Social Services Committee — Department of Health and Community Services — 29 April 1998

1998-04-29

Newfoundland and Labrador — Committees

April 29, 1998

SOCIAL SERVICES ESTIMATES COMMITTEE

Pursuant to Standing Order 87, Edward Byrne, MHA,

Kilbride substitutes for Loyola Sullivan, MHA, Ferryland; Perry Canning, MHA,

Labrador West, substitutes for Gerald Reid, MHA, Twillingate & Fogo; Gerald

Smith, MHA, Port au Port, substitutes for Wally Andersen, MHA, Torngat

Mountains; and William Ramsay, MHA, Burgeo & LaPoile, substitutes for Mary

Hodder, MHA, Burin - Placentia West.

The Committee met at 7:00 p.m. in room 5083,

Confederation Building.

CHAIR (Mercer): Order, please!

(Inaudible) for your budget session. I will just

ask the members of the Committee to identify themselves, starting with Bill.

MR. RAMSAY: Bill Ramsay, MHA for Burgeo &

LaPoile. I am here on behalf of Mary Hodder, who is unavoidably absent.

MR. CANNING: Perry Canning, MHA for Labrador

West. I am here on behalf of Gerald Reid, MHA for Twillingate & Fogo.

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

Chair of the Committee.

MR. E. BYRNE: Ed Byrne, MHA for Kilbride. I am

filling in for Loyola Sullivan, who is in Ottawa.

MS S. OSBORNE: Sheila Osborne, MHA for St.

John's West.

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

I am filling in for Wally Andersen.

MR. WHELAN: Don Whelan, MHA for Harbour Main -

Whitbourne.

CHAIR: One other member of the Committee has

not yet arrived, Harvey Hodder. He will be a few minutes delayed.

The procedure for the evening is the same as in

previous years. We will ask the minister to make some opening remarks, perhaps

ten to fifteen minutes, whatever she deems to be appropriate. We will then ask

questions. The way in which we will start the questioning is, we will start with

the Vice-Chair, Mr. Byrne, and then alternate between both sides, shall we say,

for ten to fifteen minutes apiece until virtually all the questions have been

eliminated or exhausted.

I would ask, when people are speaking, that they

identify themselves for the purposes of Hansard so we can maintain a good

record.

Minister, if any of your officials wish to speak,

or you wish them to speak, could you have them come forward to the mike when you

require them?

With those few very preliminary remarks, perhaps we

could get started.

Minister.

MS J.M. AYLWARD: Thank you very much.

I am very pleased to be here this evening. I, too,

would like to have an opportunity to introduce my officials, and I would ask

that they introduce themselves. To my right is Dr. Bob Williams and to my left

is Mr. Jim Strong, and there are a number of people behind here. I know I will

forget someone's name now when I do this. Would you like to introduce

yourselves?

MS DELANEY: I am Florence Delaney, ADM of

Support Services.

MS ELLIOTT: I am Pam Elliott, ADM of

Institutions.

MS. FITZGERALD: I am Brenda Fitzgerald, ADM of

Community Health.

MR. WHITE: I am Gerry White, ADM of Policy and

Planning.

MS RANDELL: I am Vivian Randell, Cabinet

Secretariat.

MS CRAWFORD: I am Elizabeth Crawford, Director

of Child Welfare and Community Corrections.

MS LAWLOR: I am Helen Lawlor, Director of

Community Health.

Ms J.M. AYLWARD: Thank you to my officials.

If I could just start off by making a few

introductory comments, I guess the first comment I would make is that it has

been a very exciting year for this department, in the creation of the new

Department of Health and Community Services.

As you know from last year, those of you who were

present, this was sort of an announcement that was made based on years and years

of consultation, I suppose, and staff requests to move in this direction whereby

we would realign departments in a service component to try to deliver services

based on the needs of the client, the individual, or the community, as opposed

to the program.

We spent the last year in an administrative way

getting ready for those changes and recognize that we still have a number of

years yet whereby we have to, I guess, create and work on the outcomes that we

have set down for ourselves. It has been quite a busy year.

Really what you are seeing for this - a piece of

the puzzle here for the Estimates is a culmination of Social Services, Human

Resources and Employment and this department brought together. We will see that

in the Estimates for some of the numbers, I am sure.

What started out as a vision just a few years ago

by a number of staff has actually come to fruition. I guess it was made very

clear when we were at a conference a few weeks ago in Gander and a thirty-year

member of the Department of Human Resources and Employment said that he had

dreamed about this happening. He was sort of a little bit sad to be retiring

because after so many years of wanting to move in this direction he is finally

beginning to see it and the reality of it was quiet exciting.

With respect to the Department of Health in

particular, what started out as a flat-line budget, to be flat-lined over three

years, quickly turned into an increasing budget. It has actually increased by

over $60 million over the last couple of years. Now this department is the

largest department in government, with over $1 billion.

We still have many challenges, although there are

many exciting things happening. We have seen a number of very exciting things

happen this year with the new nurse practitioner program, and some of our pilot

projects in particular. We look forward to the challenges that the Department of

Health and Community Services will bring us this year, particularly as we

grapple with an aging population, among other things, in a publicly funded

system that we believe is certainly in jeopardy by virtue of what we are seeing

happening across the country.

I would say that what we are seeing is so

frightening that in some of the provinces in Canada - in Alberta particularly -

they are about to pass a piece of legislation that would create the first

private hospital in Canada. I think it is a sad day for all of us because it

would be outside the Canada Health Act. It is something that will impact, I

believe, on every province in this country. I do believe that this type of

initiative will be the beginning of the end of the publicly funded health

system, which is a very frightening thing. But it is certainly something that is

happening in Alberta, and I do not know if there is any way of stopping that

slippery slope. We certainly all have our challenges. Our environment is

becoming increasing hard to (inaudible).

With that I will turn it over to you to begin your

questions, and we will do our best to answer your questions.

CHAIR: Thank you kindly.

Ed, if you would like to start we will follow with

Mr. Whelan.

MR. E. BYRNE: A challenging portfolio,

Minister, the biggest department in government.

MS J.M. AYLWARD: So far we agree.

MR. E. BYRNE: Obviously it is a big concern.

You probably have the department where most of the public concerns are generated

today in terms of priorities, and I am sure I am not telling you anything of

which you are not already aware.

I would like to start off dealing with the Western

Health Care Board for a few moments. Obviously the Western Health Care Board

significantly is under a financial sort of duress, if I could use that word.

Audited statements are still not available for the department or for the public

view.

As a former chairperson of the Public Accounts

Committee, I recall holding hearings in Corner Brook dealing with the Western

Health Care Board. One of the items was the financial stability of the Board

itself, and a proper accounting for public monies.

Would you care to comment on where that is today

with the respect to the Western Health Care Board? What sort of deficit

situation do they have? What measures have the department taken to correct the

situation that exists, or even the perception of the situation that exists, in

the Western health care region?

MS J.M. AYLWARD: There has been quite a bit of

difficulty with the Western board, it is no secret, and that is one of the

reasons why we identified the need to do a major monitoring by an outside group.

The Atkinson group was contracted to do that work, and they are still in the

final stages of completing that work.

Because of the difficulty they have had in Western

over the last number of years in actually recording their data and being able to

pull it together, the Atkinson group is quite hesitant to deliver a final report

until the audited statements are in. You do have the draft of one of the

statements from the year before last. I believe the other one is probably in a

draft form, although I am not aware that it has been submitted. It is very close

to being finalized. Once that is finalized, they will then complete their

report. Their report is a very comprehensive report looking at a number of

things, including not only the operational needs of Western but also the

financial component.

In addition to that there has been some

instability, as you know, when it was brought to our attention. I guess it was

about two years ago now; there were some practices that were being carried on by

the then former Administration that were less than acceptable in terms of their

spending activities. They had

an act that allowed them to act in that way. Since

then we have put some other controls and monitoring processes in place.

In addition to the outside report, we are in the

process of completing our own audit and our own monitoring of what is going on

out there. So I guess we will have the outside view, we will have the audited

view, and we will have the departmental view, and try to bring the three of them

together. Because what we will do at the end of it is, we will not only try to

realign the regionalization process which really has not occurred to the same

extent as it has in the other regions, but we will look at the services that

need to be delivered, particularly as they relate to physician services but also

in terms of how we are going to cluster the types of services that need to be

delivered in the region.

That is how we will be looking, and from there I

would assume that once they have their COO - they have their CFO and their CEO

and now we are trying to finalize the COO. Got all of that? Chief Financial

Officer, Chief Executive Officer and Chief Operating Officer. Once that team is

in place, I think that will be key. I also know there will have to be

significant changes to address the cultural needs in the organization, which are

lagging behind the rest of the Province in terms of where they are.

MR. E. BYRNE: Are you in a position to

approximate - I am not going to hold you to it anywhere else, but just in terms

of when the audited statements would be ready? You said you would have a draft

copy of last year's, (inaudible) another copy shortly. Within your own purview

from the department, and your own operational review that you have conducted,

has that been completed?

MS J.M. AYLWARD: Our operational review has not

been completed within our own department for the same reason.

MR. E. BYRNE: When was it started, and when do

you see it being completed?

MS J.M. AYLWARD: It has been ongoing now since,

I guess, probably March. The problem is, you cannot complete your own review if

the audited statements are not in and all the information is there, so we are

waiting for that. Plus, part of our review is looking at some of the practices

in the hospital. For example, Corner Brook closed beds three times and those

beds are still open. They have some of the highest utilization bed rates in the

Province. They have the highest bed utilization in bed occupancy; they are not

maximizing their ambulatory care services. I guess they have been like a ship

without a captain for quite a while and it is evident in the types of practices

if you compare what is happening there, for example, with the Health Care

Corporation in Central Newfoundland. There is no comparison.

Our view is that we see it as a priority issue

because the sooner we get done what we need to do, the less drastic it will have

to be. The further on in the fiscal year you go, as you know, the more drastic

the measures would have to be to try and live within some reasonable budget.

MR. E. BYRNE: Criticisms out there at the time,

I guess emanating from some of the comments in the Auditor General's Report with

respect to that board - I would like to give you a chance to respond to it - I

think are reflective of themes throughout other health care boards as well. The

Auditor General indicated, she said, that the financial analysis of the Health

Care Corporation not only at Western Memorial but here, from the point of view

of the Department of Health and Community Services, has been minimal to

non-existent over the last three years. How do you respond to that?

MS J.M. AYLWARD: Are you talking about the

monitoring component or (inaudible)?

MR. E. BYRNE: Yes, in terms of, I guess, the

monitoring component. At the time that hearing was ongoing she indicated that

had she not gone out to the Western Health Care Board, the Department of Health

and Community Services would have never picked up the situation that existed out

there. In terms of monitoring the expenditure of public dollars into a publicly

funded system I guess is what she is referring to, so I will just leave that.

How do you respond that? Was that a legitimate criticism at the time? Has any

action been taken since that time to correct that? Or where the boards are in

place, government provides the funding and lets the boards manage as they see

fit with very little sort of financial analysis or monitoring of these boards?

MS J.M. AYLWARD: I guess I cannot say that it

is totally inaccurate, everything she said, but one of the things I will say, we

have actually asked the Auditor General to go in and do audits on some of our

boards specifically so that we will have the information. She has declined to do

the type of auditing that we have asked her to do because, if I remember

correctly, she made some comment about not having the proper staff to do the

type of monitoring that we have asked her to do.

I will be the first to admit that we have to

strengthen our monitoring. I have admitted that in the House and I will admit it

here, that we have to improve on the monitoring. I guess that is one of the

reasons why I just previously answered the question, we are out now doing our

own monitoring and trying to set up a protocol whereby we can do this on a more

regular basis with the boards. While I spoke to Western, we are actually doing

it with all the boards. We have been to Labrador, we have been to Central; we

will be doing all of our boards. In some of them we have already implemented

measures, even though we have not been there because some of the things are very

obvious to us.

In fairness as well, some of what the Auditor

General put in her report was not accurate information. She did not reflect the

$20 million that we put in for health stabilization. That was put in in August;

her report was released March 31. She has had a lot of contact with our

department, and that kind of major type of change would have reflected quite

differently in the Auditor General's Report. That was never, ever updated.

I am the first to admit that we need to improve our

monitoring, and we will be doing that. We have started to do that with a number

of agencies and boards, but we have also asked to have a lot of the auditing

done. Because obviously, if you are monitoring with public funds, you want to

have the best information possible.

MR. E. BYRNE: The Auditor General obviously

goes in with a purview, looks through a certain set of lenses in terms of the

scope and legislation, and it is a very black-and-white sort of process. My

experience is that some of the concerns that she has raised on a variety of

issues have been legitimate. Some have been legitimate but really are - the

individual working within a particular department or group did what was

necessary to get the job done, so I am not trying to point a finger at your

department. I am trying to get a sense of - it is a huge department. The amount

of money that is expended within the department speaks for itself.

The accountability aspect of it in terms of so much

pressure in the health care system today when it comes to providing services,

mostly because of the federal government's downloading on the provincial system

and the provincial government, but in terms of monitoring, will improvements in

monitoring and maybe an increase in expenditures in monitoring in the long run

actually save money that could go back into more front-line services? I guess

that is the issue, and situations like that which do not need to occur, should

not occur, if the proper monitoring was in place up front on a continuous basis

of all the health care boards, not just Western Memorial's, because the one she

did on the St. John's Health Care Corporation raised some concerns as well. If

there was a weakness, it might have been that. Outside your own operational

review on Western Memorial, in terms of monitoring, what tangible steps has the

department taken to improve its monitoring, I guess, for the system generally in

the Province?

MS J.M. AYLWARD: As I have mentioned, we have

put a monitoring committee from within our own department to monitor all the

boards. We are doing an initial analysis right now. I cannot say we are not

doing anything because we are doing a fair bit of monitoring. We do our monthly

monitoring, but what we are trying to do is set up a very clear protocol of

monitoring so that both the department and the various boards are clear on what

their roles and responsibilities are, and how we will be keeping a closer eye

on... We do need to improve our monitoring in every part of the system, because

when you have a $1.1 billion operation that is crucial, crosses all sectors, you

have to have good monitoring.

Yes, we can definitely improve on our monitoring.

That is one of the reasons we started visiting the boards with which we had so

many more concerns. If you look at the St. John's Health Care Corporation, and

you read the Auditor General's Report on that, and when you consider they

brought six organizations together, you have the single largest board, about

$300 million, changing from a system, a medical model which was strictly based

on a medical model, to program-based health care delivery, it is a huge

undertaking. The types of comments that were in the Auditor General's Report are

certainly, I do not think, in any way, worrisome with respect to the size of the

operation and what has been accomplished in the last two to three years.

Yes, there is room for improvement. Yes, they still

have things to do to improve on. But if you look at the magnitude of what they

undertook as a corporation, and you compare that to a major private sector

(inaudible), and you look at the volume and the number of employees they have

worked with, they have done a very superb job in a short period of time,

recognizing there is still room for improvement.

We have some areas which we are very worried about

- Western is clearly one - and we have others that we know we need to monitor.

Yes, we will be putting monitoring in an even more stringent way and under, I

guess, both Florence's direction as well as one of the other deputy ministers,

each board would be realigned in a way that is looking at the big picture not

just institutional and not just community but on the whole region, so we will be

looking at things from the full picture.

MR. E. BYRNE: I think the Auditor General

clearly indicated that the St. John's Health Care Corporation had a significant

number of balls in the air, so to speak, and did a tremendous job in bringing

together what they had to bring together in a short amount of time. I think the

largest criticism was in that the restructuring of debt that was said was going

to be done, the savings that would be realized from restructuring within the St.

John's Health Care Corporation, public announcements from government and from

the Health Care Corporation, as a result that x number of dollars, I believe it

was $20 million or whatever the case may be, would go back into front-line

services; and she found that, I guess, their estimates were way off. They were

not off a little bit, they were way off in terms of what the cost of

restructuring would be. Has there been a final analysis done, a final tally, of

what the overall cost of restructuring will be for the Health Care Corporation

and the -

MS J.M. AYLWARD: Well, the - I am sorry.

MR. E. BYRNE: No, go ahead.

MS J.M. AYLWARD: Actually, they are not way

off; the $20 million is still on target. Some of that they have already

achieved, obviously; because the Rehab Centre, for example, has moved over to

the Janeway. So they have achieved some of those savings, and what they have

saved they have put back into operations.

There is another portion yet, the $13 million, of

which they have some of it accrued and some of it yet to be accrued, which will

be put toward the cost of the new capital construction and that is where it will

go; but you have to keep in mind that you are not going to get the savings if

you have not completed all of the reform. For example, the Grace Hospital is

still open and that is a significant component; the Janeway is still open and

that is a significant component.

If you are talking about the increase from $100

million to $130 million, the actual $30 million more was completely separate in

terms of new needs. If you look at why we are spending it: cardiovascular

surgery, the parking renovations to St. Clare's and the Health Sciences Complex.

The Health Sciences Complex now is a twenty-year-old building; it opened on May

15, 1978. So even though we all think it is a new site, it is twenty years old

and it needs refurbishing. If you have been in it lately, you can see it needs

refurbishing. So this is doing things like the HVAC or the ventilation system in

the ORs and those kinds of things to keep them updated.

All I can tell you at this point is that they are

on track and the $13 million that they still hope to achieve from the completion

of the reform will be put towards offsetting the operational or the capital cost

of the new Janeway site.

MR. E. BYRNE: One last question. You mentioned

in your opening comments about the situation as it exists with the new, first

time in Canada, private hospital, and the impact it is going to have. It seems

from your comments it is unavoidable what the impact will be. Could you

elaborate on that in terms of not only nationally on the system, because it is

an important public policy issue.

MS J.M. AYLWARD: It is a frightening public

policy issue, frightening to me.

MR. E. BYRNE: To some people it is not.

MS J.M. AYLWARD: A lot of people do not know

about it, actually.

MR. E. BYRNE: I think it is a frightening

issue. Some people have talked to me and said that in education we are allowed

to have private colleges and we maintain a publicly-funded education system; why

could we not have a private hospital with a publicly-funded system? Some

individuals with whom I have spoken said that we should not throw the idea out

altogether. Personally, I do not believe it, I do not accept that sort of notion

at all, but what would be the impact of that initiative, based on your opening

comments? I am interested to hear.

MS J.M. AYLWARD: The bill is called Bill 37,

and it is a bill to open and privatize the health care under Ralph Klein in

Alberta. What they are hoping to do is to create a private health care facility

to be funded out of private funds; therefore it would not come under the

auspices of the Canada Health Act. What you do, if you look at the American

model and what has happened in places like New Zealand and in the US, you create

a two-tiered system whereby people who can pay for the service get the service

first.

MR. E. BYRNE: I understand that, but in terms

of the impact... You indicated there would -

MS J.M. AYLWARD: Okay, just let me finish. That

is the

preamble.

MR. E. BYRNE: Oh, I am sorry.

MS J.M. AYLWARD: If you look at the models like

they have in the US where they have private facilities and the HMOs, where they

have people who have to medicate or whatever, you end up with the most qualified

people working in a private centre. They have a lot more access to specialities

and services, and all those kinds of things, which works out perfectly if you

have the money. But what ends up happening is that you drain your ordinary

system, you are left with a lot fewer choices, and God knows we have a few

enough choices in this Province, in Atlantic Canada particularly, and now in

general in Canada overall.

What you end up with is a two-tiered system. You

end up with fewer services, you end up with a lot less specialities, and you end

up with a greater dichotomy between the rich and the poor. Right now, as you

know, our system is based on where we take turns. We are getting less tolerant

in taking turns, so the public is driving governments towards privatization and

politicians are feeling a lot more pressure to privatize facilities. People do

not want to wait, they do not want to take turns, and it is based on the fact

that people who are the sickest get the service first.

Whereas the way it is in

a private operation is that if you have the money you get the service.

It is just that in a country where there are more

poor than rich, the pendulum swings very much in favour, even more so, of

jumping lines and jumping the cues and having access, even though it is paid out

of private money.

If you look at what is happening in Alberta, they

have so much money in their heritage fund that they do not know even what to do

with it. Their heritage fund was put in place to offset another oil disaster,

and they just cannot figure out enough ways to spend it.

So basically it would be privately funded. I do not

know if Allan Rock is going to make the decision on it but, from what we can

understand from the justice people, it is outside the purview of the Canada

Health Act. Therefore, if you look at that with the internal trade agreements

that we have in the country, and free trade, it is a slippery slope once you get

it in one province, unless another province is visionary enough to put something

in place in the legislation to prevent privatization of clinics and hospitals.

MR. E. BYRNE: Are we moving towards that?

MS J.M. AYLWARD: We sure are.

MR. E. BYRNE: Fair enough. I will turn it over

to somebody else.

CHAIR: Thank you.

Donald. Then we will go to Sheila.

MR. WHELAN: Thank you, Mr. Chairman.

Just going through the Estimates, Mr. Minister,

there are a few things there that sort of prompted -

MS J.M. AYLWARD: You said the same thing last

year.

MR. WHELAN: Did I?

MS J.M. AYLWARD: Mr. Minister.

MR. WHELAN: Two down!

MS J.M. AYLWARD: Do you remember this last

year?

MR. WHELAN: Yes. I will never learn, will I?

MS J.M. AYLWARD: I tried to grow my hair and

everything since last year.

MR. WHELAN: It didn't help a bit.

MS J.M. AYLWARD: Not a bit, obviously.

MR. WHELAN: Ms Minister.

MR. E. BYRNE: Just say `Minister', Don. You

don't need to dig a deeper hole than what you are in already.

MR. WHELAN: At functions I get away from it.

Sometimes, with regard to clergy, I just say Reverend Clergy. It sort of

neutralizes the gender.

MS J.M. AYLWARD: Bless you and carry on, right?

MR. WHELAN: Minister, I noticed in 3.1.01.10,

Grants and Subsidies, Memorial University Faculty of Medicine, there has been a

decline, albeit a small decline. I was wondering, is that setting a trend? It is

about a half-million dollars, or something like that, in Grants and Subsidies to

the Faculty of Medicine.

WITNESS: Page?

MR. WHELAN: Page 201 in the Estimates.

MS J.M. AYLWARD: Okay.

That actually is because we have moved towards

American students and we add an increase of five American students to the

medical school each year. We charge the medical students from the United States

$30,000, which is what we estimate to be the cost, the real cost, of providing

medical education. We are expected to increase again by another five, so that is

why -

WITNESS: A total of fifteen.

MS J.M. AYLWARD: Yes, to a total of fifteen.

That is why the revenue is down. It will increase to a maximum level once we

have the fifteen US students in place.

MR. WHELAN: So the fifteen contributes about

$450,000 per annum?

WITNESS: About $450,000 each year.

MS J.M. AYLWARD: For three years.

MR. WHELAN: US?

MS J.M. AYLWARD: No, Canadian.

WITNESS: Eventually we will have sixty in, so

we will have an income (inaudible) each year.

MS J.M. AYLWARD: So we have fifteen US, five

Canadian, and the other -

MR. WHELAN: So that is almost $2 million,

eventually, (inaudible) years. That clarifies that.

Indigents.

MS J.M. AYLWARD: Give me the page on that now.

MR. WHELAN: Same page, 3.2.02. I am looking at

Total: Indigents. "Appropriations provide for the subsidization of prescription

drug costs..." That is upwards of almost $31 million.

MS J.M. AYLWARD: Yes, that is the social

assistance recipients.

MR. WHELAN: I am just wondering, when you say

`indigents' -

MS J.M. AYLWARD: That is the category by which

the social assistance recipients are classified. There are seniors and

indigents.

MR. WHELAN: I was a little bit baffled about

that. I thought it may have been some other group of people or something

(inaudible).

MS J.M. AYLWARD: No, that is what the program

has always been divided into -

MR. WHELAN: Nearly $31 million a year in

prescription drugs.

MS J.M. AYLWARD: We have a total of about fifty

for a whole drug program, divided between social assistance recipients and our

seniors.

MR. WHELAN: So your seniors, do they pay a

certain percentage of the cost of their drugs?

MS J.M. AYLWARD: They pay what it costs to have

the prescription filled. If you are on GIS, Guaranteed Income Supplement, and

you are a senior, you automatically qualify for a drug card. You will get

whatever drugs are on the formulary as prescribed, and then you pay for the cost

of having your prescription filled. That is their cost requirement.

MR. WHELAN: With regard to ambulance services

you have, on page 203 in this book, 3.4.01.10, Grants and Subsidies, $150,000.

Over here you have, "Appropriations provide for the payment of mileage subsidies

to private and community ambulance operators...", $1,741,300. How do you

differentiate between the two?

MS J.M. AYLWARD: What is your question again,

Don? I am sorry.

MR. WHELAN: We have, "Appropriations provide

for the development of programs and policies for emergency health services,

organization of emergency medical response and management of the road ambulance

program". We are looking at the road ambulance program, and there are Grants and

Subsidies there of $150,000, and over here we have Grants and Subsidies for road

ambulance service as $1,741,300. What would be the -

MS J.M. AYLWARD: One part of that is the 911

program, and the Emergency Response Program. The reason it is only $150,000 is

because we are only one of the funders of that particular program. That is

housed mostly under the Department of Municipal and Provincial Affairs. It is

one of the programs that really needs, in my mind, to have a bringing together.

I guess that is one of governments projects, but the reason is that we are only

one of the payers associated with the full 911 program.

MR. WHELAN: You have what seems to be two

headings for the same service. Is that wrong?

WITNESS: (Inaudible) operations.

MS J.M. AYLWARD: Did you hear that? One is the

operational side of it and the other is the administrative side. One is the

administration of the program, and the other is the operation of it.

MR. WHELAN: Okay.

The other one, I do not know if I should get into

it because I was hoping to see the last period of hockey tonight. Health

Facilities Operations, Grants and Subsidies, $621,960,800, that goes towards the

upkeep, the maintenance, and for allocations to hospital boards and all that

type of thing.

MS J.M. AYLWARD: Let me tell you what that is

for, now. The $10 million of new money that we put in, that is part of that. We

also have a salary increase provision put in there based on the 2 per cent this

year. In addition to that, we have funding for the reinstatement of the Lakeside

Home kitchens. We have a number of other provisions. For example, the one-time

transfer of allied health positions to community health, plus the transfer of

the additional (inaudible) million dollars that we put in earlier the year to

stabilize the health funds.

MR. WHELAN: (Inaudible).

MS J.M. AYLWARD: No, it is more than that.

Are you looking at the variance, or do you want me

to go through the full... Are you asking me to go through the full (inaudible)?

MR. WHELAN: Just sort of a general outline,

$622 million actually. I know you can't get into it in great detail but I was

just wondering generally, what does that cover?

MS J.M. AYLWARD: What I did was over and above

the cost of operating the hospitals and the nursing homes, but that is what that

includes.

MR. WHELAN: Okay, so you are talking about from

$604 million to $621 million. You are talking about the difference in that?

MS J.M. AYLWARD: Yes, that is what I was giving

you, the variance in the $7 million, and why it went up. Because the baseline is

what we give to the boards for the running of the hospitals and nursing homes,

but there is a $7 million variance. I thought you were asking me what that were

spent on, and I just gave you some examples.

MR. WHELAN: Basically, I just wanted you to

sort of - I didn't want you to get into any great detail. There are four or five

lines there telling me what you spent (inaudible).

MS J.M. AYLWARD: I can give you the breakdown,

if you want, of all the boards. For example, in the Health Care Corporation

there is about $276 million or whatever it would be now with the increases built

in, but that is what it is. It is all of the board budgets for the delivery of

hospital and nursing homes. Then there is a variance and that includes the extra

$10 million that we got on top of that. It does not include the $2 million,

obviously, for the community health because this is the facilities budget, but

it also includes the other things I mentioned, which works out to about a $18

million variance over what was identified.

MR. WHELAN: I wanted to touch on the personal

care homes, what the policy is with regard to the Department of Health, what

their policy is on personal care homes, and what you plan to do with home care

services in the future, whether you plan to upgrade health care services with

regard to home care. What is the long-term view for personal care homes as

opposed to health care? Will there be a normal concentration on one as opposed

to the other?

MS J.M. AYLWARD: First, let me tell you that if

you are looking at that you have to look at the whole continuum of what we call

continuing care, from home support to personal care homes to the long-term care

provided in the nursing homes. It is a whole gamut.

In this region, in St. John's, we are just in the

process of undertaking a study to look at what our needs are and where we need

to go, because in St. John's we have very few personal care homes. I suspect a

lot of it is due to the cost of the taxation involved to fill the personal care

home in this area.

With respect to home support, are you talking about

the home support for seniors, or home support for the disabled, or the full

program?

MR. WHELAN: There is home support for people

who are not necessarily seniors, it could be a ten-year-old child but they are

(inaudible).

MS J.M. AYLWARD: Right, so you are talking

about the whole program?

MR. WHELAN: Yes.

MS J.M. AYLWARD: I think the question you are

really asking is: Are we competing, as a government, providing home support with

a personal care agency which is competing for the same dollars?

MR. WHELAN: Yes, basically. That is what

(inaudible).

MS J.M. AYLWARD: I guess what we are saying is

that we feel that the home support program is an important component of the

publicly-funded system. In many areas - we have one of the more generous home

support programs in the country, even though we are probably the poorest. I give

the example of a woman here who was in an environment where she did not want to

be living in Newfoundland. She flew out to British Columbia, to live out there,

because she had some relatives and the weather was much more conducive to her

condition. When she got out there and applied for the home support program, she

could not get twenty-four hour coverage. She did not have the same rates, she

did not have the same ability and access to home support workers, so she flew

back here.

MR. WHELAN: Can you get twenty-four hour

coverage here?

MS J.M. AYLWARD: Yes.

WITNESS: Not in every instance, though.

MS J.M. AYLWARD: Not in every instance, but we

do have twenty-four hour care provided. With seniors we have up to a maximum of

$2,100.

MR. WHELAN: (Inaudible) them.

MS J.M. AYLWARD: No, it's for the disabled

community, particularly. With the seniors we have a $2,100 service limit for

home support. I guess at a point where you require more than that then people

generally make a choice of going into some form of institution like a personal

care home or nursing home.

MR. WHELAN: (Inaudible) case the people

themselves do not make a decision. It is more like their family makes the

decision: I don't want to see my mom go into a personal care home so she has to

have home care at home. In other cases I found that people who really need

twenty-four service find it very difficult to get it. I also find in some cases

the expectations, when you provide that type of service, go right through the

ceiling. If one person has it, well, up the street gets it somebody else wants

it, across the road somebody else wants it. If they have it I should get it.

I am wondering about the cost of it and if we are

being realistic in producing that type of service. Because once you introduce

it, and if it is there for any length of time, it's not a privilege then, it's a

right. I'm running into that all the time. I find it is very difficult to get

twenty-four hour service.

I was in Whitbourne last week and there was a lady

there - I was into her parents' house and I was inquiring if they wanted

twenty-four hour service. She had seventeen hours or something like that. I

questioned as to whether or not that was sufficient. I said: Maybe I should go

up to see her. They said: You don't have to see her, she is just going down the

road. She was going down the road in a wheelchair. She was deformed and her mind

was practically gone, she could use one hand, you know, this kind of thing. No

phone in her house, and she was there for a number of hours during the day by

herself. She didn't have twenty-four hour care. I am wondering what do you need

to have, what kind of an infliction do you need, in order to get twenty-four

hour care?

The other thing is it's almost an open-ended

program whereby there is almost no amount of money that will ever cover the cost

if you want to give everybody exactly what it is that they want. I am not saying

it is a bad program, it would be great if we an afford it. I go to some of the

personal care homes. Obviously some of them are not as good as others, and maybe

the standards need to be picked up. Some of them are great. They are ideal

situations for a person to live in, the environment. They are among their peers

pretty well. I'm wondering what the wisdom is of promoting one as opposed to the

other. I do not know if you want to comment on that or not.

MS J.M. AYLWARD: I agree with you. Some of the

homes are much better than some of the other homes. I think a lot of personal

care home operators spent a lot of money trying to upgrade their homes to be

competitive. We have a system in place where we have some personal care homes

that are subsidized with respect to the beds and others that are not subsidized.

We are looking at finding ways to address the whole issue of giving people a

choice as to where to go with their personal care homes (inaudible).

MR. WHELAN: Don't they have that choice now?

MS J.M. AYLWARD: It depends. They do and they

don't. If they are in a non-subsidized bed they can go where they like. If they

are in a subsidized bed you don't take the subsidy with you, the subsidy stays

with the bed.

MR. WHELAN: There are so many subsidized

nursing homes around that you can almost pick your choice of either one of

those.

MS J.M. AYLWARD: We have not given out

subsidies since 1991. We have a number of subsidized beds in the Province, but

the beds are in the homes. You cannot take the subsidy with you as an

individual. It does not go with the person, it goes with the bed.

We are looking at revamping how we are doing the

whole personal care home issue, and maybe linking it more with the person as

opposed to the bed. We have some areas where we have a lot of personal care home

beds, and we have other areas like St. John's where we do not have enough

(inaudible). It is that kind of thing. It is a publicly funded system and there

is a private system competing with one another. I think that is the point you

made. We have gone from, I guess, a $500,000 program to a $31 million with home

support.

MR. WHELAN: Still not nearly enough to satisfy

the wants and the needs (inaudible).

MS J.M. AYLWARD: Yes, and I think that is the

other part too. The home support program is never meant to replace the informal

care structures. Like in any community and any society, whether it is health or

anything else, the informal system, people or economists have said, equates to

three to four times what we normally pay in that funded system. If you look at

our system of $1.1 billion, you are talking about a $5 billion system of

informal care that is given through the community. It's just by nature of you

caring for your parent or your child caring for you, that sort of thing. There

is that balance too.

MR. WHELAN: This creates another problem. It

was the rule of thumb I suppose back when I was younger (inaudible) that when

your parents got old the family took them in and looked after them until they

died. Now when a parent gets old it is home care. Nobody even considers the fact

that they are going to take a parent in and look after them gratis until they

die. That seems to be pass.

MS J.M. AYLWARD: There are some cultural

changes happening.

MR. WHELAN: If there is someone (inaudible) it

seems to be the exception rather than the rule. I was wondering if we are not

(inaudible) promoting -

MS J.M. AYLWARD: There are still a lot of

people providing a lot of care. I know what you are saying, and you are right.

Because we have done some assessments and I do not think this is the rule, I

mean I think it is the exception, where we have gone in to do a reassessment on

home support and probably found four or five family members living in the home,

and they had a home support worker coming in. Then you have another extreme

where someone has nobody belonging to them and you are not able to get enough

hours.

It is trying to find a good assessment tool that

will measure what you need. You have to include your family resources in terms

of people that are able to help. I think that is important and that is probably

what needs to be done. If you are living in a household with four or five people

and they are all unemployed, for example, it would be a reasonable expectation

that they would provide some of the care. Not necessarily all of the care, but

some of the care.

It's a very difficult area, one that we need to do

a whole lot more work on. It really has not had a whole lot of attention because

it has been a growing industry. Over the last eight years to move from $500,000

to $31 million, it's quite an industry that has been built up.

I do not know if that answers anything. It is

something we do have a couple of studies ongoing, one in the St. John's region

and one for the Province, where we are looking at the personal care home issue,

if and how that competes with the home support program. I would not want to

decrease a publicly funded program for a privately owned program to the

detriment of the people who can't afford to pay.

MR. WHELAN: What is the cost of personal care

homes? Because they are being subsidized to a small amount by the provincial

government, (inaudible) of $150 dollars a month for guests?

MS J.M. AYLWARD: No, I think it is $900-and

something, is it, and we subsidize?

DR. WILLIAMS: We pay a subsidy of over $900,

$940 or something a month.

MR. WHELAN: The $900 that they get for a month,

doesn't that come from their senior citizens' cheque, about $800 or $750

(inaudible)?

MS J.M. AYLWARD: And if it is a subsidized bed

we pay a portion of it.

MR. WHELAN: I believe the portion the Province

pays is $150?

DR. WILLIAMS: We pay the difference between

their comfort allowance and the money that they get from OAS/GIS. The amount of

the monthly rate, they are allowed to keep $110 for comforts allowance.

MR. WHELAN: But the monthly rate is pretty well

set, I think.

DR. WILLIAMS: Yes, the monthly rate is set, it

is a standard monthly rate.

MR. WHELAN: Nine hundred and twenty dollars a

month or something, is it?

MS J.M. AYLWARD: Nine hundred and something

dollars.

WITNESSES: (Inaudible).

DR. WILLIAMS: Nine hundred and forty dollars a

month.

MR. WHELAN: And the Province pays how much of

that?

DR. WILLIAMS: The Province pays a difference

between what the person can pay, if they get OAS/GIS they are able to keep $110

a month for the comforts allowance, which removes that amount. They get to keep

that. Then the difference between what is left and the $940 or approximately

that amount is what the Province subsidizes.

MR. WHELAN: So that is somewhat less than $200

a month, is it, (inaudible) Province per person?

DR. WILLIAMS: It is less I think than $10 a

day, put it that way. (Inaudible), yes.

MR. WHELAN: I was just wondering. If it costs

the Province that much to keep patients - they call patients guests or residents

in one of these homes -, I was wondering what facilities we would have in a

similar... For example, if we pumped $30 million into that particular system,

what service we could provide to the people who are in those residences.

MS J.M. AYLWARD: You mean in a home support

program or in a -

MR. WHELAN: Yes, you could almost have an

individual for each resident who is in there. The homes themselves could be

upgraded to the point where they are practically castles. You could have a much

improved -

MS J.M. AYLWARD: You have to look at what you

are providing though, right? When you look at personal care homes it is Level 1

and Level 2. In some cases they are people who are ambulatory, they need very

little care, maybe some help with washing. Certainly the biggest component is

someone to cook their meals.

MR. WHELAN: Thirty million dollars would look

after all that. A lot of the people who are in home care situations, they are

ambulatory, they can walk around, unless they have a certain amount of dementia

or senility associated with the problems they have. In a lot of cases they are

ambulatory, walking around.

MS J.M. AYLWARD: Some of the seniors aren't.

They have Alzheimer's and (inaudible).

MR. WHELAN: Anyway, just a suggestion. I am

finished. Thank you, sir.

CHAIR: Thank you, sir.

Sheila, and following that, we will have Gerald.

Dr. Williams, when you speak could you move that mike a little bit closer to you

and identify yourself, please? Thank you.

MS S. OSBORNE: I am looking at 1.1.03, 1.2.03,

1.3.03 and 4.1.03. All these deal with Transportation and Communications. I am

just questioning the difference between the budget and the revised in each case.

MS J.M. AYLWARD: You want to do them

individually? What are you asking again, Sheila?

MS S. OSBORNE: The difference between the

budgeted amount for Transportation and Communications and the revised, and if I

could have a breakdown of what was transportation?

MS J.M. AYLWARD: I can do that for you verbally

if you want to do the breakdown.

MS S. OSBORNE: Okay.

MS J.M. AYLWARD: Because you are referring to

my travel, in this particular case, in the Minister's Office.

MS S. OSBORNE: In 1.1.03.

MS J.M. AYLWARD: Right. The budget amount was

what was allocated for budget, the revised amount was $35,000, which was

increased by close to $12,000. I will just go through some of my

responsibilities. Almost all of the travel included was federal-provincial

travel, and travel within the Province for meetings and that sort of thing. I am

on the ministerial council which -

MS S. OSBORNE: That was since the budget, was

it?

MS J.M. AYLWARD: This would be from last year

to this year.

MS S. OSBORNE: That is the difference from when

the $24,000 was budgeted, up to the $35,700. That explains what -

MS J.M. AYLWARD: What was allocated in last

year's budget, right, the vote was for $24,000. What was actually spent was

$35,700. From that period of time some of the responsibilities include that as

the Premier's representative on the ministerial council, which is the council

that is dealing with some of the issues I have raised, like the privatization of

health care, that is one of the biggest issues.

Also, this year we have had numerous meetings with

respect to hepatitis C, the blood, and the whole creation of a new national

blood agency replacing the Canadian Red Cross. In addition to that I had some

other meetings with respect to seniors', because I am also the minister

responsible for seniors', as well as some of the youth that cross-sections with

Health and Community Services. This does not include the new responsibilities. I

will say right at the outset now that the $24,000 will be under, it is

underrated for what will be spent this year.

MS S. OSBORNE: That is what I mean. That was

unanticipated travel that came up after that was budgeted.

MS J.M. AYLWARD: I have actually commented on

it. I think that perhaps it's not a realistic figure to put in there.

MS S. OSBORNE: Okay.

MS J.M. AYLWARD: In addition to that, I

attended two First Ministers conferences' with the Premier as his

representative, because of the emphasis put on the social policy agenda, namely

the health and the whole revamping of the social policy. Right now all the

ministers on this council are looking at a new social union contract for Canada,

including looking at issues like equalization and the whole concept of health

care delivery, the Canada Health Act, and all of those. That would be just off

the top of my head, but in addition to that there were numerous meetings around

the Province meeting with various boards and hospitals since I became minister.

This is not all my Budget. I didn't start until May

10, which is about six weeks after. It is very clearly outlined where the travel

was allocated. Most of it was on federal-provincial meetings.

MS S. OSBORNE: 1.02.03, Executive and Support

Services, Transportation and Communications once again.

MS J.M. AYLWARD: I will say the same thing.

Because generally before a meeting with the ministers you would have senior

executive meetings at the deputy and assistant deputy levels. There are the

preparation meetings.

Unfortunately for us, if you are hosting a meeting,

if you are the host province, most of the other provinces travel to you, so you

have less cost. If the host province is somewhere else - this year the host

province is Saskatchewan - but we have, for our purposes, if you are travelling

any further west than Toronto you lose two days. Most of our meetings occur in

Central Canada, or the centre of the universe as they call themselves sometimes.

It's the same rationale for the senior executive.

MS S. OSBORNE: 4.1.01.01. There is a difference

in the budgeted salary and the revised. It is down by $49,000. Did you lose a

couple of positions there?

MS J.M. AYLWARD: Just let me get that for you

now to give you the exact details there. Can you find the page for me?

WITNESS: Page number?

MS S. OSBORNE: Page 205. That is in this book,

the Estimates, 4.1.01.01.

MS J.M. AYLWARD: Actually we had one - or it is

a vacant salary of $49,000, which would attribute for that.

MS S. OSBORNE: What was that position?

MS J.M. AYLWARD: What was that position?

WITNESSES: (Inaudible).

MS J.M. AYLWARD: Actually it was not one

position particularly, it was a number of positions that were not filled. Do you

want the specific positions that weren't filled? Because I don't have the

specific positions. All I know is that there were positions that were vacant and

that is why the budget was less than what was allocated.

MS S. OSBORNE: Yes, okay, so -

DR. WILLIAMS: Basically, it was the interim

time between when a position became vacant and the time it got filled. It may

have been a week, two weeks -

MS J.M. AYLWARD: Yes, it is not a loss of a

position. It is a vacant position that was not filled. For example, we delayed

in filling a number of positions and I don't have the dates that they actually -

MS S. OSBORNE: They are filled now though, are

they?

MS J.M. AYLWARD: They are filled, yes.

MS S. OSBORNE: In terms of nursing homes, do

you have a breakdown of what it actually costs to keep a senior in a nursing

home, what it costs the government approximately? That isn't including the

drugs.

MS J.M. AYLWARD: Per person, is that what you

mean?

MS S. OSBORNE: Per person, yes.

MS J.M. AYLWARD: Is that the $2,800 amount that

we are paying?

DR. WILLIAMS: Closer to (inaudible).

MS J.M. AYLWARD: Yes. By month it is $2,800.

MS S. OSBORNE: It costs $2,800. That is what

people pay if they can afford to pay, they cover the cost?

MS J.M. AYLWARD: Right, yes. What it costs us

depends on the level of care and the ratio of staff. For example, a Level III,

IV or V is a much higher resident to keep in terms of cost than someone who is

Level II. We have very few Level Is and IIs in nursing homes. We mostly have

Level IIIs, IVs and Vs.

MS S. OSBORNE: The maximum that you pay for a

senior, though, to stay in their own home is $2,100 for twenty-four hour care.

MS J.M. AYLWARD: Or a portion thereof.

MS S. OSBORNE: Or a portion thereof. I'm just

asking this for information. Have you ever considered leaving people in their

own homes, say with their spouse, as opposed to putting them in a nursing home

and paying the $2,800 to the person or (inaudible) to take care of the person in

their home?

MS J.M. AYLWARD: We have never gone to the

point where we actually pay a relative to take care of -

MS S. OSBORNE: No, not a relative. If they are

two seniors in their late 80s, for instance, and one of them needs to be

institutionalized because the other cannot take care of them, have you ever

considered leaving that spouse there, or leaving the two people together, who

have spent so much of their lives together, and paying somebody to go in for the

whole time, in lieu of putting them in nursing care? Is this what that $2,100 is

to cover?

MS J.M. AYLWARD: The $2,100 is to cover up to -

I mean, in some cases a lot less than twenty-four hours, as you know. Because

most of the people who are working there have to be paid at least minimum wage.

Most of them are hired because as you know they are unionized. Once they reach

the $2,100 mark then they have to make some choices. They either have to get

some family assistance or they have to have some other option. We will never

force them to leave their home, but the maximum that we pay is $2,100. We don't

pay the $2,800.

Generally you can't get twenty-four hour care with

$2,100 unless you have other people helping. Some people have been able to get

an arrangements where if someone is sleeping, which they generally sleep at some

point in the day, they can sometimes make an arrangement to have someone come in

for four nights a week and give them a lump sum payment to sleep in the house.

Then they are able to do it within that amount of money. If it is actual hours

of work here it is not able to be accommodated.

MS S. OSBORNE: Would you ever consider paying

$2,800 for somebody to come in and take care of the person? Because obviously

the quality of their life, if they can stay in their home with their spouse, and

the quality of their spouse's life, would be enhanced by the person staying in

the home.

MS J.M. AYLWARD: I guess the best answer to

give you there is that you would have to do an individual assessment on each

one. If you are looking at the needs in the home it would include things like

preparing the meals, doing all those kinds of things. You cannot always get a

worker to do high level nursing care and cook the meals as well. It is the

combination of care that is required. In some cases, if it is a lower level care

you will find someone who will come in and cook, clean and do the care of the

individual. I would have to say it would have to be done on a individual basis.

MS S. OSBORNE: Because for $700 you wouldn't be

expending any more to keep the person at home, and their life would be enhanced

by staying with their spouse. That is what I'm saying.

MS J.M. AYLWARD: I see your point.

MS S. OSBORNE: In some cases. It would not cost

the government any more, and this person would remain in their home till they

absolutely got sick and had to go to a home.

The other question that I have is, and you are

addressing it, is subsidized beds do not got with the person. It would be nice

if the subsidized bed went because that would give the person (inaudible)

choice.

One final question. Are you planning on taking the

kitchens out of the nursing homes in St. John's and having the food delivered?

MS J.M. AYLWARD: As you know, we just have a

brand new board started now in the nursing home sector in St. John's. They are

affiliated on their own. They are not affiliated with the Health Care

Corporation in St. John's, nor are they affiliated with Community Health. They

are their own board.

I guess at this point in time I can say it has

never been mentioned to me or discussed with me. I know they will be looking at

trying to do better service delivery, because we have bits of programs here and

bits of programs there for seniors. I am looking forward to some of those types

of things. I can honestly say they have never mentioned anything about that to

me.

MS S. OSBORNE: Thank you, that is all.

CHAIR: Thank you, Sheila. Gerald Smith and then

Harvey Hodder.

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

just a few general questions. First of all, in terms of the recruitment of rural

physicians, I know we have made some efforts over the last number of months to

try to address this. I'm just curious as to whether or not this is happening.

Are we seeing, or is it too early to see, any sort of a positive impact from

these interventions?

In the last couple of the days I have just been

dealing with a situation in my own area. As a matter of fact I had a phone call

this evening before I left. There was a concern that where two clinics operated

in my area on the Port au Port Peninsula there has been one physician handling

both clinics for the last year or so, and that physician is leaving some time in

May. In the latest contact I had with the CEO of the Western Health Care

Corporation, I was advised that they still had no one. He couldn't give me a

definite answer that they would have someone there. They are hoping the

physician who had previously been at Cape St. George would be returning.

First of all, I'm not asking for a specific on

that, because I can deal that with the CEO. I guess that begs the question, how

successful are we in terms of recruiting physicians, especially for the rural

areas of the Province?

MS J.M. AYLWARD: I just want to premise by

saying that every single province in the country is experiencing a lot of

difficulty recruiting physicians to work in rural areas. The definition of rural

is very far-reaching. In some places in Ontario they cannot get physicians to

work because they are rural to Toronto. I mean just a few miles away. So you can

imagine how much difficulty we are having here.

We have had some excellent discussions with the

physicians, as sort of a spin-off of the negotiations. We are looking at ways to

try to move it forward. They have actually identified the same concerns as you

raised and we, as a department, raised. One of the reasons is that if you have a

doctor spotted here or there they don't last. If you have a doctor in an area

where there is only one or two doctors they will not last. Those days are gone.

The days when you would have a physician who stayed in the community in Grenfell

or in Port aux Basques and they ran the show, they are gone. Physicians do not

want to work like that any more, particularly if they have young families. They

do not want to be on call, they do not want to be working the weekends.

The only way out of it that we see is by using a

clustered model. That is what we are calling it and what the physicians are

calling it. It is going to take a lot of acceptance, and probably no acceptance

by some communities. Physicians do not want to work in clusters of one or two,

they want to work in larger clusters. Our population is such that we have to try

to create clusters of physicians and other practitioners to deliver services and

try to out-reach to various areas. I use the example of Clarenville and

Bonavista. You have a much better chance of having doctors go to one or the

other rather than somewhere in between where they are by themselves.

I guess the shorter answer to your question is that

we are very concerned about the recruitment issue. We know we will never be able

to compete in terms of monetary packages with Ontario, Alberta, the United

States, or even Nova Scotia, I will be quite honest. Nova Scotia blew the top

off their budget in health care with respect to physician services. I frankly do

not know how they are going to be able to cover - they do not even know what

their costs are going to be, they have lifted so many restrictions.

We also know in some places in rural Newfoundland

we are paying physicians one and a half times their salary because there should

be two physicians there and we only have one. In an effort to keep them we are

offering to pay them one and a half times as much as the salary. For a physician

to go to some place like Burgeo, for example, they would get almost as much

money as the CEO of the largest health care corporation in the Province. We

can't get people to go there.

The point I am making is that we are actively

recruiting. Money is not the only answer. Lifestyle is a big part of it. I guess

as a province we are going to have to look very seriously at how we are going to

deliver health services in a way that we are able to keep doctors. We will never

keep a doctor here and a doctor there any more, they do not want that. Even

doctors that might be unique enough to want that type of practice can't last,

they burn out.

We are working closely with the boards. We are

working to develop a new strategy to work even more closely with the boards. We

have some other things we are actively working on and hopefully we will have

some announcements in the near future on that, but it is something we are very

concerned about. It is not just the government, but the doctors are also quite

concerned about it.

MR. SMITH: Related to that, one of the things

that has always caused me some concern - I remember the debate surrounding the

establishment of our medical school. One of the strong articles made at the time

was that we needed a medical school in this Province to train physicians who

could stay, live, and work here in Newfoundland. I notice in this year's budget

that we are looking at there is an allocation there of some $16 million in

support of that program.

I have a number of questions related to that. First

of all, how successful are we? How many of our graduates of our medical school

are staying to practice in Newfoundland? On the average, can you give me a

percentage as to how many of these graduates are staying on, giving any service

at all to the Province after graduation from our medical school?

MS J.M. AYLWARD: First of all, I need to say

that there is a lot more to a medical school than graduating physicians, as you

know. Physician training is only one component. If do not have the medical

school you will not attract specialists, you won't attract specialities, and in

effect you will be working really like a third world country with respect to

being able to provide speciality services like neurosurgery or complex back

surgeries or anything else. It is that research and development process as well

that is so important.

By and large, over the last ten to fifteen years we

have not had a very bad response rate to the medical school because we went

through a period of time when we had a bursary program and there was a return of

service. We have some concerns too about the number of physicians who are

leaving, but we have created the difficulty too in conjunction with the medical

school. When we implemented the Needs Assessment Committee rule, the fifty per

cent billing rule in St. John's and other under-serviced areas, then physicians

were not willing to go out and work in rural areas because they did not want to

be stuck in rural areas, if they wanted to come back and do the speciality, or

if they wanted to come back and work in urban Newfoundland. That is one of the

issues that is on the table right now at negotiations, lifting the 50 per cent

rule. That will allow new graduates who are coming out of the school to set up

practice in St. John's or go to work in an emergency department and build up

their patients, which is what they all do, whether they stay here or move away.

I can actually give you the breakdown. I don't have

the breakdown here with me and the actual percentages, but it is something that

we will have to look at again in the very near future because it is a concern

for all of us.

MR. SMITH: In any given year how many students

would be graduating from medical school?

MS J.M. AYLWARD: We accept fifteen from the US,

or we will accept fifteen from the US, five from the other provinces and forty

from Newfoundland residents.

MR. SMITH: Forty from Newfoundland. I can see

the fifteen from the other Canadian - how many from the other Canadian

provinces?

MS J.M. AYLWARD: Five.

MR. SMITH: Five. How many Newfoundland

students, on the average, do we have applying for admission to our medical

school and how many of them are being accepted? You are saying we have a maximum

of forty. How many students, on average, would we have applying?

MS J.M. AYLWARD: The same as the law schools

across the country. Hundreds of people apply for (inaudible).

MR. SMITH: My next question would be, the

fifteen seats you say that we have allocated for Americans, is that just to

generate revenue for the medical school?

MS J.M. AYLWARD: Yes.

WITNESS: Critical mass improves the numbers

that are there -

MS J.M. AYLWARD: Well we could get the numbers

all from in here, I suppose, but you have to remember that of the forty that go

through, twenty will go to a family practice residency program, which is a GP

program, and the other twenty goes on to do a residency programs in some

specialty. Of the forty, twenty will go into the general practitioner arena.

Some of them will practice here and some of them will go elsewhere. The problem

is that when you come out of medical school and somebody from the US comes up

here and offers to give you a $60,000 signing bonus and pay off all your debt

and give you this, this and this, we cannot compete with that. I mean, that is

our problem. We will never be able to compete with that.

MR. SMITH: (Inaudible) I am addressing right

now is a bit different from that. I appreciate where you are coming from and

what you are saying there. I am just looking, right at the outset, at the entry

level. For example, the fact that you have fifteen positions that we are setting

aside for American students, and you are saying that this is pure economics.

These people pay the full cost, so this helps to subsidize the program for the

other students.

I guess from my perspective it has always bothered

me, with the medical school, I always believed - I can remember the initial

debate, and I was one of the people who believed the arguments that were being

put forward at that time. I thought that programs would be put in place whereby

some of our students - I mean we have many students who are coming in from rural

Newfoundland who could possibly be prepared for some sort of subsidies in the

program.

I was a teacher by training. When I came into the

teaching profession one of the things that attracted me - and not coming from a

background where I could have availed of a university education - was the fact

that there was a bursary program in place. There was, at one point in time, the

same thing offered to medical students. It seemed to me that with a medical

school we could be looking at some of those same sorts of things. When I see

that there are fifteen positions which right off the top go to students - and I

am sure the majority of those fifteen students... You are saying to me we can't

keep our own people, so I doubt very much if many of these Americans are staying

to practice here in Newfoundland. Right away we are saying that there are

fifteen gone. I'm just questioning that, and I'm just wondering.

This is not something that your officials are not

aware of, and that you aren't dealing with on a regular basis. I'm just

wondering, in terms of trying to address the very real concerns that are out

there - because I live in an area of the Province and I deal with this on a

regular basis. The community I live in right now has a doctor two days a week

and by the middle of May will not have a resident position. Which means the

nearest doctor for me and my family, by the middle of May, will be thirty miles

away. If you are in that situation and the reality is there then it is

difficult. Especially when you consider as well, right now in the rural areas of

the Province, our population is aging, which means now is the time that a lot of

them are more and more in need of the health care services.

My question in a general sense is: Is there some

way that our medical school can be paying bigger dividends to us in terms of

what it is able to do to address this problem in rural Newfoundland? That is a

broad question and I'm sure (inaudible).

MS J.M. AYLWARD: It is not broad at all. The

best way to answer it is this way. We are in the middle of looking at ways to

address some of the concerns that you (inaudible). I'm not prepared to discuss

it in detail because it has not gone through the internal process. It is

something that we are very concerned about in the department. Physicians are

quite concerned about it and the public is quite concerned about it. Obviously

we are going to try to respond to it in a way that will address some of the

issues you have spoken to, but also not put students in an untenable position.

My view is that you cannot force people to do

things. We are trying to come up with a way that we can deal with it. That is

the most generic way I can answer your question without getting into the detail,

and I'm not prepared to get into those details.

MR. SMITH: I would suggest to the minister that

those fifteen positions that are there for Americans, if we made those available

to fifteen Newfoundland students who will not get into our medical school

because these fifteen positions are taken up by Americans, I suspect that if

they were given the option some of these students would be willing to sign some

sort of an agreement with this Province whereby they would be prepared to offer

service in the rural areas.

MS J.M. AYLWARD: I wouldn't doubt it, but I

have to say to you in all fairness, Gerald, I have seen some of the letters that

some of the students have written, practically signed in blood, saying that they

would do anything and would return service to rural Newfoundland, only to write

another letter at the end of it and say: I'm really sorry, but since I have gone

into medical school I now recognize I'm not able to do this and I need to do

that, or I have been given an offer. I have seen that in writing.

MR. SMITH: Would you not agree you would have a

better chance of keeping that person if he or she was a Newfoundlander than if

that person is a -

MS J.M. AYLWARD: I'm talking about a

Newfoundlander now. I'm talking about a Newfoundlander from the Northern

peninsula.

MR. SMITH: Okay, I know, yes, but I have

difficulty when we are saying - I know these fifteen Americans, I bet dollars to

doughnuts, that none of these people - and no disrespect for Americans. It is

just the idea that it seems to me if we are automatically and we are doing it

solely on the basis of economics that this is somehow intended to subsidize the

program. Don hit on that earlier in his questioning.

My question is: If the medical school is ours and

it is there primarily to serve us, I can understand bilateral agreements with

other Canadian provinces. I understand we have to go to them for some of the

facilities we do not have ourselves. I have to say I have great difficulty with

the idea that we are setting aside fifteen seats, when you and your officials

are saying to me, and I know for a fact, that there are many Newfoundland and

Labrador students who are trying to get into our medical school and can't, who

are applying to get into our medical school but will not. Those fifteen

positions could be going to Newfoundlanders.

MS J.M. AYLWARD: I do not argue, but what I'm

saying is that of the forty Newfoundlanders that you put in there you are not

guaranteed to get any of them to stay either.

MR. SMITH: You are going to get more than you

are going to get of those Americans.

MS J.M. AYLWARD: I wouldn't count on it, that

is what I'm saying. I have seen the literature. You cannot force people to stay.

What we have to do is to try to come up with a creative way of addressing the

needs of physician supply and making it attractive enough for people who want to

stay.

Right now medical students are paying $6,250 to

$6,700-something. We are subsidizing between the $6,000 up to $30,000. Right now

you are looking across the country and the medical school admission rates are

going through the roof, just like the MBA rates are going through the roof. Once

you get out, you can practically write your ticket, because it is an education

where you can pick and choose what you want to do anywhere you want to do it. It

is a very sought after profession if you can get in. Are we letting people in?

No. Like I said, it's like the law schools. There are probably 100 applications

for every position. It is just unbelievable.

MR. SMITH: One final question with regard to

that, and there is another I want to touch on briefly. In terms of the fifteen

units that are allocated for Americans, has there been any consideration, has

that been revisited from the point of view of reducing that number, or

eliminating it altogether?

MS J.M. AYLWARD: Everything was and everything

is being revisited.

MR. SMITH: I will move to something else. This

is another issue that I have some concern about. We have been talking about

seniors and seniors in care in particular. One of the topics that is currently

in vogue now and that is a concern, and it's something I have some concern

about. My mom, for the last year and one-half, lived in a senior citizens' home.

She died when she was ninety-six so she was quite advanced in that stage. I had

occasion to have some dealings directly with the people in care and that sort of

thing

The area I want to touch on is this whole area of

elder abuse that now we are becoming more concerned about and now people are

suddenly becoming aware of it. I think I am primarily concerned about it in

terms of when it is exists in an institutionalized setting. I think we can all

recognize it. We really have very little that we can do in terms of dealing with

it within the homes. It is kind of a family thing, and very often,

unfortunately, people who find themselves in that kind of situation - I have

great sympathy for them - but it has to be a terribly tragic situation for those

people who are there. I'm just wondering in terms of the institutions as they

exist in this Province: Are there any incidents that are being reported, or

where there are prosecutions dealing with elder abuse, in any of our

institutions in the Province?

MS J.M. AYLWARD: Let me answer this way. First

of all, I would not have access to what was being reported to the police, as you

know. I just took over the whole issue of... The Neglected Adults Welfare Act

was under the governance of the department of social services up until April 1.

I was aware at that time when I was in that portfolio previously of an

increasing incidence of elder abuse. I cannot give you the numbers. I know right

across the country it has increased, and I suspect it is probably more likely to

increase in a home support environment than it would be in an institution.

Because there are a lot more witnesses, I guess, if you want to call it that.

Because if you are one-on-one in a home with someone, I mean, you really do not

know.

One of the things as well, I guess, that we have

not done in the department is monitor that type of (inaudible) reporting. I do

not have any liaison, for example, with the police if they get the reports,

whereas it is a different set up with children. We are directly involved. People

who are abused may or may not be under the auspices of a nursing home, or it

might be in a private home. I do not really have the full picture of that. Most

of the cases that are involved with elder abuse are dealt with through the

employee-employer relations mode if it is in an institution that is unionized.

It does not always come to me.

MR. SMITH: So there would be no monitoring per

se on that sort of thing, other than just as an ongoing sort of thing, such as

checks and visits to the home.

MS J.M. AYLWARD: I think the best way to answer

it is if there are different levels of monitoring - if is serious enough the

police would have it. If it is in an institution where a staff member does

something, the staff member would be disciplined and then the employer would

make the decision whether that staff member would be referred to the police or

disciplined through the collective agreement. If it is in a nursing home

environment and it is at a senior level, then it might be brought to my

attention. There is no single reporting mechanism like there is, say, for

example, child abuse.

MR. SMITH: Just a comment in relation to

(inaudible) year and a half. I had many occasions to visit somebody in this

institution. This was a large institution. I have to say to you in all honesty

there were many times I left there concerned at what I had witnessed while I was

there, things I had overheard, things that I had seen. This was a large

institution. I often wondered when I left there, I would like to be a fly on the

wall and see what was happening after I was gone and the lights went out and

there was really nobody else around. I said it in all sincerity.

That is why I raise it this evening. This was a

large institution, and I couldn't help but wonder. These were professionals.

Sure, they had the rules of training, but over the course of the year and a half

I was there many times. I guess maybe after a while people see you around and

they take you as part of the trappings or whatever. There were things I saw, and

I often wondered. I do not know internally what is built in. You yourself were

part of the establishment for a number of years. I do not know what internally

is built in, what kind of controls are there, and if you see something going on,

like a co-worker cannot... Do you intervene? What do you do? Do you just ignore?

MS J.M. AYLWARD: Well, no. Most organizations

have an abuse policy in a part of the policy manual where if somebody witnesses

abuse there is a protocol that you have to follow and do a reporting. I do not

know how much of that is done, but I suspect that if you had access, I suppose,

or if there were some way of looking at it, there would be a number of incident

reports that would have been filed; whether you make a medication error or

whether you have an incident of abuse, that they would be reported. That is all

I know at the organizational level.

In terms of anything more serious than that, it is

not brought to my attention. Since I have been there in one year I do not recall

one incident of elder abuse being brought to my attention as Minister of Health

and Community Services.

MR. SMITH: I think what has really disturbed me

most, of course, since then, like over the last year or so, I have seen on some

of the American networks where they have carried some of these exposs where -

MS J.M. AYLWARD: I have seen those.

MR. SMITH: If you see it, it is very

disturbing, when you see that they have managed to bring out pictures of things

that happened, when somebody is behaving in a fashion where they figure nobody

is around to see them. If you are a person who has put someone who means a lot

to you in that kind of a situation, when you see that sort of thing going on,

and you think the possibility is you did that, it is not a very nice feeling

when you see (inaudible). I guess it causes you to wonder if in fact it can

happen here. Can it happen here? What are we doing to try to insure that it does

not happen here, and it does not happen to our relatives?

MS J.M. AYLWARD: I saw the same programs and

they were very disturbing. I remember seeing them.

MR. SMITH: Thank you, Minister. That is it for

me, Mr. Chairman.

CHAIR: Thank you, Gerald. Harvey, and then Bill

Ramsay.

MR. H. HODDER: Thank you very much.

Just a follow-up from what Gerald was saying, there

were some seminars that were held in the St. John's region just recently,

dealing with this issue. They were put off by the various community health

agencies in cooperation with the RNC, with various stakeholders. Some of the

people I know attended these sessions, and the general attitude at those

sessions was that elder abuse may be much more prevalent than we, as elected

people, may think it is, and that we do not have in place a diagnostic - that is

not the right word, but - an identification program that would let the channels

of communication be easily followed, and a way in which those people who would

make complaints would have follow-up of things happening, and also how the

people who were working in those facilities would be looked after in terms of

job security.

The same thing used to happen in teaching. I am old

enough to remember that when child abuse, when children were strapped at home,

when children were treated terribly at home, the school system said: What

happens in the home is the responsibility of the home and we do not have

anything to do with it. We went from that to where we are now.

I wanted to follow up and ask if you, as the

minister, would take on the responsibility of probably doing a departmental

review, and working with the (inaudible) agency. I know the information is

there, and I am surprised that reports are not coming to you from the agencies

indicating the prevalence of the problem.

MS J.M. AYLWARD: How I will answer that,

Harvey, is that our department is quite interested in seniors and have, in fact,

established a seniors secretariat within government to look at and try to bring

together issues that are of concern to seniors. We have been working quite

closely with seniors and some of their issues in trying to meet them, because

they are disjointed in many ways in the types of service delivery organizations

and what not they have representing them. I would certainly want to assist

seniors in any way possible, but there are a lot of realistic barriers that we

have.

Many of these frail elderly are not able to

advocate for themselves, and often times the very people who are advocating for

them are the people who are abusing them, because they are the sole providers.

There is a lot of work that needs to be done in

trying to - I think you would probably need to be in a situation similar to the

situation we have now for child abuse, that it would be incumbent upon you

legally to refer and report any suspicion of abuse, maybe move towards that

direction, which would mean a cooperative liaison with justice and a number of

other departments.

Certainly the other thing, it is very much outdated

and something that I had begun to work on when I was with the Department of

Human Resources, is the neglected adults act, which is also linked into that as

well. That is something that has been on a priority list as well. There are a

number of facets to it, that whole issue of elder abuse and trying to deal with

it, and it is something that I would not rule out.

In addition to that, there is a provincial strategy

against violence, which does not limit it to children, of course, it looks at

the whole family, and that is also (inaudible). We have representatives from our

department, justice, social services and education, and community groups at

large. There are things being done. I think we could still do more, but I think

in our own department we recognize how we want to help seniors by creating a

seniors secretariat in our department.

MR. H. HODDER: I would like to point out too,

Madam Minister, that when we refer to this we are not referring only to the

health care givers. This is (inaudible).

MS J.M. AYLWARD: No, no, this is like family

members. It is most common, family members.

MR. H. HODDER: This is family members, it is

financial, it is emotional, it is multi-dimensional, and also sometimes it

happens even with the clergy who come in. I know of one instance where the

clergy came in and within a short visit the senior had signed over his bank

account to the church. If you think it does not happen today, it does happen,

and it happened just recently right here in St. John's. These kinds of things

are things that we think do not happen, but... The family had to step in and

take remedial action there, which is a bit of a sad story but one with which I

am familiar.

I wanted to think about the Janeway for a second.

First of all, I was pleased a couple of days ago to (inaudible) the launching of

the telethon. I looked carefully at the schematics for the new Janeway Centre

and, as you know, there is a great deal of excitement with that. Having had a

long-time interest in the Janeway and the health care of children, I am excited

by it and the opportunities that are there.

The waiting time for child psychiatric care, that

used to be 600 people on a patient waiting list - I asked this question before

and you know where it is likely to come from - it is now down somewhat. How are

we doing with that list now, and what are the prospects for getting that list

down to a more manageable level?

MS J.M. AYLWARD: I cannot tell you the actual

number on the list. I do not have that updated information with me tonight; I

could not tell you that. I do not know, Bob, if you want to speak to that.

MR. WILLIAMS: The only thing I can say is that

there was a meeting with the Health Care Corporation and one of the items on the

agenda was the issue of mental health services, because they were just reviewing

their mental health program, and the waiting list was over 400 last year. I saw

in a document today, it was approaching 300 this year. They are making some

progress, but I was not able to stay for their discussion on that particular -

we can get that information for Mr. Hodder.

MS J.M. AYLWARD: The only other thing that I

would add in terms of - and I said it earlier in answer to a previous question -

when you talk about services to children, what you are talking about is the end

of the continuum. Our focus is trying to be on the other end, which is the

prevention end. That is one of the reasons why we put in place this year the

(inaudible) Child Benefit Community Youth Network which is focused on children,

particularly a large focus on mental health, and trying to deal with all of the

issues around mental health, particularly in rural areas. Because if you have a

Janeway, and if you have one service, while we need the expertise, I think what

we need more so is a strong community development focus to try to do prevention

and early intervention on a lot of these programs which are very closely

associated with the lack of role models, dropouts, literacy rates, and the whole

gamut.

So the process that we have taken to try and

address it, while we will always have a need for the tertiary end component or

the intensive type psychiatry approach, we also need to do the preventative

community development model, and that is where we have put our emphasis this

year in developing these regional networks to build on our CAPC programs that we

already have in place and creating even a new entry called Community Youth

Networks.

MR. H. HODDER: I totally agree with the

intervention at an early stage. Obviously, (inaudible) the school system cutting

back on guidance counsellors. I see what the intervention might be doing on the

one hand is sometimes compromised by another department because of its budget

constraints, and it seems like it could be counter-productive; but you are

correct, and I am glad to compliment you on the interventions. You know that I

have been an advocate of that for a long time.

I wanted to just mention on thing in that regard,

and that is your department's position, because again it is an intervention

strategy - you were the former Minister of Social Services, now called Human

Resources and Employment - and that is the placement of things like social

workers within the school system, and whether or not you see that as part of the

intervention strategies that you are supporting.

MS J.M. AYLWARD: You know, I am sure, through

the Classroom Issues Report, we have done a lot of work on that issue. There is

a pilot project under way. I would not rule out that possibility. I do not have

money in my budget to do that sort of thing, but in my mind you cannot just deal

with the problem without dealing with the whole problem, and that involves

dealing with the school, the family and the community. We definitely have some

areas that need a lot more attention than others, in the city as well as in

rural areas of the Province, and we are very much aware of it; but I have to be

honest. When I talk about these Community Youth Networks, I am not talking about

a strongly bureaucratic or professional model. I am talking about a community

development model whereby we would focus on peer advocacy and peer support, as

most community development models focus upon, and basing it on that we would try

to build strengths with a similar program to the YES program they have all

across this city, I know, in particular whereby they are doing the peer

tutoring.

It is all of those kinds of models we are focusing

on. I would not rule out professional help, but I also think we have to try to

strengthen the community, because we will never have enough social workers to do

the type of work we need and I am not sure if we want to have social workers or

if we want to have any other professionals.

We are trying to regroup some of our communities

that have lost their focus through the fishery, the impact of the loss of role

models. The focus that I have with Community Youth Networks is the twelve- to

eighteen-year-old age groups, with a focus on eleven to zero being the CAPC

program, so it is a very clear focus. It would have to link with the schools,

and it would have to link with the recreation facilities and the municipalities.

It would be a community development model.

MR. H. HODDER: Of course that would be a

renewed commitment to things like family resource centres and that kind of

thing. I would assume that if you are going to get into - if you are going to

let the village raise the child, then you have to go and make sure that the

village resources are brought together in some meaningful pattern.

MS J.M. AYLWARD: That is the CAPC program. The

CAPC program is a family resource centre model. That is what we are expanding

through the National Child Benefit monies, in addition to creating the Community

Youth Network. When you know a model works, you don't want to create something

else; you build on something that is working. Our CAPC programs in Newfoundland

have the most positive evaluation of all the programs across the country. We

have been written up and recognized as being the most successful community

development groupings across the country with respect to family resource centres

in particular. So if you know something is working, you just want to build on

it.

MR. H. HODDER: There is some (inaudible) that

is national, written here in Newfoundlander, as you know.

MS J.M. AYLWARD: Yes, I do.

MR. H. HODDER: It appears (inaudible). Gerald

and I came across that extensively when we were doing the work on Children's

Interests.

MS J.M. AYLWARD: Yes.

MR. H. HODDER: I have a couple of questions. On

the burn unit, a comment made to me just a few days ago was that we don't have

the latest in the arts, you might say, for our (inaudible) burn unit facilities,

and it came as a commentary after the unfortunate disaster at Come By Chance and

the fire on Bell Island. What are the plans of the department? I know you are

updating the burn unit at the Health Sciences, but the comment was made that

maybe we should be evacuating these people to Halifax a lot faster than we do.

That was made by a medical person. I just want to get your reaction to that. Can

we handle burn patients better?

MS J.M. AYLWARD: Well I think there is always

room for improvement, no matter what you are doing, but I would say that you

have to answer that question on an individual basis, quite frankly. If somebody

is burned quite badly, there is a period of time when you have to stabilize the

person because you have major fluid shifts in a burn situation where a person

will come into a life threatening situation within six to eight hours after they

are burned. In many cases they are not stable enough to be transported. They

would need to be (inaudible), they would need to be debrided, they would need to

have antibiotics, they would need to perhaps go on a respirator.

I cannot say that we have the latest equipment. I

know, if you are talking about some of the things that the Shriners have done,

no, we do not have a burn trauma unit but with less than 500,000 people - over

500,000, but - I don't know how many percentages of serious burns we get every

year. It is the same principle as that - we don't have a paediatric

cardiovascular surgeon any more in this Province because if you are a skilled

practitioner you need to have a certain number of cases to maintain your skills,

and if you don't then it does not matter how state of the art the equipment is,

you don't maintain the skills.

We have a burn unit that provides the bathing

requirements. We are going to upgrade the burn bath again and do some other

refurbishing. A lot of the treatment of burns is around good medical management.

You have to have very good specialists but a lot of it is on maintaining fluid

in the electrolytes and controlling infection - the two biggest killers. I

worked in a burn unit myself for nine months, and most people died from

infection as opposed to the burn. A lot of it is very individual, and I think

the types of renovation - we will never have a burn unit like they have in

Boston because we would never be able to maintain that with the number of burns

we have. We have to make some choices, and maybe transport out some people and

stabilize other people.

MR. H. HODDER: This person was advocating that

the Atlantic Provinces should work together, given the numbers and that kind of

thing. I might say as well, this person would not say that the ultimate outcome

of the unfortunate fire at Come By Chance would have been any different. This

was not the issue, because that would be individualized and there was never any

comment made to that extent.

MS J.M. AYLWARD: But you would never want to

leave yourself in a situation where you did not have the ability to have at

least enough equipment and staff to be able to provide the emergency care and

stabilization required even to make that decision.

MR. H. HODDER: That is right.

MS J.M. AYLWARD: That is key. I hope you are as

open-minded when we think about centralizing other services in Atlantic Canada

because I wouldn't be. I would want them to come here and not go there.

MR. H. HODDER: I think this person has

sufficient knowledge to realize that there is a certain practicality, and again

maybe there is some sharing of resources that we could do. I guess the first

choice would be, we would have a full-scale facility right here in this

Province, of Boston type. As you say, that is not likely to happen. I think they

were expressing the opinion that maybe we could do more, and that is the opinion

I bring here.

MS J.M. AYLWARD: I think it is appropriate to

compliment, at this point in time, the fabulous work the Shriners have done as a

community group who have put a lot of money in, most recently, to two very

serious burn cases that I think have done so much better because of that type of

access.

Once you get over the burn, it is the rehab that

make a lot of difference. A lot of these areas that have huge volumes have much

greater rehab programs for burn patients than we would ever be able to have,

because of the expertise.

MR. H. HODDER: Let me go to another topic,

which is travel outside the Province for medical care. What is the status of

that program now? I did see some memorandums a little while ago whereby the

first $500 is paid... How does that work when somebody has to go outside to get

medical care that is not available here, particularly when it comes to children,

heart patients (inaudible)?

MS J.M. AYLWARD: It is a program that is for in

and out of this Province. It is considered non-emergency travel. How it is

organized is that the person would pay the first $500 and, after that, 50 per

cent of the cost would be paid. Generally the way we would do it is that people

pay the cost up front and then put a claim into the department.

MR. H. HODDER: The reason I ask it is because

of the up front part of this. Very often people have the $500 but they cannot

put it all up front. They, in essence, have to get a bank loan and sometimes

they cannot arrange that.

Is there any provision made for ordinary

middle-class families who, over time, are able to pay the share that is

allocated to them, but when the situation arises they cannot immediately come up

with that up front money? Is there any way in which they can have financing

included through the department?

MS J.M. AYLWARD: No, we do not generally do

financing. You have to put some reality onto it. If your claim is $1,000, you

will get $250 back. The person is required to have the majority of the money

anyway.

It is a program which is limited to just help

offset the cost. It is not to replace the cost or provide the cost. I think if

you look at it in that context you will see that it is 50 per cent of what you

spend after the $500. Each case would be looked at individually, and I would not

rule out that we would assist people in a way but only assist them based on what

you think would be the maximum. If you are going to spend $1,000, then maybe

there is some way we could assist in providing the $250 component. I don't know,

but that is what it means. It is not a program to send people out of the

Province with full expenses. We do not have the ability to do that.

MR. H. HODDER: Or even within the Province.

MS J.M. AYLWARD: Or even within the Provinces,

that is right. What we also do is let people know that when you are travelling

in a non-emergency way, if you book ahead, in many cases you can get a medical

rate for travel which is cheaper, if people apply for that. That is another

service that is available that would still offset the costs.

MR. H. HODDER: We hear tell of a fair number of

MS J.M. AYLWARD: Don is gone out to get the

score is he, or what?

WITNESS: He is gone out to get the score of the

hockey game.

MR. H. HODDER: Oh, he is gone out to get the

score? That is good. Now that the Leafs are not into it we are not so

interested.

MS J.M. AYLWARD: Fine by me, me neither. Carry

on, (inaudible) shoot!

MR. H. HODDER: We hear a lot of talk in the

community about a lot of suits that are against the Health Care Corporations,

civil suits. These are paid ultimately by the taxpayer, the damages that are to

be paid out.

MS J.M. AYLWARD: Is this third party you are

talking about?

MR. H. HODDER: Third party. Well, in this

particular case (inaudible) by the health care profession in some way. Are there

any available stats that show how many cases are being brought against each

Health Care Corporation? How many have they successfully challenged in court?

And how much has been paid out of the taxpayers' dollars in terms of

settlements?

MS J.M. AYLWARD: First of all, Canadians are

becoming much more (inaudible) by nature. I guess it is because of our

affiliation with our southern partners, and our access to that type of

information on television, et cetera. I do not have a listing of how many

complaints we have had. I know that there are a couple of ongoing ones that are

before the courts, but I certainly do not have a listing. I have to be quite

honest; of all the priorities I have had to face in the last eleven months since

I have been here, that was not one to which I have sort of reached out to try to

identify. It has been an extremely challenging year.

I know there are people in the system who are not

happy with what has happened and they certainly have access to the courts. In a

publicly funded system I am sure that is the case, not nearly as much as in a

private system.

I have just heard - it was interesting and I think

it is worth saying - that a physician recently shared with me that when you meet

someone in a Canadian health care system about surgery they do not even ask in

very much detail about what surgery they are having done, or what it involves,

what size dressings, and it never occurs to them to ask how much.

If you are a physician practising in the United

States they will ask - when a physician tells the patient, for example, that

they need to have surgery, they will not only ask about the type of surgery and

the number of tubes and the number of bandages, but the whole cost structure.

It is a different thinking mechanism that you have

in a private system whereby you are paying for everything and you have to get

your money's worth mentality,

whereas in a Canadian system you are paying for it

but it is through the public system and we do not have the same number; although

I know there are more complaints made against professionals, through their

professional associations, that are responsible to protect the public than we

have seen before. That is generally done by the profession, and the first step

of the complainant, as you know, is they would go to the professional bodies in

writing. I do not always have access to that until it goes to the court system

and it is brought to my attention.

MR. H. HODDER: Thank you.

In the various parts of the Province we hear, as

Gerald was saying, that it is very difficult to attract physicians to rural

Newfoundland. We have certain parts of the Province, and the Bonavista Peninsula

is one of them, where there may be physicians there - and the Burin Peninsula is

another case - where doctors are saying: No we cannot see you; (

a) Our patient

list is full - they are obviously in general practice - and you will have to go

to the nearest hospital or whatever.

Do you keep any stats on the physicians in the

Province who are not accepting any more patients, whose patient load is full,

and where they are located, that kind of thing?

MS J.M. AYLWARD: Well, Newfoundland has the

highest percentage of salaried physicians in the country, and salaried

physicians work on a different focus, I guess, than the fee-for-service

physicians, so I would presume you are talking about fee-for-service physicians.

We do keep some statistics on that, particularly in

St. John's. We have a listing that was made of us for a number of reasons, but

most recently when a prominent physician in St. John's died, who provided a lot

of care to seniors and was one of the few physicians who did house calls. When

he died, a lot of seniors were having difficultly finding a replacement who was

willing to offer those services. So when we were contacted, we went and revised

the list to find out how many physicians were accepting new patients, not on the

premise of giving it out to the public but on the premise of helping seniors.

When they would call in and say, "I am looking for a doctor", we would say,

"Well, what area are you interested in?" Rather than have them go through all

the yellow pages, we would say there are seven doctors in this clinic; three of

them are accepting new patients, the other four are not. That is the kind of

service we do and it does change, I do not mind saying.

There are problems in how services are delivered.

For example, a lot of our fee-for-service physicians are providing fabulous

service; however, when they close their offices at noon on Fridays, or at 5:00

p.m. on Fridays, you will often here a recording encouraging people to go to the

emergency department if they need care. I think that is an issue that we have

which means that a lot of the patients going to emergency really need to go to

some ambulatory care facility and not an emergency department. It frustrates the

system because you spend three hours waiting to get your ankle checked while

they are doing cardiac resuscitation, and so they should. That is the nature of

our system.

Yes, we keep lists, mostly around fee-for-service

physicians, and not necessarily in Bonavista or Clarenville. I cannot say that I

have a list out there, but I do have a list for St. John's.

MR. H. HODDER: But you are aware that it is not

just St. John's where it is difficult to find a family doctor?

MS J.M. AYLWARD: Well my recruiting, through

direction in the department, has not been in St. John's. It has all been

focused, without exception, on rural Newfoundland. So I am more than aware of

the difficulty.

You know we have a 50 per cent rule in St. John's;

we have not been recruiting at all. The listing is to make it easier for people

who are looking for a physician living within their area of residence. We are

more than aware of the difficulties we have. We have dedicated people in our

department who are doing it, as well as the boards themselves. The boards got

together and hired a recruiter as well. Yes, I am aware of that.

MR. H. HODDER: One last question before I let

my colleague over here (inaudible) -

CHAIR: Your colleagues on this side are

suggesting that might be appropriate.

MR. H. HODDER: - and that is with the

practitioner nursing program of which there is just now, shall we say, some

evidence of it in the Province. How is that going, the training for it? And what

impact do you think it is going to have in the next year or so on easing up some

of the problems we have in rural Newfoundland?

MS J.M. AYLWARD: It is going very well. The

nurse practitioners are actually out doing their clinical placements in various

areas around the Province. We see it as the beginning to address the medical

service and health service needs of the Province by creating a

multi-disciplinary clustered approach to service delivery.

If you look at one of the reasons physicians

commonly say they have difficulty working in rural Newfoundland, they will often

refer to money as a big issue, but they also talk about lifestyle. They do not

want to be on call, they do not want to have to do everything themselves, and

nor should they.

If you have a practitioner, namely a nurse

practitioner, who can do diagnosis within the realm of regulation, prescribing

of medications within the realm of regulation, it should take a fair bit of

pressure off. Not only that, you will have someone to work in partnership with

you.

We have a lot of physicians who are working very

closely with these nurses in the education and training component, and also in a

way where they are trying to work towards how they are going to work as a team

after. (Inaudible) Port aux Basques, Twillingate and Goose Bay right now.

The issues are not around nurse practitioners. That

is a great program. It is going very well and we are very proud of it. The

difficulty remains that we hope it will be one more tool in attracting

physicians to work in an area because they will not be seen as sole

practitioners or lone rangers or whatever you want to call them, because those

days are gone.

We have new funding in the budget as well to

continue on with the program, and will be taking in a new class again in

September.

MR. H. HODDER: One little question following on

that one is to ask about the recruitment program for entry to the nurse

practitioner program. There is an application process out there now, and the new

class will begin in the autumn is it?

MS J.M. AYLWARD: Yes. We are not having any

difficulty. We had so many applicants for the last one we had to pick and choose

for the most part, although we had a couple of areas where we actually recruited

- namely, Ramea was one area - to try to put something back there.

One of the principles we used in the first place

was to try to recognize people who are actually living in various communities

who are experiencing difficulties so that we know they will go back to live

there and work in that capacity, which is a way to sort of - you know we

provided a bursary program as well as a deferred reverse salary leave plan to

assist those people to do the course.

MR. H. HODDER: Has there been national

recognition of the designation?

MS J.M. AYLWARD: There has. I have spoken on

the program at a couple of national venues. The regulations are still being

finalized. Once they are finalized, we will be doing something much more public

on the full package. The legislation is the first part but it is the regulations

that are actually the teeth behind the practice. We are working towards those,

and I do believe we have -

WITNESS: They were passed today at the ARNN

council level.

MS J.M. AYLWARD: Oh, they were passed today at

the ARNN council. So there you go; we are moving full steam ahead.

MR. H. HODDER: Thank you very much.

MS J.M. AYLWARD: Thank you.

CHAIR: Thank you, Mr. Hodder.

Mr. Ramsay, followed by Mr. Canning.

MR. RAMSAY: Minister, I want to commend you on

that specific action. I think it grew out of the health forum, although it was

something that was in the works, I would suggest, to a certain point, the nurse

practitioner program and this sort of thing.

MS J.M. AYLWARD: No, it was not in the works.

MR. RAMSAY: It wasn't?

MS J.M. AYLWARD: It was not even in the works.

It was after -

MR. RAMSAY: But it had, at one time in the

past, been contemplated and passed through the department, but then it was

processed -

MS J.M. AYLWARD: It was only an education

program. There was never, ever a legislation component or a specific designated

program except one through the university, which was a sort of a three-month

type of thing or six-month type of thing.

MR. RAMSAY: You are to be commended for the

action taken under the health forum, certainly. It has provided a level of

comfort to the people in the area that I represent, and I think also a level of

excitement about the potential for the total health system and how that will

affect us in the future.

I had a number of different things here I wanted to

touch on but I will not take too much time. I know the Opposition have further

questions. You did mention something which caught my ear, some doctors receiving

a higher or one-and-a-half salary units for certain areas. Could you elaborate

on that a little because I understood that one - I knew there was some

flexibility there in certain areas to try to offset the requirements but maybe

if you could just elaborate a little on that?

MS J.M. AYLWARD: Okay, in an area of the

Province which is isolated that has notoriously had two physicians, one left,

and in an effort I guess to recognize the added workload responsibility, and

more importantly to retain that physician, the board made an offer to provide an

increase in that physician's salary until another physician could be recruited.

The problem with it is that the physician is a sole practitioner and is really

experiencing a lot of challenges with respect to people coming knocking on his

door all hours of the night. So it is one sort of recognition but it is only

partly addressing (inaudible).

MR. RAMSAY: It is not the kind of thing that

will potentially solve problems in other areas because, of course, it gets away

from the multi- the cluster (inaudible).

MS J.M. AYLWARD: Plus, people who are not even

making one-and-a-half times the salary, if you consider the rural bonus system

we have in place, plus the fact - whether it is fee-for-service or salary - some

of the physicians that we need to work in rural Newfoundland would make almost

as much as some of the highest paid CEOs in the Province, which are really not

that highly paid compared to other provinces, I might add. So it is not the

money; the money is only one part of it.

WITNESS: (Inaudible).

MS J.M. AYLWARD: I was talking about publicly

funded, not privately funded, let me tell you.

MR. RAMSAY: Anyway, over to the issue, you are

dealing with the medical community now in negotiations. There was a study which

came out recently which suggested that doctors drive the cost of the medical

system; and, of course, commensurate with that is the people's demands on the

medical system which in turn - the doctors are then driving the system as far as

the costs. It noted some difficulty with doctors seeing huge numbers of

patients, and because of the fee-for-service method of payment that was driving

the overall cost of the system up.

You did maintain that we did have a higher salary

portion, percentage, than other Provinces. I know we have looked at and probably

discussed, and there have been studies and that sort of thing on the different

models for paying physicians, but I wonder - one case in point was

cardiovascular, which was mentioned in the past. If you took that kind of thing

where the physicians are paid on a basis of people flowing through system, and

that is probably one of the higher paid physicians or specialists, if they were

to be paid a salary of the same amount that they would make on all of the

different procedures they perform, do you feel the actual utilization of the

system would drop?

MS J.M. AYLWARD: First of all, I believe that

in order to have an effective system we have to have a balance. All

fee-for-service is not good, and I do not think all salary is good either.

Salary is not a panacea either because some physicians on salary are on salary

because they only see a handful of patients a day. The population does not

warrant a fee-for-service model. So, if you have all salaried physicians you

might not get as many patients seen that need to be seen because it is sort of a

different approach to service delivery.

Our challenge is to find a balance, and we are

looking at a number of different models. As I said earlier, we have the highest

percentage of salaried physicians in the country, albeit they turn over quite

quickly, but I think we have around a 23 per cent to 30 per cent mark, which is

the highest in the country. We are looking at other models. One of those models

includes the capitation model whereby a physician would go out to you, for

example, and make a contract with you to be your physician. The government,

then, would pay that physician $1,000, for example, to care for you for a period

of a year. The incentive would be for that physician, then, not to see you ten

times. In fact, the more infrequently he saw you, the more money he would make

for caring for you. It puts more emphasis on the prevention and the health as

opposed to the illness part of it. That is one of the models, for example.

MR. RAMSAY: That can potentially be one of the

research elements of the new system of the cluster; as part of the research

element, they might undertake that as an overall part of the strategy?

MS J.M. AYLWARD: Yes, that is one that we would

look at. Right now we are looking at physicians who actually approach the

Department of Health (inaudible) two areas of the Province, and they are trying

to develop a new model of service delivery which is a combination of

fee-for-service and salary. If it is within the budget, if it make their lives

earlier, we have been giving them the message quite clearly that we are open to

new models of practice.

MR. RAMSAY: I want to make a little prediction

to you, but I do not know how accurate it is. We are losing a lot of our GPs to

the United States now. The United States is moving away from a lot of

specialists. From what I am led to believe, there will be a lot of displaced

specialists in the US as a result of HMOs and other companies in medical care

getting into more specialists. I would suggest that eventually there will be

specialists re-qualifying as GPs and floating back into the system.

MS J.M. AYLWARD: Some have. I know in British

Columbia there have been a couple of specialists working in a GP role that I

know of, but you have to factor in a couple of other things. We have an aging

physician population, and we also have a prediction not only for a general

practitioner shortage but also for a specialist shortage.

MR. RAMSAY: Coming up?

MS J.M. AYLWARD: In the new millennium.

MR. RAMSAY: One point out of the figures of the

Budget, I note that MCP cost us $4.2 million to administer $150 million worth of

medical payments. Do you feel that is high or low

Document details

Collection	Newfoundland and Labrador — Committees
Citation	1998-04-29
Type	committee
Volume / chapter	committees_standingcommittees_socialservices_ga43session3_1998-04-29_ssc-hcs_.htm
Language	en
Format	html
Source	PROVINCIAL
Identifier	d28bcdebaf243bfcb4fb735d0dbb96f2708ca8cc

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