got. If your advanced planning has been

done, then it would appear to be, at least, an exercise of then following

through the next day and advising the boards what it is they get out of your

piece of the pie that is allocated in these Estimates. Is there some difficulty

with the boards getting to know earlier about their allocations?

MR. SMITH: Just to respond, I am glad to have the opportunity because

yesterday the Chair had determined that the time had concluded on the Estimates

debate. The hon. member was speaking by leave, so I thought it would be

inappropriate for me to rise and ask for further leave.

I think in terms of the issue that he has raised, it is valid. First of all ,

I should say that I think the comment that boards have no idea is certainly not

an accurate representation. The hon. member would, I am sure, acknowledge that,

because obviously these boards do submit their budgets and they do their due

diligence, and they do know these services that they have been maintaining for a

number of years.

In terms of the exact numbers, he is accurate in saying that they don't

have those. He was saying, in fact, the letter would be going out tomorrow, from

what I understand, and they are ready to go.

I am going to ask Donna if she can speak with some detail on the process and

why the reason for the delay, which is the issue that the hon. member raises.

MS BREWER: Certainly, since July, the boards certainly knew the

parameters in which their operating plans would be developed for fiscal year

2002-2003. At that time, when we sent out the requests for the budget, we were

quite clear that even though we had not yet received the Treasury Board budget

guidelines, that we were making the assumption of status quo budget plus

allowances for salary increases in any negotiated occupational

reclassifications.

MR. ROSS WISEMAN: That would be July of -

MS. BREWER: July of - last summer.

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

MS BREWER: Right. So boards certainly knew the parameters in which their

operating plans would be developed for 2002-2003.

What was outstanding as of today was a budget announcement that again the

department did not know 100 per cent until the Minister of Finance stood in the

House, she had allocated an additional $5 million on top of those salary

increases, and based on discussions with the CEOs they basically said to the

department: Don't be in a hurry in terms of how you allocate that. We gave

them the opportunity to come back with some suggestions and some methodologies

as to how they would make recommendations to the minister as to how that $5

million would be allocated.

My understanding, Jim, is that about maybe two weeks before the actual Budget

day we shared with them the budget schedules, because the boards came in.

Despite our indication of saying that we don' t think the government can

afford to provide any more money for health beyond the salary increases, some

boards did still come in and say: We would like increases for X, Y and Z.

Basically we, within the department, over the three to four months from

October to February, would have analyzed those and we would have advocated to

Treasury Board on their behalf, but it was only since Budget day that we were

able to tell to the boards that beyond the salary increases in reality the only

extra funding that government allotted was the $5 million.

Then, late in March, we had gotten word from Treasury Board that there was $6

million allocated for the Health and Community Services Boards. Now, we

allocated that on a one-time basis for the fiscal year 2001-2002, but Treasury

Board has asked us to hold back that money until we await the report from Goss

Gilroy.

My understanding is that the boards, even though they have not gotten the

official sign-off from the minister, that they have been given a draft budget

schedule which outlines for them their calculations for salary increases, pay

equity, occupational reclassifications. Even then, over the year there will be

changes, like the nurses agreement that was just negotiated. That is not yet in

our budget; it is not yet in the board schedules. We only got word last week

from Treasury Board about the precise impact of the arbitration award on pay

equity, so my staff now are going to be working with the boards as to the

allocation of that fund, which is roughly around $4 million to $5 million on an

annual basis.

In terms of the parameters the boards have to work with, I would agree with

the minister, they certainly know and have known for quite a while what

assumptions they can make in terms of what funding will or will not be available

to them.

MR. ROSS WISEMAN: Just for clarification, just so I make sure I

understand, boards were told last year, in July of 2001, that basically what you

now have as a budget is what you should assume you will get next year because

you did not anticipate government giving you any more money. Is that the sense

the boards are -

MS BREWER: Other than for the salary increases. I guess it is guidelines

as to what they can expect they would get in funding increases.

MR. ROSS WISEMAN: If I could back up a little bit, because I wold like to

understand for the Committee that I have a sense of the position the boards are

now in financially today and where they may be going. As I understand, last year

in September, when the minister announced that there were some major deficits in

boards in the Province and that they had asked for a strategy to ensure that

boards live within their budgets, I think at the time there was $17 million for

the institutional boards and then there is another piece that was not identified

for the community health boards. So there was a chunk of money - $20-odd million

- that was anticipated to be in deficit for this year.

As I understand it, some of the strategies the boards came forward with in

order to balance their budget last year were changes and adjustments that they

were going to make that were one-time changes, deferring of certain expenditures

for the balance of last year that were going to definitely happen in this year.

So I guess the question becomes - and the picture as I am seeing it - if, last

year in July, you tell boards that what you now have today is what you should

learn to live with because next year that is all you are going to get as well,

and two months after that in September you come out and say that collectively

all fourteen of you have a $20-odd million deficit, and we want you to balance

that and make adjustments in your programs and services so that come March 31

there is no deficit, and the strategies you get come across your desk include a

number of one-time adjustments, so they are not to be permanent changes in the

system, then, as I think through that, you have to come to realize that if you

then follow through and incur those expenses come April 1, because you only

deferred them from the previous year, then you automatically have positioned

yourself to have a deficit in this year if there is no new money.

I guess, if my logic is correct, and I have that picture painted accurately,

then it would have been reasonable, I guess, last year in September when boards

came through with the strategies as one-time strategies, at that particular

point, to sit down with those individual boards and map out what would be a very

permanent kind of arrangement for those boards so that they could stay within

their budget. I guess, in the absence of that having happened, it is safe to

assume that they will now have deficits again this year. Is there any flow to my

logic?

MS BREWER: There is a missing piece of the puzzle in terms of, yes, there

were some savings that were one-time, but there were also some savings that the

boards only accrued maybe in a month or two of savings. Next year they will have

the full twelve-month benefit of those savings, and in total for all boards the

annualization of the savings pretty much eliminated the negative impact of the

one-time savings.

Now, it is true that maybe for two or three boards the math is not that

exact, but I think the difference in total is like $600,000 or $700,000 on a

$900 million budget. We, within the department, just did not think that level

was that material. So again we are going out, subject to the minister signing

the letter. The expectation is that the boards will manage within the funds that

they are given this fiscal year - for the institutional boards, not the health

and community services.

MR. ROSS WISEMAN: I guess on the flip side of that, there is an

annualization of new programs that were implemented last year, too, I assume.

Would that be the case as well?

MS BREWER: I am not aware of anything in particular. Part of the $5

million will deal with not necessarily new programs, but if a board has

indicated - like, for example, a few boards have indicated that their dialysis

caseload is increasing. That was some advice given to us by the CEO so we should

at least, before we just do any kind of across-the-board allocation of $5

million, at least acknowledge that specific utilization and we intend to do

that.

MR. ROSS WISEMAN: You just mentioned, you qualified your comment by

saying the institutional boards and not the community health boards. Can we

bring the community health boards into the picture? I guess, Minister, you have

heard me make a few comments in terms of the reference to health boards.

Frequently, the reference is made to health boards only to include the

institutional boards. I keep reminding everybody that there are fourteen health

boards in the Province who get money, and I guess they get it under these two

headings here on pages 194-195.

When we are talking about health boards, I tend to talk about all fourteen

health boards. So if we are looking at the deficits of health boards, and that

is how I tend to look at it, in that context, does that same logic and same

rationale apply to community health - like, where are community health boards

going with their deficit in this year then?

MS BREWER: I will turn it over to Robert.

MR. THOMPSON: Last year, we did not ask the community health boards or

the community components of the two integrated boards in Grenfell and Labrador,

we did not bring them through the same budget reduction or deficit management

exercise in September. Our priority last year was to focus on the ten

institutional boards and components and try to ensure that they are stabilized

on a balanced basis. That occurred last year and we came out of the year

virtually balanced within those boards.

This year, our priority effort is to do the same for the community boards and

the community components of Grenfell and Labrador, and to stabilize those boards

on a balanced basis. It was referenced earlier, the Goss Gilroy report is being

done in order to help us understand better the biggest cost drivers in those

boards and then to work with the boards to come up with solutions to ensure that

those budgets are balanced this year. That is our main priority for this year.

Then we will have both sectors on a balanced basis, on a go-forward

MADAM CHAIR: Excuse me, Mr. Wiseman.

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

MADAM CHAIR: I am hesitant to interject; the line of questioning is very

interesting. I am just wondering, because we will go past 12 o'clock and we

have arranged for a five-minute coffee break, if we could take that break now.

The coffee has arrived. It is in the government members' caucus room. Then we

will come back and resume in five minutes.

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

MADAM CHAIR: Thank you.

Recess

MADAM CHAIR: Order, please!

If everyone is ready, we will get started again.

I will go to the Member for Trinity North to finish up on the line of

questioning that he was on, and then we will move to another Committee member.

We will try and do this in twenty-minute intervals of questioning. Don't feel

that you have to use up the full twenty minutes, but certainly that time is

available to you.

The hon. the Member for Trinity North.

MR. ROSS WISEMAN: Thank you, Madam Chair.

When we broke for coffee, I was pursuing a line of questioning around the

health boards; health boards meaning all fourteen boards in the Province, their

deficits. I want to just pick up on that, if I could. We were talking about the

stabilization of community health boards. I think the deputy was just finishing

telling me how the focus for this year was going to be the stabilization of the

community health boards, having done the institutional last year.

I wonder, could we talk a little bit about - because that stabilization

process is an agenda item for this year, so obviously it has not yet happened.

In terms of the budget here, the allocation that is in here for the

stabilization, do I understand that to be the $6 million that the minister

announced she wanted it spent in, or Finance had said there was $6 million that

was being allocated in last year's budget, at the end of the year, that was

costed out to that year - that $6 million - is that the $6 million stabilization

fund?

MR. THOMPSON: No, we do not actually have a stabilization fund per se.

The process I am referring to is one where we analyze the programming, identify

what the factors are that are causing the cost to increase over time, where

opportunities may exist for more efficiency, and then to develop a plan very

soon, as soon as we can, so that we do not get too far into the fiscal year,

where the set of programs in those boards can operate within the allocated

budget and what other options might be available. Then, we would have to seek

the minister's and government's approval for whatever plan or program

profile that may entail. That is the process we are going through. We do not

have a stabilization fund set aside.

MR. ROSS WISEMAN: Okay.

As a capsulized picture, the health boards, all fourteen of them, today, or

as of March 31, the fiscal year just ending, can you tell us what the total

accumulated deficit was of all those boards as of that date?

MR. THOMPSON: The community or all?

MR. ROSS WISEMAN: All. All fourteen health boards. What was the total

accumulated deficit on not just last year's deficit on operation but the total

accumulated deficits of those fourteen boards as of that date?

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

MR. ROSS WISEMAN: You can probably break it down, if you want to, if you

have the figures like that.

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

you?

MR. ROSS WISEMAN: Sure, by all means.

MR. BREWER: Just in terms of process, Mr. Wiseman, we will not know the

exact figure for this fiscal year until the audits are completed. We would like

to have the audits by the end of June. In reality, we get some at the end of

June but the majority of them will come August and September months. So these

will still be projections.

MR. ROSS WISEMAN: Yes, okay.

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

MR. ROSS WISEMAN: One hundred and ten million. Could you break that down

for me? The institution is how much?

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

MR. ROSS WISEMAN: I do not want to contradict you, however last year in

the House, in the fall, the minister tabled - the first week in December I think

it was - a report that showed the total accumulated deficits of health boards as

of March 31, 2001 was $97 million. I am assuming that this past year there has

been some deficit on this year. So that would indicate there is only a $13

million deficit in total this year. That is a bit different than information

that I have been getting.

MS BREWER: I think part of the confusion is the way Jim's table is laid

out. It has a subtotal for the ten institutional boards, it has a subtotal for

the four community, and then it has a subtotal for the two integrated. So we

would almost have to go back to the office and put these numbers in the same

format that the minister would have tabled to you back - I would assume it would

have been last December.

MR. ROSS WISEMAN: The first week in December of 2001 she tabled those,

$97 million or so.

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

MR. ROSS WISEMAN: That would have been 2001, so we have a full twelve

months on top of that. As I understand it, those fourteen boards have generated

additional deficits in this year.

MR. STRONG: It would be $97 million in total, as was indicated last fall.

The institutional boards are in the range of $3 million to $4 million and the

community boards around $8 million or $9 million.

MR. ROSS WISEMAN: What about the cancer centre?

MR. STRONG: They are on budget, basically.

MR. ROSS WISEMAN: Minister, earlier you made a comment in reference to -

and I appreciate you answering the question - with respect to boards getting

their budgets tomorrow. If I understand it, tomorrow all fourteen health boards

will get a letter from you indicating what their budget is, together with the

attached schedules indicating the breakdown of that budget. Would that be

correct? Is that the process? Is that something that I could ask the minister to

table in the House tomorrow when he sends that to the health boards? Could he

table that in the House of Assembly tomorrow?

MR. SMITH: I do not think there is any problem. It will be public

knowledge tomorrow once the letters are released. I am assuming they are ready

for my signature.

MR. ROSS WISEMAN: Okay, so we could have those tabled tomorrow. Does that

schedule include a process for debt servicing of the accumulated debt?

MR. SMITH: Not in this.

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

MR. ROSS WISEMAN: But the current year's budget - I will just use

Peninsula's Health Corporation because that happens to be in my district. If

they get a budget letter tomorrow saying they have $45 million and the

schedule

is attached as to how that is broken down. Is there a figure on that

schedule

which shows them servicing that $9.6 million with whatever the service cost

would be? Is the debt servicing in that schedule?

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

The cost to service their accumulated deficit is included in the total amount

of money that will be provided. We will expect them to service their deficit out

of the total amount of money that is provided.

As to whether there is a line item for interest, I do not think so, but the

funding they will use for that purpose is included in the global figure on the

schedule that they will get.

MR. ROSS WISEMAN: (Inaudible) qualify servicing now for a moment. When I

talk about debt servicing I am referring to retirement of the debt which

includes a repayment

schedule based on somewhere between three to ten years,

whatever the amortization becomes. So, my reference - and let me qualify my

question. Does the schedule, and will the schedule, include a figure where the

board has committed a figure for debt retirement? Not just debt servicing, debt

servicing obviously meaning interest only; and to qualify the question -

MR THOMPSON: I understand.

We will not in this

schedule have a line item that says build into this

budget x amount for retirement of principle. No, that will not be in it. We will

expect that some boards will be able to start accomplishing that in the upcoming

year through efficiency measures. Maybe one or two boards may, in the past year,

have been able to allocate a small surplus to that end. We will be working with

all the boards, the institutional boards, during the course of this year to

develop a provincial approach to addressing the debt retirement issue for the

total amount of accumulated deficit, but with this letter we are not asking them

to set aside a specific amount for that purpose.

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

that same issue.

MS BREWER: I want to clarify, just for the minister and the deputy, the

letters for the ten institutional boards are ready. We do not yet have drafted

the letters for the four Health and Community Services boards. The reason being,

government has to April 30, which is today, to pay the bills for goods and

services received for March 31. Myself and Jim, and some of his staff, have been

really busy this past week making sure that we do not leave any unintentional,

what we call, dropped balances on the table. We are making sure that whatever

funds are left from old year - consequently, in our work

schedule the ten

institutional boards are done. We were planning to work on May 1, hopefully, to

get the letters to the minister by Friday for the other four boards.

MR. ROSS WISEMAN: Deputy, I appreciate your comments and the

clarification around what debt servicing and debt repayment means. I understand

your comment about the plan to work with the boards in developing a strategy for

the retirement of the debt, which is the repayment of the principal. That is

going to occur in this year.

Is it fair to assume - no, I will not phrase the question that way. Is the

expectation that repayment of that principal, when boards under - whatever

strategy you develop, whether it is next month or the month after. But, when you

develop that strategy and the repayment commences, that repayment will come from

the current allocation they are getting in that letter. This is - and I am

careful about how I phrase this because in response to a question a moment ago,

said: The boards were given an understanding in July of 2001 what they could

expect. When boards give understandings people have different

interpretations of

that. They lend their own

interpretation to it, I suspect. So it needs to be

clear, and I would like to have some clarity around it if you could.

When boards get their letters tomorrow or the next day and they are told that

they have - let's say hypothetically, let's personalize it and look at

peninsulas because it happens to be in my district. They have about a $9.6

million accumulated deficit and their budget is roughly $45 million. So,

tomorrow you write that board and tell them that $45 million is their total

bottom line. The breakdown in the

schedule breaks out a bunch of things that are

in there and includes in that figure - but not a line item. The assumption is

that they continue to pay their service, the interest cost at the bank. So that

is not broken out. Then in a months' time you sit down with that board, as a

part of this provincial package, and the board now starts to realize: Hey

listen, you really had expected them to free up another $600,000 or $700,000

this year to start repaying that principal. It is an understanding but it is not

in here.

The expectation is that the board repay that principal from this amount you

are giving them tomorrow in that schedule. Would it not be more prudent - and

more, I guess, fiscally responsible - to facilitate much better planning? The

board could decide how they are going to deliver programs next year if they had

that piece of information tomorrow rather than spring it on them in September

and tell them: Hey listen, you now need to service the principal. I am assuming

that the money has to come from the same envelope. So, where is the strategy

here? Where is the planning that talks about a board that allows them to map out

the programs they need to deliver, and what programs they need to make some

changes in and whether they can implement new programs? Because you cannot allow

them to implement a new program tomorrow.

MR. THOMPSON: If we had a precise answer to that we would actually have

the plan done, and we do not have the plan for retirement completed. As I said,

that will be completed over the course of this year. But, one can outline

certain generalities about what is logical that will be in - or some of the

parameters that may exist there. One is that if there are any surpluses which

occur in board budgets this year, that those surpluses can be allocated to debt

retirement. The second is that if later in this year there is conversion of - if

this is the course we take - accumulated deficits into long-term debt with an

annual repayment

schedule then the first payment may come due in the following

fiscal year and might not have an impact on service levels in the current year.

At this point in time we are not asking the boards to carve out any

allocation for current year repayment. We are asking them to join with us in a

planning process for the current year and then we will have all the factors on

the table. One of the points you focused on: Is there going to be a negative

service impact this year? The answer is no, because we are not asking them to

plan in that regard.

MR. ROSS WISEMAN: It is clear though that as you develop the strategy for

debt retirement, that the debt retirement comes from that envelope of money they

have been given now.

MR. THOMPSON: That, of course, has to be our operating assumption at this

point because we have not been provided with any additional funds for that

specific purpose. Where we do not have a plan developed yet we do not know what

kinds of flexibility, creative solutions, short or long-term options that may

exist. So it is premature to say exactly how it will all unfold. We have no

additional revenue to apply to this problem at this point in time. That is one

of the planning parameters that we will have going into this process this year.

MR. ROSS WISEMAN: Do you have some sense of what the interest cost is on

that $110 million or $115 million?

MR. THOMPSON: It is a good question, because it is not simply taking the

$110 million or $80 million, as the case may be, and taking an assumed interest

rate and plotting it out over a full twelve months. As you may know, the way we

flow cash to boards means that for a substantial portion of the year they will

not have a requirement for any line of credit at all. Only towards the end of a

fiscal year will they start accumulating that line of credit which represents

the inherited accumulated deficit. As well, on top of that, some boards may have

deferred revenues for specific capital projects or other programs that will help

in their cash flow management. So it is not a precise figure that we can say - I

don't know, Jim or Donna, if you have ever estimated what the total interest

costs of carrying that deficit would be. What we can assume is that it is only

there for part of the year and that it is there at whatever interest rate may be

applicable to a line of credit.

MS BREWER: Any estimates I have Robert, has been a combined interest; and

principal has been assumed (inaudible) payment.

WITNESS: For a future -

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

interest only.

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

MR. ROSS WISEMAN: Okay, so what you are relying on is board's - all the

cash flow being flushed with money until the last quarter of the year so they do

not incur an interest cost.

MR. THOMPSON: Well, that is part of the way that they help to manage

their costs, that is right, by pushing out the need to use a line of credit as

far as they can in the year and that reduces the cost of the interest charges.

MR. ROSS WISEMAN: Based on those, just as a wrap up on this particular

point, Mr. Chair, I just hope I have captured what I have just heard over the

past little while correctly. I guess what I am getting at is the implication for

boards tomorrow when they get these letters, because in as much as many of them

may have been given an assumption or given an understanding last year in July,

maybe they should have prepared differently but I suspect, if history is held

true, that boards will wait until they get that letter before they take any

action because they say: Well, we still do not know what the department is

giving us yet so we are not going to do anything.

When they get this letter tomorrow or the next day, are they all going to sit

there and say: I have been given enough money in this letter to continue to

operate the programs that I have in place today and I am allowed to now cover

off those one-time deferments that I had from last year - we talked about a

moment ago. So I have covered off the one-time deferments, I continue to

maintain my current level of service, and there will not be any adjustments in

service levels for any of the fourteen health boards for the coming twelve

months.

MR. THOMPSON: In the time that I have been in the department I have never

heard from a board that they have enough money. So we are not likely to hear

that.

MR. ROSS WISEMAN: Will they have enough to do what I just said? Not

enough to expand, not enough to add new, not the wish list, and all that kind of

stuff. My question was very precise.

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

MR. ROSS WISEMAN: No, not at all. I understand, because you are

absolutely right, boards will never say: that's great, thanks very much and I

am wonderful.

MR. THOMPSON: We expect that some boards will have one-time measures last

year that they will say: this is a concern for us, how are we going to find

efficiency to balance? By the same token, as Donna mentioned earlier, there will

be some boards with annualized savings that create some flexibility but even

those boards, and all boards, will have, on top of those two items, pressures

from increasing utilization of services. For example, dialysis or cancer

treatment and medical-surgical supplies. There is price inflation as well as

utilization costs. Our effort has been to take the additional $5 million and

spread it over these types of pressures, in order to reduce the level of

pressure that a board will feel in terms of balancing the budget.

As you can appreciate, because you have been there, these are very complex

organizations and there are cost pressures that are coming consistently from

many, many different sources. There are sometimes flexibilities opening up in

other sources as well. This is the puzzle of sustainability right across the

country, that we have heard about for so long. The task that the department has

is to try to manage the growth in health care costs, because there is more money

going into the boards this year as there has been in recent years, and to work

with the boards to ensure that they can target a balanced position, taking into

account all of these things that are going up and down all the time.

I am not try