April 19, 1994

SOCIAL SERVICES ESTIMATES COMMITTEE

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

Assembly.

MR. CHAIRMAN (D. Gilbert): Order, please!

I think we can now open this committee meeting.

There are a couple of little formalities we have to take care of first. I

believe the Clerk is supposed to conduct an election, or is that already done

from last year?

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: That's alright; we're alright,

are we? We're confirmed from last year, so I don't have to subject myself to a

vote today. I am very glad of that.

In that case, I will welcome the Minister of Health

and his officials to this meeting. The procedure for these Estimates Committee

Meetings is that the meeting will go on until 12:00 and if we feel that we can

get the heads closed at 12:00, or a short time thereafter, we will carry on for

a short time thereafter. If we feel that it's going to require more than ten or

fifteen minutes past the three hours, we will adjourn at 12:00 to meet again

another day.

Maybe for the sake of some of the officials I'll

introduce the Committee before I ask the minister to introduce his staff. I

point out that the Committee will introduce themselves, and then any members who

are here who are not on the Committee can introduce themselves.

The way that they are recognized is that I will

start off and the minister will have an opening statement. Then, as I

understand, Mr. Sullivan will be the critic and he is going to have ten minutes

- fifteen for the minister and ten for the critic - to respond, I think is the

way that it has been done. Then, it goes into a period and the member can use

the ten minutes to talk to the minister, or they can use the ten minutes in

between to question the minister and get the answer back, but that's the

procedure, is it?

AN HON. MEMBER: Ten minutes total.

MR. CHAIRMAN: Ten minutes total.

If the member wants to talk to the minister and

praise him up or whatever for ten minutes, that's fine, I am sure he will take

that; or if he wants to ask a question and then wait for a response, the ten

minute period will be in effect.

The members who are not members of the Committee,

the members of the House, are allowed to ask questions, but it is by leave of

the committee, as I understand it, is the way it has worked; is that not so?

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: Very good.

My name is David Gilbert; I am the MHA for Burgeo -

Bay d'Espoir, and I am Chairman of this committee.

MS. VERGE: Lynn Verge, MHA, Humber East.

MR. HARRIS: Jack Harris, MHA, St. John's East.

MR. LANGDON: Oliver Langdon, MHA, Fortune -

Hermitage.

MR. SMITH: Gerald Smith, MHA, Port au Port.

MR. SULLIVAN: Loyola Sullivan, and I am sitting

in as the Opposition health critic.

MR. HODDER: Harvey Hodder, MHA, Waterford -

Kenmount.

MR. CAREEN: Nick Careen, MHA, Placentia.

MS. YOUNG: Kay Young, MHA, Terra Nova.

MR. CHAIRMAN: Welcome, Mr. Minister. If you

would now introduce your officials, make your opening remarks, then we will get

on with the Estimates Committee which we hopefully can conclude this morning.

I would say for the members of your executive, that

if they are going to question, that they identify themselves first for the sake

of the people who are doing the copying up there. They recognize some of our

voices. Yours they might not recognize as readily.

Mr. Minister.

DR. KITCHEN: Thank you, Mr. Chairman.

Ladies and gentlemen, it is a privilege for us to

be here today and to be able to tell you all the wonderful things we have done

in the Department of Health and all the things we hope to do, and some of the

problems we have encountered and are encountering.

On my right is the Deputy Minister of Health, Dr.

Robert Williams. On his right is Ms. Joan Dawe, who is the assistant deputy

minister in charge of community health. On her right is Ms. Primrose Bishop, who

is the assistant deputy minister responsible for all institutions except the

Waterford, which comes under Ms. Dawe, and then the assistant deputy minister,

Gerald White, who is responsible for policy and just about everything else, odds

and ends.

AN HON. MEMBER: Policy and programs.

DR. KITCHEN: Policy and programs.

On the far right is Mr. John Downton, whose

responsibility has to do with drug programs; Mr. Chris Hart, who is the

Assistant Deputy Minister in charge of Finance and Administration and next to

him is Max Osmond who is the Director of Finance and Operations and then our new

member, just recently here, Mr. Denis Davis who is the Director of Ambulance and

Emergency Health Services which includes the (inaudible).

We are very pleased to be here and I would like to

set the stage for indicating some perspective as far as the departments are

concerned. Health is changing very rapidly everywhere and is certainly changing

rapidly in Newfoundland. We are putting a lot more emphasis than we have been in

the past on things like illness prevention, health promotion, early recognition

of diseases so we can do something about it and certain other points. Let me

have a few words about health promotion first.

We have launched as you know, our smoking campaign,

it was talked about a lot last year and that's going ahead fairly well, with the

new legislation to be implemented in June. We are concerned also about alcohol,

the ease with which alcohol is available in this Province, we recently had a

very private conference here we had seventy or eighty people gathered together

to try to get some new initiatives in this whole question of alcohol which

probably is more serious in this Province than is smoking even, because of the

tremendous social implications it has, virtually all crime in the Province is

related to alcohol, not all but almost all. The battering and the abuse and

things of that nature. a lot of it is health related; a lot of the reasons

people are in hospitals. Excessive alcohol exacerbates the problem so we want to

move into that but we haven't yet, not in a very great way.

We are also thinking, and we have had some

discussions about where we should go and putting a heavier focus on nutrition. I

think nutrition is very important in disease prevention and so this whole

question is push, we are pushing quite heavily. Now the other measure, the early

recognition of diseases, for example: may be not generally known but half the

diabetics in Canada and half in Newfoundland roughly, are unknown; they don't

know they have this disease and that's a disease in many cases, which, if

arrested early can prevent even more serious consequences from happening because

things can happen by appropriate diet and taking care of ourselves and so on, so

if we put more emphasis on prevention, our health care budget - people will live

longer and happier and healthier lives and health care, and hospital budgets may

decline.

Also, we are putting emphasis on community health.

We have set up some community health boards and hope to set up others which have

the responsibility of bringing in more appropriate home care. We have home care

in some parts of the Province fairly well developed and in others parts there is

virtually none, very little except what can be delivered by a public health

nurse, so what we want to do with these boards is to have a very carefully

well-integrated system of home care and that too will take the pressure off the

hospitals. It will enable hospitals to make earlier discharges and to keep

people home longer before they are admitted to hospitals and also, it will take

the pressure off our very expensive nursing homes, and also, in addition to that

many people would prefer if they can, to remain in their homes if they can be

appropriately taken care of so these are the initiatives that we are working on

and there is more money in the Budget for that.

We have made a fair move on the establishment of

these community health boards. We have the St. John's one up and running. The

CEO is hired, the board is in place and having meetings, and they will be taking

over the budget from the St. John's Home Care Program that was there before and

was extended more widely than was. They now have responsibility for all the

public health in the area, public health inspectors, for alcoholic and drug

dependency, and all those other things that help prevention in this whole

general area. We also have the board up and running in Central, not quite up and

running, they are in the process of hiring their Chief Executive Officer and a

board has been appointed.

We are almost ready to do the same thing in the

Eastern Region to appoint the board and to look after the community health in

that whole area in the Eastern Region and that is between St. John's and

Central, and then we will see what we will do in Western Newfoundland and we are

in the process of just trying to figure out what we are going to do in Northern

and in Labrador. On the hospital boards: they did report that the St. John's

Hospital Board has been appointed for all the hospitals in this area and they

are in the process of hiring a Chief Executive Officer so that they should be up

and running in several months; it takes a while to get these things finished and

there are a number of details to be ironed out with respect to the circumstances

under which various hospitals will be coming in. We are working out the details

of that now and should be coming along fairly well.

The Central Boards have been established and they

are in the process of hiring their Chief Executive Officer, we have made this

move and have made it very deliberately and it has great cost implications

because we feel that we can reduce administrative costs and by reducing

administrative costs we feel that we can preserve money where it can be

appropriately spent, which is on the front line health care workers, on the

hospital themselves, on the nurses and the doctors and the drugs. There are a

few major problems in health care in the Province which I am very concerned

about, and one has to do with our drug programs.

We have no comprehensive pharmacare program in this

Province, we do have a relatively good pharmacare program for seniors and we

have one for people who are on social assistance, neither one of these is

perfect but they are there. The weakness occurs for people who are not on those

programs and who are not on private programs; we call them the working poor if

you like or people who are working for private organizations or who are not

working at all and are not on welfare, and if they really get sick, they go into

hospital. Their hospitalization is taken care of, doctors are taken care of but

if a drug happens to be prescribed they have to figure out whether they are

going to eat or buy drugs and for many people we are trying to come up with a

program. It is very expensive, our officials are working on it and I have raised

it at national meetings to try to get the Federal Government to get in on this

and the first time I raised it there wasn't any response, the second time I

raised it, several of the other provinces picked up on it. I don't know how far

we are going to go on it but that will be a great thing for this Province so

that there will be some uniformity across Canada when people get sick because

the emphasis on medicines is much better now than it was.

I think, Mr. Chairman, I will conclude here and we

are ready for some questions.

MR. CHAIRMAN: Thank you, Mr. Minister.

It was agreed that Mr. Sullivan as the health

critic would have ten minutes to respond so, Mr. Sullivan.

MR. SULLIVAN: Thank you, Mr. Chairman.

I have been a little perturbed overall on the basis

on which the government is moving in the re-organization of the institutional

hospital boards and community health boards, and the minister of the department

to my knowledge, has never tabled anything in this House, and I am not aware of

any basis upon which this re-organization is occurring from a cost-efficient or

a patient services basis.

Now the Dobbin Report does not address the

economics of reorganization, it doesn't address in any specific way the

improvement of patient care services and these should be the two reasons why we

will want to reorganize. Now I am all for efficiencies and all for savings,

administratively, and I feel that more dollars should be going into the front

lines as the minister stated but really what we have occurring here in the

Province - in cases I'll admit and be first to admit there are efficiencies I

can see, some efficiencies in some areas but there seems to be nothing more then

what an architect could have drawn or an engineer and divided the Province into

seven regions and said: here is going to be the regional areas here and here's

what we're going to do. If bigger is better, not necessarily at all, I haven't

seen any comparisons of the cost of administering larger boards. I'll give just

one example, the Burin Peninsula, Bonavista, getting the board together, the

cost associated with setting up that board, running the board, scheduling the

meetings, reimbursement of operational expenses, et cetera, for people on boards

that serve larger regions that could be localized in smaller areas, I haven't

seen that. If the department has it I'd very much like to see that.

We have taken this Province and divided it along

hypothetical lines. We've attempted to fit the health care system into those

specific regions without any strong foundation for doing that. I'm a little

perturbed that we proceed without doing analysis and identifying savings. If

we're going to spend dollars efficiently in the health care system we must do it

on a planned basis and show that there's a rationale for what we're doing and

not find out when the next budget is filed on what our costs were for the

previous year. It's not the way that I'd like to see it done.

Now, I have great concerns in combining the schools

of nursing, the hospital based ones, without any advanced planning. Again,

without any consultation occurring in the nursing profession when people in the

spring of the year have set career options and probably have waited for a year,

two or three to get into nursing schools and do not know, as of this time, what

they're going to be doing in September.

We got into a situation in Corner Brook last year,

a very similar situation, and again this year. It doesn't show very well the

planning that's occurring within the health department. If there are a surplus

of nurses in this Province then maybe limiting the entry in the nursing

profession could be very well the way to go but if that's the way to go it's got

to be done on a planned basis identifying the projections of the nursing

requirements in the future so that the nursing schools can meet the expectation

level that you need.

We know we're training nurses to go out of this

Province, we don't want to do that. We don't want to train doctors to go out of

this Province at a cost to taxpayers of the Province. We'd like to be able to

serve our own market here with our own people who have a vested interest and

want to be here in the Province. That hasn't happened and I don't know but maybe

when we get to questions a little later I'd certainly like to know what's

happening there. Where is the centre going to be, is it going to be in one area,

the number of people, how they're going to be notified? Some of these areas here

haven't been addressed and it's very, very unfair to the individuals that are

seeking a career in the health care field.

We have limitations on fees for service and

limitations on setting up practice here in the City of St. John's and there are

drawbacks to that. We are forcing some people to leave this Province. I know

doctors who have punched twenty and twenty-five years in rural Newfoundland and

have certainly paid their dues in serving the people of rural Newfoundland. With

families raised, they have a tendency to move to the City when their kids go to

university and elsewhere, and are now prevented from doing that. New doctors are

coming out of school with new ideas, new techniques and are more cost efficient.

It's part of their training to be able to make a

decision on a certain medical procedure that's cost efficient, too, and still

get the desired result. We're losing that new input of ideas and so on that are

very effective in maintaining a certain level and a certain degree of efficiency

within the medical system here, and that's a big concern of mine.

I have a grave concern with reorganization of

boards for the Janeway, for example, which is encompassed under a larger area.

Will the Janeway receive its proportionate amount under this budget over all at

the most preventive stage of development?

I know from calls I get from all over the Province,

too numerable to even mention in cases, that people have been waiting for months

- almost nine months - with a psychiatric problem; to get into the Janeway

Hospital is impossible. There are four psychiatrists there. I understand there

is probably one leaving, for example, not going to be replaced.

Cutbacks of beds is putting an increased pressure

upon the community, and this Province, while it's in the embryonic stage of

doing it, has not reached a stage whereby reducing hospital beds is going to be

positive for the overall health of the people, because we haven't developed a

community health system that's going to be able to care for these shorter stay

visits at hospital.

We're not going to increase the number of nurses

out in community health who are going to have to attend to people who stay in a

hospital, even day procedures at the outpatients' department; visiting the

hospital probably reduced to two days for certain procedures, and they are

having extra pressure upon the people out in the field, and we are pushing

people out of hospital beds and reducing numbers when the people are overworked

as it is and are not ready to be able to involve that in the process. This has

to be a gradual lessening of hospital beds, if that's in the direction we're

going, and build a structure out there to be able to encompass that there and be

able to deliver health at a cheaper price.

I don't see any indication where there are going to

be new people hired in the front lines out in the field. I do see, in this

budget, where there's an increase from $1.5 million to $2.5 million in

transportation and communications over the health budget. I total up the

headings under transportation and communications, $1,552,700 to an increase of

$2,588,500. I see an increase in transportation and communications, and I see

increases in certain other areas of service, but I don't see an increase in the

front line service. I see a reduction in the number of positions and people

employed in the front lines. I see people pushed out of hospitals and out into

the community where they have to be cared for by community people with no

increase in the number of personnel there, I am seeing in the system.

I am delighted to see cardiovascular surgery

addressed because I think it's a very life threatening disease, and $800,000

allotted there to bring the numbers down to an acceptable level, at least where

now you can perform an operation that's not on an emergency basis. That's one

positive area over all, but I haven't seen, at least the department hasn't done

a good job of letting us know how they're going to achieve efficiencies within

the overall confines of the system. They are attempting to achieve efficiencies

by limiting what they're going to pay doctors. That's not necessarily going to

get the results you want. We're finding that it's very difficult to get

specialists in certain areas, where they have less than the number of

specialists in certain areas.

We are finding that there are increased pressures

on rural Newfoundland now with more outpatient surgeries, with shorter hospital

visits. We're finding an increase in rural Newfoundland because people who live

greater distances from the hospital can't step in the hospital in five minutes

if an infection occurs, or something gets out of control. I know they have

doctors in their areas, and that's a cost to, to visit a doctor in an area when

a nurse out in community health could be attending to it, so we haven't been

structured to incorporate that phase or shift from an institutional type care

overall to the hospital care, into a community care, and I believe strongly in

developing a strong community care.

Prevention promotion you speak very strongly of,

this budget shows an increase under that heading from $14,000 to $43,000 - a

$29,000 increase in prevention promotion under that line item there in the

budget. I think we need a stronger effort to be put in under prevention

promotion. We're not going to see the results today, or probably in ten years

time, but I think we have to accelerate our emphasis in that area, and we've got

to make decisions that are going to be done on a cost efficient basis, and we

have to give a lot more thought to a planning process, and not reacting after

the fact.

Thank you, Mr. Chairman.

MR. CHAIRMAN: Mr. Minister, you have ten

minutes to respond to that.

DR. KITCHEN: Thank you very much.

I appreciate the comments that the hon. critic has

made. Let me try to address the first question as to why we're putting these

boards together, and there are a number of reasons.

I take it that we have to accept the proposition

that the amount of money we spend on health is going to be pretty restricted.

The budget is what we have. Unless times improve greatly, or things change, we

will have to live within that budget for a long period of time, for a number of

years. Now that means that we have to make sure that the money we have is

properly spent rather than improperly spent.

Each board in this Province, and up until recently

there were fifty boards in the Province, nursing homes and hospitals, each one

of them prepares its own payroll, has its own human resource department, does

its own purchasing, basically, does its own accounting, hires its own auditors,

and by combining boards this can be done centrally, with much fewer staff, that

is a major cost saving. How much it will be I don't know, because it depends on

how things work out on these various boards, but it will be substantial. That's

one reason for making the move.

Another reason is to try to get a handle on the

health care in the Province. Dealing with fifty hospital boards, nursing home

boards, individually, is a horrendous undertaking for all the officials in the

Department of Health, just look at the communication back and forth between the

Department of Health. The boards come in, they want to meet with the officials,

they want to meet with the minister.

I won't say every town council in the Province,

feel that they have a mandate for health care, so when they come to St. John's

on their annual visits, or semi-annual visits, they drop in to see how the

hospital is coming on, or how this is coming on.

The time that is spent dealing with all of these

multifarious institutions is almost - and that's part of it. Then you have to

realize that every health profession has its own professional body. We have a

denturist body, you have a denturist association, you have a denturist board.

You have the dental association, and you have a board to regulate dentists. We

have nursing assistants, and a council of the union, as well as the board that

regulates them; nurses and the professional association of nurses, doctors, and

so it goes. Then you have every disease, pretty well, with its own association

as well. You name the disease and you have an association.

Everyone is at the department's door, so the whole

thing is horrendous, meetings and discussions, and back and forth all the time,

and what we have to do is rationalize the system so that we can get on with the

business of planning and monitoring and controlling. This is the job of the

department, to monitor and to plan and to make policy, but we spend a great deal

of our time dealing with all sorts of individual boards and organizations, many

of whom are at cross purposes all the time. There are a lot of cross purposes

going on here.

A board comes in and doesn't want to amalgamate

with another board, or they want to preserve services which are presently

obsolete and this is part of the problem. The other reason is that we need

regional planning. For example, in the Bonavista - Burin area - in the

Clarenville area there's no nursing home, yet there's a good nursing home in

Bonavista and there's two nursing homes on the Burin Peninsula. The St. Lawrence

one we're not opening all of it and there's no great reason to open it. We

haven't got enough cash - we could fill all the place if we wanted to but what

we want to do is have people think about a region and if necessary share where

it's possible. If it's not necessary to share then they don't have to share but

they should think on a regional basis rather then each person thinking of their

own town or their own defined area. Some people are able to make that transition

but others can't and I believe that that's the third major reason that we have

for forming boards, to get people thinking regionally rather than - I don't want

to use the word parochially but pretty well that - so that people are thinking

of their health care. We had to do that because of the limited budgets under

which we work and I think it's working out pretty well, it's working out quite

well.

We thought we were going to run into major problems

in St. John's but we didn't. We thought we were going to have major problems in

this tremendous region of central-west which takes in the area from Baie Verte

and Fleur de Lys, actually, up as far north as, pretty well as far as you can go

on that peninsula, and right down to Harbour Breton. That's a tremendous board

and it goes out as far as Lewisporte as well and takes in Springdale, Buchans,

then there's the geography there and yet people are thinking regionally but they

came along very, very well.

There was a bit of discussion, we had some

discussions and were able to make certain accommodations for people. They wanted

appropriate representation on the board so they were sure that their interests

would be looked after and some of them wanted certain assurances which we were

able to give. So that's the give and take that's going on. It's very difficult

and rather pointless to start saying we're going to save $150,000 or $160,000.

The savings to me are obvious and that means that we can redirect that money

into prevention and into some of the other health care things that we need to

do.

On the schools of nursing - there is the issue of

the schools of nursing - there are four schools of nursing in the city; the

Faculty School of Nursing at the University and there are three hospital schools

of nursing; one at the General, one at St. Clare's and one at the Grace. They

each turn out something like sixty-odd graduates per year - and the one in

Corner Brook similarly - and most of those people are unable to find jobs at the

moment. It's true we're going to need people in community health nursing, more

then we do.

I don't know if you realize how the budget works

but we were confronted with a fixed budget. This is how we started off, your

budget this year is fixed, it is the same as last year but we know that our

costs are increasing. The people we have employed very often get step increases

and that's their right. The cost of supplies in hospitals and other places have

gone up. So to live within a fixed budget means you have to cut certain things.

You have to look at what you can cut out and then you try to adjust and say; gee

whiz, we can't allow that particular group to be cut - we have cut them to the

bone - we'll have to do some cutting somewhere else. We saw all these schools of

nursing in St. John's - we have to do something here.

Now here in St. John's what people are doing is

planning a common curriculum. One of the difficulties that emerge in these

schools is to get a common curriculum so that the curriculum is exactly the same

and they can teach the same things. We've been working on this common curriculum

for some time but it's not quite done, and so we had some preliminary

discussions with the people in the schools of nursing to see how we might

accommodate this budgetary cut and they are going to meet with me shortly, I

think it is this week, and at that time we will see how they are going to come

up with this budgetary money, this money they have to come up with; eventually

there will be a merger but at the moment we are looking at cash.

You also raised the question of doctors, our 50 per

cent rule in St. John's which will be extended to other places where, in the

opinion of the joint committee of the Newfoundland and Labrador Medical

Association and the department, we will be looking at that. There are two

committees actually. There is a short-term committee and there is a long-term

committee called PRAG. If you want to know what it stands for, you can ask in a

form of question and you may have someone answer it but it is a long-term

committee which will report eventually on how we can properly accommodate the

physician supply, to make sure that the physicians are where they are needed

rather than where they are not needed.

One of the problems with physicians is that they

nearly always make a good income wherever they are because of the way patients

are referred and so on but that's alright and when you have a capped budget it

wouldn't cost the government any more for physician's salaries because that's

capped for five years but, what happens is that they order all sorts of

procedures which are not capped and that's why we can't have too many physicians

in one place because of these extra procedures that cost so much money, and in

St. John's we have to make some changes right away, so we agreed that we would

put in the 50 per cent rule as a temporary measure in St. John's.

MR. CHAIRMAN: Your time is running out.

DR. KITCHEN: Just a minute or two. It seems to

be working out well but I am a bit concerned about the physicians who are

graduating from Memorial; they tell me if they can't practise in St. John's,

they are going to practise in Texas or somewhere like that. Well, you know, I

find that hard to accept, that they wouldn't practise anywhere else in

Newfoundland; their commitment to the Province is limited. I don't know but I

guess they want us to give them more money for going out there than they do by

practising in St. John's. That is a problem, but I am also concerned about the

attitude of people who seem to be totally motivated by dollars. The dollars are

there in the Province, they don't have to have 50 per cent, they can go to many

places in this Province and earn 100 per cent of the fee schedule, but they

can't do it in the City of St. John's, and there are other places which we will

be bringing it in now because there are other places too who are over supplied

with doctors.

One more point and I will quickly finish up and it

has to do with the waiting lists that you mentioned at the Janeway. I might add

that the waiting lists for hospital admission in this Province is the best in

Canada, on almost everything except the cardiac area which we have been able to

clear up and I believe plastic surgery. Apart from these two and maybe one or

two little items, we are really good as far as the Canadian averages are

concerned in other provinces and we are very proud of that; we knew that for a

number of years and it is improving. I am sure the committee will be very glad

to know that.

Thank you, Mr. Chairman.

MR. CHAIRMAN: Thank you, Mr. Minister.

Mr. Harris.

MR. HARRIS: Thank you.

I would like to ask a few questions of the minister

and staff in the areas that you have mentioned and some areas that I have been

on over the past several years at estimates committees. First of all, in the

area where, I suppose perhaps the largest chunk of the Budget might be spent,

aside from institutions themselves, is the area of physicians' salaries and it

seems to me that the 50 per cent rule for new graduates is a rather crude tool

out of administration to handle that problem, and while it may well be agreed to

by the senior members of the medical profession who make up the other half of a

committee, it's a severe treatment for new entrants to the profession.

Have other methods been considered - and perhaps

some of the officials can handle this question - it strikes me that within the

medical profession there are what one might call expensive doctors versus

doctors who earn the average salary, and it's based, because it's a fee for

service system, on the number of patients or the number of services provided in

a particular day.

Has the department considered looking at that

issue, because the number of patient services is really what we are talking

about here when we are talking about cost. I am sure you have statistics from

MCP as to how many patients per day a doctor might see, or some doctors may see,

doing a thorough examination, spending time with a patient. I know there have

been variations in the amount of time that doctors spend with patients, and it

seems the ones who are spending more time with the patient may be doing a more,

I will say thorough, some doctors might say slower, job, but that there are

others who might see thirty, forty or fifty patients in a day and therefore make

more money themselves, but at the same time will be having a cause in limiting

new entrance to the profession in the St. John's area, for example, or others.

Would you care to comment on that issue, and what

other alternatives were considered?

DR. KITCHEN: I will speak briefly, and I will

later ask Dr. Williams to comment in more detail.

We thought about various arrangements. There are a

couple of other arrangements we could make. We could hire everybody. All doctors

could be salaried doctors. We have some now. That is one way of looking at it;

we will hire so many for St. John's and so many for everywhere else.

Another way might be to use the capitation system,

where you get paid for the number of patients you have. You would look after a

number of patients, and if the patients didn't like you they would go somewhere

else; but there is a variable fee right now in place. We brought it in for

seniors. When seniors usually come to see a doctor, they come with several

complaints, usually, at a time, and the fee for that visit is more than the

normal fee for a quick doctor's visit.

I might add, too, that the higher earning doctors

are cut. There's a formula in place by which after they go over, I think it's

$300,000, they get 75 per cent?

AN HON. MEMBER: I think two-thirds and then

(inaudible).

DR. KITCHEN: Two-thirds, and then after it goes

over three fifty they get half their salary. So there may be some specialists

who earn quite a bit of cash, but not very many, and this is kept under control.

I might also add that we are hoping that this

long-term committee, the PRAG committee, Provincial Physician Resource Advisory

Group, is it?

AN HON. MEMBER: (Inaudible).

DR. KITCHEN: Got it, right. That group would

bring in - that is the one that is chaired by Ian Reid.

We're hoping they will bring in this long-term plan

to deal with this problem. What is there, I should say, is a crude index, a

crude measure. It was done as a temporary measure. We had hoped that the big

committee would be able to report earlier. I think they will report this fall;

is it this fall?

DR. WILLIAMS: In September.

DR. KITCHEN: In September.

DR. WILLIAMS: We were hoping to have an interim

report in April. We were hoping to have a full report by April, but that won't

be possible.

DR. KITCHEN: I don't know if you would like to

add some more to that, Dr. Williams, because you are on the joint committee. Is

there anything else you would like to add to that about the physicians salaries

and so on?

DR. WILLIAMS: Not much, Dr. Kitchen. I guess

the problem we are dealing with is common to the problem that they are having in

some other provinces of Canada. The whole world for physicians has changed

dramatically in the past perhaps two or three years, and many provinces are

putting restrictions on the number of physicians, or practice locations of

physicians. This Province is no exception.

I just took a look at the latest Needs Assessment

Committee Report. Right now we could accommodate thirty-four general

practitioners throughout the Province. We have jobs for up to thirty-four people

according to our latest report but we do have an appropriate supply in some of

our larger centres in the Province. We have what we call, as the minister says,

a Physician Resource Advisory Group which was put in place last year to look at

the issue of physician resourcing, management of the physician human resources

on a long-term basis and looking at appropriate policies that would provide for

the appropriate number of physicians, the appropriate kind of physicians in the

appropriate settings in the Province that deal with health care services.

As the minister says, unfortunately they haven't

come in with their long-term recommendations, apparently because many of the

issues they're dealing with are so complex. Some of the issues the minister

discussed may be a fundamental change in the way medicine is practised or funded

but some of these issues have to be grappled with, in a short term, as a measure

so that we wouldn't have new physicians coming into areas, not necessarily new

graduates but physicians who are in other locations coming into areas where we

already have an adequate supply or over supply. They put in some short term

measures which were only in the short term. Hopefully by the fall, when the

Physician Resource Advisory Group reports, we'll deal with some of the long term

issues and then some of the short term measures can be removed.

MR. HARRIS: On the same point, it's also been

said that physicians who see a lot of patients - and I mean well more than the

average -are also very quick with the prescriptions and that of course ends up

costing a lot more money to the system. What I want to ask is, is the government

serious about doing something to provide, shall we say, a disincentive for that

type of medical practice and some way of providing an incentive or rewarding a

kind of practice that is - one of the other options that Dr. Kitchen mentioned

perhaps looking after your patients - you'll get rewarded for looking after your

patients as opposed to writing out prescriptions. You'll get rewarded for

providing a practice that is a care base as opposed to generating income. Is the

government prepared to take some strong measures to both reduce costs and

provide better care in that way?

DR. KITCHEN: Well there's two points to be

made, one is that we're hoping that the joint management committee will

eventually be able to address this issue, because, as you say, this part of the

quality practice of medicine - but there's nothing, I know of, at the moment on

the go on that except the whole question of fair review of physicians. I don't

believe there's anything on the go in this Province at the moment in that but

I'll let you speak on it.

The other point I wanted to make is that, for

patients who see a variety of doctors looking for various drugs - that's another

problem which is related here to. We had thought we'd be able to launch this

year a triplicate prescription program by which a report of prescriptions would

come to the department. One would go to the Medicare Commission and the

physician would keep a copy of each prescription so that we could correlate what

was going on here. Then if we have some high users of various drugs and so on,

we could keep track of that and perhaps take some action on it because some

people get a lot of prescriptions but we're unable to do that, it's not in our

budget. We may even be able to proceed during the year with it if we can save a

few dollars here and there but at the moment we are not moving. Doctor Williams

I don't know if you'd like to add a few more points?

MR. HARRIS: All those prescriptions are given

by doctors, stop blaming the patients.

DR. KITCHEN: Some of it may be the doctors

fault but some of it may be the patients fault too because the patient doesn't

have to stay with the one doctor.

MR. CHAIRMAN: Mr. Harris your time has expired

now and I recognize Ms. Verge.

MS. VERGE: I would like to ask the minister

about the Memorial University School of Medicine. The minister indicated that in

St. John's there is, if anything, an oversupply of physicians and despite

efforts to attract Memorial graduates to rural parts of the Province, there is

still a shortage of physicians in rural areas and the minister talked about his

disappointment with graduates opting for Texas if they can't stay in St. John's.

What kind of value are the taxpayers getting out of the medical school these

days and since resources for health are limited and difficult choices are being

made, how can we justify continuing a school of medicine in the Province?

DR. KITCHEN: Thanks very much for that

question.

Generally speaking, I think the Province is

well-served by Memorial School of Nursing. We are able to attract people here

because of the school specialists and people who are interested and that helps

increase the quality of care here very much, and there is also a research

component at Memorial which we hope to build on as well, but the basic question

is what value are we getting?

I like the Family Practice Unit at Memorial and we

encourage that very much; we have a clinic at Shea Heights which we put in so

that they can practice in a community setting close to the city which helps, and

we also have one in Whitbourne which is a little farther away and we also have

one (inaudible) in Goose Bay, and it is generally recognized that the Family

Practice Unit at Memorial can take pride in being a leader in the field, but I

am concerned and I am hoping to be able to meet with people in Memorial to see

why it is that graduates don't want to go to rural Newfoundland and perhaps

something can be done about that, I don't know what the problem is.

I thought about many things and right now the fees

at the School of Medicine is about $2,000 I think or something of that nature,

but the cost is tremendously more than that to the Province and of course, so is

every other program, more costly than the fees generally, but maybe we should

charge higher fees and then put those who are going to practise in Newfoundland

on a long-term contract, to take care of their fees or something of that nature.

Maybe we have to bring in some new plans on that to make sure that people who we

train, a lot of the Newfoundlanders who we train will either pay their own way

or else, at little cost to the government, some little cost, the same practices

as any other student, and then they can practise wherever they want but if they

want to be heavily subsidized, then there should be a return for service and we

ought to be able to send them to rural areas, so my only concern is with the

School of Medicine and has to do with the fact that they can't get the graduates

to stay and practise where we want them to go, but I suppose that is the

problem.

MR. CHAIRMAN: Ms. Verge.

MS. VERGE: I would like to ask the minister

about the long, drawn out, apparently not very well planned process of

re-organizing boards. I concur with the remarks make by my colleague the health

critic. What is going on in the western region? I ask this question every year

and I am always told that it is coming soon but it never seems to happen, and to

my knowledge there is no public consultation taking place, I don't think that

was ever even contemplated.

More than a year ago health administrators in the

region indicated to the public, through the news media, that they, meaning both

public health administrators and institution administrators had come together

and decided among themselves that the best model was one super board with

responsibility for public health, hospitals, nursing homes, the works, and

having a territory ranging from Port Saunders in the north to Ramea in the

south.

The minister's earlier

schedule and his

predecessor's

schedule had the western region at the top of the list and now we

see St. John's and central and eastern coming ahead of western, and we hear this

morning that central isn't up and running, eastern not even off the ground. Can

the minister give me any indication that I won't have to ask him the same

question this time next year?

DR. KITCHEN: Well, I hope you won't.

There are a couple of problems with western. You're

right that some of the administrators and the board chairs did come to me and

made a proposal to government that everything be rolled in, all aspects of

health in that area would come under one board. There are two snags there. One,

I am not sure that is the right approach and not everybody over there agrees

with it, and I haven't had time I suppose to sort it out; maybe they are right

and maybe they are not. You see the community health part has to be built up, we

all agree with that, it has to be built up everywhere in the Province pretty

well, and I am nervous that - you see the western merger is going to include a

very heavy merger; it is going to probably include as you said, the Port

Saunders Independent Board, the Western Memorial and its associated

institutions, the Bonne Bay Hospital, the Western Memorial and the O'Connell

Centre and the -

MS. VERGE: Roddickton, Stephenville and

Stephenville Crossing, Port aux Basques -

DR. KITCHEN: Yes, they run the hospital in

Burgeo, that's a large thing as well and then along with that comes the

Inter-Faith Home in Corner Brook we hope and the Board in Stephenville which

runs the hospital there and the Independent Board in Stephenville Crossing which

runs a tremendous nursing home there, so that itself, a merger of these various

boards and institutions is a major thing to do; it's a major thing to do and you

want to be sure that the organization that is put up can handle that well.

That is the first thing you have to be sure of and

on top of all that, we have to develop regional community health service, take

over the public health nurses, responsibility for promotion for single point of

entry into all the nursing homes and personal care homes in the area. That too,

is a very major responsibility and the question is: can we put that under one

board and one city (inaudible)? That was their proposal and that's my question

and quite honestly I have questions -

MS. VERGE: I would like to ask for some

clarification. What I am hearing the minister say is that he has pretty well

decided that at the very least the institutional boards should be merged, but

the question that has to be - to use his phrase, sorted out - is whether to

combine institutions with public health. Is that the basic question?

DR. KITCHEN: Yes, that's one of the problems we

have; that's one problem. There's another one.

MS. VERGE: I am sure the minister realizes that

his own public health people in the western region are in the forefront of

advocating the combination of public health with institutions under the one

super board.

DR. KITCHEN: Yes, I've heard representations

from our people over there, too. They believe that it's right, but that doesn't

make it right.

The other problem I want to mention that adds to it

is what's going to happen in the northern region. The northern region right now

includes the tip of the Northern Peninsula and Labrador. We have had tremendous

representations from some parts that they are not very happy with the existing

arrangement. There are several boards there. There's the Grenfell Regional

Health Services, which operates in most of the area. We have a board in Labrador

West which operates the hospital.

MR. CHAIRMAN: Your time is up now, so I will

now recognize Mr. Harris.

MR. HARRIS: I want to ask about the community

health efforts in the area of smoking, for example, as one of them. Can you show

us where in the estimates the budget for the smoking campaign is presented?

DR. KITCHEN: I think the amount - what is the

amount?

AN HON. MEMBER: Right here.

DR. KITCHEN: The amount is $80,000 is it?

AN HON. MEMBER: Yes.

MR. HARRIS: How much?

DR. KITCHEN: Wait now; there is $65,000 in the

budget to undertake educational and promotional campaigns relating to the

implementation of the Tobacco Control Act.

MR. HARRIS: Where would that -

DR. KITCHEN: I am trying to find out where it

is.

DR. KITCHEN: It's not under prevention and

promotion. It's on page 238 -

MR. HARRIS: It's under administration and

consultative services, is it?

DR. KITCHEN: 2.1.01.06 - $168,900.

MR. HARRIS: It's part of that $168,000?

DR. KITCHEN: Yes.

MR. HARRIS: So approximately $65,000 is related

to the Tobacco Control Act?

DR. KITCHEN: Yes, Sir.

MR. HARRIS: And what is the implementation date

on that now?

DR. KITCHEN: June?

AN HON. MEMBER: June 17.

MR. HARRIS: June 17, because I still don't see

lots of signs around stores quoting the federal act, and the federal age limit

of eighteen, and all that sort of stuff. How is that going to be overcome? Is

that going to be readily accepted? Are they going to take down these eighteen

signs and put up the nineteen ones? Is that what's expected to happen, Mr.

Minister?

DR. KITCHEN: Well, let me see. It will be

moving in fairly quickly there now, because that comes into force in June. The

regulations are currently being developed. It's not just the act; there are the

regulations. The information packages for employers have been developed, and so

have radio and television ads, and a flyer for households throughout the

Province. So the implementation should occur in the next several weeks but, as

you say, it's not on the go yet.

Would you like to add some more to that, Ms. Dawe?

MS. DAWE: Thank you, Dr. Kitchen.

As Dr. Kitchen had indicated, we have been, over

the last few months, involved in developing educational promotional packages

dealing with the implementation of the legislation, and that should be ready by

the end of April for mass public distribution to employers, households, the

media, both radio, TV and newsprint.

MR. HARRIS: And the regulations themselves are

not passed yet?

MS. DAWE: No, not passed yet. They have been

developed and they are working through the mechanism within the department.

MR. HARRIS: And of that $168,000, sixty-five is

allocated to this particular program. That still represents an increase of about

$60,000. In addition to that, under purchased services, under that vote, what is

the other increase for, I suppose, the other increase of $60,000? Is that

allocated to another health promotion program, and can you tell us about that?

DR. KITCHEN: $80,000 of that is for AIDS. It's

for the education and prevention of AIDS among young people.

MR. HARRIS: About $80,000?

DR. KITCHEN: $80,000 yes.

MR. HARRIS: And what does that program consist

of? I know there are some good materials out. I know the National Film Board

film Talking Positive that was done here in Newfoundland is a very good

program. I know that's being used in the schools. What does government's program

consist of for the $80,000?

DR. KITCHEN: Ms. Dawe, would you like to

respond?

MS. DAWE: Mr. Harris, you may be aware of the

comprehensive strategy that was released in December by the minister. A number

of the first recommendations indicated the need for education prevention

targeted at some high risk areas, the youth being the first group that we are

planning the educational programs. So the development of these programs is under

way now, and that's going to take into consideration the use of some of that

funding, specifically targeted at some of the high risk categories.

MR. HARRIS: Would the $80,000 be used for

promotional materials, or is that consulting fees?

MS. DAWE: Both consulting and promotional,

targeted at education particularly.

MR. HARRIS: So it would -

MS. DAWE: I may say, it's not really finalized

yet. We are in the process of discussions with people in the field, and some of

the voluntary associations as well, trying to really focus to make the best use

of the dollars that are available.

MR. HARRIS: So you can't say at the moment what

proportion of that is consultative fees?

MS. DAWE: No, because the details have not been

sorted out yet.

MR. HARRIS: In vote 2.2.01 under community

health services there is an increase of about $500,000 in grants and subsidies

for community health services. I know a number of organizations in particular

were complaining last year about having their support from the government

removed. Some of the organizations that in St. John's operated out of the King

George V Institute Building were amongst a group of agencies that had support

from the Department of Health. I see that there was, in fact, last year, in

terms of grants and subsidies, an underspending from the budget of about

$300,000 and it appears that the grants and subsidies are, in fact, $1.4 million

more than was actually spent in 1993-'94. Can these organizations look forward

to an increase in support of the government as a result of this vote, or what's

the explanation for that?

DR. KITCHEN: You are asking why the grants and

subsidies went down and then went up since we got $1.2 million over last year's

budget, and almost $1.5 million over our revised budget. Might I ask you, Ms.

Dawe, to give the details of that?

MS. DAWE: Mr. Harris, the funding under grants

and subsidies, really, for the home care, home support programs, not those that

you have identified, the voluntary agencies. That funding, if you consider St.

John's, would be additional funding to the St. John's home care program had it

been still in place, okay? So that's a different level of funding.

The reason for not utilizing all the funding that

was approved last year is that some additional funding for home care, home

support services, was approved in anticipation of having the community health

boards in place in several regions of the Province, and increased funding is

there again of $500,000 for continuing care services in the 1994-'95 budget for

these services, which will be allocated out through the community health boards

if they are in place, and if not through the public health units.

MR. HARRIS: Can we get a copy of the breakdown

of that grants and subsidies under vote 10 there?

MS. DAWE: Sure.

MR. HARRIS: You say some of that will be just

passed out next year, for example, to the community health boards and won't

appear in this. They're in a different form in this budget, I take it.

MS. DAWE: It will be a different format next

year.

MR. HARRIS: I would still like to, if I could,

get a listing and breakdown of that.

MS. DAWE: Yes.

MR. HARRIS: Similarly I see a difference on

vote number 1 there, as part of that, of approximately $250,000 in difference,

or in money that wasn't spent. Is that part of that same situation?

MS. DAWE: Yes.

MR. HARRIS: Okay.

AN HON. MEMBER: (Inaudible).

MR. HARRIS: I have half a minute? Well, I can't

do very much in half a minute except to say that I am interested in the

operation of the programs at Humberwood and Talbot House, and there won't be any

time for a response, but I would like to have an idea from the department as to

what the level of care is there. How many individuals have been treated at

Humberwood? What's the waiting list for that, and what's the demand for that

service?

AN HON. MEMBER: You will have to wait for that

answer.

MR. HARRIS: Yes.

MR. CHAIRMAN: Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman.

My first question relates to page 237, item 1.3.04,

the vital statistics registry. Just for clarification there under line 12,

information technology, $46,500; does that refer to just purchasing computer

equipment, or an upgrading? What exactly would that refer to?

DR. KITCHEN: We want to improve the efficiency

of the vital statistics, and that has to do with... I don't know if it's new;

it's a computerization program. Mr. White, do you want to address that?

MR. WHITE: (Inaudible) new computer program

system installed in vital statistics over the last couple of years, and this is

in connection with that, and fully implementing that. It's actually implemented,

but there are some modifications being made to register events and store data on

a computer base so there will be quicker retrieval, and better organization of

the data. So this is really, if you will, the finalization of that process.

MR. SMITH: Okay, thank you.

3.1.01, this relates to Memorial's Faculty of

Medicine as well. We had some questions about that this morning and my question

was: in terms of the graduates of that program right now, first of all the

percentage of graduates of that program who are residents of the Province of

Newfoundland, and the second part do we have any stats as to how many of these

graduates remain in the Province, remain to practise within the Province?

DR. KITCHEN: I can give you the breakdown by

students at Memorial. Of the first years up to now, in medicine, there are

fifty-six, forty are Newfoundlanders or come from Newfoundland. In second year,

there are fifty-six, forty-one are from Newfoundland; in third year, there are

sixty-two, forty-five are from Newfoundland and in fourth year, there are

fifty-six, forty from Newfoundland. Now, as to whence they come and where they

go, I don't know if anyone can answer that question as to basically how many of

those can be expected to practise in Newfoundland. I don't know what to say.

Maybe Dr. Williams - you met recently with the group and you probably know as

much about it as we do because the talk is that some of them don't particularly

want to practise in Newfoundland. I don't know if we had any historical records

as to how many of the graduates from Memorial end up in Newfoundland.

DR. WILLIAMS: We do have some historical

documentation. I think Mr. Sullivan may have asked that question the last time

around and I provided something to him about eight or nine months ago or a year

ago now and I will get that information out to you, but it is based on prior

years up to last year. I can get that information for you and give it to you but

our retention rate for Newfoundland residents going into Memorial is consistent,

in fact it is better than some other medical schools across the country, but it

is consistent with the retention rates of Saskatchewan for instance, or

Dalhousie for Maritime provinces residents, so our retention rates for our

students, residents of Newfoundland to go into medical school and eventually

practise in Newfoundland is equivalent.

Sometimes there is a lag period between when a

medical student graduates and when they actually set up practise especially if

they are in a specialty becomes sometimes it takes five years sometimes six

years to train as a specialist, so while it might seem like they are gone

because they are not in the Province, five or six years later they will come

back when they have finished their specialty training programs, but our figures

are consistent with other provinces. If I could recall correctly our retention

rates are probably a little bit better than some other provinces for residents

of Newfoundland who actually practise in the Province but I will get that data

for you.

MR. SMITH: Yes, I am just curious about it and

I think I raised it last year and I believe it has been referred to today. I

live in a rural area of this Province, and lived there all my life and live in

an area that has always had difficulty in attracting and retaining doctors and

in the whole of my district it is a problem, and in recent years, to my

knowledge, there certainly has not been a graduate of Memorial who has chosen to

come out and practise in my area of the Province, and I am just wondering is

that the situation with rural Newfoundland generally? I know with the hospital

board that serves my area, they are constantly recruiting and most of the

recruitment is from outside the country, to get people to practise in the rural

areas of the Province.

Now I was around in the days when Memorial was

being called upon by the government of the day to try to redress the problem

that was plaguing the rural areas of the Province. It began first of all with

the program that was brought in to support students, encouraging them to go in

and to pay their way through and subsequently, I guess the ultimate would have

been to me, that when we construct and set up our own medical school but it

appears to me that in the interim, that certainly that problem that has plagued

us is still there and having a medical school in the Province certainly doesn't

seem to have helped it, it certainly hasn't solved the problem so I am just

wondering if you would like to respond to that.

DR. KITCHEN: It's a very important point you

have raised, from our point of view, we have the same problem and also, Canada

is sort of closing the door to people from other countries now too, and also

some medical schools are cutting down on the number of people who are being

admitted because the general shortage of physicians is no longer there but the

problem remains. I think we will ask Memorial to provide a list of their

graduates of the past years and tell us which of these are presently practising

in Newfoundland and where they are practising; that may be a good statistic for

us all to have a look at, I think that is possible isn't it, to get that?

DR. WILLIAMS: I would like to make a few

comments on that. That is possible to get and we will update it for you over

what we had last year. Having been involved in the previous program back in the

60s, where we did not have a medical school here and we had to go to Halifax

which was the nearest medical school, and as somebody who has been involved in

the program, I think the program was successful at that time when most of us

came back and practised in rural Newfoundland and some of us stayed a lot longer

than we had anticipated when we came back.

Then Medicare came in in 1969 and I think that's

when things changed in getting physicians to fulfil some of the commitments to

rural Newfoundland; the whole economics of medical practise changed in 1969 in

this Province when Medicare came into effect, and that was a factor, however we

started up three years ago, a new bursary program for residents of the Province

who wished to make a commitment to practise in an underserviced area and

students, after they finished their first year, are eligible to apply for this

program.

We have ten grants a year and it carries a student

for the second, third and fourth years so that at any one time we could have up

to thirty people receiving money; they get $12,500 a year in their second, third

and fourth years and in return they have to practise in an underserviced rural

setting. We just started the program, it is the third year of its starting up

now and I find it interesting, it is not fully subscribed, I think there were

nine students who went in one year, seven took up the ten grants that were

available in the next year. The students have to spend a year for a year of each

grant and the arrangements this time around are not made with the government but

the Department of Health.

What we have done is, we have allocated the money

to the regional hospital boards around the Province and so the student makes the

commitment with the hospital board that is responsible for providing the medical

service in that area. For instance, if you had a student who was committed to

Jeffrey's, then that arrangement would be with the Board of St. Thomas Roddick

Hospital, so that is not a departmental arrangement but it is with the board and

in that way the student over those three years and the student's spouse can

develop a relationship with the hospital board, go out and see the area, get to

know some of the administrative people, the other staff and physicians who are

there and hopefully that will make the commitment a little bit more binding, a

little bit more morally binding anyway, than having it with somebody in

government or in a department where they don't actually have that relationship.

MR. SMITH: I think what might be worthwhile it

seems to me, in talking to the University, would be talking with some of these

students as well who are about to graduate and just getting their views as to

why they would opt to - because personally, I can see some of the concerns. If I

were, right now graduating, because as attractive as my area of the Province

might be, being in a clinic where you are in sole charge for that entire area,

which basically is a twenty-four-hour a day, seven-day week, is not very

attractive for anyone. I mean, you do need some time to yourself and especially

if you have a family, but I am wondering in terms of talking with these people,

are there some alternative ways that we can deliver these services to the rural

areas whereby we can eliminate some of these problems that are there right now?

AN HON. MEMBER: Well -

MR. CHAIRMAN: You will have to wait for the

next time round.

MR. SMITH: Thank you.

MR. CHAIRMAN: Mr. Langdon.

MR. LANGDON: (Inaudible).

DR. WILLIAMS: That's a very good question, it

is something that has been discussed. Over the years the department has gotten

away from the solo-practise settings and tried, even though maybe the population

in itself wouldn't justify more than one physician, we have tried to put in two

physician practices in certain areas of the Province.

One discussion we had, and Mr. Langdon might relate

to this, because it is in an area with which he is very familiar and represents,

the issue of servicing places like Mose Ambrose and Hermitage, these were always

solo physician practices but some years ago we made them two physician practices

even though as I said, the population base may not be there to support two,

because physicians can have time off and can go into some other centre and work

with their colleagues and this type of thing, and keep in touch more, that way

it is a better lifestyle for them.

One other suggestion that has come from some of the

physicians down there is, why not, instead of having physicians spread around

over so many different communities, why not have instead of three positions as

Harbour Breton has, six or seven there who would then practice out of there and

every day they would go out to the practice locations and have a clinic every

day of the week, you know five days of the week so that way the physicians would

have a better lifestyle and they may be more amenable to stay there.

The issue of lifestyle, on calls responsibilities,

are very important to physicians even though, if you are the solo doctor there

and even though you might feel that you need to be off, the fact that you are

there and something happens people are going to call you so really, you are

never off when you are there; so these are some issues we might want to be

exploring I guess, in terms of how to best service rural areas, in terms of

getting service to people, yet in terms of keeping physicians there on a

long-term basis.

MR. LANGDON: I would like to comment in the

same vein that Mr. Smith did.

I have a daughter who is at MUN now studying for a

Master's in Nursing and Community Health and my son-in-law is a resident

pediatrician at the Janeway, and daily I hear them commenting on the

department's, if you wish, ostracising them from this Province to Texas or

wherever the case might be, and I think there is some merit in what Mr. Harris

said earlier, the fact that you have a board that is probably made up of senior

people in the medical profession and of course, with the cap on the board and so

on, they can, almost at will provide prescriptions which take dollars out of the

particular fund but it might very well be that some of the younger people could

also be a part of that particular board and find ways of which you are working

at to accommodate them more.

Like, for example, the people who are close to me

have said: I don't want to be in Harbour Deep. I just don't want to go there.

The situation there would not be advantageous for a family that would have all

the different sorts of licensing and skills. Also the pediatrician is saying;

twenty-four hours a day, seven days a week, what type of a lifestyle do I have

there? I know in my area especially, in Mose Ambrose, we go through doctors

almost like somebody would go through candy. It's the same thing in Hermitage,

they stay there for a little while and off they go but it is changing. Your idea

of having them operate out of Harbour Breton probably would make some sense

because recently the town itself, due to recreation and other things, has made

life better for these people that practice there. I understand that one of the

graduates at Memorial now, a graduate, a Newfoundlander from the Burin Peninsula

has agreed to go into Harbour Breton when he graduates. That is a positive sign

and hopefully we can work at that.

Another point of contention for me, especially the

area that I represent, the Connaigre Peninsula, is the quality of the health

care as provided for the structure that's there now. I talked to the minister

about it a number of times and earlier I was somewhat interested in the comment

- I don't know if I listened attentively and got it right from the minister,

I'll get him to comment in a minute - on the Burin Peninsula, I thought he said

in St. Lawrence right now the long-term care, chronic care, is not filled and I

don't know if he said there's a partial need for it or they didn't have the

dollars and so on. I see the rationale of what the department is doing and I

commend the department on the reorganizing as far as boards are concerned. I

think that once these regional boards are in place then you'll have a better

grip on what's needed in a particular area. With the scarce number of dollars

that we have, we'll make sure that in a particular area where there is acute

need, then that would be taken care of.

In the Harbour Breton area for example - I don't

have to tell Dr. Williams, he's familiar with it from that part of the coast -

it takes us three hours to get to any medical facilities in Grand Falls. There's

not much being done at the Harbour Breton Hospital now. The terrain is such in

the wintertime - I challenge anybody to try to get over what they call the

highlands. It's practically impossible, so you're cut off. The need has to be

addressed and I believe that the minister and the department will, so let the

minister respond to that.

DR. KITCHEN: The two points you raised, one

concerns the new positions going out - I might indicate that on this Physicians

Resources Advisory Group that's looking in a long-term way and which they hope

to report on in September, there are two students, one representing the

organization PAIRN, Professional Association of Interns and Residents of

Newfoundland and one representing the union and the other is, I suppose,

selected by the medical students at Memorial. So there are two students, two

people on that PRAG Committee and hopefully the points that you made will be

introduced by them into that committee.

MR. LANGDON: Are the students, these two people

on that board voting or non-voting?

DR. WILLIAMS: On the PRAG committee they have

an equal say.

DR. KITCHEN: You're thinking about on the

Newfoundland and Labrador Medical Association where they're associate but

non-voting members?

DR. WILLIAMS: I don't know the details on the

medical association, council or board or whatever you call it, that council or

board is elected every year at an annual meeting. All physicians have a right to

go to the meeting and vote.

There is representation on there from the medical

students, but I don't know how much. I think there is one person on the board

out of a number. There is regional representation, and there is a provincial

executive; then there is regional representation, and together they make up the

council.

DR. KITCHEN: There are how many on the total

committee that Mr. Reid is chairing, I wonder?

DR. WILLIAMS: I think there is Mr. Reid and

about three or four others, plus the two that you referenced. I will have to

check that.

DR. KITCHEN: Okay, so that's a fair component

on that, and we are looking forward to doing something in the Harbour Breton

area as soon as we get cash to do it, and as we line up the many priorities that

we have, so hopefully things... But I think in Harbour Breton the service that

is provided by the staff is extremely good service, from what I have heard, and

I think that's more so, even though a new building is nice to have, the service

is the main point. If you have good staff, good nurses, good doctors and all the

other staff who are committed to providing good care, I think that probably

makes up for an awful lot of other things, and we have a number of small

hospitals in the Province which are providing extremely good care because of the

quality of the staff. That's not meant as an excuse for not putting in a new

building, but sometimes there is a tendency to put all our emphasis on

buildings, and health care is only part delivered by a building.

MR. CHAIRMAN: Thank you, Mr. Minister.

Your time has expired now, Mr. Langdon, so it might

be a good time to take a break. The Clerk tells me that coffee is going to be

served in the board room upstairs, so everybody will have to follow the

government members who know where the board room is upstairs.

We will return at 10:45 a.m. Mr. Hodder will lead

off, followed by Ms. Verge, Mr. Harris, Ms. Young and Mr. Smith, so we have an

interesting little group here this morning.

Recess

MR. CHAIRMAN: Order, please!

Mr. Hodder.

MR. HODDER: I want to ask a question to the

minister relative to the 911 system in the St. John's region. It's been a

persistent problem. It's been raised on a number of occasions by the municipal

councils, and it's been raised here in the House.

I know that the minister is well aware of the protocol

that supposedly operates, and I am wondering if the minister has looked at that

system and if he has made recommendations to the Health Sciences Centre to

change some protocol, and if he can give some assurances as to what new

procedures will be put in place, if any.

DR. KITCHEN: Thank you very much for that

question. Part of the 911 service has to do with health emergencies - not all of

it, but part of it. Some has to do with fire, and some has to do with other

things, but we had recently a couple of complaints with respect to the 911

service, and I have asked for a report, and I have had a report, as to both the

short-term one, that sort of thing, what happened, and also trying to evaluate

the system as presently in place.

We had an initial discussion with the people who

prepared the report, and I asked them to go back and get some more pertinent

information as to how things go, and when I get that information we will have to

work on it.

I don't know if there's anything more we could add to

that at this time. Some of the problems have to do with the volunteer fire

departments. There is a problem there because volunteer fire departments are

great for responding to fires and to look at any first-aid that is there, but

most of the volunteer fire people are not trained to handle the emergency

medical problems. We can't really put them on a full-fledged response program

because a full-fledged response program under 911, for health emergencies,

requires appropriately trained people to be in that ambulance to respond to that

emergency. That is part of it.

I don't know if there is anything else to be added.

Dr. Williams or Mr. Hart? How would you like to handle that?

DR. WILLIAMS: As the minister said, there are

probably two components to the issue that we are dealing with in the 911. There

is the issue of the protocol and the first responder issue, when we do have a

fire department that is not volunteer but is fully funded and have people who

are very well trained to respond to emergency health care situations. It is that

proportion of the 911 that we are working on and it is a proportion that relates

to, in some of the peripheral areas, volunteer fire departments, and are they

going to be involved as first responders. There are certainly issues related

there to training. There are issues related to insurance coverage, in case

something goes wrong in terms of their responding. We are looking at those two

issues and we've asked for some more information.

We do get quite a number of calls to the 911 on an

annual basis and we do get a number of complaints. I think there were three

recently: two related to situations in Mount Pearl, one of which the General

Hospital has said publicly that there was an improper following of the

procedures in place and they've taken measures to correct that. Once we get the

report to the minister I guess then we are going to look at these two issues and

try to resolve them.

MR. HODDER: A supplementary question on that.

Several of the other provinces - Nova Scotia in particular - have initiated

procedures to do a province-wide review of their emergency responses.

Nine-one-one covers a whole gamut of things, not just emergency health response.

Has the Province examined the need to do a province-wide analysis of the 911

system similar to what is being done in Nova Scotia?

MR. HART: Yes, Mr. Hodder, maybe I can address

that question.

MR. CHAIRMAN: Would you please identify yourself?

MR. HART: Chris Hart, Assistant Deputy Minister

with the Department of Health.

There was a committee struck some three or four months

ago through the Department of Municipal and Provincial Affairs actually. The

mandate of that committee, as I understand it, is to look at the advisability of

putting in place what they call an E-911 system for the Province of

Newfoundland. "E" stands for "enhanced," I believe. There is a number of

representatives obviously on that committee because it deals with a wide range

of services - police, fire, and health related. We have from the department our

Director of Emergency Health on that committee. We also have a representative

from the Newfoundland Private Ambulance Operators Association. There are private

individuals on there, I understand.

Mr. Peckham, the Assistant Deputy Minister with

Municipal and Provincial Affairs, is heading up that group. I'm not exactly sure

at what point they are. I know they've met on three or four occasions now.

Whether they are ready to release the results of their review or not, I'm not

sure. Maybe that is a question you might keep in mind once you talk to Municipal

and Provincial Affairs.

MR. HODDER: To switch to another topic. I wanted

to raise the question of the Burin Peninsula health care regional board. Those

people who know my family history, they would know that is where my roots are.

There are probably 700 relatives of mine who live in that part of the Province.

One of the real issues there, and I raise this as well

on behalf of my colleague the Member for Burin - Placentia West, is the issue of

governance. I attended the rally that was held up there two weeks ago. I just

happened to be up there visiting my aging father and went to the rally.

Twenty-five hundred people turned out for it. The issue on the Burin Peninsula

seems to be one that they already feel that when we close a hospital in Grand

Bank and we close a hospital in St. Lawrence, and then all of the joint town

councils got together and build this hospital which is really in neither

community. It is within the municipal boundaries of Burin but it is not really

in Burin. It is partway between Marystown and Burin, kind of neutral, and

suppose to be a regional approach that was kind of setting the way, you might

say.

I wanted to ask the minister if he has done any -

again he says he (inaudible) do any cost benefit analysis, and to point out

there is a difference here with the other regional boards. In the other boards,

Grand Falls, with which I have some familiarity, there is, shall we say, an

existing regional centre that is operating. On the Bonavista Peninsula you have

no what we call main centre like you have in Grand Falls operating in that

region. You have the hospital in Burin, the one in Clarenville and one in

Bonavista. Is the minister reviewing that particular decision, or that proposal,

I should say?

DR. KITCHEN: A group met with the Premier some

time ago and we did make a commitment to look again at the decision. We gave no

assurances that we would change it or not change it, so we are in the process of

whether we will do that before long. It is true that in the eastern region we

will say, there is no single hospital to which everybody gets referred as there

would be in the western region or in the central east or central west, but there

are three more or less equivalent hospitals. There is the one in Carbonear,

which is larger than the one in Burin, and which in turn is larger than the one

in Clarenville although they are similar in the services they offer, but at the

same time recognizing that difference is there, the question comes up: can any

good come out of putting Clarenville, Burin, and Bonavista together as one

board? It is a governing board and we are not attempting to merge services. It

is not a matter of emerging services in the hospitals or in the clinics, it is a

matter of board services and administration.

We think there will be some savings there. Certainly

the savings will not be there as would be in St. John's because there is

tremendous duplication in the city here, and we may be able to do other things

here as well. It would be of some value, I think, to put all under one board.

The other problem is this, I wanted to cut down on as many as possible of the

number of boards that we have operating for the reasons I mentioned.

MR. CHAIRMAN: Ms. Verge.

MS. VERGE: Thank you.

Coming back to board mergers and reorganization,

perhaps some people in the western region, before a decision is made about

reorganization, would like to see the report the Department of Health did last

summer on the instructions of the Premier. The Premier, last July, told people

in Western Newfoundland, following the furore over the cancellation of

first-year nursing intake and then the reinstatement, that he personally had

ordered an immediate assessment of aspects of management at Western

Memorial Regional Hospital. The media in Western Newfoundland at intervals since

then have asked the Premier about the report and most recently when he was asked

by CBC Radio, the Premier said he'd have the Minister of Health release it.

Now, people in Goose Bay were interested in getting a

three-year-old report about the Grenfell Regional Health Services and the

contents of that report, while being three years old, are undoubtedly affecting

their thinking about the best organization of boards in their region. I would

think people in the western region should have the benefit of the contents of

the Premier's report, and I am wondering when the minister is going to do what

the Premier said he would do and release that report to the public.

DR. KITCHEN: It's a straight question; I don't

know if I can give you a straight answer.

We have had a report on the `doings' last spring and

the difference between that and the one in Grenfell - Grenfell was an

operational review of the services there - a comprehensive operational review -

which we looked at because there are certain things you can release, but where

individuals can be clearly identified you don't particularly want to release

that because it's not appropriate.

I think that's the basic difference here between the

two reports. The one in Grenfell was on individuals that can be identified. It

was just a general statement about the way things should be done in that general

area, while this had to do with a series of events whereby a decision was made

and then changed.

MS. VERGE: When I've asked the minister about this

before, on occasion he has described the report about Western Memorial Regional

Hospital as an operational review report. Now this morning he seems to be

indicating that the report, in fact, has to do with the nursing school fiasco.

Are there two reports done since last summer about Western Memorial Regional

Hospital?

DR. KITCHEN: There are two reports; one is an

operational review of Western Memorial and subsidiaries, whatever you call it,

that system over there, which was conducted by - was it conducted by our

department, by our officials?

DR. WILLIAMS: Yes.

DR. KITCHEN: And some of them are here now, I

think. The other was a special report having to do with the decision to stop

enrolment and then to -

MS. VERGE: (Inaudible) report. The Premier has

told people in Western Newfoundland that he would have the minister make public

that report and I'm wondering when the minister will do that.

Since we now know that there is an operational review

report, and the GRHS report was an operational review report, will we have to

wait three years to get our Western Memorial operational review report, or do

you think we might get it now while it's fresh.

DR. KITCHEN: Well, we'll have to see. We don't

normally like to release these things because, what it is, we send our staff in

to have a frank look at what's going on in the system and they look at various

things and make various suggestions as to what may happen. This is not the be

all and end all; it's just our staff's opinion of what goes on. Then the

operational review, the people there in the system respond to it and they make

some of the changes or all of them or none of them. So, that's basically what it

is. Now, the question comes up: What good can be served by making this available

to the general public? Perhaps in some cases it can.

I think the other one in Goose Bay was released under

the Freedom of Information Act. Somebody asked for it, and because it didn't

offend the guidelines for releasing it we decided to release it. I suppose we

could have a look at that to see if anyone who really wanted it might have a

look at the operational review and that individual wouldn't be compromised by

it. I'm a bit reluctant to have a general policy of releasing publicly all

operational reviews for the media and others to be commenting on because it may

destroy the effectiveness of the review. The officials who go to review, or the

consultants who do these things, might be a bit constrained in what they say if

it's known that whatever they say is going to come out and be subject to the

interpretation of the news media and other people. There is a sensitivity there

but we could have a look at that to see if it's appropriate, if anyone really

wanted it, and ....

MS. VERGE: Obviously people want it or I wouldn't

keep asking for it.

DR. KITCHEN: No, but the news media want it and I

don't dance to the tune of the news media. I refuse to do it.

MS. VERGE: I'm not a reporter.

DR. KITCHEN: And I refuse to dance to the

Opposition too, by the way, but we'll listen to appropriate requests.

MS. VERGE: We've noticed that. I'm got another

question now about the non-emergency medical transportation program. I've asked

the minister about this in the context of representations by cancer patients and

relatives of cancer patients in the western region who say that the cost of

travelling to St. John's and staying in St. John's for six weeks or five weeks

or seven weeks for radiation therapy is prohibitive. The minister has

acknowledged the shortcomings of the former non-emergency medical transportation

assistance program - we have to get an acronym for that - which reimburses

people only 50 per cent of allowable costs exceeding $500 a year. I'm wondering

if the minister has done anything to provide adequate assistance to cancer

patients who have to come to St. John's for lengthy periods of radiation

therapy.

DR. KITCHEN: Thanks for that question we are on

the same wavelength. I agree with you that there is a problem here. That people

who must come to St. John's are sometimes subject - we have this general policy

which in my view is not totally adequate. It is far from adequate. Whereby we

pay, as you say, half the cost over $500 in a given year, in a given twelve

month period. We have not been able at this stage to adjust that formula. I wish

we could. I look forward in the future to be able to adjust that formula, but at

this moment it has not been adjusted. There is a shortcoming and I'm sorry about

it. We are on the same wavelength.

MS. VERGE: I appreciate the minister's honesty. A

quick word of praise. I was glad to see in the Budget Speech the announcement of

the breast cancer screening program. I would like the minister to explain what

will be done this year.

DR. KITCHEN: We've got a fairly large sum of money

to examine that whole program because we want to have an appropriate program for

breast screening in place. The details have not all been worked out. We know

that the cash is there. We have to have some discussions in the department as to

the precise methods by which that be expended. I think I would like to ask Ms.

Bishop who chaired the committee which brought in the report on breast screening

to have a few words on this.

MS. BISHOP: Thank you, Dr. Kitchen. As Dr. Kitchen

has indicated our committee worked very diligently in bringing together the

report. We will in 1994-1995 be initiating a three-year pilot project for an

organized breast screening program. This is the same route that the Province of

New Brunswick has decided to pursue, as other provinces have done. The program

will consist of professional and public education that will be designed to

target all women in the Province to promote breast self-examination and to

discuss breast screening.

The program will draw on other agencies to assist with

the component of the program - for example, the Canadian Cancer Society and the

Breast Cancer Information Exchange project sponsored by the federal government

for Atlantic Canada. The second component will be clinical breast examination.

Women over the age of forty will be encouraged to have their breasts examined by

a trained health professional on a regular basis. The third component: breast

self-examination. Women of all age groups will be taught breast

self-examination, will be given literature, and shown videos on the subject.

Then the fourth component will be screening mammography. Asymptomatic women

between fifty and sixty-nine years of age will be offered two view screening

mammography on a biannual basis. Referrals for screening will be accepted from

physicians, from other health professionals, family and self. The screening

pilot will initiate and maintain a system of client follow-up to ensure

continued attendance for screening. Quality control mechanisms will be

implemented as part of the screening pilot project, an evaluation protocol will

be integrated in the plan for delivery. The breast screening program will not

replace the current service of diagnostic mammography which is available in

eight centres already established in the Province but will be an enhancement.

MR. CHAIRMAN: Thank you, Ms. Bishop.

MS. VERGE: Just for clarification? Will there be a

mobile screening unit or will the screening be available at the same eight

centres as the diagnostic?

MS. BISHOP: (Inaudible).

MR. CHAIRMAN: Mr. Harris.

MR. HARRIS: Thank you, Chairperson. I guess the

questions I asked the last time, I'm sure you've had lots of time to think about

the answer. Just some information on the take up rate at Humberwood and Talbot

House. I know they are different types of operations but I would like to know

some statistics on the operations of Humberwood and Talbot House.

DR. KITCHEN: (Inaudible) we have these two

institutions. The one in Humberwood is for the treatment of people who have been

referred there, for alcoholics and problems similar to Don Wood in Ontario. I've

asked for an evaluation to be done on Humberwood because we've had some

proposals to extend that whole area of treatment. Before doing so I want to know

just what the success rate is and things of that nature. I know some people

who've gone through it who've had severe recidivism problems there. I'm not

doubting it, I agree with you, that we need some evaluation of what is going on.

Because we want to do what is appropriate.

I don't know if we do have statistics as to the number

- Joan, do you have all that? Ms. Dawe.

MS. DAWE: Thank you, Dr. Kitchen. Just to explain

the difference, Mr. Harris. The Humberwood Centre is an in-patient treatment

centre

whereas Talbot House is strictly detoxification. In Humberwood there are

ten in-patient beds. There we operate a twenty-one day treatment program. The

normal waiting period for admission to Humberwood is just the one program, so

within the month people can be accepted for treatment. That component, then, is

linked with the out patient counselling the follow-up service which is offered

by the drug dependency services.

As Dr. Kitchen had said, we had contracted with Dr.

Dennis Kimberley from the School of Social Work at the university. He has

conducted a review of the Humberwood program and we expect a report in May month

on that.

The Talbot House, as a detox component, we have

twenty-one beds there for admission for males and females in the detoxification

area. The normal length of stay is from three to six days in that area, and that

as well is linked with the drug dependency out-patient services as well, so we

are endeavouring to provide for the full continuum of service from the treatment

to out-patient counselling.

MR. HARRIS: Is it safe to assume that given a

twenty-one day treatment program and ten beds that we might have between 120 and

150 people a year go to Humberwood? Is that about right?

MS. DAWE: Yes, in that range. It's normally fully

occupied.

MR. HARRIS: And it's referrals from physicians

only?

MS. DAWE: No.

MR. HARRIS: How is it done?

MS. DAWE: A person will have to be seen by a

physician, but it can also come through the out-patient counselling services,

and would have to be seen by one of the addictions counsellors before actually

being admitted to the unit, and then followed up after with the out-patient

service.

MR. HARRIS: I wasn't questioning the success rate,

Dr. Kitchen, although obviously it is of interest. I wouldn't be surprised at

all if there was a recidivism - I wouldn't say healthy, an unhealthy recidivism,

but a not uncommon recidivism. I suppose I would have to compare that with what

happens at Don Wood and other centres, but given your opening remarks, Dr.

Kitchen, about the importance of alcohol as a problem in society, I am very

interested in the success of that program. I don't know what the cost of that is

compared to the Talbot House. Is there a per patient cost you can just dab at?

MS. DAWE: The per patient cost for the Humberwood

is in the range of $110 or $115 a day.

MR. HARRIS: Per day?

MS. DAWE: Per day.

MR. HARRIS: The other question I had of that

nature, looking at page 247 in grants to hospitals, 4.2.01, the overall budgeted

amount, or the voted amount, is $454 million. From that is a revenue from the

federal sources of $1.07 million, down about $200,000 from the budgeted figure

for last year, and revenue from provincial sources increased from $5.4 million

to $7.4 million, which is almost a 50 per cent increase, perhaps 40 per cent

plus increase. What is that revenue from provincial sources? Is that fees and

charges to patients, or is it something else?

DR. KITCHEN: The provincial is revenue from third

parties who are financially liable for the cost of hospitalization. That would

be that. Am I right there?

AN HON. MEMBER: (Inaudible).

DR. KITCHEN: Then there is reciprocal billing from

other provinces. That would be under provincial as well. The third party is

about $4 million, reciprocal billing is $3.4 million; that's about it, and

there's a very small amount there for rentals from environmental health services

of $4,000, so basically it is third party liability and the reciprocal billing.

That is what it amounts to, but I guess your question is, why are they up?

MR. HARRIS: Well, there is a fairly substantial

increase there and if the provincial sources are other provinces under third

party billings I guess they are doing a very good job of recovering the monies

from insurance companies through motor vehicle accidents and things like that.

Is that what we are talking about here in third party?

DR. WILLIAMS: Probably, Mr. Harris. Government

recently made a policy decision with respect to third party liability issues and

going to a levy system as they have in other provinces of Canada whereby the

insurance bureau would pay the Province a certain amount based upon the number

of vehicles in the Province and in turn we would not have to go through this

long exhausted process of collecting third party liabilities through insurance

companies. Therefore, because it often takes two or three years to collect third

party liabilities because the cases have to go to courts, sometimes they are

settled out of court and sometimes they are settled in court, there will be a

period where we will have increased revenues for a number of years.

The levy system will come in this year and we will get

money for this year with the levy system, but we will also be collecting

revenues from last year and the year before. So, for the next three years we

will have sort of a windfall in terms of increased revenues for two or three

years. That is the main reason.

DR. KITCHEN: Now, what was the other question as

to it being up about $800,000? Did you ask a question on that one, too?

MR. HARRIS: Well, the decrease in the other one is

covered there, but certainly there is a decrease in the federal source of

slightly under $250,000. I also see a decrease in dental services, a budgeted

amount for dental services of about $300,000. In fact that budgeted figure for

the current estimates is the same as the revised estimates from last year. Has

there been a decrease in services? Has there been some policy changes that have

resulted in that decrease? Is there an explanation for that?

DR. WILLIAMS: Mr. Harris, I will give you the

overview of it and if you want some more details I will get Mr. White to

respond.

Over a year ago there were some changes in the dental

health services plan for children and we estimated that to implement those

changes would cost some $6,040,000, but actually this year within the changes

that were made only $5.7 million was spent. As this is an open ended-Budget the

estimates are based on this year's revised Budget, so it is $5.7 million put in

this years because that is what we spent this current fiscal year. The figure of

$6,040,000 was an estimate based on changes to the program but it actually came

in as $5.7 so this is the amount in this year's Budget, but if the amount goes

to $5.8 then that is the amount it will be next year, sort of an open-ended type

of system.

MR. CHAIRMAN: Ms. Young.

MS. YOUNG: Mr. Chairman, I certainly want to

congratulate the department on its initiatives, especially on the restructuring,

I guess, or the regionalization of the hospital boards, as I am certainly

looking forward to it in the eastern region. I think the duplication of services

in the administration area will certainly be an improvement. As well the breast

screening program is something that I am sure will be very well accepted by the

female population of this Province.

There is some clarification that I need in some of the

areas. I am thinking specifically of homes for ex-psychiatric patients, just

wondering how well that is working, and what is the cost per patient. Do you

have any breakdown on that? That is 2.3.02, page 241.

DR. KITCHEN: Psychiatric patients.

MS. YOUNG: Approximately how many patients are

availing of that particular service?

DR. KITCHEN: Yes, we will have all that for you

now in a second. We have 255 individuals residing in twenty ex-psychiatric homes

across the Province. Most of them are close by St. John's. (Inaudible) mostly in

Conception Bay South. There are 255 individuals in twenty ex-psychiatric homes.

MS. YOUNG: How well is that working? Has it been

assessed recently?

DR. KITCHEN: I have had, as far as complaints are

concerned, no complaints about that. Some of the money goes for care and

personal care allowances and there is a feeling that perhaps these allowances

should be increased. Not only for ex-psychiatric patients but also for other

people who are in similar situations, which we call personal care homes. That

allowance is a bit light, but at the same time we feel that we can't afford to

increase it at this point in time.

Some of the cost goes towards the night security

personnel because people who are in these ex-psychiatric homes, the operators

get a special allowance to cover the cost of night security. Also, for some

supplies that they use for their patients like dressings and lotions and things

of that nature.

MS. YOUNG: Thank you. Also, 3.3.03, Dental

Services. I notice there that in your budget for 1993-1994 you budgeted for

$6,040,000 and you actually revised it to $5.7 million. That is the estimate for

this current year. Can you tell me why the budget had to be revised? That is

page 244.

DR. KITCHEN: Oh yes, that is basically the

question that Mr. Harris asked there, why it went from $6 million down to $5.7

million.

MS. YOUNG: Yes, I'm sorry, I didn't hear his

question.

DR. KITCHEN: That was the dental service budget

that was decreased from $6 million to $5.7 million. That is basically the take

up. This is, as Dr. Williams says, an open-ended budget. The take up this

current year was $5.7 million. If more people had come to avail of the services

then we would have spent more than $5.7 million. That means that the current

year, the coming year, we budgeted for what we actually spent last year.

MS. YOUNG: I'm wondering. In the school where I

taught there was a program whereby the dentist came in and he saw a high number

of students. I just forget whether they needed a permission slip from parents or

not. It seemed to me a very good program. There were kids who probably would

never have been referred to a dentist and received the kind of work that these

kids availed. It was really good. I thought it was an excellent program. I don't

know how much of that has gone on throughout the Province.

DR. KITCHEN: We are thinking about changing the

program a little bit now. Because now the children who partake of this program

go to dentists' offices and they get fluoride treatment and other things, but we

are hoping that we can change that - in fact, we've agreed to change the

fluoride treatment so that it will be done on as a pilot project. Go ahead, Ms.

Dawe, give us the details on that one. It is a nice program.

MS. DAWE: Thank you, Dr. Kitchen. Over this last

year we have been in dialogue with the Newfoundland Dental Association regarding

establishing a preventive program for children in the school setting called a

fluoride mouth rinse program. Whereby children from grades I to VI would rinse

their mouth with a fluoride rinse once a week as a preventive program. As I

said, we are in dialogue with the dental association. This whole proposal will

be brought to the dentists' association at their annual meeting next month and

some final decisions will be made there.

The cost, if you consider the cost of the topical

fluorides in the dentist office now, around $300,000 annually, and they are able

to care for less than 45 per cent of the children in the Province in that age

range of grades I to VI. The proposal that we've been working on with the dental

association will be using that same amount of money but reaching over 90 per

cent of the children in the same age category throughout the educational system

in the Province. We hope with the approval of the dental association over the

next month to be able to start instituting that program in the Central

Newfoundland region to begin with in September, and then gradually across the

other regions as well. Hopefully within a year and a half, if all goes well, we

should have this preventive program in place in the Province. A very effective

one.

MS. YOUNG: I also want to ask a question as to

have there been any studies done with regard to the effects of the school milk

program on the overall well-being of our Newfoundland school population.

DR. KITCHEN: Yes. The reason we're huddling here

is because that is not in the Department of Health's program. It is the

Department of (inaudible) comes from the milk producers, I think, and is

supported by the Department of Health but it is supported morally rather than

financially. Is that right? Apparently we are on the committee that administers

it, but it is basically an initiative from the milk producers to sell more milk.

MS. YOUNG: Yes, I realize that, but I also saw it

as being an excellent source of calcium and the other great things that we see

in our milk product.

With regard to Pay Equity, and that is 4.2.03, page

247. Could you just clarify for me what is being done with that issue?

DR. KITCHEN: Basically this is the conclusion I

think of this particular round on pay equity. Quite a number of employees in the

health care sector are receiving pay equity adjustments. These have resulted in

an increase in pay rates of approximately 85 per cent of the female dominated

job classes, affecting about 5,000 employees. These adjustments range from $0.09

to $1.99 an hour, with the average adjustment being $1.05. As I understand it,

and somebody can correct me if I'm wrong, the extra amount of money that is in

there this year is to conclude this round of negotiations? Who would know about

that?

AN HON. MEMBER: Dave Saunders.

DR. KITCHEN: Did you want to say a few words about

that Dave?

MR. CHAIRMAN: Actually your time is up. So if it's

by leave of the committee to clue up Mr. Saunders, we'll give you just a short

time.

MR. SAUNDERS: Yes, the March 20, 1994 pay equity

adjustment was annualized and there's one more instalment to come on March 20,

MR. CHAIRMAN: Now before I recognize Mr. Smith we

have two more - Mr. Langdon and Mr. Hodder. Ms. Verge has indicated she'd like

to speak but she said if it was a time she would be willing to give over to Mr.

Harris who wants to speak. So we're in a situation that - Ms. Young tells me

that she has an appointment. She has to leave here at about 12:15.

MS. YOUNG: At 12:00 o'clock actually.

MR. CHAIRMAN: At 12:00, that would put the

committee in some degree of jeopardy if we had to come to a vote. The people who

are asking the questions; Mr. Smith, Mr. Langdon, Mr. Hodder and Ms. Verge, if

they could shorten it up from ten to five minutes for the questioning we could

conclude this this morning, otherwise I'm afraid we're going to have to adjourn

at 12:00.

MR. HARRIS: Mr. Langdon has suggested before he

left that he would be prepared to give up his time if that would conclude

matters.

MR. CHAIRMAN: Well that will certainly help it.

Now we need a little more concession from somebody along the way because we need

to get it into 12:00 for this. So will we assume that we'll be able to call a

head by 12:00 with all the questions we have?

MR. HARRIS: (Inaudible) twenty-eight to

twenty-four, I guess, that'll give us eight minutes each instead of ten.

MR. CHAIRMAN: Alright, I now call on Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman. I'll try to be

brief and I'll ask for brevity in the answers as well, maybe that'll facilitate

matters.

If I could just get back to the medical school,

there's one other point with regards to it that I wanted to raise in that - it's

not necessarily something that you would have right now but possibly, if you

can't respond to it, as part of your review which is something that you could

maybe look at and make the information available. With the figures that you gave

me it looks like the - just doing some rough calculations, it would appear that

about 70 per cent, approximately 70 per cent of the graduates of the school are

residents of the Province. I would assume that that's the arrangement that's

agreed to - arrangement that we had with other provinces that are buying the

service from us, is that the set ratio?

DR. WILLIAMS: That was in the range that was set

years ago when the medical school started up. There are ten seats that are

purchased by the Province of New Brunswick every year, forty seats are from

Newfoundland residents and usually most medical schools in Canada take in other

residents of the country. All people admitted to the medical school are Canadian

citizens. To provide for some mixture of people from across the country, there

are six seats that are for residents of Canada but not necessarily residents of

Newfoundland, forty from Newfoundland and ten that the Province of New Brunswick

pays for. As well, residents of Newfoundland are able to get into other medical

schools across the country but there's no transfer of dollars in terms of that.

That's just a policy decision.

MR. SMITH: Okay. The other part of that question

and you may not have that information in terms of - I'm just wondering, in terms

of the ability of the university to respond in the number of applications that

they're receiving, how would this be reflected here? How many students are we -

are we getting 100 applications from within the Province and we're able to -

DR. WILLIAMS: I understand this year, and I can't

tell you for other years, there was approximately 200 applicants for the forty

positions for Newfoundland graduates. Now these are applicants, not all of these

would be - when you weed them down - would be qualified to get in but that's 200

applicants of which I think they did 100 interviews and of which they'll select

forty people.

MR. SMITH: Okay, thank you.

The other area I wanted to just focus on for a minute

because it is an area of some interest to me, 3.4.02, the Road Ambulance

service. Having recently, within the last three or four years, had the

experience of working at establishing a service in the rural area I can relate

to some of the difficulties that are involved in trying to set up a community

service. I notice under Allowances and Assistance that there is a slight

increase. Does this refer to the assistance given to, let's say, in my home town

of Lourdes where we've set up a volunteer group that runs a road ambulance

service, that they are the - I think it is on the basis of fifty cents a

kilometre right now that they are reimbursed for the runs that they make.

Because I had been contacted by the committee a few

months ago and they were of the opinion - I don't know where they got the

information - that this was under review and in fact that there were going to be

some changes there. Does this confirm - am I reading this right now, that that

has not changed? That the rate will continue as it has been up to this point in

time.

DR. KITCHEN: There has been a rate increase

approved for road ambulance. Dr. Williams, would you want to go into more detail

on that?

DR. WILLIAMS: It is in the range of $200,000. It

is $200,000 approved this year. It is linked in with the provision of quality.

We are developing a program in consultation with the ambulance operators and

Treasury Board that will utilize these funds in terms of the attendant package.

There is an attendant component to the mileage subsidy and this will link into

having a qualified attendant on various trips. They will get more money if they

have a qualified attendant. It is related to quality. We are trying to use this

money to improve quality of service. There is $200,000 extra going into the

mileage rate, yes.

MR. SMITH: So would that move beyond what is the

present level or...?

DR. WILLIAMS: Yes, it will be $200,000 beyond the

current mileage rate but it will be linked into the issue of having people

trained, trained attendants.

MR. SMITH: Okay, but my question is, bringing it

back down at the local level, how will that translate, for example, in the

situation that I referenced? Say in Lourdes to the ambulance system there. Right

now I think they are receiving fifty cents. They do use qualified ambulance

attendants. Will they see an increase beyond that or will it remain at that

fixed rate?

DR. WILLIAMS: No, there will be an increase

depending on the level of attendant and the attendant's training that they

provide.

MR. SMITH: Okay. The other matter that I wanted to

raise with regards to the Road Ambulance service is that - I know we are pressed

for time - we were about three years trying to establish the service. We

fund-raised in the local area to come up with $25,000, had made the agreement

with the Province, purchased the vehicle, had it sitting in our garage in

Lourdes, only to find out that no one had told us that it was going to cost us

an astronomical amount to put insurance on the vehicle. We were ready to

establish service, had trained attendants, had the vehicle sitting in the

building, only to find out when I started contacting the insurance companies

that the best quotation that I could receive is something in the area of $4,200.

At no point in time had we ever - I didn't have the vaguest notion that it would

be so expensive.

We managed to get through in the first year but since

then, I understand from the committee, that they, through the ambulance

association, the independent operators, that I think they have worked out some

sort of an arrangement now for better rates. But I'm just wondering in terms of

the department, is this something that is being addressed? Because it seemed to

me to be a - first of all I think up front, when I had the initial meetings with

representatives of the department, I think it would have been very worthwhile

from my perspective that someone had said to me: We would just like to alert you

to the fact that it is going to cost you a lot of money to ensure this vehicle

so you can build this into your fund-raising effort.

Also, another part of that, is the department, or has

the department been active in trying to lobby to do something at improving the

insurance rates? Because in this instance, when you are talking about

communities that set it up, run it on a voluntary basis, it is certainly a

deterrent to have to go out and raise those additional funds to purchase

insurance. When we started out we were looking at a service that we thought

would probably mean fifteen runs a year, sixty miles return, but still the best

that we could look at was in excess of $4,000 for insurance. I'm just wondering

if someone would like to respond to that.

MR. HART: I can address that. I would just like to

say that generally speaking we have dialogue on a regular basis with the

operators of the ambulance business in the Province. Primarily that has been the

private operators, but we have been trying to establish a relationship with the

volunteer or community organizations because that has been (inaudible). I know

there have been some discussions as to the possibility of the volunteer or

community organizations forming their own association to have direct

representation with the department; or alternatively they've been looking at

linking in with the Private Ambulance Operators Association. Because a lot of

the issues are very common.

On the matter of operating costs, we've recognized for

some time that a lot of these volunteer organizations have - when they were set

up initially they were set up in areas of the Province that were remote, I

guess, to a large extent, that wouldn't be viable for a private operator to move

in because they just wouldn't be able to make a go of it with the existing

subsidization rates. Because their trip statistics wouldn't be up there in an

area where there would not be a lot of volume in that sense.

There is a separate arrangement that went in place

years ago for volunteers in terms of the department will subsidize 50 per cent

of the cost of acquiring an ambulance unit, with the understanding that the

community then would pick up in various forms - through volunteers, driving, and

through fund-raising efforts they were able to operate. It appears that over the

last little while we've seen a trend where volunteers are not as free with their

time any more. I guess they have their own financial problems to a large extent.

We've seen a lot of stress on the community or volunteer organizations where a

lot of them have been coming to us and indicating that it is much more difficult

to operate than it was in the past. It is an issue that has been on our agenda

for some time.

Dollars are short as you are aware throughout

government so what we are trying to do is accommodate where we can through

developing efficiencies in the whole road ambulance program. That is something

that is going to take some time. It is not something that can happen overnight

but we are seriously looking at it. We are hoping too that this volunteer group

- actually I attended a meeting out in Gander about a month or so ago. That was

the first indication that they wanted to get together, form their own group, so

they could discuss common issues. The problem is, when you deal with segmented

groups it really is difficult to get a handle on the whole thing, but I think

with an organization formed that will make that process much more efficient.

MR. CHAIRMAN: Thank you, Mr. Hart.

Your time has expired now.

Mr. Langdon, I understand that you have in the

interests of time decided that you wouldn't require your time.

Mr. Hodder.

MR. HODDER: Just one basic question and it is to

do with the vote that is 2.2.03, Prevention and Promotion. If we look at the

total vote there, $443,400, and take that as a percentage of your total budget,

which is $872 million - that might not be a fair comparison because as you know

that doesn't quite work that way - but at the same time I'm very interested in

prevention and promotion, both as it applies to the Department of Health and the

manner in which prevention and promotion is integrated as a function of all

departments of government.

I can't think of any department