June 1, 1993

SOCIAL SERVICES ESTIMATES COMMITTEE

Pursuant to Standing Order 87 Mr. Nick Careen,

M.H.A. (Placentia) substitutes for Mr. Glenn Tobin, M.H.A. (Burin-Placentia

West)

The Committee met at 7:00 p.m. in the House of

Assembly.

MR. CHAIRMAN (Gilbert): Order, please!

Ladies and Gentlemen, I would like at this time to

welcome the minister and his officials from the Department of Health. Tonight we

are going to examine the estimates of his department. I will give him a chance

in a few minutes to introduce his officials and then have his opening remarks.

Just before we start I want to talk about the

procedures and how this committee operates. After the minister makes his opening

remarks, Ms. Verge will be given an equal time of fifteen minutes to address the

remarks made by the minister. Each participant will be given ten minutes to

question the minister or his officials.

I will ask the members of the committee now to

identify themselves starting with Ms. Verge, the vice-chairman who is next to

me.

MS. VERGE: Thank you, Lynn Verge, MHA, Humber

East.

MR. LANGDON: Fortune - Hermitage.

MR. SMITH: Port au Port.

MR. SULLIVAN: Loyola Sullivan, I am sitting in

as health critic.

MS. YOUNG: Kay Young member for Terra Nova.

MR. GILBERT: I am David Gilbert. I am the

Member for Burgeo - Bay d'Espoir and I am the chairman of this committee.

There are three hours allotted for this committee

to pass the heads through the House and what we try to do is get the work done

in the three hours that is allotted. If it is going to go over the three hour

period and we feel that we can reasonably get the heads passed tonight - I will

stop the session at about 10:00 p.m. or thereabout and then get the agreement of

the committee to see what they want to do.

So, with that I will now ask you, Mr. Minister, if

you would introduce your officials. Then you can have your opening remarks or

you can pass it to the opposition critic, the decision is yours.

I would ask participants to identify themselves

each time they speak as this session is being recorded and will be published by

Hansard.

DR. KITCHEN: Thank you very much, Mr. Chairman,

I am Hubert Kitchen presently Minister of Health. To my right is Dr. Bob

Williams who is the Deputy Minister of Health. To his right is Ms. Primrose

Bishop, who is the Assistant Deputy Minister of Health, responsible for all the

institutions; the hospitals, the nursing homes and personal care homes. She

plays the biggest

part in the Budget. To my left is Ms. Joan Dawe, she is

responsible for community care and I believe the Waterford comes under this

also. This is the one hospital that does not come under Ms. Bishop. Behind me,

to my right is assistant deputy minister, Chris Hart, who looks after the

finances and keeps his eye on the internal audit in the department, this is a

new position we created recently. Behind him is, Mr. Gerry White, who is

assistant deputy minister, he looks after policy, drug programs and a whole

variety of things in the department which we will come to later.

I would like to say, by way of opening, and I will

not speak long, that the Department of Health has a very substantial budget from

the point of view of the overall budget - over $800 million, close to $900

million a year, which is a very large sum of money - and like all Departments of

Health in the Canadian provinces, it occupies about 25 per cent of the total

budget - somewhere around there. Every year we think we do not have enough when

other people think we have too much.

We are looking very much at the cost of health care

in Canada because it is one of the big drivers of deficits. Health care

expenditures over the past number of years have been going up quite rapidly and

there is considerable concern about what may happen.

So what we are attempting to do in the Department

of Health is perhaps to redirect. What I have been doing myself is to try to

formulate some vision as to where we might want to go, and for the past ten

months since I have been here, nine months or so - nine months is better, a good

time for incubating some ideas - we have been trying to get a handle on what the

health care system is like. We visited the nursing homes and the hospitals, and

talked with the boards, and met with many organizations, because every disease

in health has its own organization pretty well. Every disease has it's own

organization and they are operating in different ways - pretty well every

disease. Then there are all sorts of other groups and agencies that are

interacting, so I have been trying to get a handle on the health care system so

that an approach can be devised, an overall vision, as to where we might want to

go.

As far as I am concerned, there are certain ways we

must go, and that is that we must take the emphasis off the institutions where

we have been placing it. We have been very much preoccupied with curing the sick

rather than keeping people from becoming sick. I think that is the direction in

which we would like to go. We do not want to neglect people who are sick by any

means, but that is one of the directions in which we are going and we will be

attempting to put some money into that area without hurting the care of the

sick.

In this prevention thing, we have seen our

initiatives in the smoking area, and we will have other initiatives in that area

as well. That will be coming up before long, because smoking is a killer disease

and I do not want to repeat my remarks here which I made yesterday. Then we have

to look at the question of alcohol, which causes all sorts of health problems,

and we have to look at the question of improper diet, lack of exercise, and

things of that nature, so that we can keep our population as healthy as long as

we possibly can.

Also we would need early diagnosis. That is another

point that we have to focus on, I think. I may be a bit out here because these

are just tentative thoughts on this. I was impressed when I met with the

Diabetic Association the other night. They told me that half the diabetics in

Canada are not diagnosed, and they should be, they said. Whether they can be, I

do not know, but that is what they said. I am also impressed with other people

who find out late in life that they have certain things wrong with them. So

there has to be prevention and there has to be early diagnosis so that diseases

and conditions can be treated before they get too far advanced. I believe that

will be the thrust of the department while I am here. That is what it seems like

now.

As far as hospitals are concerned, I believe we

have twenty-five hospital boards - I think something in that vicinity, something

like twenty-five hospital boards. We have had a report from a very competent

health care consultant, Ms. Lucy Dobbin, and she has told us how we should

reorganize the hospital board system. We will, as soon as we get a chance now

when the House clues up a bit, get at that.

The way we are going to go about that is to try to

have discussions with the existing boards to see how many of them can be

amalgamated and put together so they can have a good philosophy, a good way of

handling things in their general area, so that we can have fewer boards and less

competition, less turf protection within them. There has been a fair amount of

turf protection amongst hospitals and it seems, in my view, that in some cases,

the hospitals are there to try to have jobs in the area rather than,

necessarily, to have health care. And health care has to be the primary

responsibility. Similarly, with respect to the nursing homes, we have a

tremendous number of nursing homes and boards in the Province, most of whom

cater to people who are quite sick. But there are a lot of people in nursing

homes who are not very sick, and the cost of operating a nursing home is quite

heavy. So, what we are trying to do there is to institute community health

boards; and we have the legislation - it went through the House last Spring -

and we have certain things in mind, but again, that is another thing that we

will have to get at just as soon as we can now when the House closes, another

Summer job. We are thinking about it.

So we will be establishing community health boards

that will be able to provide home care in a more comprehensive fashion than it

presently exists in most parts of the Province. We have fairly good home care

programs in some parts of the Province but not in all, so what we want to do is

to have a more elaborate system of home care, so that not quite as many people

will have to go to nursing homes. Nursing homes are a very expensive proposition

- home care need not be expensive. So, these are directions for the future, and

that seems to be where we are headed.

We are also concerned about the high cost, in my

view, of Medicare, the high cost of physicians' salaries, and we have been able

to bring in a system and an agreement with the Newfoundland Medical Association

by which, in exchange for a cap, they get a floor, in a deal in which we spend

so much on physicians' salaries - and there are certain ways to adjust that, but

that really helps us. They are pegged to management salaries, if management gets

a raise, the amount is increased, if management gets a decrease, then the pot is

decreased. There are a few other little wrinkles in that, which we will go into

if anyone wishes. So we have some control over that. But physicians are driving

the health care system, to a large extent, and they are key there.

Another thing we are trying to do there is through

the Joint Management Committee that we have established between the Department

of Health and the Newfoundland Medical Association. We have a Joint Management

Committee which is responsible for managing this money and for doing other

things, and there is a committee there - I don't know where the peer review is

at the moment, but it is either started or is about to start - a regular process

by which what physicians do is reviewed by other physicians, so that people who

do things that are out of order can be discussed and addressed so that the

system is not overused. Because, one of the big problems we have in health care,

some people say, is the abuse or overuse of the system. Some people are saying

we should bring in user fees to control that.

It is my view that we should not bring in user fees

unless it is absolutely necessary, because there are other ways, such as I have

just suggested, through physicians reviewing physicians, and also for people

taking responsibility for their own health. That is extremely important and I

believe that these community health boards, when they have, and maybe they will

have subcommittees and so on in various areas in communities, that would go a

long way, whereby communities and individuals assume responsibility for their

own health rather than leave it to physicians or other health care staff.

Mr. Chairman, I think these are the directions in

which we are going and I would like, if you would - you may not want to do this,

but I would certainly appreciate your questions being directed against that

direction, to see if these things are appropriate and whether our budget is in

conformity with these points. With that, I will pass.

MR. CHAIRMAN: Thank you, Mr. Minister.

Before I recognize Ms. Verge, I would like to

welcome Mr. Careen, the Member for Placentia, the other member of this Committee

who just joined us. I would like to point out that Jack Harris, the Member for

St. John's East, is also a member of this Committee. He came to me this

afternoon and pointed out that he had another commitment and, by virtue of the

fact that his caucus is rather small, he didn't have anyone to appoint like the

rest of us, so he said he would be attending later.

I have talked to Ms. Verge before the meeting

opened and we agreed that, with the leave of the Committee, if there is a list

of speakers when Mr. Harris comes in, we will let him go ahead when the last

speaker, after he arrives, is finished, so at least he will have a chance to get

his ten minutes in sometime in the early part of the night - if that is alright?

SOME HON. MEMBERS: Agreed.

MR. CHAIRMAN: Okay.

Ms. Verge.

MS. VERGE: I would like to thank the minister

for his opening remarks in talking about his ideas for the general direction in

which the health care system should be aiming. He anticipated my first question.

I was going to ask just that, the same as I asked his predecessor here last

year. I am pleased to hear what he had to say, but the Budget Estimates that the

government has put forward, that we are examining, do not conform to those aims.

The Estimates indicate a forecasted total spending by the Department of Health

of $874 million, more than any other department of the government.

We realize that our friend, the Minister of Finance

and President of Treasury Board, is going to reduce that total significantly if

he achieves his objective of cutting total spending by $71 million, by taking

that out of public sector compensation. Most of the health budget goes for

salaries and $71 million from all public sector employees will have a serious

impact on workers in the health care system.

We have $874 million before us. The bulk of that is

forecasted to be spent, once again, on institutions - $604 million - MCP, $135

million; drugs, $35 million. Community health, which encompasses the only

specific efforts at promoting good health and preventing illness, gets only a

pittance - $26 million, or 3 per cent of the total. That percentage is no better

than what was provided in last year's Budget.

I realize the challenge is formidable, because our

Newfoundland and Labrador health care system, the same as the model in other

parts of Canada and most of the Western world, is physician-dominated,

physician-driven. Yesterday, in the House, I said to the minister, in debate

about his bill to prohibit and limit smoking in public places and workplaces,

that it is not he and his officials, much as they might want to, who really

control our health care system. It is not the highly-paid administrators in the

institutions who control the bulk of the spending - it is the physicians. The

physicians control almost all of the spending of the $874 million or whatever

the revised total ends up being. Physicians basically provide limitless services

to patients, provide referrals for limitless tests and other diagnostic

procedures, and provide limitless invasive procedures, if that is the jargon.

MCP, the Medical Care Plan, gives physicians a

monopoly for most services, a monopoly for publicly-funded services. Legislation

gives them, I suppose, a monopoly.

I would like to ask the minister whether he would

expand his horizons to entertain or to contemplate a vision of public funding

for services given by other health care professionals. These comprise, for

example, nurses, midwives, nutritionists, fitness consultants, physiotherapists,

chiropractors - any of the whole range of health care professionals who can

provide many of the services for which physicians now have a monopoly, arguably

better, depending on the service and the training of the professional, and at

considerably lower cost.

DR. KITCHEN: Thank you very much for that

question.

This is something that we, in the department, have

been discussing, I guess fairly frequently, as cases come up. Because

individuals ask: Why can't I see the chiropractor? I can see him, but I have to

pay for it. Why doesn't Medicare cover it? Why, if I have pyorrhea of the gums,

can't the dentist take out my teeth without charging me? That is really a

medical condition. The doctor doesn't really take out teeth anymore. So these

are interesting points.

I don't quite know how to handle it at this stage,

because Medicare, as conceived, is for physicians rather than for chiropractors

and dentists and so on. It is something we are going to have to come to grips

with, I think, because these other health care professionals do have something

to offer. I don't quite know how to go about it at this stage but I think, as

you say, it is something we have to address. We will be addressing it, but it

will take a while, I think. I have to try to figure out how to go about it.

Some provinces do cover these services, but it is

difficult in these times to expand our Medicare budget with the finances we

have. I agree that it is something we are going to have to address somehow. It

shouldn't just be additive, it should almost be a zero sum in the sense that if

the midwifes are going to do it, if anyone wants a midwife to deliver a baby,

then perhaps the obstetrician shouldn't also take a fee. I am not sure how that

works. We can't just add to it. If the physician is going to take out the teeth

or we are going to cover that through these services, with a limited pot someone

else will have to give it up. It is certainly something that has to be

addressed. I agree with you there.

MS. VERGE: When we were considering the

chiropractic legislation regulating the practice of chiropractors, there was a

debate about whether the act should provide, as it does now, that physicians

refer patients for hospital diagnostic services after chiropractors first make a

request for such tests. Chiropractors were arguing, I think with justification,

that they are in a position to know when X rays and lab tests are required. By

making patients go to physicians puts patients through unnecessary inconvenience

and is putting an unnecessary imposition on the taxpayers. That is the kind of

duplication that the minister was just saying is undesirable.

I am wondering if the minister would consider

amending the chiropractic legislation to eliminate the necessity of physician

referral for diagnostic services, X rays and lab tests, that chiropractors want.

DR. KITCHEN: It is a worrisome point. We all

trust physicians to know; this is the culture that we have grown up in. If we

have a referral - I don't know who is the best able to determine what kind of

service is required. Is it the patient himself: I think I will see a

chiropractor, I will see a doctor or I will see a midwife. I am not sure. I am

not debating it, I am just discussing it, as you are. Perhaps we will have to

look at that whole question as to how referrals are made to other professionals.

Should the family physician be the referral point or should the person with the

complaint make the decision as to who is to be seen? Should I see a chiropractor

for my - whatever? Do I make that decision myself and spend government money, or

do I see the physician who says: Well, you should see a midwife or you should

see this person or you should see that person. I am not sure how that goes, but

it is certainly something to be contemplated.

Dr. Williams, would you like to add something to

that?

DR. WILLIAMS: Chiropractors can't have X rays

directly ordered, they have to go through physicians.

DR. KITCHEN: Dr. Williams tells me that

chiropractors can order X rays directly without going through -

MS. VERGE: You see, when a patient goes to a

chiropractor and the chiropractor examines a patient and asks for X rays or lab

tests to do a complete diagnosis, the patient then has to go to a physician

simply to get a referral to a hospital to get the X ray, which in turn gets sent

back to the chiropractor with whom the patient wanted to deal with in the first

place.

DR. KITCHEN: Dr. Williams, do you want to take

that? Because you may have some...

DR. WILLIAMS: Under the proposed regulations

chiropractors will be able to have x-ray equipment in their offices, or can

access hospitals and out-patient departments for x-ray services.

MS. VERGE: Directly.

DR. WILLIAMS: Yes.

MS. VERGE: Oh good, okay.

DR. WILLIAMS: Without having to go through

physicians. So they can order that. The chiropractor will be able to order that

on behalf of his or her patient directly.

MS. VERGE: Are those regulations in place now?

DR. WILLIAMS: Those regulations are just in the

final stages, I guess.

MS. VERGE: Okay. Many people say that our

health care system is in a crisis, that the cost of providing services with the

model we have has outstripped the growth of the economy in Canada. Whether

people like the system or not, whether people think we're getting good value for

the investment, we have no choice but to change it. So far governments have

tinkered with it and lopped off certain parts but haven't really tackled the

much more difficult job of reforming the model.

This government has tinkered with and cut certain

institutions and agencies and must be now grappling with the ever-increasing

fiscal difficulties. Has the government done a cost benefit analysis of the

Memorial University Faculty of Medicine? This Budget calls for the government

providing $18 million to the Faculty of Medicine. Are we getting $18 million

worth of benefits for that investment? What are we getting as taxpayers in

Newfoundland and Labrador from the Memorial University school of medicine?

DR. KITCHEN: I guess what we're getting from

the Faculty of Medicine are several things. Fifty-six medical students enter

each year and approximately the same number graduate each year. So we're getting

a flow through of physicians.

MS. VERGE: I might interject, where are the

graduates ending up?

DR. KITCHEN: I'm not sure where they're all

ending up. Some are ending up in Newfoundland and some are going abroad, but

that's one aspect only. I think too that we are able to attract physicians to

this Province and to this city largely because of a good medical school, a good

medical school where people can do research and can meet with top-flight

colleagues. It is a situation that is much to be preferred, particularly since

we're so far away from the main centres of Canada and the United States. Without

a medical school people would be practising medicine remote from these areas.

But the medical school does have a continuing education function of physicians

and an interaction with the community that I believe would be sorely missed.

I believe a number of different types of

specialists are attracted to this Province because of the medical school and the

fact that they can take time to be associated with the medical school and

practice part of their time and be on salary with the medical school, that is

the argument that is raised, that in addition to the training of physicians.

There are all the other things that a medical school can do that otherwise

wouldn't be done. Even though the supply of physicians is not as desperate as it

was some years ago, far from it, yet in any thought of cluing up the medical

school you have to think of all these other benefits that would be lost as well

- and it is expensive.

MS. VERGE: The community health boards, where

are they?

MR. CHAIRMAN: Your time is up.

MS. VERGE: Okay, I will come back later.

MR. CHAIRMAN: Mr. Sullivan.

MR. SULLIVAN: Thank you.

I guess I will probably just start where Ms. Verge

left off. With reference to the medical school, New Brunswick also has students

going there. Are the charges back to New Brunswick on a per capita cost of the

total cost of the budget of operating the school, or are certain established

capital costs factored in and just operational costs factored back to New

Brunswick?

DR. KITCHEN: In answer to that question, there

is an arrangement with New Brunswick by which New Brunswick has, I think, ten or

so people ever year in the facility, and they pay a figure to the government. I

think it is $14,000 or $15,000 a year.

AN HON. MEMBER: It is $14,500.

DR. KITCHEN: It is $14,500 which, if you take

the average cost of the medical school you divide the $18 million by the 220

people who are there, you will get a figure far in excess of $14,000 or $15,000.

That was a question that I had written down myself

to find the answer to, and I will probably ask Dr. Williams in a minute to see

if this - because it looks to me that if we divide a couple of hundred into $18

million -

MR. SULLIVAN: $80,000 per year.

DR. KITCHEN: - we are getting $80,000 per

person - not $14,000 or $15,000; even if you subtract the other services that

the medical school provides to Newfoundland but not to New Brunswick. The main

function of the medical school, or one of the main functions, is the training,

it is certainly not cost recovery.

I also point out that we have arrangements with New

Brunswick for the training of other professionals, and I suspect that the cost

that they charge to us is less than the average cost.

I do not know, Dr. Williams, if you have something

to add to that, or if some of the other members of the staff could address that

question as to whether we are charging New Brunswick enough is basically the

question, is it not?

MR. SULLIVAN: Maybe if I just put it this way.

I understand you said there are fifty-six students per year taken into medical

school, and that is really a cost per student to go through about $320,000 per

student, or $80,000 per year, of which we are recovering roughly $14,000 per

student. So really it is less than that. It is about 17 or 18 per cent really of

the total cost of sending them there.

I guess students go to New Brunswick, possibly to

law school, and have a similar arrangement and so on, but I guess the cost of

medical school, too, is a fairly costly venture. It is something to be looked

at, whether our cost recovery is sufficient in light of the demands on our

health care system over all. I think it is something that needs to be looked at.

I know there are other spin-off benefits and

overlapping things, but I would assume the figure here is what specifically

applies to Memorial University Faculty of Medicine as it relates to the hospital

there. I am sure other hospital costs are picked up at other aspects here in the

budget too, so I would assume that this is portioned out specifically as it

pertains to the Faculty of Medicine. Would that be correct?

DR. WILLIAMS: The background to this figure is

based upon the Maritime Provinces Higher Education Commission. That is an

organization of the Maritime Provinces which provides for the funding of various

programs in the different universities, and there is a formula based upon

certain disciplines. For instance, Newfoundland purchases seats at Dalhousie

School of Health Professions in occupational therapy and physiotherapy, speech

language pathology, and we pay according to that formula. The formula that the

medical school reimbursement is based on is based on that formula as well.

We have attempted to have some discussions with New

Brunswick very recently on the matter of the $14,500 that we get. When I say it

is based upon that amount, we would like to see if we can increase that amount

above that area. Given the situation that New Brunswick has arrangements with

Laval for training their French speaking physicians, and Dalhousie for training

downsizing in Canada, and there is an excess capacity, I guess we are concerned

that if we push too hard we would have to balance off losing half-a-million

dollars worth of revenue in terms of New Brunswick pulling out, so we have to

watch that. Right now, though, the amount we are getting is based upon a formula

that is consistent across Atlantic Canada in terms of other health professions.

For example, if some Nova Scotia students enrolled in the Department of Forestry

at UNB, there is a certain formula that applies for those seats as well. So, it

is based upon that and the agreement we have with Dalhousie University for

training people in health professions which we do not have at Memorial is based

on that formula as well.

MR. SULLIVAN: Have you looked basically at the

cost of delivering that service at Dalhousie for certain areas and the

percentage of that we are paying? Are you saying the same percentage applies or

the same basic formula or are there specific formulas for each specific field of

study?

DR. WILLIAMS: That is right. There is a

specific base amount and then there is a multiple factor applied depending on

the type of system that somebody is in. If they are in forestry, it is the base

multiplied by x. If it is in medicine, it is the base multiplied by another

factor. It is greater for medicine than in the other disciplines. We are paying,

I think, about $6,000 a year for instance at Dalhousie for our seats in

occupational therapy. So it is based upon a formula and this formula of 14,000

is fairly consistent. However, we try to have some discussions to get it up but

our concern is that if we push too hard we may lose the whole $500,000 worth of

funding which will be a significant amount of funding.

MR. SULLIVAN: Yes, I know, I can see the

concern there. It is probably costlier to train a person in a medical field than

any other field so I guess that gives some impetus for trying to get a higher

base amount before you apply your factors. I guess another area related to the

medical school overall - Dr. Kitchen was not aware basically, he indicated that

he is not sure, he does not have any figures on how many of these doctors might

be staying here and continuing in service here in the Province. So, I am

wondering if the department has done any tracking recently over the past few

years to see exactly if we are training doctors to practice elsewhere and how

many of these graduates, over the past let us say four years, have stayed here

in the Province? Has the department taken any steps to follow that through and

see if it is money that we are using in training that is sort of lost forever?

DR. WILLIAMS: There was a study done a few

years ago where medical school graduates of Memorial were tracked to see where

they stayed and, in terms of comparing ourselves with other medical schools in

Canada, Memorial graduates were consistent where they went with other schools in

terms of the number that stayed in Atlantic Canada or the number that stayed in

their home province. I do not have any specific data that I can give you tonight

but we can get some data for you which will give you an indication of how well

we fare in retaining graduates from Memorial. As well, we have fifty-six

students, ten come from the Province of New Brunswick so we would expect those

ten to return to New Brunswick in order to give the school less of a parochial

flavour because usually there are about six students taken in from other parts

of Canada. So, there are forty Newfoundlanders who go to medical school.

Sometimes as well we see that a lot of graduates, about 50 per cent, go into

speciality training, so they will not reappear back in the Province until about

five or six years after their training. You will have to give us a chance to get

it but we will get it specifically for you, the number of graduates who are now

in the Province who are graduates from Memorial University and where they are.

MR. SULLIVAN: Okay, thank you, that would

certainly put a focus on where we are heading in the future. Are we spending our

dollars wisely down the road? It can give us a little bit of insight.

The next area which I want to touch on, in the

process now, Lucy Dobbin's report: she is recommending seven hospital boards at

the moment and possibly five down the road, recommendations in two of these

areas, like Central combining into one and so on. I am wondering of the

structure to be put in place from a cost point of view. Those boards or the

officers there: is there remuneration there and what type of structure where

they are serving a larger area now, will it be built into the system, extra

related administration costs, salary and otherwise that probably were not there

with the smaller boards in more regionalized areas?

DR. KITCHEN: As far as the cost is concerned,

we anticipate that there will be an overall saving in the administration costs

because of the efficiencies of scale, particularly in things like handling

accounting and payrolls and things like that which can be handled by a large

organization as efficiently as, or perhaps more efficiently than having it done

by twenty-five hospital boards and an equal number of nursing homes, and so by

combining these there should be substantial savings in administrative costs,

even though we may have to pay some individuals slightly more.

MR. CHAIRMAN: Ms. Young.

MS. YOUNG: Thank you, Mr. Chairman.

I would like to ask the hon. minister a few

questions. But first I want to comment on my privilege as having served on the G

B Cross Memorial Hospital foundation in Clarenville. It was indeed a wonderful

experience and then moving on to the hospital board. I am very proud of the way

that hospital was run and a lot of credit goes to the administrative staff

there, who certainly stayed as well in budget as possible without reducing

services to any great extent, and from the people in that area I have heard a

lot of praise, not only for the staff but for the facilities as well, and they

are very pleased with the hospital.

With regard to Medicare, I wonder if users have any

idea of the cost of services, and if at the end of a visit to the hospital a

user could see a statement showing the expenses that were incurred, if they

could see something like that, I am sure it would give them a greater

appreciation of the cost of services. I imagine that it would be very costly to

do that but it would be quite a shocker I am sure; when I found out just how

much it cost for one x-ray, I was quite surprised.

I live in rural Newfoundland and I am very

interested in hearing more about the home health care services, because often

the transition from the rural family home to an urban centre is quite a

traumatic experience, so I am sure a lot of our seniors would be very interested

in the home health care.

DR. KITCHEN: A few points - one has to do with

the bills. I believe it is Alberta, one province used to, or attempted to -

AN HON. MEMBER: BC.

DR. KITCHEN: BC as well?

AN HON. MEMBER: Yes.

DR. KITCHEN: - attempted to send, not so much a

bill marked paid to every person in the Province, just to indicate how much they

had used the health care system, but just to build up an awareness. I do not

know if someone here can tell us if that is still going on or if they have

stopped doing it for cost reasons -

AN HON. MEMBER: They stopped doing it, I

understand.

DR. KITCHEN: - they stopped doing it, in BC?

AN HON. MEMBER: Yes, I think Alberta did it as

well.

DR. KITCHEN: Alberta stopped it as well, but it

sounds like an interesting idea. Maybe we can do it in a different way, even if

we send everybody the average cost - divide our $870 million by 500,000 and

said, here is your paid bill, your average cost was whatever it was. Now you

mentioned the point about the home care, and I think that is an extremely

important point. Some people who go into institutions find it very disruptive,

at least for a while, and some people do not last long after they go in these

institutions, perhaps because they are quite sick but also maybe because of

their being away from everything that they have ever had in their life, from

their family and their neighbourhood, friends and everything like that, so I

think it is just reacting as one person to another rather than from any study

that has been done.

I do not know if any studies have been done or if

anyone here has any information to give as to how effective home care is. Do

people who get home care, as opposed to similar people who go into institutions,

live longer? Are they happier? It's hard to say. You're suggesting, and I

believe I'm agreeing, that they probably would be better. Right now in many

parts of the Province that choice is not really there. I think that's fair to

say. So do you know, Doctor Williams, if there's any study been done about

comparing people who go into institutions as to people who have adequate home

care? Or Ms. Bishop?

DR. WILLIAMS: I'm not aware of any studies that

have been done to give any indication to longevity versus home care versus care

in an institution. I think there's a quality of life factor there, that people,

a certain element of people, would like to stay as close to their friends and

family as they can for as long as they can. We know I think too that

psychological, emotional factors play a major

part in people's health care.

There's lots of information and things that we don't know about people's health

that would link their health into psychological factors and factors that are not

purely physical in nature. I would expect that somebody who is at at peace, home

with their family, and in comfortable surroundings, psychologically would

certainly be better off. I presume that would have an impact on their health,

but I don't know of any study that's been done to say they live longer in home

care. My intuitive feeling would be that there's certainly a benefit in that.

MS. YOUNG: There is also the factor as to

whether I guess the family unit is really prepared to keep the elderly person at

home.

Back to the cost of services: I'm just wondering

even if we ran it in our local papers as to just how much it costs for an x-ray

and some of the things that we just take for granted when we go to hospital, I

think it would certainly be an eye-opener. I'd certainly like to suggest that.

Thank you, that's all I have for now.

MR. CHAIRMAN: Mr. Smith.

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

Minister, a number of questions. Unfortunately I neglected to bring my copy of

the MCP annual report which you tabled in the House just a couple of days ago.

I'm just trying to recall from my memory, on the report the reference to the

salaries for this past year. I know every year when this report comes out that

the media certainly make for that, and that's a pretty popular page. I guess it

gets pretty dogeared after the first few days. I guess falling into that trap

that was the first thing I looked at when I received my copy of the report and

read with interest - I don't recall the exact figures - but just a couple of

things with regards to it.

First of all, in terms of the salaries being

reported, I'm sure somewhere along the way that there's some sort of a

comparison being made as well in terms of trying to cost factor our health

services generally. How do the salaries that we're paying in this Province

compare with the rest of the country?

DR. KITCHEN: I'll ask Dr. Williams to give you

more detail on that. I understand that they're somewhat below what they are in

places like Ontario, but they may be comparable to other areas. Dr. Williams,

you probably have better figures than that.

DR. WILLIAMS: Incomes, these are fees for

service incomes we're talking about, would be a product of the fee

schedule and

the number of services provided. The fee

schedule in the Province when we've

tracked it over some time, aside from the Province of Quebec, where it's

difficult to get comparisons with their fee schedule, usually the fee

schedule

for physicians in Newfoundland is down. Prince Edward Island, New Brunswick and

Newfoundland are in a group in the bottom one-third. Newfoundland can be

anywhere, of the nine other provinces, from seventh to ninth. We're usually in

that ball park, in that figure. Fee schedules in places like British Columbia

have been as much as 40 per cent higher than the Province. Ontario is usually

about 25 per cent higher. That's where we've been historically over the past ten

years.

In terms of physicians' incomes, two years ago when

a global cap budget was introduced for medical care the medical physicians

themselves proposed a proration factor be placed on high earners. That's been in

place for the past two years. General practitioners whose gross incomes - we're

talking about gross incomes here - exceed $300,000, for the next amount they

would get two-thirds of the fee schedule, and after $350,000 they would only get

to keep one-third of their income. For specialists I think its $400,000 and

$450,000. They get to keep everything up to $400,000. From $400,000 to $450,000

they get to keep two-thirds, and after that it's one-third.

Like I say, that was introduced by the Medicare

Commission and government after discussions with the Medical Association, but at

their request. There are a number of other provinces as well now which have

implemented a proration mechanism for high earners.

There's also of the Medicare budget, of the

approximately $130 million or so, there's about $26 million or $27 million for

salaried physicians in the Province. They make up, I guess, if you look at the

cottage hospital system, the vestige of the cottage hospital system, if you go

back to the '30s and '40s, most physicians in rural Newfoundland were on salary

and that system is still in place today. One would find that the majority of

general practitioners in rural Newfoundland would be paid a salary out of the

$26 million. Again, our salary scales, although compared to members of the

general public are fairly high, when you relate them to members of the general

public, in comparison with salaries for physicians in other provinces I think

we're at the lower end as well. Salary range starting off in the rural practice

setting, is around $67,000, I think. Close to that range.

MR. SMITH: Each year that these figures are

released there's always - and I'm sure Dr. Kitchen with his background in

statistics always certainly looks at the range of these salaries. I'm always

struck by the extremes. How do you account for the range itself? I'm thinking of

the range of the salaries. Especially at the upper level. There's usually at

least one GP who's up into the $500,000 bracket. How do you account for that

now?

DR. WILLIAMS: One can account for it. It

depends on where the GP is and what kind of a practice that GP has. I know some

cases where there is an explanation for that. Whether there's a satisfactory

explanation I guess that's in the mind of the - you know, when we talk about it.

As well, there's a fairly extensive auditing

program done, as you may have heard in the media, by MCP over the past four or

five years. They've strengthened their audit program very significantly. They

have a consultants committee in place. That's a committee of MCP composed of

physicians, and I think there's an accountant on it and some auditors on it.

They advise MCP on physicians' profiles and this type of thing. They have a

fairly aggressive auditing campaign which I think has seen some changes in some

of the profiles and some of the utilization patterns both by physicians and

patients.

MR. SMITH: As a layman, and trying not to sound

too cynical, when I see some of these figures I sometimes wonder, in terms of

the fee per service on the average, how one individual could maintain a level of

good health care seeing the number of patients that would be required in order

to put him up into that kind of income bracket. That is just a statement; I

don't want you to respond to that.

I was very pleased, Mr. Minister, to hear you state

in the House, and again this evening, the reference to keeping people well as

opposed to curing the sick. I think that's certainly in line with current

thinking. I think now there are so many publications that I've seen in the last

number of years coming out on wellness in the workplace and things of that

nature. It's now becoming a fairly popular theme. People are recognizing that

there are so many factors that contribute to a person's maintaining their

wellness. It's important for employers and for everyone to be concerned about

that and to try to ensure - especially in the workplace - that factors are in

place that they contribute to them. I am just wondering - I would imagine there

are quite a few employees within your department - is there a policy or a

program with regard to wellness in the workplace, or have you discussed that or

are there things in place, other practice that you are doing? Because I know,

for example, some of the schools are doing it now. My own school board where I

just came from, we embarked on that this past year. It was preceded by a survey

that is available through the federal Department of Health, and following up on

that, as a matter of fact, our school board retained a person with a primary

responsibility for that, and the idea is that you recognize in the factors,

concerns that people have in trying to put the supports in place to keep them

content and contributing to their wellness. I am just wondering, within your own

department, has there been any discussions with regard to that or, indeed, there

may be something already in place?

DR. KITCHEN: There is a Wellness Centre in this

building and we were over there the other day.

MR. SMITH: I will need to find that out,

because I think before too long I probably will be in need of it.

DR. KITCHEN: There are bicycles over there,

stationary bicycles with people peddling away with fancy uniforms on, like you

would, you know. I don't know how long it has been in effect and I don't know

what proportion of the staff of the Department of Health participate, but a fair

number I would think. I don't believe we hire any assistant deputy ministers, if

they smoke, for example.

SOME HON. MEMBERS: Hear, hear!

MR. SMITH: Where is the Wellness Centre

located?

DR. KITCHEN: It is in the new building, below

the Department of Municipal and Provincial Affairs, or where it used to be. It

is a great place, lots of room over there.

MR. SMITH: Are members of the House welcome or

is it just for employees of government?

AN HON. MEMBER: Anybody, anybody.

MR. SMITH: Anyone, okay. MHAs allowed in?

DR. KITCHEN: It is not well used by MHAs.

MR. SMITH: I think it is important, just

following up - I have been pleased to hear you state within the last two or

three days, I mean, you referenced that. There is a need for a change in our

mind-set, I think, and especially, it is refreshing coming from your department

- that I think we have to get away from it. I guess, it really hits home in

times of restraint, when you have limited resources, that certainly there are

steps you can undertake to improve the general overall health of our people and

certainly, down the road, there is going to be a tremendous saving. I think one

would logically predict that there would be a tremendous saving on delivery of

our health care services as there would be less demands on them.

MR. CHAIRMAN: Thank you, Mr. Smith. I recognize

Ms. Verge.

MS. VERGE: Thank you.

When I was cut off there a while ago, I was just

getting into asking about the community boards. Last year, and I have Hansard

here as evidence, the previous minister and the ADM responsible, have the

circled graph showing the responsibilities intended for regional community

health boards and we were told there would be five regional boards covering the

whole Province, four on the Island, and that the first would be the Western

regional board, which would be in place and providing services last fall. Of

course, none of that has happened, we don't even see the circled graph anymore.

What is happening?

The legislation was very disappointing. In the

middle of the night during that marathon sitting, I proposed amendments which I

thought would have made the legislation much better, preferable for a Minister

of Health voicing the objectives that this minister has spoken. Is the

government going to set up regional community health boards for the whole

Province? What responsibilities will they have, what will be the boundaries of

each of the regions and where will each board be headquartered? Will the

minister provide for the public election of all or some of the regional

community health boards? - since he talks about wanting to foster individual

initiative - and, just where is this now?

DR. KITCHEN: Thanks very much for raising that

question. I am under constant pressure from my left here to get those boards

appointed, and I have been - I wouldn't say, dragging my heels, because we want

to put the boards in place in appropriate fashion, and I don't want to do

anything in too hurried a fashion and find myself, after they are in place,

wishing to dickens we had done something different and had different people in

it.

Since that time, we have been doing more than

thinking. We will be setting up those boards soon. Since we talked, something

has happened to me. I have seen what happened down on the Southern Shore, and if

we set up a regional board which is very large, encompasses a very large

territory, with ten or fifteen people on it, what happens to a smaller component

of that board as far as the responsibilities are concerned? That is something

that has come to mind recently. It is obvious that we are going to have to have

a regional type of representation, but if you just have one person on a board

that encompasses all of St. John's and a large part of this peninsula, will that

be able to get the public participation in each of the various areas that a

number of smaller boards do? Maybe what we have to do is set up the overall

board and, at the same time, make provisions for other committees to be

operating and feeding in to another person. That thinking, in my mind - and I

have not really had an opportunity to discuss it. That is why I have deferred it

until the House closes so that we can get a chance to think about these points.

I don't want to rush in and do things under great pressure, because we may make

mistakes. We build institutions sometimes - when people come to government and

say, I have to have it in the district, I have to build this, I have to build

that, and suddenly it is there and you realize it shouldn't have been there, and

that is frightening. So, I am really not putting off, the decision has been

made. We are going to have regional community health boards but we want to put

the mechanism in place appropriately.

The other problem I have is, How many professionals

should be on those boards? What should the composition be? Should it be

professional health people or should it be basically citizens of the community,

who take responsibility? I think these are questions and the proper mix is

important to be thought of. There is no trouble for me tomorrow morning to

appoint four boards, just to name them up. We know lots of people in all parts

of the community. Traditionally, these people have been suggested by other

members of the House, and there is nothing wrong with members of the House

having input into it, but it has to be, I think, broader than that. Now, whether

they should be publicly elected, I don't know - maybe. I am not sure about that,

because usually where they have public election of board members, you usually

have some financial responsibilities, as they do in Western Canada, where the

health boards traditionally have had taxing powers. We don't have that in this

Province, so, I don't know about that part of it.

MS. VERGE: One of the large hospitals in the

Province, Western Memorial Regional, by provincial legislation, has some of its

members chosen by public election and that has worked very well. Some of the

members on the board are appointed by the Cabinet. I think one is appointed by

the City of Corner Brook but others are elected, and this has been done at

public meetings called for the purpose. So, there is a precedent in this

Province for public election of hospital board members.

DR. KITCHEN: Some of the members of the

hospital board?

MS. VERGE: Yes.

DR. KITCHEN: Yes, that is the sort of thing

that I think we should get into without delaying too much. I don't propose to

delay this procedure because we need the community care - that is the point.

MS. VERGE: Yes.

DR. KITCHEN: And maybe we will put the boards

in place the best way we can and tidy them up later if we have to, but we need

the community care. I won't put a date on it but it is the first thing we are

going to do now, as soon as we get the decks cleared.

MS. VERGE: Okay. I had a checklist of

questions. My first question was: Is the government going to do it and will

there be boards covering the whole Province? I think I heard a yes to the first

question. Will there be boards covering the whole Province?

DR. KITCHEN: Yes, I think - that is the plan,

anyway. The reason I am hesitating about that, we have Grenfell up there which

presently does it for the North, and it is not a board, as such.

AN HON. MEMBER: It does all of the institution

DR. KITCHEN: I have some concerns about that

model, personally. It has been proposed by another board, too, to have it all

lumped together, the home care and the hospitals all run by one board. I am not

sure, because that tends to be dominated by the health care professionals. I

don't think that the experiment which took place in Ferryland would have been as

successful if we had it dominated by health care professionals. I am not sure

about that. That is something we should think about. We should talk about it

sometime.

MS. VERGE: Are you thinking about roughly five,

as stated by the previous minister?

DR. KITCHEN: That is something that is worth

thinking about - four plus Grenfell.

MS. VERGE: Okay, four for the Island -

DR. KITCHEN: Yes.

MS. VERGE: - other than the St. Anthony area,

is that it?

DR. KITCHEN: Yes, and Labrador, but there are

questions about that, too.

MS. VERGE: Where will each Island regional

board be headquartered or based?

DR. KITCHEN: I hadn't thought about that. I

don't know. I suppose it will be - I do not know, traditionally, I suppose, one

on the West Coast, maybe in Corner Brook, and one in Central Newfoundland,

probably in Gander or Grand Falls - that is a hard one to solve at this stage of

the game. One in Central - I am sure Ms. Young would love to have that in

Clarenville, but I don't know. These are questions. We haven't worked that out

yet.

MS. VERGE: You could put the Eastern one in

Clarenville and then St. John's in St. John's.

DR. KITCHEN: Each member can get one. How about

that?

MS. VERGE: Okay, great.

What about responsibilities? Is that circle graph

dead? Do you have a new graph or chart?

DR. KITCHEN: Oh, we still look at the graph.

MS. VERGE: Chart, I should say.

DR. KITCHEN: Whatever it is, yes, the

intersecting circles.

The basic reason we are putting them in place is to

look after home care - single point of entry for home care. That is the main

reason. And while we are at it, we might as well put in the public health units

because they have certain home care responsibilities, as well. So that is

important.

MS. VERGE: What about all that great stuff you

were talking about in terms of education -

DR. KITCHEN: Yes, the other things are there,

too, (inaudible) health.

MS. VERGE: - and eliminating smoking, and

getting people to eat better and exercise more.

DR. KITCHEN: Yes, sure.

MS. VERGE: And sleep adequately -

DR. KITCHEN: And do all these great things.

MS. VERGE: - do all those good things.

DR. KITCHEN: Yes, that will be a

responsibility, to some extent, for carrying out the policies.

MS. VERGE: What about family planning, birth

control, information, education -

DR. KITCHEN: The sort of thing that the public

health nurses do now, that would be part of it. Whatever public health nurses do

now, that would be passed over to that, and the medical officers of health would

be part of that, as well.

MS. VERGE: Two quick questions: The original

intention, or stated intention, of the government was to place responsibility

for the former Alcohol and Drug Dependency Commission, which has been disbanded,

under the regional community health boards. Is that still the intention?

DR. KITCHEN: It is the same thing. That is one

of those circles.

MS. VERGE: One of those circles.

DR. KITCHEN: Yes.

MS. VERGE: And what about mental health

services? That was another circle.

DR. KITCHEN: Yes, the same thing.

MS. VERGE: So you are committed to the circles.

DR. KITCHEN: Pretty well committed to doing -

MS. VERGE: Any alteration, or the same circles?

DR. KITCHEN: Well, I haven't thought about

changing the circles, so they will be much the same.

MR. CHAIRMAN: Thank you, Ms. Verge.

MS. VERGE: Thank you.

DR. KITCHEN: There may be six circles, or

seven.

MR. CHAIRMAN: Mr. Langdon.

MR. LANGDON: I want to go back to the

institution versus the community-based program and talk about mind-sets and so

on. I think, over the past, that the mind-set for a lot of the population,

especially seniors, is: I am sixty-five years of age. I can leave my house, and

seniors' cottages, here I come.

I am wondering, in the number of seniors' places

that we have, in the health care units and so on, has there been any assessment

done of the numbers of people who are in the seniors' homes who could be looked

after properly and just as well in home care, that would then alleviate the

problem you have with Level III people who are out there in the homes, where the

home care that is there cannot adequately care for them. I was wondering if you

had done anything along those lines.

DR. KITCHEN: Well, part of the problem with a

number of the institutions, the nursing homes, some of them are equipped to

handle Level III care and higher. Some are equipped for that, but some are not.

A number of institutions can handle some Level III care, but the way they are

configured inside, the way they were built years ago, is such that the doors are

too narrow for wheelchairs, the bathrooms are not appropriate and the beds can't

be effectively turned in the rooms. They are almost like hotel rooms rather than

hospital rooms. So there have to be some major renovations done to a number of

these homes.

We are renovating the Bonavista one this year.

Other major renovations that will have to occur, I think, are: There is one in

Lewisporte that needs renovation; one in Corner Brook that needs renovation;

and, I think, the Interfaith Home needs renovation.

AN HON. MEMBER: Brookfield.

DR. KITCHEN: Brookfield, yes, Bonnews Lodge. We

are working on that now too, I might add. We are putting some money into that

this year.

AN HON. MEMBER: Blue Crest.

DR. KITCHEN: Blue Crest. There are a whole slew

of them that, in order to accommodate high level care, will need more

renovation.

I don't know if there are people who are Level I or

Level I and a bit who are in nursing home rooms that can accommodate Level III

people. That is an interesting point. I don't know. I am concerned with the

number of not-too-sick people who are in nursing homes. Even now people are

entering nursing homes. If they can't get in one way, they will marry a resident

and move in. That has happened too. They really don't need to be in a nursing

home, in my opinion.

MR. LANGDON: Further on that point, has there

been any research done or any figures compiled to show what it would cost to

keep a person in a nursing home, even at Level I or Level II nursing home care?

I mean, we are looking at a number of dollars, as has already been said by Lynn

and Loyola as well. As you know, dollars are scarce. We are operating on an $800

million budget and so on. We can never seem to get enough dollars for it.

Have you done any comparison on home care versus

the institution?

DR. KITCHEN: I am going to ask Ms. Bishop to

comment on that, but first I would like to say that there is an intermediate

institution called a personal care home where usually twenty people are in a

sort of nice personal atmosphere run by somebody who looks after people. The

cost to government is very minimal really because the old age pension and a

supplement can pretty well take care of the cost, or almost all of it, except

for security that we put there. That is a much more cost-efficient way and

probably a better way because the people are in smaller groups and so on than

they would be in a nursing home.

Now, I don't know - Ms Bishop can probably tell me:

Do we pay nursing homes differentially? In others words, if someone has Level I

residents and also some Level III residents, does that nursing home get more

money for the Level III residents from government than they do for the Level I

residents and that kind of thing?

MS. BISHOP: Persons who are admitted to nursing

homes, we now assess them and only those that require Level III care are being

admitted, except in homes where the physical design is such that it is not

conducive to caring for a high-level care patient. We do charge people a per

diem rate, but we review the budgets and the budgets are set based on what the

staffing requirements are to care for the number of people who are in that

nursing home.

For example, if we have a 100-bed nursing home and

there is a physical unit in that home which is not appropriate to care for high

level care - as I say, there are not bathrooms where you can get wheelchairs in,

the doorways are too narrow for wheelchairs to go in - we could only admit lower

level of persons to these homes. Consequently, our staffing level for that unit

would be much less than it would be for another 20 or 30-bed home where all the

people require a high level of care. So we do not provide the funding based on a

per diem, so much per person at Level I and so much per person at Level II, we

look at the overall needs and convert that to what the bottom line figure is to

run the nursing home.

MR. LANGDON: I'm wondering again, if, with all

the difficulty that we have with the health care problems in the Province - I'm

thinking of Labrador and the Island as well - if in certain areas, like in the

past, there might be overcapacity, where in others there is under capacity. I

think of the South Coast and I think of the Bay d'Espoir area where Dave serves

and my area in Harbour Breton. We have no facilities for Level 111. Then, on the

Burin Peninsula, you have one at St. Lawrence and one at Grand Bank, and so on.

I'm wondering if you can probably comment on that. Probably there is

overcapacity in some areas, under capacity in others. Would you like to comment

on that?

DR. KITCHEN: Just a comment and I'll then pass

it along for further comment by others. As I understand it, we have sufficient

capacity in the Province to take care of - we have something over 3,000 nursing

home beds, which is certainly an appropriate number for all hands. The question

is, the problem is of location. It's something like the school buildings too.

Lots of school buildings but they're not always where the people are. As people

move and family patterns change, and so on. There's no doubt that there is a

problem.

Another point though is, what is the appropriate

size of a nursing home? Is it ten or fifteen or twenty? Or is fifty or 100? If

you have a certain level you can employ staff that can bring in recreational

programs. You can have a physiotherapist or an occupational therapist. If you

have a very small nursing home it may be difficult to employ staff in that

manner. You may have to make some adjustments in staff. I don't know if it makes

it impossible, because it's possible to share staff with other institutions, I'm

sure, and have them visit. I'm not sure if that's a valid argument, but it does

require different staffing arrangements to run a small nursing home than it does

to run a larger one. These things have to be taken into account.

There's no doubt I think - and I'm subject to

correction here, and people should correct me if I'm wrong - that where the

nursing homes are is not necessarily where the people who need nursing care are.

Would you care to comment on that, Ms. Bishop?

MS. BISHOP: Dr. Kitchen is correct. We have a

formula that we use for nursing home beds within the Province. This formula and

standard is very much one that's used in other provinces. That standard is forty

beds per 1,000 for populations of sixty-five and over. When you take into

consideration that we now, with the 1991 Census, have fifty-nine seniors in the

Province, if you multiply that by that factor, we need 2,360 long-term care beds

in this Province. In fact, we have just over 3,000 beds, when you look at what's

in nursing homes, health centres, and designated long-term care beds in acute

care facilities.

Similarly, we have a formula for personal care

homes, which are homes for people who need social housing, which is thirty per

1,000 for those over sixty-five. So that would give you a much less number. We

have the capacity for nursing homes in the Province for over 1,300 personal care

home beds. As Dr. Kitchen has said, they're not always in the right place, and

that's a problem that we're having to deal with.

I'm also amazed that with that large number that

our waiting lists are quite long. However, in the past year or so - and we've

been looking at the single point of entry for people going into nursing homes -

the waiting lists have been purged somewhat, and the numbers are really, when

you look at them very closely, much less. Because what has been happening in the

past, is that if somebody wanted to get into a nursing home they made out say

five applications, so we have been counting people maybe as much as five times.

So the numbers who are really waiting are much less than it appears.

Once we get the regional boards in place - the

regional community health boards - and we get into moving into a single point of

entry for persons going into these nursing homes throughout the Province, I am

sure that we will see that our list of people waiting for nursing homes will be

somewhat lessened. Also, too, we will have a much better handle on those people

who can be cared for in a home type environment.

Right now what is happening is that many seniors -

the family unit as we knew it some fifteen to twenty years ago has changed

considerably.

MR. CHAIRMAN: Thank you, Ms. Bishop. Your time

is up.

MS. BISHOP: Thank you.

MR. CHAIRMAN: Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman.

One of the questions I had noted and probably has

been somewhat answered did deal with the situation of care for the senior

citizens homes and looking after the seniors.

One of the things that I had noted here as a

question, and I think Ms. Bishop addressed that, dealt with the waiting lists,

because I know in my area of the Province I had a personal experience within the

past year. My mother is a resident in the senior citizen's home in Stephenville

Crossing and became a resident October past, so I have gone through the process

and had some experience.

Overall, you were quoting some figures, but in

regions of the Province it appears - at least from the figures that I have - in

that area of the Province there certainly seems to be - or at least, the figures

that were given to me by the officials at the institution was that the waiting

list was fairly extensive. And in my understanding I was informed when I first

went there that it could be up to one year. Is that fairly standard?

MS. BISHOP: The waiting list, as you say, does

vary from region to region. Some waiting lists are not long but beds only become

available when residents do die in nursing homes. So the waiting time is also a

factor of the turnover of the number of people in that nursing home. It could be

up to a year or a two year wait.

MR. SMITH: Okay, thank you. Just for my

information: From the estimates, page 255, Item 2.2.02. Community Based Services

refers to the Canada Assistance Plan. Talks about services that are cost-shared

under the Canada Assistance Plan. What is the Canada Assistance Plan? Just for

the information of someone who is completely ignorant to this process.

DR. KITCHEN: What was your question again?

MR. SMITH: The Canada Assistance Plan, just

what exactly is it. It makes reference to the cost-shared under the Canada

Assistance Plan.

DR. KITCHEN: Can you answer that, Ms. Dawe?

MS. DAWE: Yes, thank you. That's the federal

program which is cost-shared with the Province for home support services. Not

requiring home care, which are considered professional or nursing services, but

support in the home. Homemaker type of services. So a person who is eligible for

services under the Canada Assistance Program would be eligible - the Province

then is eligible for cost-shared arrangements. Up to 50 per cent of the funding

for that service will actually come from the federal government.

MR. SMITH: Okay. So that would be 50-50 -

MS. DAWE: Yes.

MR. SMITH: Okay.

MS. DAWE: Up to 50-50, depending on the level

of service that's provided.

MR. SMITH: Okay. Thank you very much. One of

the other things that I was a bit curious about is with regards to the

recruitment of medical doctors for rural areas. I know in the area of the

Province where I live, in Lourdes, a little community on the Port au Port

Peninsula, we have over the years experienced some great difficulty in first of

all recruiting doctors, and certainly in keeping them in that area. It appears

that many of them in recent years who have come - very few of them are home

grown. Most of them are doctors from outside of the country who it would appear

are using a placement in a rural setting just to go through the waiting period

until they get their landed immigrant status or whatever it is they require to

move on elsewhere. They're in a holding pattern. There's really no commitment to

the area. When they come they see it as kind of just a stop along the way.

That's not their destination.

I don't say it to be critical of the doctors. We've

had some tremendous individuals. The gentleman we have there now seems to be a

superior doctor and is certainly providing a top level of care. The only thing

is, it strikes me that - and it kind of ties in, I had noted it when I was doing

this, it's been referenced, when I look at the amount of money that we're

spending on our medical school. I recall when that debate was ongoing years ago,

and one of the things at that time, we were talking about the medical school for

the Province. It was, and one of the strong arguments was, that we would be able

to redress this recurrent problem in the rural areas in getting doctors. If you

get locals in and train them that maybe they would stay and they would provide

us with that consistency that we need in these areas but it would appear that

that certainly has not happened. I am just wondering for example, in terms of

where the department is with regards to this thinking that, is this the problem

overall in terms of recruitment of people to the rural areas and if so are there

any plans in place to try to deal with this?

DR. KITCHEN: There are a number of points that

could be made here and I will ask Dr. Williams to fill in the blanks, to fill in

the gaps that I will create. We have to be careful, as you say, a number of the

foreign positions, where people came from foreign countries, really made a

tremendous contribution in rural areas. Some have not but many have and some are

still there, we agree, and we are very glad that they are there. Sometimes the

home grown variety takes off to the mainland and says: to hell with you Jack,

thanks very much for my medical education.

Some hospital boards have deals made with medical

students and they give them some money while they are at the University and they

go and work for so many years with that hospital board. Another thing that has

happened very recently in Canada, is that there is a surplus of medical school

places. As a result of that, because doctors cannot be placed, there is really a

surplus of physicians in Canada right now and because of this the physicians, as

we quite properly pointed out, are driving the health care system. In some

provinces now, if you practice in the city, the fees that you get are just a

fraction of the regular fee schedule. I believe in Ontario now, if you practice

in Toronto it will be 25 per cent or 30 per cent of the fee

schedule that you

would get if you practised in a rural area. We are expecting that there will be

a great influx of Canadian doctors into Newfoundland. In fact the doctors in

Newfoundland are a bit nervous about this great influx. So I do not know, this

may very well be at an end but there are procedures and have been procedures in

place to attract and hold local doctors and doctors from abroad. Perhaps Dr.

Williams you can elaborate on those procedures because I am not too sure of the

details.

DR. WILLIAMS: The problem you allude to is a

very real problem in this Province. It is a similar problem that they have in

other provinces in rural parts of Canada. There are no easy solutions. Other

provinces have been grappling with it in a variety of ways. Newfoundland is

dependent in many parts, I guess in rural Newfoundland, on foreign trained

physicians. Someone who has come and stayed for a year or less, some who have

stayed for quite a while, it has been variable.

In terms of some of our urban centres such as; St.

John's, Corner Brook, Grand Falls, Gander, Clarenville and Carbonear, to that

extent, we have seen some major changes over the years. Most physicians in

primary care in those centres now are Canadian trained graduates of the Province

or other physicians who have been here for a number of years and are fully

licensed but we still have a problem in rural Newfoundland.

We have with the University a financial assistance

program whereby students in their second, third and fourth year of medical

school are eligible for financial assistance in return for a return in service

commitment. Bursary programs that the Province previously ran years ago, where

the agreement was between the Department of Health and the physician - the

agreements in the future are now going to be with the local hospital board,

health care agency and the physician. So that there is a commitment on behalf of

both parties; one to have a placement and two, the physician to go back to that

area. We are hoping that as they go through their medical training they will

bind with that particular local health care board and identify with that local

health care board. It will be much more difficult for them to break a contract

than it is with the Department of Health who is not involved in the direct

delivery of services.

Another area that has been ongoing for a number of

years is what we call the Med. Quest Program which was funded to take place at

the medical school. They bring in potential physicians and other people who are

going into other health care careers, to the University for the Summer for a

week or two exposure to the various health care careers. They found that since

they started this program some three years ago, they are starting to see more

applicants from rural Newfoundland to medical school and hopefully that will

translate to more graduates from the local medical school from rural

Newfoundland and they are already seeing some of those things take place;

hopefully the bursary program will provide some inroads. As well, at the medical

school, they are starting to provide more training opportunities in rural

placements for medical school undergraduates, so that they will be able to get

some more of their training say for a month or so in a rural practice setting

and if they go into family practise residency, maybe up to six months of their

training will be taken in a rural practise setting hoping that they will latch

on to that option.

As well, with the medical association, we are now

putting in place a two-pronged approach. 1) We are developing a long-term

medical human resources plan that it is going to take about six or nine months

to develop to target where we need physicians for the next seven or eight years,

and the number of physicians we have in the Province in retirement ages and this

type of thing but in the short term, we are looking at trying to overcome a

problem of distribution that may be exacerbated if we have physicians coming to

the Province from other jurisdictions in Canada where the opportunities are less

in the urban areas than they used to be, and we do not want those physicians or

our own graduates to relocate in urban centres in the Province where we feel we

have enough primary care physicians.

MR. CHAIRMAN: Thank you, Dr. Williams. It is

now 8:30 and I think we should have a break and will reconvene at 8:45 and then

I will be asking Mr. Careen to start us off when we come back, so at this point,

I think everybody has had enough for the first session, don't you?

AN HON. MEMBER: Yes.

Recess

MR. CHAIRMAN: Well, welcome back everybody,

because we have a bit of work to do yet and I think we will get started and I

will now ask Mr. Careen if he would like to start.

MR. CAREEN: Thank you, Mr. Chairman.

Mr. Minister, I heard you earlier and my friend from

Port au Port talking about wellness and everything else, but I come from another

class, I come from a race of 'long livers with loose livers', but that is

another story. But the thing about it is, health, and whether it is the physical

or the mental well being, with poor old Newfoundland the way she is, no matter

whose watch it is, it is mental health. We have 20-odd thousand people on NCARP

and a number of these fisher types never slipped a line, but there are a good

many others who did go through all the phases during the year with deficiencies,

getting ready for one sort of fishery or another and now a lot of these people

are looking out the window or whatever. We have Social Services, our offices are

busy as any air terminal and Canadian statistics have shown that one or two in

every five Canadians see a psychiatrist once or twice during their lifetime, but

at least once.

Are there any statistics - are Newfoundlanders still

holding out, are they still on an even keel, or are they like lemmings running

for cliffs? Talking about mental health, a number of weeks ago - well the CBC is

always a negative crowd, I was disturbed to find out that they were talking

about the rate of suicides rising among the young in the Bonavista Area, so, I

am just trying to get a fix on it. Is there any great change in peoples' mental

health?

DR. KITCHEN: I have not heard of any great changes

in mental illness, whether it has increased greatly, but I do know that a number

of people are, as you indicated, worried about the tremendous changes in

people's lives as a result of no fish, and also the serious situation which has

confronted so many people who are currently on welfare. I am going to ask Ms.

Dawe, because she looks after the Waterford and also community health comes

under her, if she has noticed any great changes in the incidence of mental

illness or depression and things of that nature in recent months? I guess that

is what you are really asking.

MS. DAWE: Thank you, minister.

To respond directly to your question, we have no data

which demonstrates that there is a marked increase in suicide in particular.

Mental health service needs are great around the Province. I think that we would

all acknowledge that, and we are working within the community and the various

institutions to improve access to counselling services throughout the Province,

but this is not anything that has a marked increase over the last few months.

MR. CAREEN: Thank you.

The earlier regional boards, you were saying that you

were going at that earlier with Dobbin. Newfoundland is a great place for

rumours. If there is neither one by 10:00 a.m., someone is sure to make up one,

so I caught the tail end of it when I came in earlier. Did you say that you are

moving on it and you going to a more consultative type thing before you put

those regional boards in place, and there could be a mixture of odds and ends on

those boards, is it?

DR. KITCHEN: Well there are two kinds of boards.

There are the community health care boards which are basically looking after

home care and public health, and then there are the hospital boards. We have

twenty-five hospital boards now, some of whom look after nursing homes as well.

What we asked Ms. Dobbin to do was to see if we could

reduce the number of these boards for greater efficiency, and she produced a

plan whereby there would be seven, and then later on some fewer, regional

boards.

So the commitment that we have is that we would not

put any of these boards in place until we had appropriate consultation with the

people in the region, because even though she has made her recommendations,

there is still a lot left to be said. We are going to start in St. John's

because that is an area where perhaps considerable changes can take place. We

have six hospital boards in the city right now, and she has recommended one for

the city. Whether there will be one, two, three, we have not decided yet.

I have had some preliminary consultations with the

Chairs of all of these boards, but the election interfered, and now we have the

House, and I would just as soon leave it until the House clued up and we will

continue our discussions here. Then I think we are going to have discussions on

the West Coast. As I say, we have an interesting proposal before us, and then we

will gradually go through it, but there will be discussions.

In your own area, for example, the Placentia area,

there is some question from the people there as to where they want to go -

whether they want to be merged with eastern or whether they want to be merged

with St. John's, or whatever happens here. So there will be discussions so that

everybody will be able to say their piece and we will take into account very

seriously what people say.

MR. CAREEN: Thank you.

Another thing that arises from time to time and seems

to be getting more in the news every day, and it happens that every time there

is something new, the minister is constantly under the gun with AIDS -the money

that is allotted for treatment, the money that is allotted for whatever. I have

not seen the figures. You have all the figures that I need, but have you placed

any extra money in it this year than last year, with regard to AIDS patients - I

cannot say preventative because there are certain things that you cannot

prevent, but there are certain areas of the community - the AIDS community - is

there any extra money in it for those people this year?

DR. KITCHEN: The AIDS patients are taken care of

much the same as other patients, and we will get into what drugs are provided

and what drugs are not. I will ask people that in a minute, but I would like to

preface it briefly by saying that last Summer we set up an elaborate set of

committees to advise government as to how we should proceed with respect to care

and treatment of people who had AIDS, because we had been told that the care of

AIDS patients was not adequate. We asked that that be studied by a committee. We

had another committee looking at prevention and education, and another committee

looking at another aspect of it - treatment and so on - the actual way to treat

AIDS and so on, and HIV, as opposed to the care.

These three committees form part of a large overall

committee of roughly forty-five people composed of professionals, interested

citizens, people with AIDS and representatives of the AIDS committee. The report

of that committee landed on my desk a few days into the election. I've read it

and the report needs to be looked at very soon too. The problem with it is that

it's - in my view, I'm not putting it down - not very behavioural. It doesn't

say to me: do this, that and the other thing. It more or less says: set up a

committee to do this and set up a committee to do that. I want to look at it

very carefully so that we can....

The procedure is in place to take it. In answer to

your question, the specific question as to whether we put more money in the

Budget this year to look after people who are suffering with AIDS, I can't

answer that question. Dr. Williams, I don't know if you can add or we can ask

somebody else.

DR. WILLIAMS: Normally, people with AIDS or any

other disease are looked after in the health care system based upon their needs.

So if somebody has AIDS and is a patient at the General Hospital they would be

treated according to the needs and medical care that they required. I'm just

checking on the drug program, I'm getting somebody to check on the drugs, but my

understanding is that drugs that are specific for AIDS patients are funded. Most

of the AIDS patients - the two specialists who deal with patients who have AIDS

and obviously are sick - there are two infectious disease specialists at the

General Hospital who deal with most people who have that disease. My

understanding is that in the budget of the General drugs that are specific for

AIDS patients, specific to that diagnosis, are provided in the budget of the

General Hospital. But I'm having that checked now.

MR. CAREEN: That's all, Mr. Chairman.

MR. CHAIRMAN: Now, Mr. Sullivan.

MR. SULLIVAN: Okay. Thank you, Mr. Chairman. I was

asking the minister there earlier with reference to moving from twenty-five

hospital boards and moving into possibly seven and maybe five boards in the

future, as Lucy Dobbin reported in her report. I didn't intend my question to be

either economies, in terms of payrolls and other related costs, because you can

centralise and do payrolls without incurring any costs, without consolidating

boards.

The question I asked was: are there going to be any

paid board members? What's the cost of operating those boards from the board

perspective where they have a much larger degree of responsibility? We need

people skilled in the business aspect of the economics of operating these

boards, and we need people in the professional aspect to see that the services

are going to be rendered under a system that's I guess more streamlined, as

opposed to the boards for each individual hospital, how they currently exist.

Are there increased costs in those areas there? I'd like to know specifics on

that too. Assuming it's seven as the report says, or five. There shouldn't be a

big difference in administrative costs from five to seven, as opposed now to

twenty-five.

DR. KITCHEN: Yes. We hadn't intended paying board

members, that's the first part.

MR. SULLIVAN: You did not?

DR. KITCHEN: We had not intended to pay them, to

put them on a salary, or to remunerate them, although that might be considered,

I suppose, some nominal figure. It's meant to be a volunteer board supervising

professionals. I might add that some of the boards now administer quite heavy

budgets. For instance, I don't know what the budget of the General Hospital is

right now, it's something like $80 million. Some of the hospital boards are

relatively small at the moment. They don't administer very much, financially at

least. So merging some wouldn't, I think, alter too much a configuration there.

It may to some extent. I agree with you, that the responsibilities become more

impersonal than they did. We may very well require a different type of board

member, to some extent.

That brings up the whole question as to whether an

individual hospital or institution would still retain some sort of an advisory

committee. That has been brought to me as well. They say: we don't mind merging

into a larger system, but can we have an advisory committee here, and from that

advisory committee there may be a member put on the large board, so that we can

have some say, or some input into, and some association with the institution

that we now run. I can't see anything wrong with that kind of an arrangement,

really.

MR. SULLIVAN: No. I know there are certain

concerns, I guess, when you look at a total board and try to integrate and

operate boards with varying interests now, as they're currently structured. The

Waterford Hospital, for example, has a different type of, I guess, a mental

health interest to serve there as opposed to balancing economics. Sometimes it

comes to a decision of life-or-death versus mental health and sometimes we would

be very concerned that justice would get served in line with tax dollars that

are there.

I'm not going to pursue that too lengthily there. I'd

like to move on to another area there, especially in line with the whole, I

guess, philosophy of health care and the direction it's moving in the Province.

It seems like we're moving probably into an area where we may have five hospital

boards that possibly overlap geographically with five proposed community health

boards. That seems to be my perception of where it might be, or very close to

that overall.

The biggest concern too, I guess, would be people in

the community and getting them involved in community health care boards. It's

important to get the community pro-active and have the same developing and

changing, actually their lifestyles and improving health in the communities. I

had the opportunity for two years to chair a primary health care project in my

district, prior to being elected. I saw an increased focus by people in a small

geographical area getting involved and taking an interest in their own health

care. To get gobbled up by five larger community health boards, when they'll

lose that aspect of concern for their own specific health, which we're trying to

move today, and trying to get prevention in health matters, as opposed to the

curative and rehabilitative methods we've currently been following and in

carrying it on with increased emphasis.

I do have a concern that smaller, more localized areas

may not develop and advance into this area, because once we establish five

community health boards that cover large geographical areas it's very difficult

administratively to go out and try to set up other specific sub-boards. May be

something to keep in mind is that under each community health board there

probably should be sub-regional boards with representatives from each of these

sub-regional boards sitting on the regional board.

For example, in the primary health care area from St.

Shotts to Bay Bulls, for example, a representative sitting on the community

board for the Eastern or St. John's area or whatever the defined and designated

area is, because it's important that you move in the direction where we're going

to get local people just growing from the ground up. It can't grow at the top

and go down to the basics.

I've seen the effects over the past three years in my

area in terms of enhancing the lifestyles of people, taking a concern for their

health, whether it be smoking, people out exercising on a regular basis,

walking, those weigh-in clinics they have, taking health care out into the

community centres and people showing up on a regular basis. They're keeping

their own little checklists on their weight. There's been a change in overall

attitudes and a change in lifestyle developing there. I've a great concern with

funding - I know initially this Province committed I think $170,000 three years

ago to kick start this program here. I know it's been incorporated under the St.

John's and district health unit for the operation of that. I have a great

concern that it may lose its effect and autonomy, I suppose, a certain degree of

autonomy, for that specific area.

I certainly suggest to the minister that he consider

ensuring that these boards don't get too big administratively. That we don't get

appointees on these boards who have a different basic philosophy for health care

in the Province. We have to get a de-institutionalized attitude there. It's only

going to come with the community. Because people out in the community themselves

do have a great interest in health care. It's the cheapest and most efficient

method of saving us costs down the road in the long term.

I know Health and Welfare Canada and the

psychologists, through Dr. Ross, are doing an evaluation there. I'd also caution

the minister and the department too, that evaluation of this project cannot be

determined in the short term. It is a project that we have identified in that

area, and Ms. Dawe is certainly aware of, that areas that cardiovascular

problems and other health related things that impact, and you can only measure

the effects upon people's lives in the long term, so hopefully we will not be

too shortsighted to try to save short-term dollars at a very long-term cost that

we will never get out of this dilemma that we are in now where we have

spiralling health care costs.

We have to focus a fair share of our dollars that are

going to be spent in health out in these specific areas, and I have grave

concerns that these boards may work adversely to the specific direction that I

would like to see health care move in this Province.

I would certainly appreciate your comments on that,

and exactly what the department's feelings are.

DR. KITCHEN: I could not agree more. I agree

totally with what you said, these boards have to be grass-roots boards, the

people who are managing these boards have to be speaking for the people and

carrying the message back for the people, and there may have to be subcommittees

and things like that, because the whole purpose of community health care boards

is not institutional care, which is provided by the professional, it is

community health, which is provided partly by professionals but to a large

extent by the enthusiasm and involvement of members in the community.

I thank you for your remarks and concur completely

with them.

MR. CHAIRMAN: Ms. Young.

MS. YOUNG: I would like to pass my time at this

point to Mr. Harris.

MR. CHAIRMAN: You cannot pass it to Mr. Harris. We

have a list here. As much as I would like for you to be able to do that, Ms.

Verge is the next one to speak.

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: Yes, but he came to me and asked to

have his name put on. I told him where he was standing.

MS. VERGE: Ms. Young, would you like to have your

say now?

MS. YOUNG: No, that is okay. I will go after you.

MS. VERGE: Okay. I have three or four questions I

would like to ask, and I will try to do it quickly.

The Inter-Faith Home for Senior Citizens in Corner

Brook, to which the minister alluded earlier, when will the government be

altering that facility to convert it to properly provide high level - I think it

is called Level III - nursing care?

DR. KITCHEN: I cannot answer that question. It is

one of those that are being considered, but there are a number of others as

well. We have not worked out the priorities there. I do not think it will be

done immediately.

I think we have to look at the overall needs for

institutional care in the whole area, and we have not done that. Also we want to

look at the impact of appropriately applied home care, but there is no doubt

that that home, if it is to be a nursing home, is going to have to be altered. I

cannot say when. That depends on the budgeting, but it is on our list anyway.

MS. VERGE: Okay. It seems to me it was about three

years ago that the Department of Health budgeted for a feasibility study, or `a`

study, of the implications - the need, the cost and so on - of physically

altering that complex so that it could serve the needs of the growing number of

residents requiring nursing care - high level nursing care. Does the department

have -

DR. KITCHEN: Have any figures?

MS. VERGE: Have a report, study results, and if so

may I have a copy?

DR. KITCHEN: First of all, let us ask Ms. Bishop.

Do you know if we have a study done indicating how much it will cost to renovate

MS. VERGE: A study or a plan. Plan might be the

word.

DR. KITCHEN: Plan and so on, yes.

MS. BISHOP: There was a review done and the

planning was undertaken right to the design phase, and the cost was in the order

of about $7 million if I remember correctly.

MS. VERGE: May I have a copy of the report?

MS. BISHOP: The report is with the Inter-Faith

board right now.

MS. VERGE: Does the department not have a copy?

MS. BISHOP: We would have a copy on file - one

copy, yes.

DR. KITCHEN: Let me check into it.

MS. BISHOP: We will check it, yes.

MS. VERGE: Thanks. A photocopy would be fine for

me.

Is there a block amount of capital funding in these

estimates, out of which, possibly, an allotment may be made for the Corner Brook

Interfaith Home?

DR. KITCHEN: No, there is nothing in the estimates

this year for planning or for anything for the Corner Brook Interfaith Home.

There may be some minor adjustments that could be made - I think that is true.

We do have a very small amount of kitty there, which, I suppose, if the doors

blew off we could get it fixed or something like that but there is nothing for

renovations of the Corner Brook Interfaith Home; I think that is correct.

MS. VERGE: The next question has to do with

services for cancer patients outside the overpass and, in particular, in Western

Newfoundland. As the minister knows, people throughout Western Newfoundland were

very angry when the Cancer Outreach Clinic was cut back for seven months, from

September until the election, through the loss of radiation specialists. For

twenty years, radiation specialists, who had always, in this Province, been

resident in St. John's, visited outreach clinics in three other parts of the

Province on a regular basis. Those radiation specialist visits were suspended

for seven months. I don't know if they have been fully reinstated to the former

level - perhaps the minister can tell me. Have the Cancer Foundation radiation

specialist visits to the outreach clinics in Corner Brook, in Grand Falls and in

Burin been reinstated to the pre-September levels?

DR. KITCHEN: I will ask Dr. Williams to answer

that. I know that they have been reinstated, but whether it is to the level that

existed before or not, I am not sure. Dr. Williams can you answer that question?

DR. WILLIAMS: My understanding is that they have

been reinstated and the plan was to reinstate them at the former level. They

have a full compliment of radiation oncologists on staff now.

MS. VERGE: Is that six?

DR. WILLIAMS: No, there are radiation oncologists

and medical oncologists.

MS. VERGE: Okay.

DR. WILLIAMS: Both treat cancer but one does it by

radiation and the other by chemotherapy. The approved compliment is four

radiation oncologists and two medical oncologists. The Foundation is still

recruiting for medical oncologists.

MS. VERGE: Are the two medical oncologist

positions now vacant?

DR. WILLIAMS: Yes, they are vacant.

MS. VERGE: But the four radiation oncologist

positions are filled.

DR. WILLIAMS: The four radiation oncologist

positions are filled with another radiation oncologist coming in July, I

understand. There are a number of other positions called hematologist

oncologist, who deal with leukemias and lymphomas, with what we call the

non-solid tumours. But we are now looking for two - full compliment, would be

two medical oncologists. They are currently recruiting and have been recruiting

for awhile.

MS. VERGE: So you say the plan is to reinstate

services at the outreach clinics to the pre-September level. Has that plan been

implemented?

DR. WILLIAMS: They have already had clinics, I

understand, in Central Newfoundland and in Corner Brook. They are planning to

continue those clinics now that they are back up to four radiation oncologists.

MS. VERGE: Even with pre-September service, cancer

patients throughout the Province have to come to St. John's for many services,

for radiation therapy and for other services. These visits are costly for the

patients alone to travel back and forth. It is expensive for them to stay in St.

John's while they are getting radiation therapy. Often patients have to have six

weeks of therapy and that means staying in St. John's for that length of time.

Sometimes patients are not well enough to travel alone and a relative or friend

has to accompany them. All of this travel and accommodation away from home is

expensive. The Department of Health subsidy, first of all, is not widely known

about. Physicians, in some cases, either don't know or don't tell their

patients. Patients I have talked to have never been told about it. But even when

people discover it, when they figure it out, they find that the amount of

assistance is very low. It is only half of approved expenses above $500 a year.

Cancer patients, more than most users of our health care system, I think just

about everyone would agree, deserve to be assisted in every way, because they

have a hard enough time coping with their illness. Will the government provide

better levels of financial assistance to defray the cost of travel to St. John's

for necessary treatment which is not available to most cancer patients in the

Province in their home areas?

DR. KITCHEN: That is a good question and one that

we have been trying to come to grips with, too, not solely cancer patients, but

that is one group of people. As you said, the basic amount, anything over $500

that is spent in a year on transportation and accommodation and so on, is shared

50-50 and that comes to a fair amount for some people. We have a certain amount

in the Budget and we have been exploring recently ways in which we might be able

to help a bit more, because I agree with you, it is very harsh for people to

have to impoverish themselves to receive necessary medical treatment because of

transportation, and I believe it will always continue that way. It looks like

the radiation will have to occur in St. John's and only St. John's, because of

the extreme cost of this facility, and that means there have to be fair ways for

people from outside to handle it.

A similar situation occurs - I don't want to take up

too much of your time - having to do with drugs, too, where, people who have to

take high-priced drugs, like diabetics and others, also have to pay for these,

and they are outside the Medicare system. So there are certain unfair practices

in our health care system which I hope we can address shortly, although there is

no money for it in the Budget this year.

MS. VERGE: No. How much did the government spend

last year on this program and how much is budgeted for this year?

DR. KITCHEN: That is here, somewhere. I will try

to find that, ferret that one out for you.

MR. CHAIRMAN: The time has elapsed but, by leave,

can they get an answer to that question?

AN HON. MEMBER: Sure.

DR. KITCHEN: Okay, the answer is $350,000 in the

Budget, they tell me.

MR. CHAIRMAN: That is the answer.

MS. VERGE: How much was spent last year?

DR. KITCHEN: Last year, the amount of expenditure

was $350,000, that is the revised estimates, and that is what we have put in for

the Budget this year. In other words, we didn't change the formula, but if you

are suggesting we should change the formula, we probably should.

MR. CHAIRMAN: Thank you.

Mr. Harris.

MR. HARRIS: Thank you.

Mr. Minister, I have a number of specific questions

in, not necessarily related areas, but I will just go through them. First of

all, in the area of Health Policy and Planning, which appears in the Estimates

on page 252, I noticed that the appropriation for health policy has been

decreasing from a budgeted 1992-1993 of $152,000 to an actual of $120,000 for

that year, and an estimate for $106,000. And it strikes me, that in an area or a

time of great changes in the health care system, and the great need for revision

of policy and approach and to try to discover new ways, particularly in delivery

of health care and the new policy initiatives required to go along with that,

why are we having such a big appearance slide into almost nothingness, I

suppose, when you get down to - it looks like there are two salaries there or

perhaps one salary, I don't know, a very small amount of money directed towards

the area of Health Policy. On the other hand, in the next vote there is $924,000

in the area of Health Human Resources Planning having to do with the

availability of health human resources. I think at one time that used to be

called going over to Europe and looking for doctors, and maybe it still is, I

don't know.

Can you explain what these two areas are about and why

you have such a large amount of money for one and so little for the other?

DR. KITCHEN: Well, the reason the amount for

Health Policy has declined is that we had a lawyer employed there to help us

prepare Cabinet papers and things like that and to flesh out some regulations.

That was basically what he did. He has since gone on leave and we haven't filled

the position, because we think that is one saving we can have. We have left

there - I know the people's names but I don't know their titles. There are two

people there, one is a secretary and one is a health policy co-ordinator. That

is what that is. Everybody in the department is involved in policy, all the

deputy ministers, assistant deputy ministers and others, as well. So it would be

wrong to think that this is the only person who ever made any policy. He was

really just fleshing out regulations, I think, and helping us draft the acts.

There are people in Justice now who cover that for us.

DR. WILLIAMS: The technical aspects?

DR. KITCHEN: Yes, the technical aspect. Exactly.

Now, on the Health Human Resources Planning: There is

quite a large sum of money into Allowances and Assistance, $771,000. That is

basically what we pay institutions on the Mainland to train our

physiotherapists, occupational therapists and our speech pathologists, and some

bursaries that we give to the people who go away for these courses. They sign

deals to come back into the Province. That is basically what that is.

MR. HARRIS: I am going to ask my annual question -

I am sure the officials will be getting used to this by now - on the two areas

that I have been asking about. One is the use of nurse practitioners. I know we

have had the demonstration project ongoing now for a number of years. Perhaps we

are at the point of getting some results from that that might be useful in the

planning of changes in community health delivery. The other is in the area of

the use of midwives and the development of a policy for this Province. We do

have

an act, we do have legislation, but we do not have a board, and one hasn't

been appointed for many years. I believe Ontario has recently become the third

province to develop a policy on nurse midwives for participating in a formal and

recognized way in prenatal and delivery of babies, that type of care.

Could I receive a comment from the minister, or from

officials, on where these two issues are at the moment?

DR. KITCHEN: You asked about nurse practitioners

and midwives.

MR. HARRIS: Two separate issues now, nurse

practitioners - you understand.

DR. KITCHEN: I understand. I don't think there is

any move at the moment to replace obstetricians with midwives. I don't think

very many people would want that. At the same time, I believe the issue is under

study by the department and there should be a resolution to it. There is nobody

jumping up and down on that point.

MR. HARRIS: I say to the minister - perhaps I

should make it a little clearer - the initiative involving midwives and delivery

of babies has nothing to do with replacing obstetricians with nurse midwives. It

has to do with choices for women who are about to give birth. I had the same

difficulty with the previous minister whose immediate reaction to that

suggestion was that we thought we got rid of that years ago, and showed a

misunderstanding of the approach.

We do have an active group of nurse midwives. We have

a course put on at the school of nursing. We have a group of individuals who are

trained. Yet we do not have a "place" for them in the health care system except,

at the sufferance of individual doctors and individual hospitals, under certain

circumstances. I have been told in previous years that the department is

considering a policy change in this area, and I would just like to know whether

that has developed in any respect.

DR. KITCHEN: Somebody should probably tell me, to

what extent this has changed since last year, since the last time that question

was asked, basically. Have we moved, are we still studying or have we dropped

it?

DR WILLIAMS: We have a

fairly broad-bases committee looking at the whole issue of midwifery in the

Province. In the Province right now we have midwifery practiced in St. Anthony

at the Curtis Hospital. That is a co-operative program between the midwives and

the physicians. They physicians are in a supportive role and the midwives

provide some prenatal and some postnatal care, as well as delivery for

uncomplicated pregnancies. I think that is the program that is in place there.

We have, as I say, a broad-based committee that is

vice-chaired by a representative from the department, one of our nursing

consultants and a member of the provincial Prenatal Committee, looking at the

whole issue of midwifery in Canada, seeing what they are doing in other

provinces, looking at what is going on in the Province, looking at what the

policy options and issues are. We want to make sure, obviously, when we look at

that issue in some detail, that quality is assured to women who avail of that

service.

The committee has a timeframe; I think it is March,

1994, within which to report. They have been given a timeframe. I think they

started their work in February or so. We have an interim report in, but it is

not a report dealing with policy, it is just a report dealing with the current

situation in the Province and in Canada in general. It is a one-year project.

AN HON. MEMBER: Do you know the name of the

committee?

DR. WILLIAMS: I will get the precise name, but

certainly it is a committee on midwifery.

MR. HARRIS: Okay.

Let me ask about the vote for Drug Dependency

Treatment Centres, page 255. It see that there is an increase of about $100,000

over last year's budgeted amount, and a little more over the actual expenditure

providing for Humberwood and Talbot House.

Do these facilities provide treatment, residential

treatment, I guess is it mainly an alcohol-related program or is it for

additions other than alcohol, as well? What kind of numbers; how many

individuals can be accommodated at any one time in a facility?

DR. KITCHEN: I haven't been in the Humberwood

facility. I visited Talbot House and mostly that is a detox centre, as I

understand it. I don't believe there is any other drug treatment, but I ask Ms

Dawe or the appropriate person to comment on what goes on in Talbot House. I

believe Humberwood also basically deals with alcohol. Perhaps you would

straighten me out on that.

MS DAWE: Thank you, Minister.

The Humberwood facility is a ten-bed, in-patient

facility which provides the twenty-one day treatment for alcohol primarily. The

detox centre here in St. John's, Talbot House, has twenty-one beds for men and

women and is specific to detoxification.

MR. CHAIRMAN: Thank you, Mr. Harris. I now

recognize Mr. Sullivan.

MR. SULLIVAN: Thank you, Mr. Chairman.

I was wondering if we have any statistics. We talked

about MCP earlier, out Medical Care Plan, and we talked about the building and

the total cost paid out, of course, as in proportion to visits, etc. I am

wondering if the visitation rate is higher than in other provinces, the number

of visits per capita, if you wanted to put it in a nutshell.

Do people avail of the medical care service, visit

doctors more than people do in other provinces? That is basically my question.

DR. KITCHEN: Mr. Sullivan, I can't answer that

question directly. As far as I know, our rates of utilization are not higher

than other provinces. The one factor that we have in the province that other

provinces don't have, is the very large number of salaried practitioners we have

in Newfoundland, and we don't keep specific visits that people in rural

Newfoundland would make to a salaried physician because we don't need that

information for billing purposes, but our Province does not spend on inordinate

amount of money on physicians' services in contract to other provinces. I think

we are probably, the last time I saw, some years ago, at the lower end in terms

of payments to physicians.

MR. SULLIVAN: Okay, thank you.

With reference to page 251, line item: 1.2.01, under

General Administration, Executive Support, I see that there has been an increase

in salaries for executive support; the revised amount last year was $549,600 and

this year it is $572,700. Now, compared to 1991-1992, I guess that fiscal year,

it was $463,400. Was there any specific reason for the increase in Executive

Support an increase from last year and a substantial increase from the

previous year?

DR. KITCHEN: Thank you. The main reason for that,

is that we have hired Mr. Hart as an assistant deputy minister in charge of

finances and so on. We want to really strengthen that system. So that is his

salary and that of his secretary. I thought you might also comment on how much

the Minister's Office has gone down

MR. SULLIVAN: I wouldn't dare.

DR. KITCHEN: - and compliment me on my frugality.

MR. SULLIVAN: We are trying to save administrative

costs, I guess, in the Province and get more where it is really needed.

Earlier, there was a question asked and I missed the

number speaking quite low at the time so maybe I will just get back to a

specific question on Personal care Homes.

Was the figure used that we have 3,000 personal care

home beds in the Province?

DR. KITCHEN: No, nursing homes.

MR. SULLIVAN: Those are nursing homes, okay. I

thought you said personal care

DR. KITCHEN: I think there are 1,300 Personal Care

Homes or something like that. I think that is correct.

MR. SULLIVAN: Thirteen hundred personal care?

DR. WILLIAMS: Thirteen hundred and forty-six.

MR. SULLIVAN: Okay, and roughly 3,000 nursing home

beds in the Province, would that be correct?

DR. KITCHEN: Yes, and some of those nursing homes

those are chronic care beds; some of them would be in hospitals and some would

be in nursing homes. That is the chronic care component, I think.

MR. SULLIVAN: Did you say the need, the basic need

is 2,360? It that correct? Ms Bishop, you said 2,360 I think

MS BISHOP: Yes, Sir.

MR. SULLIVAN: - was the need, that we have a

surplus of nursing home beds, really, in the Province.

MS BISHOP: That is correct.

MR. SULLIVAN: Could someone give me the specific

figure on the cost involved with Personal Care Homes? I know, in Personal Care

Homes you cover security and other related costs, and certain costs are picked

up by the individual. What is the cost of keeping a person in a Personal Care

Home in this Province, when you factor in all departmental-related costs? On per

capita cost, I was wondering because I didn't have the number of people

utilizing them before; we had the total expenditure but not the number.

DR. KITCHEN: On page 264 of the Estimates, the

total vote for Personal Care Homes is $6.6 million and thenw ehave Revenue from

Federal Government, $3.2 million and $240,000 from the residents, I guess, so

that the net cost of Personal Care Homes is about $3,180,000.

MR. SULLIVAN: Yes, all I needed was I thought

you might have it at your fingertips but it can be worked out quite easily the

number of people availing of that and the total cost to keep a person in a

Personal Care Home; that is really what I needed.

DR. KITCHEN: It is very little, actually, it is

not?

MR. SULLIVAN: Parson me?

DR. KITCHEN: It is very little by comparison to

the other figures.

MR. SULLIVAN: Yes. And currently, is there a

waiting list on Personal Care Homes in the Province? Some Personal Care Homes

are not full, I know that, but there is a single entry, too. I think it is based

now and handled through the Department of Social Services, I believe. I know,

Social Services cases are

MS DAWE: The single entry system that we referred

to earlier is going to be developed through the community health board so that a

person requiring entrance to either a community-based services, a personal care

home, or a nursing home, will be accessed and assessed through that single entry

system. I think, what you may be referring to now, for the personal care homes,

is a service conducted by Ms Bishop's division, at the moment. When the

community health board is organized and in place, all entry to the system for

continuing care then will be through the one source.

MR. SULLIVAN: Yes. It is my understanding now that

if someone wishes to get into a personal care home and there is a vacancy in the

community; they must first go through departmental channels and be directed

naturally through there. Isn't that correct?

AN HON. MEMBER: (Inaudible).

MR. SULLIVAN: Also, in the nursing homes, too, it

is my understanding that, I guess, as of this past year or two, instead of each

of the nursing homes having their own individual waiting lists, there is now one

waiting list; like the homes here around the city St. Patrick's Mercy Homes

and those homes, too.

MS DAWE: I think we have developed in St. John's a

waiting list, tried to centralize the waiting list, in readiness for the

introduction of single entry for the whole system in St. John's. It is not fully

operational yet, because we are waiting for the St. John' Community Health Board

to be established. But the waiting lists have all been purged in readiness for

the single entry.

MR. SULLIVAN: Yes. But the board is not in place

MS DAWE: No.

MR. SULLIVAN: - and there is sort of a single

waiting list now, I understand. Each home is not operating its own respective

lists at the moment. Would that be correct?

MS DAWE: No, they are at the moment. They still

are operating their own.

MR. SULLIVAN: I have been informed differently, on

enquiring.

MS DAWE: I think what you may be advised it that

over the last year the nursing homes in St. John's have been working

collectively to get ready for the single entry system. We have a proposal just

received from them, collectively, in March past, to start the single entry

system. But

whereas the minister had announced in April, the St. John's

Community Health Board was going to be established, that we didn't move ahead

with any interim step. So I think that may be what they were referring to.

MR. SULLIVAN: Okay. So they are sort of at a

transition stage, basically

MR. DAWE: Yes.

MR. SULIVAN: - so it is not a complete flip over

when the time occurs.

MS DAWE: No. The organizations have been working,

as I said, for a year in the readiness for single entry.

MR. SULLIVAN: So it is possible that those

community health boards may not be in place over the next several months. Is

that possible, Minister?

DR. KITCHEN: I think several months may be a long

time, depending on how quickly the House closes. It is up to you.

MR. SULLIVAN: It is partly up to you, too, Mr.

Minister.

DR. KITCHEN: That is true.

MR. SULLIVAN: Another area in the Budget, too,

that I am very concerned w