May 6, 1991

SOCIAL SERVICES ESTIMATES - HEALTH (UNEDITED)

The Committee met at 9:30 a.m.

MR. CHAIRMAN: Order, please!

Ladies and gentlemen, welcome to the Estimates

Committee for the Department of Health. As you can see, we are in the process of

getting some coffee. So during the session, if you feel you would like to get a

coffee by all means do so.

I would like to welcome to the Committee, the

Minister and his officials. I would, first of all, introduce to you the Members

of the Committee who are here this morning. To my immediate left is the

Vice-Chairperson, Ms. Lynn Verge, the Member for Humber East; Mr. Aubrey Gover,

the Member for Bonavista South; Mr. Doug Oldford, the Member for Trinity North;

Mr. Charlie Power, the Member for Ferryland, who is also the Health critic; and

our Secretary, Miss Elizabeth Murphy, who is the Deputy Clerk in the House of

Assembly. I welcome the media and other observers.

The format we will take this morning is: I would

want to give the Minister an opportunity to have an opening statement and

introduce his staff, and then I would give Mr. Power an opportunity of

approximately fifteen minutes. We are not going to be totally on the second as

someone suggested the other night.

Mr. Gover.

MR. GOVER: Will the Vice-Chairperson allocate

her fifteen minutes to Mr. Power?

MR. CHAIRMAN: No, I think it has been the

normal practice that the critic have an equal opportunity with the Minister and,

of course, the Vice-Chair would take the same role as other Committee Members.

That is loaded up with fairness and balance and I think that is the way this

Committee should operate.

Without any further ado I would give it to the

Minister.

Mr. Minister.

MR. DECKER: Thank you, Mr. Chairman.

I would like to introduce the officials from my

Department: Dr. Williams is the Deputy Minister of Health; Dr. Hogan is the

Assistant Deputy Minister; Mr. Lemon, Assistant Deputy Minister; Mr. White,

Assistant Deputy; and Mr. Templeman handles a lot of finances in the Department;

we also have Mr. Downton of the Drug Programme sitting back in the gallery and

he is available if there is some detail we should want to have on the drug

programmes.

In my opening statement I want to say that sometime

last fall the Department of Health was notified there was a good possibility

that our budget for this fiscal year would be frozen at the same rate as last

year. Of course, as you can imagine, this came as quite a shock to the whole

system and we realized that we were going to have to try and reorganize the

whole Department of Health and the hospital system throughout the Province. Now,

we had already started a reorganization programme before we were aware of any

fiscal problems. You will recall, just after we took office, we changed the

roles of two hospitals on the Burin Peninsula and we phased down some acute care

beds in these hospitals which allowed us to make enough savings to open up

thirty-five beds in that hospital and made it a seventy-five bed hospital. This

was in keeping with the Royal Commission of 1985 which recommended that very

thing be done.

When we found ourselves with this fiscal problem we

decided we would speed up the rationalization that we had started. We decided we

would do it in one fell swoop. The Department went under an intensive internal

review of itself. We asked the Newfoundland Hospital and Nursing Home

Association for some representation. We asked the Newfoundland Medical

Association, the Association of Registered Nurses, the Medical School, and

between October and January we had intensive reviews and we had every single

director in the Department involved. We had presentations made to us, the St.

John's Hospital Council made presentations to us. We had concerned individuals

make presentations to us. Some hospital boards made presentations to us. We did

a total review of the health care system.

We knew we would have somewhere in the vicinity of

about $800 million with which to deliver health care to the Province. We looked

at Newfoundland and Labrador as if there was nothing there, a blank map with no

health care, no hospitals, no nursing homes, no clinics, no anything, and we

asked: what would we put there if we were starting out? I suppose it would be

the same concept as zero based budgeting. What would we put there? We looked at

the needs of the Province and we looked at the needs of an individual, and

basically what does an individual need? For most of us we need some primary care

sometime during our lives. For some of us you need a second level of care which

would involve surgery or dealing with a specialist. And for a few of us we need

tertiary care, and then as we get older some of us will need chronic care and

some of us will not need chronic care. So, we said let's start from the

assumption that everyone in this Province will at some time need some level of

care. We are all going to be born, we are all going to die, so we are going to

need some care out of the system.

Primary care is basically a visit to your GP. In

some cases in the Province it is a visit to a nurse. It is a prescription, it is

an x-ray, it is lab work, it is the gateway into the health care system. So we

looked at the rest of the nation and tried to arrive at a reasonable distance

that primary care should be available to all of our people. And we came up with

the figure between a half an hour and an hour by vehicle. We thought that no

matter where you lived in this Province it would be desirable to have your

primary care available within half an hour or an hour of where you live, and

that is pretty well in keeping with the standard across the nation.

The system that we inherited, generally speaking,

had primary care available to people within a half an hour or an hour of where

they lived, but it was not total. In the Port Saunders area there was one case

where they were trying to be all things to all people and the primary care was

suffering, so we have made provisions to build a new community health care

centre there where we can deliver our primary care. Burgeo was another case in

point. We changed the two hospitals on the Burin Peninsula totally to primary

care and in one case we are going to add some chronic care beds to it.

So it is pretty well accepted throughout the

Province now, in most cases primary care is available within a half an hour or

an hour. There are cases on the Labrador Coast where the primary care which is

available is, I suppose, not quite up to standard. Patients are still being seen

by nurses as opposed to being seen by doctors. There was some criticism raised

in the House of Assembly by the Member for Labrador that non-qualified people

were actually dispensing drugs and there is some element of truth in that. The

people who are doing it are supervised, of course, by a doctor, but the fact of

the matter is that the system is such that the primary care which is available

is inadequate. So we are working toward making this primary care system

available to all our people.

The next thing we went through when we were

reviewing the department was referred to as secondary care. We concluded that we

should make secondary care available to our people in all the regions within two

or three hours, at the maximum, of where people live. In some cases that would

be by ambulance, in other cases it would be by an air ambulance. In the northern

parts of the Province you have to use an air ambulance to get there. Thus you

see Corner Brook, Gander, Grand Falls, St. Anthony, and Clarenville where they

have specialists on staff, and they can perform surgery.

In the case of Grand Falls, and in the case of all

the secondary hospitals, they do have an area which is primary care as well, but

they are the regional centres. We realized that if we wasted too much money on

our primary care we would not be able to meet our secondary care. We realized

that if we wasted money on secondary care we would not be able to deliver our

primary care. The two are interrelated. So we ended up stopping doing some of

the things in the secondary care hospitals that we had been doing, and we ended

up regionalizing things which attempts were being made at doing in the primary

care hospitals.

The next conclusion we came to, which was obvious,

was that this Province can only afford one tertiary care centre. I have said

publicly that if the map had truly been vacant and there was no Health Sciences

Centre, and there was no School of Medicine, then I would have liked to have

seen it in Gander. I would like to have seen it in a central location, available

for people from all over the Province. However, as you know, the Health Sciences

Centre was there, so we decided to put more emphasis on making that centre a

centre of excellence for the Province as a whole. Almost fifty per cent of the

people who are taking advantage of that centre now are from outside the St.

John's area, and I would think, if you were to knock out the primary care stuff,

you would find that the majority of people who go there are from outside the

city.

We are trying to put in place, primary within half

an hour, secondary within two or three hours of where you live, and have at

least one centre for tertiary care within the Province. The nature of tertiary

care is such that if we had all the money on earth we would not be able to

attract the specialists to put three or four centres in this Province. Saudi

Arabia, which has no problem with funding these facilities, cannot get enough

staff to operate any more than one or two of those tertiary centres. It is

money, yes, but it is not only money, the people are just not available. It is

generally accepted that specialists now in the tertiary care hospitals want to

have access to research, so one of the main justifications for keeping the

medical school available is the fact that there can be some research done. We

divided the acute care centre into three levels, primary, secondary, and

tertiary, and they are all interrelated. What is done in Burgeo is just as

important to the system as what is done in the hospital in St. John's, but

Burgeo does what Burgeo is equipped to do and hopefully will have the good sense

to forward on what they are not able to handle.

The other matter we dealt with was chronic care. By

the year 2000 68,000 of our people will be sixty-five and over, so the need for

chronic care is growing continually. When we began to do some of our

rationalization we discovered, by coincidence, that some of the primary care

facilities, the old cottage hospitals, some of them, not all of them, could be

changed into chronic care facilities. Springdale was one where the building was

in reasonable repair so we took out the acute care beds and changed them to

chronic care. This allowed us to move some people out of the Grand Falls

hospital who were holding up acute care beds and move them into Springdale. The

Baie Verte Peninsula: here the acute care beds were utilized 42 per cent and

even some of them were long-term patients, so we decided that we would change

that hospital into, basically, a chronic care facility. A lot of the nursing

homes throughout the Province were built as hostels. They were build for healthy

people who just happened to be old. Over the years, and the previous

administration started this, some of those buildings had to be upgraded so that

they were capable of attending to the level three patient. That is the trend we

have been following. Early in the review we came to the conclusion that if the

Budget were indeed frozen, and in actual fact, Mr. Chairman, it was not, we

realized it would wreak tremendous damage to the system had we totally frozen

the Budget.

We took out the equivalent of $35 million on an

annualized basis. In this fiscal year it will be $23 million. The Newfoundland

Hospital and Nursing Home Association have been arguing with us all along that

we did not make enough allowance for slippage, that we really will not save $23

million in this years budget. Maybe they are right, maybe they are not. We

disagree with them; we believe we will. Notwithstanding the fact that they

disagree with the amount they are pretty well in agreement with the principle in

what we are trying to do. So if there is an argument it is whether or not we can

really save that much money.

In the system we said we would be laying off up to

900 people. To date there have only been 450 actual warm bodies laid off in the

system. There are several explanations for this; one is that some of the

hospitals back in January, anticipated that there would be problems so when

people resigned they did not replace them, so that is one explanation. So when

the actual lay offs came, the positions were vacant, normally they would have

filled them. In other cases hospitals have picked up some savings elsewhere in

their budget and they have kept some of those people on because they anticipate

vacations coming up in July and August. So I would not be surprised if before

the year is over the figure would go higher than 450. I am not sure if it is

going to go to the full 900 or not, but there are 900 positions which have been

taken out of the system. I believe that what we have done will not seriously

damage the delivery of health care. I think next year we are going to need more

money in the system to enlarge on what we have started.

In closing I want to give a quotation which was

given by Dr. Harry Watts at a meeting in Burgeo when we met with the people and

explained what we were doing. Dr. Watts said that to run his institution, the

Corner Brook Hospital, cost about $40 million. He said it cost $2 million to run

a cottage hospital. So he said you could close up Corner Brook and you could

have twenty cottage hospitals; you could have hospitals in twenty little

communities, but in his professional opinion you would not be able to deliver

health care near the magnitude that you are delivering by having regional

hospitals. Of course I agree with him. The cottage hospital era is over, and we

have to adapt to a new era, there is really no place for the cottage hospital

system as it was in 1935. It is a place for primary care, but it has to be a

part of an overall system. Thank you, Mr. Chairman.

MR. CHAIRMAN: Thank you, Mr. Minister.

Before I acknowledge Mr. Power, I just want to

welcome another Committee Member in the person of Mr. Art Reid, the M.H.A. for

Carbonear.

Before we go to Mr. Power, I was wondering if I

could get somebody on the Committee to move the minutes of May 2.

Moved by Mr. Gover and seconded by Mr. Power.

On motion the Minutes, as circulated, adopted.

MR. CHAIRMAN: Mr. Power.

MR. POWER: I don't think I am going to need my

fifteen minutes but I would like to ask the Minister some questions. Obviously

the idea of the Estimates Committee is to delve into the intricacies of where

the money is spent in the system. One of the problems we have, certainly as

Members of the Opposition in dealing with some of the lobbying interest groups

in the medical field and the health care field, is the fact that the Minister

has finally acknowledged this morning at the end of his comments the

downgrading, the cutbacks in the health care system. I think the words he just

used were 'would not seriously damage the health care system'. I guess we need

an

interpretation of what seriously damaged means. I think the Minister has been

giving off the wrong

interpretation of his budget to the public since it was

done in the Budget of March 7: the idea that this is a new improved health care

system. In effect I think you have to acknowledge that those are tough financial

times, and because of tough financial times health care has taken its share of a

downgrading, and when its share of the budget, $800 million, is such a hugh

chunk, then obviously they have, I suppose, to do their proportionate share. But

somehow this idea that we have a new improved health care system - I mean the

system in Newfoundland was always three phased, primary, secondary and tertiary

care is not something brand new. I have seen those terms for a long period of

time and combined that with chronic care, you are going to revitalized it,

reorganize it, but I think the reality that we have to acknowledge in

Newfoundland and which the Minister has now said, is that we are not going to

get the kind of money for health care that I am sure Dr. Williams and his staff

would like to have. I am sure you got $836 million this year, you could have

easily spent $860 million and you could have done a primary, secondary and

tertiary health care system which would have been simply that much better. I

think the reality is that we are in a period of very serious fiscal restraint

and the health care system is going to have to take its knocks the same as all

other parts of Government and I think you are better off acknowledging that

upfront, as the Minister should and has begun now to do, and to say that we are

going to have a tough time and lets try to live with it as best we can. That is

really where we are.

I have some concerns about the downgrading system.

I have been around Government for a fair period of time and I know that when

downgrading starts, when rationalizing starts, next year's budget is based on

this year's budget and once it starts it is a never ending sort of scheme that

goes on and on. I have, and I am sure some of the people that I have talked with

have serious concerns about where the health care system is going to go next

year. Is the Newfoundland economy going to be vibrant enough to allow the

Newfoundland Government next year to get into a spending mode? The general

feeling from anyone you speak with is that it is not and that next year we are

going to have the same kind of budgetary problems except probably worse.

We in the Opposition do not believe the health care

system is going to be able to live exactly within the Budget. There is going to

be some overrun. The $10 million figure that the Newfoundland Hospital and

Nursing Home Association put out shortly after the Budget says they cannot do

it. They do not have enough lead time. I think there was a mistake there. I am

sure the Minister can address it and I think the Newfoundland Hospital and

Nursing Home Association have looked at it since then and maybe have reduced

their figures somewhat, I do not know. But certainly the concern is they did not

have enough lead time to implement all of these new decisions in one fiscal year

and that is normal for a very large system. You have to give it some advance

warning that something is going to happen. Had that warning come last October

when the Government knew it was in financial trouble, I think they would have

had a better system starting off the 1st of March. Be that as it may, I think

you will have some significant overruns in the health care system this year. I

do not know how you can avoid that.

I hear terrible rumblings among doctors, who are

saying that the MCP system of capping at $125 million is going to cause them

untold problems later on in the year. Some doctors will get a larger chunk of

that upfront and some will not. But some general practitioners are saying that

is definitely going to cause major problems for some of those.

Look at how the health care system was done. I

believe you have to have fiscal responsibility, you have to have some restraint,

but I really think that in cases, for example, like Placentia and Port aux

Basques there is a role for people to play on the hospital boards. I do not

think the Government can simply use hospital boards as a scapegoat, as the first

line of defense to take the first lot of criticisms from the public. The

hospital and health care boards are more than that and should be more than that,

they were set up not simply to take the flack, they were set up to give advice

to the Minister and his officials. I think in many cases the hospital and health

care boards were not listened to, they were seen to be nonprofessional,

nonexpert, and when they made suggestions such as in Placentia and Port aux

Basques and Labrador West and other places I do not think they were listened to.

I think it was said: okay you are simply a bunch of amateurs, you are okay to

run the board for us but do not come back to us with any serious concerns about

how health care should be run, that should be left to the professionals in the

Department. I think that is wrong, those health care boards do serve a very

valuable function. They are a sounding device from the local people as to what

they perceive is required in health care. They may be wrong. But I think they

have to be listened to a lot more than they were listened to in this budgetary

process and I think Placentia is an example of where we really did not listen.

I would like to ask the Minister - I asked him last

week and I have not seen the answer - exactly what adjustments have been made in

the health care system. How much money has Placentia gotten? How much has Port

aux Basques gotten? Has Lab West received any extra funding? And if you are

receiving extra funding, as the Minister answered in the House, is the funding

coming from within the overall health care budget, the $836 million, or is it

going to be additional money? Are you simply robbing Peter to pay Paul all the

time, which does not improve the system significantly? The other question I

asked in the House of the Minister of Finance, and that the Minister of Health

has not tabled, is if you expect the public in Newfoundland to accept the health

care system being downgraded like it is, then you had better give us the facts

and figures to tell us why the money is in such short supply? The Minister has

said on several occasions that we are going to receive no money from EPF after

the year 2004. As one Member of the Opposition I have asked the Minister of

Finance, and the Minister of Health, to table the documentation that says that,

because I do not believe it. I do not think it is going to happen in 2004. It

may happen in 2014 or 2024 but the tax credits and cash which make up part of

the established programme funding, I do not think will run out that quickly. I

think you have to assume that an awful lot of bad things are going to happen to

the Canadian economy over the next fourteen years for us to be out of federal

transfer payments as it relates to health and post-secondary education. If the

Minister has the facts that says that, that there is not going to be any federal

money in health care after 2004, then it would be a lot easier for Members of

the Opposition, the ARNN, the nursing assistants group, the Newfoundland and

Labrador Home and Hospital Association, if we had all that information.

We have a lot of particular questions we want to

ask the Minister about different subheads but the underlying

part is that the

Minister has got to acknowledge that in effect we have had a downgrading, how

are we going to exist while we are being downgraded, and what happens? I think

the real concern in people's minds is what happens next year when we are into

the same kind of fiscal problems. Do we then have another significant

downgrading? With this plan that you would like to have, this primary,

secondary, and tertiary developed in a certain fashion, can you really develop

that without money? What happens next year if we do get a freeze?

I say to the Minister, and I am sure he is aware,

from the Budget document of March 7 the most concern of the people of

Newfoundland whom I have talked to is health care, where it is going, are we

going to be able to have a universal Medicare system somewhere in the future, or

is this really the beginning of the end of Medicare and universal hospital

access in Newfoundland, being the poorest part of Canada, and in effect is it

going to be destroyed in Canada itself? Of course the Federal Government,

conservative though it may be, deserves a fair amount of the blame for the

process of cutting back on medical transfer payments. Still we have to live in

Newfoundland and I do not think the Newfoundland Government has assisted in an

awfully great fashion. They have compounded the problem and I think Newfoundland

is going to have a worse welfare system as we go along, worse than any other

part of Canada, as both levels of Government cut back on money for what is

basically an essential service.

We have a lot of individual questions we will ask

the Minister as we go on but certainly those are our initial observations.

Thank you.

MR. CHAIRMAN: Thank you, Mr. Power.

Perhaps before I go to Mr. Gover the Minister might

like to make a short comment.

MR. DECKER: I have a few brief comments, Mr.

Chairman. The hon. Member said that I said there is no serious damage to the

system, and I stand by that. I had to face the fiscal reality. Under the

circumstances we did what we had to do within the fiscal reality considering the

amount of money we had. I am being misquoted on this. They say I am saying that:

we have a better system as a result of this. This is certainly not what I am

saying. I do say we are moving toward a better system, because the reality is

that if we try to do tertiary care in Burgeo we are not going to get the

expertise to go into Burgeo and do it. We are not going to be able to afford to

do it anyway. By rationalizing the system, I believe that if next year we have

less money we will be able to deal with that a lot better than if we tried to be

all things to all people throughout the Province.

The Member talks about next year, now the reality

is I am not the Minister of Finance and I do not know what will happen next

year, but the reality is that we might have to close some hospitals, that is a

possibility. On the other hand, if we can restore some fiscal responsibility to

this Province, which is the very thing we are trying to do and taking a lot of

flack for it, we can try to get back out of our fools paradise and start

spending the money we have instead of the money we do not have, hopefully we

will be able to overcome. But if we fail as a government, then yes the hospital

system will suffer and so will the education system and the whole thing.

The hon. Member says there will be overruns in the

system. There well may be. Thus far we have received most of the budgets from

the hospitals and the Department has gone through them and we do not see any

serious overruns. I will not argue. I think there may be one, two, or three

hospitals in the system who may have a problem with their budgets and that is

nothing new.

The MCP capping: Again the Member talks about some

of the complaints of doctors. The Newfoundland Medical Association has been

involved with what we are doing. Nobody likes to cap. The Newfoundland Medical

Association does not like to cap. There was a formula put in place whereby when

the bills came in doctors were paid under a certain formula. The Newfoundland

Medical Association have come back and said that formula may not be the right

one, maybe we should not be capping until you reach a certain income. I heard on

the radio this morning in Ontario they capped up to $400,000 then they prorate.

In New Brunswick they have had this system in place for a year or two now where

they cap at $250,000 for GPs and $350,000 for specialists and they do not cap

until they get beyond that mark. So, we are quite open to the Newfoundland

Medical Association.

The role of the hospital boards: The Member says

they were not listened to. I do not know where he is getting his information. We

had extensive consultation with the hospital boards throughout the system. Every

single hospital board made presentations to Government as to how they were to

deal with the problems this year and every single one was gone through with a

fine-tooth comb. In the vast number of cases we accepted the recommendations

which were made by the hospital boards. In some cases we did not because we had

to look at the region. Early in our review we realized that if we treated

everybody equal it would jeopardize the system. In some cases we did not take

any money from a board but we took more from some and as the Member said robbed

Peter to pay Paul, but for the benefit of the overall system we thought that was

the proper way to go.

The Member asked about the EPF: if the present

trend continues the EPF will run out in this Province the latter part of the

year 2003 or early 2004, somewhere around then. In 1995 it is going to run out

in Quebec. Now the Newfoundland Medical Association have publicly released this

information. The Association of Registered Nurses, their national body met in

St. John's last October and their was a press release carried on that. They have

done their research and they also (inaudible) Newfoundland Hospital and Nursing

Homes Association. So, the hon. Member is probably one of the few people in this

Province who has not had proof that this will happen. I am sure the Department

of Finance does have that information and I will attempt to get the Minister to

make it available to the Member. So it will be by the year 2003, late 2003, if

the present trend continues. Now, if they lift the cap it will be 2014 as he

points out and in the place of that we are getting back some tax credits. Tax

credits are great if you have the money. Tax credits are not as good to us as

they would be to a wealthier province.

Can we develop without money? No. We cannot develop

without money. If we do not have more money next year than we do this year then

allowing for inflation we will have to close more beds and probably have to

close hospitals. But I am hoping we can restore some responsibility and

hopefully not have to do that.

MR. CHAIRMAN: Thank you, Mr. Minister.

Mr. Gover.

MR. GOVER: Just to pick up on that last point,

it was a point I intended to question the Minister on today about established

programme financing and how it relates to health. At our last Committee meeting

we had a dissertation from the Minister of Education as to the impact on

post-secondary education and basically the Minister of Education felt as I feel

that this particular effort on behalf of the Federal Government to restrict EPF

transfers is basically unwinding the social net which is a major factor in

Canadian identity and a major factor in holding the Country together. Now,

perhaps in the fall when we find out the new constitutional position of the

Federal Government we will see what we have here is really a process of

deconfederation.

Getting back to the Minister's comments about Bill

C-69 which was the capping Bill. I recently received a letter from - I am sure

the Minister received it as well - the Newfoundland Medical Association, the

MDMHA update. And in that particular letter signed by the President, Peter

Roberts, as I said dated April 17, 1991 they list what Bill C-69, the capping by

the Federal Government will do in Newfoundland and Labrador: longer waiting

lists for surgery, closure of more hospital beds, further reduction of hospital

services, enormous difficulties in keeping doctors and attracting physicians to

Newfoundland, especially to our smaller communities. Basically, the letter to

MHAs is an assertion by the Newfoundland Medical Association that this

particular procedure which the Federal Government is engaged in is the first

step to the destruction of Medicare in Canada. And while we may argue about

whether or not the funds are going to run out in 2004, I think the trend is

clear from our own budget documents. In 1989 the actual EPF transfer was $224

million, the projected 1991 transfer of EPF to the Province on current account

is $210,400,000, a reduction of some $14 million from the Federal Government. In

addition to that in 1989 equalization to the Province was $942 million and this

year the projected equalization to the Province is $934 million, a reduction of

$8 million. So you put equalization and EPF together and since we assumed power

we have a net reduction, not a freeze, but an actual reduction in dollars of $22

million from the Federal Government to finance Health, Education, and indeed all

our programmes because equalization is for all programmes. And I must say that

it is to the Minister's credit that notwithstanding that decline in Federal

transfer payments on current account when we look at health expenditures on

current account, in 1989, the first year we assumed office, our current account

expenditures on health were $644 million and the projected expenditure in 1991

is $723 million, a growth of $79 million. So as the Federal contribution to

health in our Province has decreased, the amount of revenues generated by the

Province and put in health care on the backs of our own people is up quite

significantly to $79 million. I must say to the Minister's credit I am sure it

was not easy to get that additional funding with all the other competing

priorities around the Cabinet Table, especially when one considers that the

funds have to come out of Provincial sources.

So we see two trends there. It seems like the trend

is, to summarize, that more and more we are going to be left on our own, and Mr.

Power can talk about tax credits and cash, but my understanding is that you take

13.5 equalized tax points across Canada, which gets your block funding, then you

take out the amount of provincial revenue generated on 13.5 tax points and what

remains is the cash transfer. Now when EPF was set up these 13.5 points were

vacated back to the provinces, but previously they were collected from the

Federal Government, so the only difference to the taxpayer is that instead of

paying it on your Federal Income Tax you now pay it in the Provincial one, and

of course with inflation the amount of Provincial Income Tax goes up and up

every year, so the amount of actual cash transfer is on a decline.

But what I would like the Minister to comment on,

and if I have the time I have a few more questions, if not I will wait my turn

again. How does he feel this withdrawal by the Federal Government from one of

the most fundamental basic programmes in this nation, Medicare, how does he feel

that this trend is impacting on health care in Newfoundland?

MR. CHAIRMAN: Mr. Minister.

MR. DECKER: One of the main things about

Medicare right now is we have from St. John's to Vancouver a system which is

pretty well similar. The care you get in Ontario or here in a hospital is

similar, now mind you there are exceptions, but generally it is a system which

is universal right across the nation. What I see developing is going to be ten

different provinces with ten different systems, and the health care which is

delivered in each province will depend on the ability of each province to

deliver, so it is quite conceivable that unless we become a have province pretty

fast we could end up with a health care system which is not as good as that of

our neighbours over in Nova Scotia, for example. This is a concern. This

administration is committed to keeping Medicare and we certainly accept the

concept of universal access, but I cannot say what will happen at some future

date, either some future Government, or our Government if still in power. How

many highways are you suppose to stop ploughing? How much are you going to

downgrade your education to have universal access to Medicare? It will be one of

the last things we would want to do away with. The downgrading in the EPF is

definitely having an impact and it is threatening health care and universal

Medicare. If there was some other way on behalf of the Federal Government to

make up for it, but I do not think tax points is the one, unless, as you pointed

out, unless we have the tax base to do it. Maybe there is a possibility in the

transfer payments. We do not care if we receive the money from EPF or in

transfer payments, but there is no indication, as you already pointed out, that

is the case. If the dollars we need were to come under EPF or transfer payments

it really does not mean that much, but the way the trend is going transfer

payments are not being picked up either. I am seriously concerned about the

future of Medicare in this Province. Certainly, we will not be able to keep

universal Medicare unless we put in place a rationalized, streamlined system to

deliver health care.

MR. CHAIRMAN: To ensure that everybody gets a

fair first round we will go back to you later Mr. Gover. I think you indicated

you had some other questions.

Ms Verge.

MS. VERGE: Thank you.

I have a list of points here.

MR. DECKER: I cannot hear the hon. Member, Mr.

Chairman.

MS. VERGE: I will speak up, Mr. Minister.

On the subject of federal transfer payments to the

Province. I see in the first pages of the estimates document that the Province

is expecting to receive $40 million more this year than it got last year from

all federal sources. We in the Opposition share the Government's concern about

the federal changes to EPF, however, we are glad that so far there have not been

any changes in the formula for equalization or for the Canada Assistance Plan

for this Province. However, because equalization is tied to the Canadian economy

and the economy nation wide has been in a recession we have had a negative

outfall in our equalization payments. As the economy picks up we can expect to

see an improvement. Now, in the case of EPF which is designed for health and

post-secondary education, there has been a change and the change has resulted in

a freeze, or you could say a slowing in the rate of increase compared to what we

would have gotten if EPF had been left alone. The first negative change to EPF

was made by the Liberal Government in about 1982 and unfortunately the changes

made by the Mulroney Government have worsened the problem. Last Fall in the

House of Assembly we had a private Member's debate about the federal legislation

that is dealing with EPF Bill C-69. The motion was made by the Member for

Bellevue and I remember after the debate while the Member for Bellevue and some

others in the Government claimed that the federal plan would lead to a

withdrawal of federal support for health by the year 2004, a claim that has been

made by some national organizations, the Premier agreed with the point that I

made that that is not so, because EPF is made up of two components: the transfer

of tax points which is not being changed and cash. And, as the cash decreases

the extent of the tax points transfer will become more significant. That is not

to say it is still not a negative development but it is not catastrophic the way

some people would have us believe.

I would like to move quickly into the choices that

the Provincial Government has made in this Budget. I would share the view that

restraint in spending is necessary and that change in our health care delivery

system is necessary. However, I am very much afraid the changes that are being

made have not been properly researched and cuts are happening in an unplanned

uncoordinated rash and thoughtless way. The Minister talked about his theory for

primary, secondary and tertiary care and there is nothing wrong with that

theory. He also talked about his ideas for chronic care and the increasing

demand for chronic care as our population ages. I do not have any quarrel with

his outline, however, what is actually being done on the ground is different. I

will use the example of Western Newfoundland. The Minister talks about the

Government's aim of regionalizing or centralizing secondary care, in the case of

Western Newfoundland the designated regional center is Western Memorial Regional

Hospital at Corner Brook. The smaller hospitals and clinics in the region, those

at Burgeo, Port aux Basques, Deer Lake, Norris Point and Bay Verte are either

being closed or down scaled, presumably the Government is expecting people from

those areas to go to the regional hospital at Corner Brook for secondary health

care services. Therefore, the Minister must accept that the workload at the

regional hospital is increasing significantly, indeed that seems to be what the

Minister wants. However, the Government has cut the budget for that regional

hospital at Corner Brook to the point that the hospital board has been forced to

close thirty acute care beds and lay off approximately seventy staff. I will not

quibble about semantics, it may amount to the elimination of about seventy

positions but nevertheless the number of personnel has been reduced.

One area that has already provoked quite an amount

of talk and worry among the public in the area is the cuts in the lab and X ray

departments. Eleven staff have been laid off from the lab and X ray departments

at Western Memorial Regional Hospital in Corner Brook. At the same time, the

Deer Lake Clinic which provided lab work and X rays has been closed. That

inevitably has lead to much longer waits for patients and I am told from people

working on the inside - I hasten to add at a lowly level, the people who are

doing the nuts and bolts work - that just in the past couple of weeks since the

layoffs have happened, that specimens are lying around longer than they should.

Urine samples are deteriorating before they are being analyzed and the readings

are not accurate.

The Minister talked about his philosophy of health

care by headings: primary, secondary, tertiary and chronic. I am concerned

because there was no mention at all of education and prevention. The language

seems to have been perverted. We talk about health when really what we mean is

illness. I think it is very regrettable that a disproportionate amount of

emphasis and resources are going into treatment of illness, and a comparatively

insignificant amount of effort is going into education and prevention. We see an

absolute cut in the Provincial effort in education and prevention in this new

Budget.

AIDS is a deadly disease that is on the increase. I

know the Minister and the Provincial Department of Health have paid lip service

to the need to mount an education programme to try to prevent the spread of the

HIV virus and AIDS. I have questioned the Minister and his staff about this each

year since the change of Government and the answer has always been that a grand

education programme is being developed and is about to be unveiled. But I have

not seen it.

I would like to ask the Minister about the current

statistics for the incidence of HIV and AIDS. I would like to ask the Minister

if his Department has made a decision about continuing to provide AZT to people

with AIDS without cost. Since last fall AZT has been approved by Health and

Welfare Canada and technically has the same status as other fully approved

drugs. Yet the difference is that AZT is extremely costly and if patients are

made to bear the cost of AZT then some of the people with AIDS who need it

simply are not going to be able to afford to get it. I would also like to ask

the Minister whether his Department has responded to the request of AIDS groups

and the lead of the Government of Ontario in moving to anonymous testing. It has

been shown that where anonymous testing for HIV and AIDS is provided that more

people at risk are actually having a test and getting diagnosed.

Next, on the subject of MCP, I would like to ask

the Minister whether in view of the changes that are being forced upon us, and

the changes that we perhaps should be seeking ourselves, whether he favours, and

whether he is willing to make any moves towards, having MCP coverage for health

care professionals other than those now funded, namely physicians and in some

cases dentists or dental surgeons and optometrists. For example, does the

Minister in light of the new realities and the new knowledge, favour MCP

coverage for nurse practitioners, midwives and chiropractors?

We have always had trouble attracting physicians to

rural parts of the Province and I would suggest to the Minister that with the

changes the Government has made recently and the changes that they are committed

to for the future - closing rural hospitals, giving up on the cottage hospital

system - we will have even more difficulty holding physicians in rural areas and

attracting physicians to rural areas. Before the modern era nurses and midwives

provided a valuable service to people in many parts of our Province. I wonder if

the Minister favours empowering these health care professionals and providing

MCP funding for them to give primary care.

What does the Minister think about the positive

experience of publicly funded nurse practitioners and midwives in Scotland and

the Scandinavian countries? Where services provided by them, as opposed to

physicians, have resulted in better care, fewer infant deaths and maternal

deaths and illnesses, for example.

And another area that I would like to get into that

perhaps I will in my next set - I will just mention now - and that is the area

of mental health services. I am afraid that our mental health services are

woefully inadequate and the very grave needs for mental health services on the

part of children and adolescents, to cite one important example, for victims of

child sexual assault and abuse simply is not being met.

Thank you.

MR. CHAIRMAN: Okay. I am glad to see the

Minister's pen is working. And he has lots of paper.

MR. DECKER: Yes, Mr. Chairman. I am just saying

that the hon. Member does not accept the changes that we made and I can

understand that, and that they were not properly researched. Now in my original

address I pointed out that we are following the Royal Commission report very

closely. We have not done anything to date which contradicts the Royal

Commission which was an extremely valuable piece of work.

Before we speeded up our process, I pointed out

earlier that we went from October till well into January, where the Department

had the resources of the Newfoundland Medical Association, the Hospital and

Nursing Home Association, Registered Nurses, and I just name them on. And it was

a very thorough investigation of the whole system. Now, I do not know how to

convince the Member that this was enough, and maybe it was not. But in the

circumstances that we acted I am satisfied that we did have adequate research.

So it is just - I am saying we did and she is saying we did not. So I do not

know. Maybe God can decide who is right. But I am satisfied. And at this moment

it is my responsibility. But we had to make that decision.

The Member talks about the impact of the role

changes in other institutions on the west coast, the impact on the regional

hospital in Corner Brook. And again I have to say, yes we are very much aware of

that. But the presentation which was made to the Department of Health by the

board suggested that we would close fifty beds in the Corner Brook hospital.

That was a recommendation that was brought in. And considering what we would

have to do in other regions we said no, we would rather - well, we would have

liked to have kept twenty beds. But we ended up closing thirty.

Now some of these thirty that we closed, as I

pointed out in the House a short while ago, were really pediatric beds. Totally

underutilized. So we do not see any great harm done there. Also I understand a

couple of departments were not together in that hospital.

AN HON. MEMBER: (Inaudible).

MR. DECKER: Yes, that was done before, the

surgical and medical departments were put together. So that way you can get

better utilization of some of the beds which were already there.

The lab and X ray at Deer Lake: Now this has been

quite a thing in the media., I believe I am meeting with some people today. I am

meeting with a group from Deer lake today to discuss that matter.

Again, the Member for Ferryland earlier talked

about not listening to boards. Well the fact of the matter is we do take a

tremendous amount of advice from the hospital boards. And the local

administrator, when he made his presentation, suggested that the role of the

Deer Lake lab should be changed drastically. And what he wanted to put there was

a combination lab and X ray person. Yes. There are a few of them. Are they still

training them or not?

AN HON. MEMBER: No they are not (Inaudible).

MR. DECKER: No, they are no longer training

those people but there are quite a few in this Province who can do both. And in

the opinion of the hospital board it would be more cost effective for the amount

of work which is done there to have a combination. And I understand from him

that they are still trying to recruit such a person. And when they do they will

continue to provide lab and X ray. Well, they are doing lab now, I believe,

aren't they?

AN HON. MEMBER: They are taking blood.

MR. DECKER: Yes, they are still taking the

blood there. But they are hoping to recruit this person. But in the meantime we

are assured that the system in Corner Brook can still handle it. As a matter of

fact I understand some of the layoffs in the lab and X ray were actually

teaching positions, I think. That is what Doctor -

SOME HON. MEMBERS: (Inaudible).

MR. DECKER: One of them was a teaching

position, yes. And we are back and forth with Dr. Watts out there and he

explains that sure, we have just experienced a cutback. It is not as good as we

would like for it to be. But he is quite satisfied that nobody's health is being

jeopardized, and that things are going well.

But the hon. Member makes a very serious point

which I am going to pursue. She claims that specimens are lying around. So I

would ask maybe if we could call Dr. Watts even before this meeting is over.

Because that is a very serious accusation. And if there is any basis to it we

certainly will have it checked out.

Education and prevention: I did not mention that in

my speech, and I am sure there are a lot of things I did not mention in my

introduction. I only had fifteen or twenty minutes. But that is so self-evident

I suppose that it is one of the things that you are going - you cannot mention

everything. Education prevention as such is self-evident. The whole advances

that have been made in medicine have had nothing to do with treating someone who

is in hospital. It has all been prevention. I mean, tuberculosis was prevented.

Smallpox is prevented. Hopefully some day AIDS will be prevented. The whole

thing - we do have education prevention. I am going to ask the Deputy Minister,

Dr. Hogan, a little later if he would sort of elaborate, especially on the AIDS

thing.

The AZT at this moment is still being paid for by

Government. It is costing Government $8,000 to $10,000 per person. And it is an

issue in the Department which I am trying to come to grips with. What

justification do we have to pay for one expensive drug if we are not prepared to

pay for all expensive drugs? And what justification do we have to pay for

expensive drugs if we are not prepared to pay for inexpensive drugs? So there is

an issue of fairness there which I am trying to address. I just learned over the

last few days that there is now another drug on the market - not for AIDS, it is

for another disease - which costs $40,000 per year. Requests have come to the

Department to pay for those drugs.

So it is extremely difficult to know where we are

going. And the future of drugs since the generic drug formula - we all know the

situation there where it takes ten years now after a new drug is developed

before the generic drug can be used. And the cost of drugs is going to continue

to escalate. So far we do have a drug programme in this Province. It is not as

expensive as in some other provinces. But it is an issue that we are wrestling

with and trying to come to grips with. Nobody should be put bankrupt because

they cannot afford to buy drugs. On the other hand, if people do have insurance

coverage I do not see how you can expect the Province to take responsibility for

it. Or if someone is financially capable of paying for it, I (Inaudible).

The Member makes a very valuable and valid point

about anonymous testing for AIDS. It is an issue that I have discussed with the

AIDS committee over the past year. And to be quite honest I did not really have

any great belief that it should be done. Because I was of the absolute total

opinion that anything that happened in a hospital was strictly confidential, but

any illusions I had about that disappeared last week. I have decided that I am

going to look into anonymous testing because it is very obvious that a person

can no longer go to a hospital without having it, and in this case it happened

to be me, and maybe they do have a point when they talk about confidentiality.

The MCP coverage for other physicians.

MS. VERGE: Would I be allowed a couple of

questions about AIDS before we leave this subject?

MR. DECKER: I am asking Dr. Hogan to deal with

the AIDS question.

The MCP coverage for other physicians: At this

moment we have brought in a chiropractor's act, as the hon. Member knows, but we

have not expanded Medicare to the chiropractors at this time, and there is no

immediate plan to do so. We have had to cap Medicare to meet our needs.

MS. VERGE: If I might interject. Might it not

be more cost efficient to have many of our health care services delivered by

lower paid professionals? Surely, a lot of the work that doctors are doing now

could be done satisfactorily by nurses, midwives, or chiropractors who would

probably have a lower scale of fees. The point of my question is trying to

improve our quality of care and service delivery by drawing on a greater variety

of professionals and making the delivery more cost efficient, learning from the

positive experiences in other countries such as Scotland and the Scandinavian

countries.

MR. DECKER: As I was about to say, Mr.

Chairman, before I was interrupted, Medicare is really a form of public funding

and we pay doctors who bill Medicare direct. Now, we have in this Province about

300 doctors who are paid on salary, the same way nurses are paid, so the issue

is not so much MCP as public funding. If a nurse is doing her job out there in

the system it is publicly funded. All the physiotherapists are public funded,

are they not?

AN HON. MEMBER: There are a lot of

physiotherapists in private practice.

MR. DECKER: But we do have physiotherapists on

salary?

AN HON. MEMBER: Yes.

MR. DECKER: So the public funds do pay for a

lot of these things.

The role of the midwife is a role that is coming to

the forefront across the nation. The position which the Department maintains is

that we have no big problem with midwives delivering children on the condition

that they are within a very short distance from an obstetrician, or in very

short distance of someone who can perform a

section if something goes wrong.

That is the view which is held by the local Association of Registered Nurses. I

have discussed it with them. We are not prepared, at this time, to encourage

midwives setting up private practice and delivering children. I can give

firsthand information on that. I belong in the North where for years and years

that was the system, where nurses who were midwives, as part of their training,

had to deliver children, and I can tell you, Mr. Chairman, it is not the

desirable thing to do. You do it when you have to do it but any woman today who

has a choice between staying in Roddickton and having a midwife deliver her or

going to St. Anthony where a midwife might deliver her but in the next room is

an obstetrician, or two minutes away there is an obstetrician and all the modern

facilities are available in case something goes wrong, I would have no

hesitation where my wife would go.

MS. VERGE: Has the Minister looked at what has

happened in Scotland?

MR. CHAIRMAN: I think the Member has had more

than a fair chance to put a lot of questions to the Minister, and if the Member

continues to add on questions it obviously is going to impact on the time that

other Committee members have to ask the Minister some questions. I ask the

Member if she might be kind enough to let the Minister finish answering the

questions she has already asked and then in the second round she might

reintroduce the supplementary.

MR. DECKER: Thank you, Mr. Chairman. On the

southern shore -

MS. VERGE: I just want to speak in my own

defence. I am not trying to hog time, but I just thought it would be more

efficient while we were dealing with the subject to try to finish it instead of

having a lot of loose ends with it.

MR. CHAIRMAN: Mr. Gover identified the fact

that he had other questions and he gave the Minister the opportunity to answer.

If one Member constantly interjects I think it steals from the others, so I

would ask the Member if she would be kind enough to let the Minister answer

questions and she will have an opportunity to rebut the answers when we have a

second go around.

Mr. Minister.

MR. DECKER: The role of the nurse practitioner:

we are presently running an experiment on the southern shore where nurses are

doing a lot of this primary care. It is an experiment which is costing us about

$180,000, so that is a three year programme. We have the World Health

Organization involved in it; we have some input from Denmark, I believe, Danish

nurses. So the role of the nurse practitioner is one which we are looking at,

but I still believe the way to attract physicians to rural Newfoundland has to

be done through the Medical School. Over the past months I have had extensive

meetings with the Medical School and we are trying to devise a plan whereby we

grow our own physicians to serve in rural Newfoundland. That is not to downgrade

foreigners who came in and gave their service, but the changes in medicine right

now with the two year intern programme which is coming up it is going to be more

and more difficult for us to get foreign doctors to serve in rural Newfoundland.

I am hoping that we can address it with the medical school who addressed the

issue with the urban areas of the Province. I think the medical school solved

that problem, but I think now that we have to address the other one.

I am going to ask Dr. Hogan if he will address the

issues raised about the education and prevention in AIDS and mental health.

MR. CHAIRMAN: Yes. Dr. Hogan, would you

introduce yourself and your position please.

DR. HOGAN: I am Kevin Hogan, the Assistant

Deputy Minister for Community Health and Mental Health. With the Member's

questions regarding AIDS, and education in the province, perhaps I will just

give a

summary of our activities to date. The Department of Health has developed

for AIDS, ads which are now ready, and we are in the process of negotiating a

discussion between ourselves and the Newfoundland and Labrador AIDS committee

for the airing of these ads. The intention is to have the committee show these

ads and have attached to them their 1-800 number so that individuals in the

Province will be able to contact a number and get some advice and have their

questions answered. We have also participated with the AIDS committee along with

other groups in a training programme for individuals who will be volunteers who

will provide the human resources for this 1-800 number. So that is in process

and it should be available reasonably soon.

MS. VERGE: Do you mind if I ask a question.

MR. DECKER: Did you want to address the mental

health?

DR. HOGAN: Yes, I can -

MR. CHAIRMAN: Yes, I will give the Member the

opportunity for a very quick question just to pick up.

MS. VERGE: Just to repeat the latest statistics

for the incidents of AIDS and HIV infection and Dr. Hogan's projection for the

next few years. And secondly, what kind of ads? I guess what I am interested in

is the overall thrust of the Government in educating the public about the risk

of AIDS, how HIV is spread, and what people should be doing to prevent the

spread of infection.

DR. HOGAN: These ads: the four of them address

that, they address one for females and one for males and there are some general

ones for the public as well for general information.

MS. VERGE: Are they television, radio and

newspaper?

DR. HOGAN: They are.

MS. VERGE: How will they be aired?

DR. HOGAN: The strategy: these are television

ads and they will be linked in for follow up to the 1-800 number so that people

can get some direct information.

MS. VERGE: What kind of money is allotted for

placing the ads? How frequently will they run? Will they be in prime time?

DR. HOGAN: We have developed a marketing

strategy which is acceptable to the experts in this area, which I think is to

run them for a block of time, I think it is about six to eight weeks and have a

space and then run them again for six weeks.

MS. VERGE: Will they be in prime time? How

frequently will they run in the six to eight week periods?

DR. HOGAN: Well, depending upon what the ads

are. The strategy addresses the target audience. So if it is young females or

youth, for example, then it will be placed in programming times where they are

known to be viewing the television set.

MS. VERGE: When will they start?

MR. HARRIS: A point of order, Mr. Chairman.

That is a very interesting question and the answer

is even more interesting, but as long as it is clear that when the hon. Member

is finished I will have an equal amount of time to have exchanges with the

Minister and Members present. It seems we have very fluid type of rules here and

I am quite happy to hear the Member speaking.

MR. CHAIRMAN: Your point is well taken Mr.

Harris and I will ask the Member now again, the Chair does not want to

interject, I mean we are here to seek information from the Minister and his

staff then fine but please remember there are other Committee Members who would

want to partake of fairness and balance.

MR. GOVER: To the point of order, Mr. Chairman.

By my calculations the Member for Humber East has

had about half an hour and I had ten minutes. Now, I am a Member of this

Committee, we are all Members of the House of Assembly, whether I sit on the

Government side or the Opposition side is totally immaterial. I am sure my

colleagues who also happen to sit on the Government side have questions they

would like to ask about the health care system and while I do not diminish the

importance of the questions from the Member for Humber East, in fact I found her

questions very edifying and entertaining and the Minister's response likewise, I

think we have to give some consideration to the fact that not only the Members

of the Committee be they on the Government or Opposition side but also the

health critic, all have questions to ask and I mean three to one is not exactly

in keeping with the principle of fairness and balance.

That is just to your point of order but your ruling

has already cleared that up and I will abide by the Chair's ruling on time.

MR. CHAIRMAN: Yes. Just a quick comment. The

hon. Member will only find that in the end she will probably have equal time

with all the other Committee Members because the Chair is also observing the

time that she is taking now.

Are you finished, Dr. Hogan, discussing the

Member's question?

DR. HOGAN: Could you provide your question on

statistics again, please?

MS. VERGE: The incidence of HIV infection and

AIDs and your projection for the next few years?

DR. HOGAN: The prevalence at this point in time

in our Province, these are the reported numbers, there have been eighty-six

individuals reported as being HIV positive, which means they are infected with

the virus. Of those eighty-six, twenty- one people have been identified as cases

and of those twelve are dead.

In terms of provincial projections: I do not think

there is any scientific formula that is available in a population of this size

with this geography to be able to predict what the cases are going to be. The

trend has been and will continue to be occasional cases reported on an ongoing

basis.

MR. CHAIRMAN: Thank you, Dr. Hogan.

Thank you, Mr. Minister.

Mr. Reid.

MR. REID: I would be quite satisfied to let my

colleague from Corner Brook continue on all morning if she had let me know in

advance, then I would not have had to come around the bay at such an early hour

in the morning to come to this meeting. She always does that, Mr. Chairman, on

every one of the Committees she is on, do not feel one bit bad about it.

MR. CHAIRMAN: I do not feel bad. I do not think

anybody here feels bad. It is very difficult when you are dealing with

politicians to cut them off.

MR. REID: I agree with my colleague from

Bonavista.

On the question of the federal government transfer

payments, and I know I have asked this question a number of times, and I am

going to get the same answer again. But I think personally that Newfoundlanders,

Mr. Minister, today are more receptive to paying at least a share. In my riding

alone I have heard a number of people say recently after hearing about the cuts

and the financial restraints we are under that maybe it is time for the

Government - and not only the Provincial Government but the Federal Government

as well, because there is a connection - to look at the possibility of user pay.

My personal gut feeling is that yes, most people

would be happy I think, and will I think be more receptive in the next few

years, if things keep deteriorating, as it relates to Federal transfer payments

and the amount of monies that the Province can actually put into health. I think

people are going to start to realize that maybe it will mean that we as

individual people will have to pay a certain share of the cost of the health

care system.

I do not know if the Minister has made any comments

to his Federal counterpart or any other, I suppose, counterparts in the

provinces. I know that there are provinces that are trying to get out of it. But

how do you feel about the possibility of some sort of a small fee as it relates

to hospital visitations or X rays or whatever, anything? That is the first

question. I would like to hear the answer. I have a couple of other questions if

you do not mind, Mr. Chairman.

MR. CHAIRMAN: No problem.

MR. DECKER: Mr. Chairman, the Member is quite

right. More and more this suggestion is coming up about user pay. You know, it

is a suggestion. Doctors tend to use it - some doctors, not all. Usually,

normally, people who can afford will do it. And you get all kinds of arguments

as to why it should be there. One argument is that there is some abuse of the

system and this would be a deterrent (Inaudible). But I want to say right up

front that personally I find the concept revolting. I believe one of the best

things we have in Canada is universal medicare. And that is my personal feeling

on it. In the United States a person can become bankrupt if his wife has to have

serious surgery. And I would hate to see that happen in this country.

But quite apart from my feelings or Government's

feelings on the matter, the Federal Government - the first time it was dealt

with I think Monique Begin was the Minister of health, when she threatened if

any province brought in user pay to take dollar for dollar off the EPF. Now, EPF

is going to run out in 2003 for us, 1995 for Quebec, and somewhere in between

for all the other provinces. So immediately this administration in Ottawa saw

the temptation of provinces to meet their need with user pay. So they have just

recently announced that they will take dollar for dollar off the transfer

payment. If we had a government which wanted to bring in user pay, if the

present trend in Ottawa continues, it would not work anyway.

But I believe that as a Province we can deliver for

about a quarter of our Budget a health care system which will make sure nobody

is forced into bankruptcy and that nobody is denied health care services. And I

think we can do it. But I think if we ever allow that to go to 35 per cent, I do

not think we can do it. But I believe the answer is not to slap a user fee on,

not to put in a health premium as some of the other provinces have done - which

is really another form of taxes - but to streamline the system. And if there is

any abuse there I think it has to be taken out, whether it is by the patient,

the doctors, the system, or whatever. We can put checks and balances in place to

stop the abuse. But if we were to lose Medicare, Mr. Chairman, I believe we

would certainly have lost one of the best things that this nation, not just this

Province, has.

MR. CHAIRMAN: Mr. Reid.

MR. REID: I can understand and appreciate your

comments and I feel basically the same way, yes, 100 per cent universal coverage

on MCP. I have no problems and I would never argue contrary to that, but, Mr.

Minister, universal coverage of MCP is a dying entity and it will be dead. You

know and everyone else knows. We may want universal coverage but in a very short

period of time there may be no MCP at all left in either Newfoundland or Canada.

If you are here in 2004, and let us hope you are, you may be forced with having

to make a decision on user pay.

MR. DECKER: That is a possibility.

MR. REID: I have a number of individual

questions as it relates to the Estimates but I will leave that until after,

until my second turn comes around.

I am hearing a number of public health people,

especially nurses in the field, talking about home care services and how home

care services can provide and save big dollars for Government, for hospitals and

for Government. Do you wish to make a comment on that because I know you must be

familiar with some of the comments that are being made?

MR. DECKER: Right now, Mr. Chairman, there are

two formal home care programs in the Province, the St. John's district home care

program and the central which is in Gander. The one in Gander, especially, was a

pilot project to see if this home care would work. It comes as a problem from

two angles, one, is that people are being released from hospital, discharged

from hospital earlier. They are taken out of a $600 bed and sent home where the

nurse goes in and various people will visit. The other angle is that seniors, or

mentally handicapped people, or physical handicapped people, are kept in their

own homes as long as possible, and they are paid one, two, or ten visits a week.

What you will find throughout the Province is that it is quite possible, before

this day is over, that someone somewhere will receive four or five home care

visits. They will probably get the person from social services, they will

probably get the health nurse, and they will probably get the VON. There is over

kill in some parts but in the vast parts of the Province there is no home care,

so it is patchy.

We announced in the Throne Speech that we are in

the process of putting in place five regional home care boards which will take

responsibility for all this area you are talking about. We plan now that the

next step is going to be Western Newfoundland. Hopefully by this Fall we should

be ready to go there. In the North the Grenfell will be the board to deliver the

home care. Basically, it is a single point of entry into the health care system.

If you are living in Bonne Bay and you are a senior citizen, right now, or it

has been, that if you had some contact in the nursing home you probably got

admitted. If you knew the Minister of Health he would probably phone and get you

into a nursing home, but we are going to do away with that so a professional

body will determine whether Aunt Mary should be in a nursing home, whether she

can be sustained on home care, whether she should be in a personal care home, or

whatever it should be. The social services program, the Enriched Needs Program

will be tied in very closely with the home care program to the point that they

will determine where the enriched needs people go. It still has to be charged

through social services because it is funded by the CAP funding. Our home care

program is indeed being enlarged and we are going with it.

MR. REID: Is it saving you money?

MR. DECKER: We are hoping in three years to

have the whole Province covered. Is it saving money? In Alberta it is costing an

absolute fortune, however the institutionalization in Alberta is substantially

down compared to what it is here. You will find that there are some people in

home care at this moment who are costing the Province $5000 or $6000 a month so

that is not really saving any money, but you will find in some of our nursing

homes there are people who could very easily be out there in their own home, yet

they are costing the Province $30,000 in a nursing home. They should be out

there for about $600 a month, that is the difference. If we could only deal with

that. We are hoping the single point of entry - we are not going to take anyone

out of the homes and put them on the street, but we are hoping that once those

boards are in place that people who go in the level three nursing homes really

need the service. At the moment there are people in there who are not

appropriately placed. It is not fair to them, nor is it fair to the system, nor

is it fair to the Province who is paying the shot, but it can cost less money.

But more important than that, it would be a more appropriate treatment because

the Senior Citizen Federation and the senior citizens are saying, 'we do not

want to go into an institution until we have to. We want to stay in our homes as

long as we can.' Of course you get into the whole issue of adequate housing in

the Province, so there are other factors that come in, but home care is one of

the things that we are following.

MR. REID: I will yield now, Mr. Chairman.

MR. CHAIRMAN: Thank you, Mr. Reid.

Mr. Minister.

MR. DECKER: To avoid duplication our public

health nurses which are out there, they will now become employees of those

public health boards. At the moment they are direct employees of the Government,

but they will become employees of the board

whereas a few years ago in the

hospitals the nurses were employees of the Government, now they are employees of

the hospital board. And so the public health nurses -

MR. REID: Are they going to be set up in

Conception Bay South and particularly in those areas?

MR. DECKER: That is right. That is the eastern;

that one will not be going until next year.

MR. CHAIRMAN: Thank you. I guess this is

probably a good time to take a short break, anywhere between five to ten

minutes. When we come back I will give Mr. Harris an opportunity.

Recess

MR. CHAIRMAN: Order, please!

The Minister has a prior commitment, we are going to

lose him for ten minutes, I suppose.

MR. DECKER: How long does it take to get to the

Radisson?

MR. CHAIRMAN: About five minutes I suppose. The

best way to go is down Cochrane Scree and right up Duckworth Street and you are

there, or you can go up here and then go in around and down. It is only five

minutes maximum.

We would have to adjourn at 12:20 p.m. at the request

of the Minister who has an engagement but I am sure the second time around,

because there is no way we are ever going to get a chance to pass all these

subheadings, that we can make up that ten minutes. In saying that I would now

pass it over to Mr. Harris.

MR. HARRIS: Thank you.

The Member for St. John's South obviously does not

know St. John's East very well. I would suggest that you go up by the Basilica

and down Garrison Hill and turn west, you would get there a lot quicker.

First of all, I have a lot of issues I would like to

raise with the Minister and his officials, but I want to say first of all I was

very pleased to hear the Minister's comments this morning regarding the

situation with midwives and to hear that the government has no difficulty with

midwives being the primary person involved in the delivery of children provided

it is within reasonable access to health care or other emergency care in case of

medical emergencies.

I wonder if the Minister would be prepared to indicate

his Government's position or intention, I suggest today or this week, because

yesterday was International Midwives Day and this is the special week for the

nursing profession in this country and as most of the midwives are registered

nurses as well, I wonder would the Minister be prepared to indicate his

Government's intention to move on this issue given that we do have a Midwives

Act which is on the books and is still on the books. There is provision in The

Midwives Act for a board which would certify individuals as qualified to act as

midwives. I understand no board has been appointed although I believe the Act

says that the Minister shall appoint, but no board has been appointed for some

years. I think perhaps since the early fifties maybe even since Confederation, I

do not know.

Would the Minister be able to tell us whether or not

they are prepared to move now to start to recognize midwives and what they do by

the institution of that board as a first step?

MR. DECKER: There is the problem of saying

something and the

interpretation of what you have said after you have said it.

MR. HARRIS: Yes.

MR. DECKER: As I have said, we have no objection.

I was quoting the position of the Association of Registered Nurses that midwives

can deliver children with the understanding that all the backup services are

within a reasonable distance. That is not to say that we are actively

encouraging that midwives would do all the deliveries from here on. I think you

will find it is a stated fact that in some hospitals, especially in Labrador,

the midwife is doing the vast number of deliveries I would think, with all the

doctors on standby.

Now the Member talks about our Midwives Act. There are

midwives and there are midwives. We really have not written the Act for the

trained midwife who is a nurse, or at least that is my understanding. In this

Province, in addition to the trained nurse who is a midwife, we had lay people

who delivered babies. That was very prevalent. My grandmother, as I said before,

could spell one word, and I do not know why that word happened to be cat, c-a-t

was the extent of her vocabulary in spelling, yet she delivered 500 babies. She

boasted on her 94th birthday that she had not lost one child in delivery, that

she was lucky. But that was quite prevalent in Newfoundland and Labrador, that

was a necessity. Women who - what is that one: she never saw the ocean and she

never saw the sea, but she did all the things that women do. Women - it is a

natural act, and usually an older woman in the community took it upon herself to

deliver children. In the fifties, I believe, Mr. White, did we start training

them? Was that the fifties or earlier?

MR. WHITE: During the fifties and later probably.

The modern midwife is primarily - I stand to be corrected, but the modern

midwife is probably a nurse in the first instance.

MR. DECKER: Yes, I know, but I am just thinking

about our act. The Government of the day recognized that maybe some training

should be made available so they started to bring them in for a six week course,

I believe it was. Something like the lay supply school you get in the Church.

They took them into locations and they gave them -

MS BISHOP: (Inaudible).

MR. DECKER: Maybe Ms Bishop can address the whole

because this comes out of her area, but the act which we have does not really

address the nurse midwife, it was a special case, that is why we have

an act. We

want to address the role of the old midwife, the untrained midwife.

MS BISHOP: Thank you, Mr. Minister. Mr. Chairman,

the access on the books now from my understanding - I have not look at it in

some time. It was developed in the early fifties and it did address those people

in the community that acted as lay midwives and they were sent into larger

centres for about six weeks to observe what is going on and then went back to

the community. And the work that they have done over the years for the most

part

is now extinct.

MR. DECKER: That is correct.

MR. HARRIS: I should say that maybe I should take

back my congratulations to the Minister then because he did say it was the

Government's position, but now he is saying that it is the ARNNs position, and I

would suggest perhaps -

MR. DECKER: (Inaudible).

MR. HARRIS: I have read the act. Ms Bishop has

not, but I have read the act and although it may have been designed for

non-professional practitioners, it appears perfectly adequate to establish a

qualification and set the standards for people who could be designated or

licensed I think is the word used in the act. The Minister may not be aware, but

I am, that the school of nursing at Memorial puts on a one year course usually

for nurses to get midwife training (inaudible).

MR. DECKER: (Inaudible).

MR. HARRIS: It is a post-nursing course for RNs to

get specific training in midwifery, and it strikes me that this aught to be

examined by the department if the department is serious about what it has said,

that perhaps the act can be looked at to see, although as Ms Bishop has pointed

out it may have been designed for specifically another purpose. It seems that it

would be quite adequate to allow this designation, and perhaps the Minister

could undertake to do that.

MR. DECKER: This issue came up, Mr. Chairman,

about six months ago, I believe. Just out of the blue someone in the media came

after me, a woman in the media wanted to talk to me about our role in midwifery.

And I did undertake at that time to look at the act because I do not believe

that all of the other provinces have midwife acts, do they? I believe we are one

of the few Provinces that do. But the direction over the past number of years,

Mr. Chairman, has been to get to a position where we were not totally dependent

on midwives. Now the problem we have had in Newfoundland and Labrador, is that

the only person available to deliver a child was, either the untrained midwife

or a British nurse who, under their training studied midwifery for a year to be

a registered nurse in Britain; I do not know if it still is or not, but it was

understood that you were practically trained to be a midwife, but the problem

Newfoundlanders had is that we only had midwives.

Now we recognize the role of midwifes in the overall

health care programme, I have no problem with encouraging it in the context of

doctors and nurses and midwives and everyone else who make up the very elaborate

health care system, but what we were trying to get away from for years was, the

position where only midwives were there to deliver children and that certainly

was not adequate.

Now we are at the stage at this moment where midwives

in some hospitals are probably not playing as big a role as they should, but I

am more concerned with having safe delivery of children than I am with making a

specific job for a nurse or a midwife or whatever, it is by necessity you do

what you have to do, but it is not something that we have any strong position on

one way or the other; I am hoping to get to the point where we can have the safe

delivery of children, which is really the issue.

MR. HARRIS: I think the Minister, if he does look

into the matter, will find that the issue is part of the quality of the delivery

of health care, part of choices for women who are about to give birth and there

is a high degree of, certainly quality of care and delivery and that is why the

choices are being made, not because they cannot get a doctor or it is a remote,

isolated area, and provinces like Ontario are now actively developing a

programme to licence and give assistance to it, and in fact I have requested

information on that and I will make it available to the Minister.

MR. DECKER: I appreciate that.

MR. HARRIS: That is one point on which I will ask

for the Minister's comments, but I want to say something about the overall issue

of the Medicare system and the whole debate about established programmes

financing.

The Minister seems to be a bit schizophrenic about

this issue, on the one hand saying that he has a great degree of commitment to

the Medicare system, particularly its universality, and on the other hand keeps

telling Newfoundlanders and told us this morning that it could end up all

falling apart and obviously as we all know we would have serious problems

keeping up the system.

On the other hand, the Minister has made a statement

that we can have a system that would prevent people from being forced into

bankruptcy. Now, I do not know if that is the criteria in terms of what level of

individual support for health care the Minister could tolerate on a user pay

basis though he objects to what the Member for Carbonear says; he used the term

forced into bankruptcy, presumably as the standard, so I am a little worried

about that and if I did not know better I would be worried that the Member for

Carbonear's comments about user pay is part of the softening up of the populace

for this type of approach by Government and I am concerned about that because we

have seen the whole debate on C-69.

I know there was a Private Member's motion, not a

Government resolution in the House last November, debating Bill C-69 while the

Bill was in the Senate and I wonder if the Minister can tell what plans he has

to deal with this issue with the Federal Government, in view of the fact that

his Government did not see fit to participate in the debate about Bill C-69 when

it was before the House of Commons and when the Committee was holding hearings

in Ottawa.

The Government apparently sent no representatives to

that and did not make any representations to that Committee, did not have

anything to say really about Bill C-69 until a private member from their own

Government side, decided to raise it when it was I suppose, too late, it was

already in the Senate; the debate had taken place and the Newfoundland

Government had not participated in it. Can he explain how we measure the

commitment that Government has to the Medicare system if the Government is not

prepared to be engaged in the national debate on it?

MR. CHAIRMAN: Mr. Minister.

MR. DECKER: I attended a function at the Arts and

Culture Centre, it was a graduation for nurses, and I was confronted by some

people on picket lines waving those placards and that sort of thing, and every

single word I said they plucked out of context: Hear this. Hear this. The

Minister said this. This is the same mentality which my friend here is using

today. I said, forced into bankruptcy. I referred to the United States where

people can be forced into bankruptcy. So, the same mentality with respect, Mr.

Harris, I see in people on the picket lines. If you say it is raining, they say,

the Minister wants rain. This is the same thing, so I do not know, and I would

not suggest that there is any relationship between the unions and the NDP. God

forbid, I should not even say that, but I cannot help but notice the similarity.

That is not the criteria, of course it is not. I said that this administration

is totally committed to universal health care. I did say that if we do not

restore some common sense to the finances of this Province the whole darn thing

could fall apart, and I believe that. I believe it is fortunate, that at this

particular time, this administration is sitting where we are, because I do not

believe, and as Peter Fenwick pointed out, certainly the previous administration

did not have the political will to do what we are doing, so I believe it could

fall apart but it is not going to fall apart, because as Peter Fenwick points

out, we do have the political will to do it. The issue of federal/provincial

financing: what my plans are and what we plan to do with it, at this moment

there is a review going on which will be completed in 1992. It has been

suggested, and again I must say now that I am not speaking Government policy,

but it has been suggested, and other things have been suggested, too, but one of

the things which has been suggested is that maybe if we could pick up more

transfer payments the EPF might not be as serious as you would think. EPF is

paid on a per capita basis, Ontario gets so much, and all the provinces, so

maybe as this review is going into place we might be looking at dealing with the

transfer payments because health and education are the responsibilities of the

provinces anyway, so rather than the Federal Government going directly in that

might be a way to do it, through transfer payments. Finance is doing a total

review as Dr. Williams pointed out.

MR. HARRIS: What the Minister did say was that he

believed that for about a quarter of our health care budget we could have a

system that would not force individuals into bankruptcy. Those are your own

words and I did not put them in your mouth, and I did not take them out of

context. That was the exact context in which they were stated, and if the

Minister does not want to be quoted then he better not use those kind of words

because that is the impression he gives, that, that is the standard that works.

He has not answered the question as to why his Government and his Department

chosed not to participate in the hearings that were held on Bill C-69 when the

matter was before the House of Commons and when the parliamentary committees

were considering it. I believe other Governments did participate but this

Government chose not to. Was it a part of your strategy to stay away from these

things and wait for one of your own Members to bring it up in the House in the

Fall, or was there some other reason that I do not understand?

MR. DECKER: That was a Parliamentary Review

Committee of the Parliament. Is that the one you are talking about here? We have

taken the position that we talk directly to Government level and the system is

in place to do that, so that is going on, but I should say in addition to that

Bill 69 has been given considerable debate by all the health Ministers. As a

matter of fact we had a special meeting of all the health Ministers right across

the nation, the ten provinces and the territories, to discuss this matter. Just

because we are not out waving placards and shouting does not mean that we are

not negotiating. Negotiations are going back and forth and the Federal

Government knows full well our position on Bill 69, a position I should say by

the way is similar to all the provinces regardless of their political stripe, it

is a matter which all the provinces have to deal with. Our strategy is to deal

directly with government and that is why we have not been appearing generally to

senate hearings or to the review committees.

MR. HARRIS: On an other matter that the Minister

alluded to in terms of the increased cost of drugs as a result of the

consequences of the Federal Government drug patent legislation Bill C-22 - which

the Minister will know was debated for some time nationally - one of the

political comprises, I guess, reached by the Federal Government in order to sell

this legislation was that each Province is going to get a certain amount of

money which is part of the selling job, there was to be more research all across

this country and that this money was going to come from federal revenues.

Can the Minister tell us how much money the

Newfoundland Government has gotten since Bill C-22 was passed for its research

purposes? Can you tell us what has happened to it?

MR. DECKER: We received $2.5 million and we are

paying $18.5 million for a medical school which is doing a considerable amount

of research funded by us as well as funded by various grants which they get from

different sponsors. We took the $2.5 million, for a while we kept it in a trust

account, but this year when we were met with the fiscal problems that we had we

put it into our general revenue.

MR. HARRIS: So, this $2.5 million that is ended

now, there is no more coming for that now is it?

DR. WILLIAMS: (Inaudible) the spring. I think so.

MR. HARRIS: Was there not a committee set up at

one point in time to decide what to do with that money and how it might be used

to promote research (inaudible)?

DR. WILLIAMS: Yes, they recommended that a

research foundation be set up but we decided against that when we reviewed the

programme planning.

MR. HARRIS: I am sorry, you were talking back and

forth, what did this committee recommend?

MR. DECKER: The committee recommended a research

foundation, I believe.

DR. WILLIAMS: There was no committee. The

committee that you referred to was the possibility of sitting up a health

research foundation in the Province. That would be the committee.

MR. HARRIS: Okay.

MR. DECKER: Where did the recommendation of that

research foundation come from?

DR. WILLIAMS: It came from our discussions with

people in the system and through a royal commission implementation committee.

MR. DECKER: Okay, so I will say that at one time

consideration was given by the department into setting up a research foundation,

that action was never taken. This year we decided to put the $2.5 million into

general revenue.

MR. CHAIRMAN: Thank you, Mr. Minister.

I would want to consider that I gave Mr. Harris of

course twenty-four minutes. I am sure he would agree -

AN HON. MEMBER: How long did you get Jack? Did you

get your half hour?

MR. CHAIRMAN: Of course, we will get back to Mr.

Harris but I wanted to give Mr. Oldford an opportunity to put some questions to

the Minister and his staff.

AN HON. MEMBER: (Inaudible) people jumping the

line, I think.

MR. OLDFORD: Thank you, Mr. Chairman.

Mr. Minister I would like to make a general comment

and some suggestions to you. Your budget from this year to last year, you put an

extra $34 million into the budget.

MR. DECKER: Pardon?

MR. OLDFORD: You put an extra $34 million into

this year's Budget and about $25 million from the revised Budget from last year

to this year's estimates. But you are still being criticized as tearing the guts

out of our health care system. I realize it is the Opposition's role to

criticize and to oppose and the union's role to protect their membership. I

guess what I am getting at is if that Opposition is not constructive eventually

you get into a situation where people lose confidence in the system and when you

do that I think it undermines the system. This doom and gloom that we have heard

over the last little while I think needs to be counteracted and I think people

have to have their minds put at ease that you are committed and that Government

is committed to a quality health care system.

I think what I would suggest, and I do not know if

this is possible, that you probably need a better system of public relations to

let the people know because there are some people out there, and I am thinking

of seniors in particular, who are possibly upset because the only thing they

hear is what the Opposition and the unions are saying and I would ask that maybe

you would consider this, not for political reasons, but to put their minds at

ease.

Now, I would like to get into a couple of specifics,

and I would like to ask you a couple of questions about the average cost per

visit for the same services in a public clinic as opposed to a private clinic. I

think back to figures that were being kicked around when the Come by Chance

Clinic was being closed. Could you tell me what the cost is in a private clinic

versus a public clinic per patient for the same type of service?

MR. DECKER: Would you like me to take down your

questions?

MR. HARRIS: Okay, this situation was brought up a

few days ago in Catalina. I am not sure if this is right or wrong.

MR. DECKER: I have to question what you mean by a

private clinic.

MR. HARRIS: In communities you have private

practitioners operating their own clinic, if I were to go there with a broken

finger or whatever, what would the cost of that service be to the Government

versus if I went to the Cottage Hospital in Bonavista?

MR. DECKER: Maybe a broken finger might not be the

one. It would be $14 or $15 if you went to your GP and it depends upon what he

does. You might have to have a general assessment which is $30 something.

Usually it is $14 or $15.

DR. WILLIAMS: I think the question arises out of

the study that was done probably on the clinic in Come By Chance where the board

did a study and showed I think the average cost was $185 a visit, that included

the salaries of the three physicians who worked there, the support staff who

worked there, in other words, the whole budget of that clinic. That would not be

the norm.

In the case of the clinic at Come By Chance with three

physicians employed, two physicians who had been working in the area for about

eighteen years and had set up private practice in Arnold's Cove, and, of course,

the vast majority of patients were going to these two physicians in private

practice. So, in essence we had an underutilized facility and that is why I

think the cost was extraordinarily high.

If you look at a fee for service and a salaried

system, the fee for service payments are higher than we pay in salaries to

physicians. One of the reasons for that is that the physician in private

practice has an overhead component which is the cost of doing business, the cost

of their office, supplies, equipment and this type of thing. Depending on the

person's level of income, the cost of operating a private clinic for a general

practitioner might run $40,000 a year, it varies on where the person is located.

I think the figure you are discussing is so much out

of whack when you compare a public funded clinic to a private practice setting

was because of the utilization factor in that particular area. I do not know

what they included in the cost, they may have included more than the doctor's

cost.

MR. OLDFORD: Generally speaking thought the cost

of a public clinic would be much higher than a private clinic?

DR. WILLIAMS: I would not want to make that

statement. I think one would have to do a detailed analysis and one would have

to look at a salaried medical system. In fact in this Province we have a larger

number of physicians generally being remunerated by a salary basis than we do in

most provinces of Canada, a much higher ratio, and you have to look at our past

history to recognize why that was. Back in the 30s and 40s they set up a system

called the cottage hospital system because Newfoundland was very rural and still

is very rural with 50 per cent of the population in communities of 2500 or less.

It was very isolated because most of the transportation went by boat and many

physicians were paid on a salary basis and that has continued today in some of

our smaller communities. In comparing the cost of a publicly funded system, such

as salary versus a publicly funded system such as fee for service for

physicians, I think one would have to do a detailed study to see for the

salaries we pay physicians how many people they actually looked after. Not

necessarily the number of visits that were made to them, but how many people

they were responsible for, for their health care. I do not think the figures we

are looking at for Clarenville are a valid comparison. I would not want to make

a judgement, and it would be a judgement issue of what system works best and

what system is less costly.

MR. OLDFORD: This leads to what I was getting at.

In Catalina the question was asked, why is it that if I go to a private clinic

in Catalina, say, and I have to have a bandage replaced, I get charged for that

bandage and I get charged for that service? This is what was related to me so I

am just wondering if this is a fact. Yet, if I go over to Bonavista to the

Government run clinic it does not cost me anything to have my bandages changed.

I am just wondering what the relationship is between those two, and if there is

a possibility, or if it is covered here some place that some of these services

can be paid for if they are in a private clinic. Eventually what could happen

is, if the Government run clinic is busy or their services are overextended, or

whatever, then it would be to the benefit of Government to encourage people to

go to the private clinic. Do you know what I am getting at? I am not sure what

the cost of those bandages is. Maybe it is only minimal and maybe it is not

worth your while to drive all the way from Catalina to Bonavista to have that

service.

MR. DECKER: Well, in that particular case I am

sure it is not, but the issue could be broader.

MR. OLDFORD: It is a broader issue, I am sure. I

would like for you to comment on that, and then there are a couple of programs

at the hospital in Clarenville, the cytology program and the mammography

program. They are important to women, not only in my district, but in Bonavista

South and in the whole catchment area that is serviced by the Clarenville

hospital. These programs are not licensed. I am not sure if that is the

terminology, licenced, sanctioned, or whatever. Is there a possibility that

those could be?... because the expertise is there, the medical people are there,

and, of course, we have a problem attracting specialists to rural Newfoundland

anyway.

MR. DECKER: I do not know what you mean by

licensed. Dr Williams could address that afterwards, but certain hospitals have

a mandate to carry out, have a role to play, and I do not know what the

situation on mammography is in Clarenville, do you Dr. Williams?

DR. WILLIAMS: We are talking about two issues. The

Department has just had a review done on cytology with people from the Province

who are expert in that area. It has just been presented so we have not had a

chance to review the issue of cytology. When you look at a service such as

cytology where specimens are taken and can be sent in, and where there is no

inconvenience to the patient, if the cytology service is done at some other area

there is no inconvenience or no problem. In looking at cytology service one has

to look at the issue of quality, and that is an issue that we have to look at in

cytology service in the Province. For instance in a province like British

Columbia which is recognized to have the best PAP smear screening programs in

Canada they have a centralized cytology service operated by the Cancer Control

Agency of British Columbia. So there are certain economies built in to if you

have people in that kind of a system, and a centralized system, with put

through. They have a high volume, they have expertise there, and we know that

there is a good quality assurance.

Now when we look at cytology, if we break it up and

piecemeal it, we are a little concerned about the quality assurance issue. I

know the arguments from Clarenville. There is no decision made on that. As

regards Clarenville, it is not an approved service. It is a service that the

board, with the funds that we gave them, have been operating and providing that

service. The service would still be provided, if Clarenville did not do it then

it would be done at the centralized service, at the General Hospital.

So we are looking at the whole issue of cytology

services from a perspective of quality. We want to make sure that if we do have

a Provincial screening, where it is so important with this particular disease,

and with a disease that we know and have good experience that is preventible, we

want to make sure that the quality is there. And we want to make sure that we

deliver the service in the most efficient manner possible. So that is why we are

looking at the whole issue of cytology screening for the Province. But that is a

quality issue and I guess an efficiency issue.

MR. OLDFORD: Seeing we are doing estimates I just

wanted your assurance that it was not a cost issue, cost in this case

(Inaudible) -

DR. WILLIAMS: No. We have to look at quality.

Quality is an issue and this committee was set up to look at the whole issue of

the delivery of cytology services in the Province.

MR. OLDFORD: Okay.

DR. WILLIAMS: That is a committee made up of

health professionals mostly from outside the Department of Health. And they did

actually have an opportunity to visit the programme in British Columbia. Several

of the committee members did visit British Columbia to see what system they have

because they are recognized to have a very good system.

MR. OLDFORD: Okay. I do not think I have any other

questions (Inaudible).

MR. DECKER: (Inaudible) because I think it is a

good point which the hon. Member made, Mr. Chairman and I have to agree with

him. For some reason - and I cannot tell the media what to do - but the media

takes more - they accept piecemeal criticism whether it has been researched or

not. And some of the things which have been carried - well, the Baie Verte case

were the absolute lies which got out there. The word in Baie Verte was that we

were going to not do any more obstetrics in Baie Verte. That we were not going

to make provision for emergencies in Baie Verte. And the people actually

believed that.

The board finally came in and met with myself and

officials of the Department. And when we explained to them what we were doing

the board went on the public record as saying that they were in agreement with

what we were doing and thought that it was in the best interest. So how do we

get that message out? Where we have boards which are cooperating it is not as

difficult. Generally the boards go back and they have a level of expertise and

they listen and they get the message out. You would be surprised at the number

of changes we have made leading up to this Budget. Things which the board

suggested and we went back and said we do not agree with that. And then the

boards came back again. Springdale is one case in point where (Inaudible),

Bonavista is a case where boards were back and forth in the process.

So what is happening is done with the knowledge but

our PR is not good. Now one way to deal with that I suppose would be to put on a

big media campaign where you pay to have your message out. But you have to ask

yourself: is it really right to take $1 million, $500,000 or fifty cents and put

into PR when you are forced to close beds, when you are forced to lay off

nurses? So it is a judgement call. We would love to get our message out, and if

our message was out based on health grounds - base it on the delivery of health

care for $800 million; it is no good to base it on politics - and I think we do

have a good message.

But we have decided not to take any money and pay for

a PR campaign. Because as much as it is probably desired politically, but it

would not really make any difference to the health care system (inaudible) but I

agree totally, we have a PR problem.

MR. OLDFORD: May I say one thing.

MR. DECKER: Yes, go ahead.

MR. OLDFORD: If you have a hospital that has

thirty beds in it and you know that over the last five years only ten have been

used, that is it, ten is the maximum that have been used; you take the other

twenty beds out of the system, are you really closing beds?

MR. DECKER: That is right. The Curtis Hospital in

St. Anthony, there were forty-two beds which we closed, but the reality was that

those beds were underutilized, so, did we close forty-two beds or did we not

close forty-two beds?

MR. CHAIRMAN: Okay, thank you; those were

interesting comments. Now that we have had an opportunity for all the committee

members to ask questions, in the time remaining, we have half an hour, maybe we

should now lead with Mr. Power, who opened up, and have some more direct type of

questions and answers, so we give everybody an opportunity. Mr. Power.

MR. POWER: Do I have five minutes or ten minutes?

MR. CHAIRMAN: Well, let me say there are five

committee members; we have thirty minutes left so, how about six minutes?

MR. POWER: I have a brief question so I hope the

Minister gives a brief answer. In 1990-1991, about your long term plan which the

Minister said on several occasions began in 1989 when you took office, in

1990-1991, you opened more hospital beds, you hired more staff, you had a health

care funding increase in excess of 11 per cent. In 1991-1992, you closed

hospital beds, you laid off staff, you have a funding increase of about 3.6 per

cent, how is that a plan?

MR. DECKER: We closed 400 and some odd beds, 442

care beds, then we changed eighty of them to chronic care, so they were not

closed; I think the net was 360 beds, half of these beds will never be opened

again in the Province, but the other half will, so 160 beds are closed because

of the fiscal problem and that is the planning because you do not have enough

money to pay your installment.

The other half were underutilized and they were in

places like St. Anthony as I just pointed out, there were forty-two; they were

in places like Springdale where we changed the role but we use them as chronic

and places like Bonavista that sort of thing, but it was not the plan to close

the 160, that was re-acting to our fiscal problem.

MR. POWER: My second question which I do not

really care to bring up after last week, but the Minister has mentioned it twice

in an off-the-hand kind of remark. The Minister says that he will look at the

confidentiality of Aids testing because of his own problems last week relating

to confidentiality.

I would like the Minister to acknowledge that the

problem last week was not a matter of confidentiality, it was a matter of the

Minister of Health receiving, I think the term is: prominent citizen status, to

get some work done in a hospital.

If that is true, if the Minister would acknowledge

that that status: prominent citizen, is obviously not available to every one,

will he also re-assess the reasons and the complaints about long line-ups in lab

and X ray which we have received in a large amount of phone calls and letters to

our office?

First of all, will you acknowledge, and I checked

after I asked the Minister some questions the other day in the House; I checked

with thirteen hospital boards, they all use walk-in service for lab and X ray;

it is not different in other places, it is the same all across the Island, so

will the Minister simply acknowledge that what happened last week was not really

a confidentially problem, it was a problem of somebody receiving special

treatment?

MR. DECKER: Mr. Chairman, that is not (inaudible).

MR. CHAIRMAN: I will give the Minister the

opportunity to say he will answer or he will not answer, because we are in an

Estimates (inaudible).

MR. DECKER: Well that is like 'do you beat your

wife?'... you know one of these do you beat your wife questions. I think Sister

Elizabeth answered that question to the best I have heard; it is unfortunate

that she had to be dragged into this, but when she explained that in her

opinion, and it was her opinion, that I had a special need and a special need to

protect my privacy. I do not apologize for that. It is ironic but I did not want

the whole damn world to know that I was going in to piss in a bottle to put it

in plain terms. I thought this was a very legitimate reason as the Sister has

pointed out. She has done it for other people as well and she explained the need

where she took the old lady and gave her a ride home, she had a special need, so

there is no big deal with that.

The other thing is on a province-wide basis whether or

not you have appointments or whether or not there are long waiting lists, that

is being monitored daily and whether or not you have to wait all day to have a

blood test, the reality is that you do not have to wait all day to have a blood

test done. The fact that we do have walk-in clinics is testimony to that. I

could not conceive that the system was so efficient that you could have a

walk-in clinic. But the fact of the matter is the walk-in clinic is testimony

that there is no long waiting list. If there was, then there would be

appointments and you would be making your appointment for next week or the week

after which I assumed I was doing. But the walk-in clinic is testimony that

there is no problem. That is the way I interpret it, Mr. Chairman.

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

MR. GOVER: I would like to go back to the point my

colleague for Trinity North raised about the health care system. It is very easy

when you are in Opposition, I suppose, even if you wanted to be a controversial

Government Member it would be very easy to say the Government is ruining the

health care system when it closes an acute care bed and it is very easy to be

political about it. In fact, the Member for Humber East said that it is for sure

we did not have the political will to do what the current Government is doing.

And the Member for Ferryland says that these things have not been very well

researched. But, just by way of preliminary comment as we all know there was a

royal commission on hospital and nursing home costs and out of that royal

commission came a bed study in 1986. Now the Minister may have some dispute with

the exact recommendations of the bed study. Of course, we know these

recommendations will change over time but I believe in that bed study it was

recommended in rural hospitals, since it did not deal with urban hospitals, that

360 acute care beds close in rural hospitals around the Province and the

hospitals were listed out by region and utilization was all considered. Yet we

find that when I was researching this and I went down through the list of

recommended bed closures unfortunately, I believe, the only ones I saw acted

upon were by and large the majority happened to be in districts held by

liberals.

For example, the eighty-six bed study recommended the

closure of Grand Bank and St. Lawrence as soon as the regional health center in

Salt Pond is build yet that was not actioned when the hospital commenced

operation. So it is very easy to be political and hurl political epithets at

this particular Government but when one looks at the record of hospital closings

one can see where the politics was played and where the priorities were not

adhered to.

Getting back to my point about bed closures, it is

easy to say that when you close an acute care bed the system is worse. But I

will take my own case as an example. In Bonavista we had fifteen acute care beds

and the hospital board did an extensive questionnaire and survey of the needs of

the patients who utilized the facility and the people in the catchment area. We

have fifteen acute care beds at the hospital, we did, and we had sixty long-term

care beds at Golden Heights Manor. What the study found out based upon patient

needs, catchment needs, and physicians opinions and nurses opinions was, there

was a great need for respite care for people who were looking after their

elderly parents in their own homes, there was a need for institutional care for

elderly people, there was a need for Alzheimer's care and there was a need for

community services both for acute care people and for people who looked after

their elderly parents in their home.

I suppose, it is a comment on our society that we find

fewer and fewer families now caring for their elderly parents in their home and

it seems like we have gotten over the years more and more of an attitude to put

our elderly parents into institutions. But notwithstanding that, when a survey

was conducted we find a need for respite care, long-time institutional care,

Alzheimer's and community services. In conjunction to that, when this issue came

up I asked the administrator of the hospital to do a utilization study of the

acute care beds in the hospital and he found by and large acute care beds in the

hospital were used by chronic care patients, people who should be in Golden

Heights Manor and not in the hospital. In fact the number of specifically acute

care problems, even including long-term patients who were there on an acute care

basis in the hospital we needed seven point five to eight beds.

With the restructuring that the Minister has

undertaken we now have ten acute care beds which is two in addition to the

prevailing demand that we found, and we have a fifteen bed Alzheimer unit, which

can take people out of the hospital and put them into an appropriate setting or

people out of the home and put them in an appropriate setting for their

condition. By closing five acute care beds at Bonavista Hospital and opening

more long-term care beds, in this case a particular wing, services on the

Bonavista Peninsula have been enhanced and not downgraded.

There is no point in me coming to the table and

saying: My God, the Government is ripping the guts out of the health care system

because five acute care beds have closed on the Bonavista Peninsula, or indeed

360 or whatever the number is all around the Province, because if you looked at

the 1986 bed study that is exactly what is happening. There is a misallocation

of resources which has been allowed to go on under the former administration who

did not have the political will to act, did not have the political will to

rationalize the system, and what we are doing now is not necessarily a downgrade

in service but may enhance the delivery of health care to people around the

Province. I would just like to comment on that.

MR. CHAIRMAN: After that very, very good question,

I would ask the Minister to make it short.

MR. DECKER: Okay. The Member is absolutely

correct. Acute care beds are only a small portion of the overall health delivery

system, you deliver the system as the Member pointed out.

What did the royal commission suggest about the number

of acute care beds that we should have in this Province? The royal commission

recommended that we should have 2198 beds by now, this year. How many do we have

this year? We have 2,191. So, we need seven more beds to meet the recommendation

of the royal commission on acute care beds. But as the hon. Member points out

health care is not just an acute care bed in a hospital, there is a (inaudible).

MR. CHAIRMAN: Thank you, Mr. Minister.

Ms. Verge.

MS. VERGE: I would like to come back to western

Newfoundland where people generally are seeing and experiencing -

MR. DECKER: I cannot hear the hon. Member.

MS. VERGE: I am coming back to western

Newfoundland where many citizens are complaining about what they see as a

deterioration in the quality of hospital services through the combination of

closure and downgrading of the smaller hospitals and clinics in Burgeo, Port aux

Basques, Deer Lake, Norris Point and Bay Verte, placing many more demands on the

central facility at Corner Brook when at the same time the regional hospital in

Corner Brook has been cut to the point of having to close thirty acute care beds

and lay off about seventy people including seven staff in lab and X ray.

Among the negative outfalls that are immediately

apparent are the delays that I talked about in diagnostic services, with people

havin