April 28, 1997

SOCIAL SERVICES ESTIMATES COMMITTEE

The Committee met at 7:00 p.m.

CHAIR (Mercer): Order, please!

I ask the members of the Committee to introduce

themselves, starting with you, Gerry.

MR. G. REID: Gerry Reid, MHA for Twillingate &

Fogo.

MR. H. HODDER: Harvey Hodder, MHA for Waterford

Valley.

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

Whitbourne.

MR. OTTENHEIMER: John Ottenheimer, MHA for St.

John's East.

CHAIR: Bob Mercer, MHA for Humber East.

With those preliminaries out of the way, Minister,

I would ask you perhaps to identify your delegation for us. I would also ask, as

we proceed in the evening, that the members who might be answering a question

identify themselves for the purpose of our friend here in the back who has to

keep some written records of things.

MR. MATTHEWS: Thank you, Chair, for enabling us

to reconvene in such a timely fashion. It is good to get this exercise done once

you are on a track, and we appreciate being here tonight with you.

Before I make any remarks and comments, and not

that I do not know who my officials are, because I have introduced them for two

years in a row, I am going to do it this year by asking them to introduce

themselves to you so that they will be for certain accurately identified as to

who they are and the area of interest that they work in in the department.

I will start with my deputy. Sometimes I call him

the Premier, sometimes I call the Premier's Deputy, but he is the Deputy

Minister of Health, for the record.

DR. WILLIAMS: Dr. Bob Williams.

MR. WHITE: Gerry White, Community Health and

Drug Programs, ADM.

MR. MANUAL: Roy Manual, ADM, Institutions.

MR. HART: My name is Chris Hart. I am ADM of

Support Services.

MR. MATTHEWS: Okay. I will start with Debbie

Sue.

MS MARTIN: I am Debbie Sue Martin and I am the

Director of Mental Health and Community Health.

MS GARDNER: I am Eleanor Gardner. I am in

Community Health, the Director of Continuing Care.

DR. HUNT: Ed Hunt, in Medical Consulting.

MR. ASHLEY: Joe Ashley, Executive Assistant to

the Minister.

MR. DOWN: John Down, Director of Drug Program.

MR. OSMOND: Max Osmond, Director of Financial

Operations.

MR. STOWE: Gerry Stowe, Financial Manager,

Institutional Financial Services.

CHAIR: Thank you, Mr. Minister, for that

introduction of your staff. Before we begin, perhaps I will just outline very

quickly how we intend to proceed this afternoon. We will start by having the

minister make some introductory remarks. Then we will ask the Clerk to call the

first head. It will be under that head that most of the discussion of your

Estimates will occur. We will then turn the proceedings over to the Vice-Chair

to initiate the questioning, and we will continue with each member until all

questions are exhausted, or until we and you are exhausted.

Having said that, Mr. Minister, perhaps you could

give us your introductory remarks.

MR. MATTHEWS: Thank you, Chair, and again

thanks for having us. We are looking forward to the opportunity tonight as a

department to answer any questions that might be posed from the Committee. It is

an important exercise in our view, the appearance before you as a Committee,

because not only is it a necessary exercise technically, it gives us as a

department, on behalf of government, to discuss fully one-third or more of all

of the discretionary spending this government is responsible for doing in a

fiscal year. After pension obligations and debt charges, out of our $3

billion-plus Budget you will find that Health at $900 million-plus represents

probably more than a third of what is left to be spent. In that sense it is an

important area to have examined.

The Department of Health started one year prior to

this fiscal year on a three-year planning cycle in its budgetary exercise, based

on a commitment that government gave in the 1996-1997 fiscal Budget that Health

would be given a flat line operational budget for a period of three years. It

would be done so that it would enable the health care system to respond to the

significant degree of restructuring that had taken place within the health care

sector over the past two or three years prior to.

This is the second year of the three-year planning

cycle we are in. The only significant, I guess, caveat, that was placed within

the three-year budget time frame, was that we live within it, but having said

that, we had the latitude or the flexibility of adjusting the budget as would be

necessary as we went through that three-year planning cycle, because, obviously,

we were making significant changes in the system. I refer to an ongoing and

greater emphasis in the area, for instance, of community health as opposed to

institutional health care, and to some extent you will see that reflected in

some of the changes in the line items in the budget as we go forward.

Notwithstanding the commitment of a flat line

budget last year, when all other departments were taking significant reductions,

this year the health budget was again increased, not by a large amount vis--vis

its total budget, but certainly in absolute dollars, there was a fair degree put

back into health care or added to the operational side of the health care budget

in addition to, of course, some things in the capital side of it and so, this

year again, while all departments were taking reductions in expenditures, health

care, because it is of such a significant priority for government and the people

of the Province, received some additional funding for very specific areas that

were announced in the Budget, and I will not get into repeating them. You may

want to chat about them as we go through.

The business of running a health care system is a

significant challenge regardless of what your budgetary situation is, but in a

time when dollars are scarce, methods of delivering services are changing,

population is aging, new technologies are emerging, expectations of the

population, the people whom we serve continue to rise, and in that context,

delivering health care services is not only a challenge for us but for every

jurisdiction in the country and will continue to be a significant challenge in

perpetuity, I would suggest.

I think, Chair, that, without my elaborating much

further, it would be a wiser use of time if I gave the Committee the benefit of

the time to ask some questions. I was thinking last night, as I was going

through my review exercise - I was reading the comments that I made last year at

this point in the proceedings - that I could just as easily have reprinted

Hansard and pass that out to you from last year and you would have had

appropriate comments for this evening. So, without wasting any more time, not to

suggest that I am wasting time, if I should be so immodest, I think it is better

if I just said: these are my concluding remarks and we look forward to the

opportunity of answering any questions you may have.

CHAIR: Thank you, Mr. Minister.

CLERK (Mr. Noel): Subhead 1.1.01

CHAIR: John?

MR. OTTENHEIMER: Thank you, Mr. Chairman.

I guess the procedure is as we did with the other

Committee; we can all jump in as we see fit. Is that right?

CHAIR: Exactly, and we shall continue until

exhausted.

MR. OTTENHEIMER: Okay.

MR. MATTHEWS: You look pretty tired already.

CHAIR: It has been a long day, yes.

WITNESS: This calls for a check up right away.

MR. MATTHEWS: There are two doctors tonight

(inaudible) last year.

CHAIR: The questions are in Hansard - are the

answers there as well?

MR. MATTHEWS: They are in the Budget.

MR. H. HODDER: We always read Hansard,

(inaudible) second opinion, anyway.

MR. MATTHEWS: Most people do.

MR. OTTENHEIMER: Mr. Minister, maybe I could

begin with a question which is perhaps really an extension of the Estimates and

the Budget information. It has to do with the issue raised today in the House

concerning the health forum which was announced last week.

I wonder if you could be, perhaps a bit specific in

terms of, really, what do you envisage this health forum being all about in

terms of, you know, who will play a role in the forum and what role will the

public have. And I guess, seeing that we are reviewing the estimates, what sorts

of costs would you expect such an exercise to be to the taxpayer of the

Province? I wonder if you could just expand on this concept which has been -

MR. MATTHEWS: First of all I have to

congratulate you for attempting right off the top to elicit from me the

announcement that I indicated I would make Thursday in the House, that is the

nature of the forum, the location of it, the composition of the stakeholders,

who will be there and the general purpose of the forum. I can only say to you

tonight, until I announce that on Thursday I really do not have much that I can

appropriately share with you.

The Premier announced that it would be government's

intention to have an early and rather succinct round of consultation with

specific stakeholders who are attached, who work in, and have a lot to do with

the health care system. Until I get the details worked through the Cabinet

committee process and that sort of thing, which will happen in the next two

days, I am really not at liberty to scope it out any more than that in a public

fashion.

The cost that will be attached to it will be very

minimal in that it will not be an expansive group, nor will it be held in

elaborate surroundings, nor will we be serving gourmet meals. A caller to Open

Line suggested we should have it in a hospital and eat hospital food. I am not

sure we will do that because of the necessity of having it in an appropriate

location that has the facilities to accommodate it. It will be an early

consultation process. It will be announced in detail on Thursday. I think that

will be the extent of my answer.

MR. OTTENHEIMER: Okay, fair enough. I

appreciate that, under the circumstances. Perhaps then more specifically, in

terms of the Estimates and the information before us, we see - and maybe Mr.

Manual may be a person who may want to respond to this - in terms of the

hospital and nursing homes. We will all recall less than a year ago the great,

you know, public sort of reaction to the proposed increases to those residents

of our nursing homes. Obviously, the increase has come into effect.

I am just wondering if there could be some comment,

either from yourself, Mr. Minister, or from one of your officials, as to the

impact, I guess, if any, from the point of view of the institutions themselves,

from a financial point of view, that this has had on the institutions. I am

wondering in some general sense could you give some comment as to where we find

ourselves today in terms of the satisfaction level, I guess, which was really of

great concern to the public at large many months ago, and how our residents

within our institutions have reacted to this transition.

MR. MATTHEWS: You have directed the question to

my ADM of Institutions, and I think probably I should let him answer the first

part of the question, as to how this has worked out from a fiscal point of view.

The more general question of where we are in terms of client satisfaction, if

you like, I can comment upon that after. Roy?

MR. MANUAL: With respect to the matter of the

financial impact that this has had, we are pretty confident that the revenue

base that was projected for the nursing homes related to the revenue change in

the rate is pretty well on target for this year. We have in one or two

facilities provided some adjustment to shortfalls on revenue in relation to

that, but by and large, most of the nursing homes in the Province have been able

to operate within the approved fiscal arrangements vis--vis the adjustment to

the long-term care rate. The exact revenue amount that we have received, or that

nursing homes have built into their budgets, I do not think we have that with

us. I can defer to Mr. Stowe and see if we do, but we could provide that if it

were requested of the Committee. Gerry, could I ask you if we do?

MR. STOWE: Tentatively, Roy, we were looking at

somewhere around $1.5 million, $2 million, but those estimates certainly were

not made on a real scientific basis. The rate first went from $1,510 to $4,000.

That was a fair jump, and we really were not sure how many of the private paying

people would be able to pay an additional $2,500. But we estimated roughly about

$1.5 million to $2 million.

MR. MANUAL: We have provided adjustment to a

couple of nursing homes that were short. There was a shortfall in the amount of

revenue, I know, in a couple of nursing homes this year, and we did provide that

adjustment back to them.

MR. MATTHEWS: I think it is important to say

again, although it was said a number of times, when that rate increase was put

in place that about 87 per cent, 88 per cent of the residents of the home were

totally unaffected by this inasmuch as their income was OAS, GIS, and that

caused them to be paying even less than the $1,510 that was in place at the

time. So it is only the 12 per cent that are referred to as private paying

residents who were in any way impacted upon, in the first instance, with this

rate change.

As Mr. Stowe has said, there is no scientific basis

on which to indicate how much revenue we thought we would get from the change,

so we made a budgetary estimate. It turns out that even with the reduction back

to $2,800 it means we have basically met the targets, except in a couple of

instances. Really, what that says, I guess, is that even at $2,800, that

substantial decrease down from $4,000, there are still very few, if any people

between the $2,800 and $4,000 anyhow who would have been - you know? So inasmuch

as we met the projections, there is a pretty clear indication that there is a

very small amount of money involved from $2,800 to $4,000. I guess frankly there

is not a lot of people involved in the $1,510 to $2,800 increase. Twelve per

cent maximum are impacted upon, and some of these are impacted upon very

minimally.

In terms of client or resident satisfaction, I

personally have not heard a word as to any complaints about the homes'

operation, whether they are better or worse as a result of the rate increase.

There was some obvious reaction to the increase when we announced it. The

Glenbrook Lodge, one lady put on a bit of a pretty decent campaign, and there

was some reaction in your area, Mr. Chair, from some seniors out there. But once

the rate was adjusted back to $2,800 there has been virtually no reaction since

then. Obviously, people do not like rate increases.

MR. H. HODDER: Yes. We took some satisfaction

in seeing you be put in your place by a ninety-six-year-old, but these things

happen from time to time. Do not underestimate these people. You cannot win at

that kind of a debate, so you took the honourable route and said: Hey, let's

back off here.

MR. MATTHEWS: Yes, we only doubled it.

MR. H. HODDER: And then you only doubled it

after that. Still on nursing homes, but not quite on the finances of it, if you

want, directly on that. The occupancy rate for nursing homes all across the

Province - there is a waiting list here in this region, but are all the nursing

homes - like in certain parts of the Province - for example, the Interfaith one

in Grand Bank, is that totally occupied now, filled up, or are there vacancies

there? What is the situation like region by region across the Province?

MR. MATTHEWS: Well, on a provincial basis, we

have probably have more nursing bed spaces than we need at the moment, but not

by many. We have about 3,104 beds I think in the system. There are areas where

our beds are not all full. We have ten beds, as an example, in the St. Lawrence

health care centre that have never been opened to date. There are ten not opened

in the - not the Blue Crest -

WITNESS: No, Golden Heights.

MR. MATTHEWS: Golden Heights Manor in

Bonavista. From time to time we have, let us say outside the overpass, bed

spaces. There is no pressure on long-term care bed spaces. Here in the St.

John's area we are running at about eighty to 100 spaces, I believe, for levels

III -

WITNESS: Yes, there are just over 100 spaces.

MR. MATTHEWS: There are probably 100 and - who

would have that figure?

WITNESS: There are 136 people on the waiting

list.

MR. MATTHEWS: Yes, 136 people on the waiting

list. How many of these would be level I, gentlemen?

WITNESS: Fifty.

MR. MATTHEWS: Fifty. So we have about eighty

which we would consider true nursing home clients out there, levels II and III.

There is a turnover in the system here in St. John's, where we have about 1,200

beds, I believe. There is a turnover of about thirty-five to forty a month. That

is natural attrition. That tells you that there is theoretically a maximum

waiting list of about two months, which is certainly -

WITNESS: Dr. Parfrey's study says about two to

three months.

MR. MATTHEWS: I am sorry?

WITNESS: Dr. Parfrey's study says about two or

three months maximum.

MR. MATTHEWS: Yes, Dr. Pat Parfrey. The health

research crowd over at the University are doing some work in long-term care

needs and trends for us. His preliminary report told us that we are looking at

two to three months maximum waiting lists here in the city which is our, say,

heaviest demand area and that, as compared to the rest of the country is very,

very acceptable, very, very low; Ontario is about nine to twelve months as a

comparative example.

MR. H. HODDER: In the regions of the Province

now, I am going region by region, are we still taking in people say, from some

parts of the Province and having to move them to homes, for example? When I was

in Grand Bank last year, I met a person there who was from Bonavista Bay,

actually. Is that still happening or are we able to accommodate people within

reasonable distance of their extended family?

MR. MATTHEWS: That is the objective. Sometimes,

the needs of the resident dictate where they have to go. For example, we have

some homes that are fairly new and have good, what we would call Alzheimer's or

protective care units and sometimes people have to be located where it is best

for them; and you do hear some commentary about very senior and elderly couples

being separated because of having to go into a nursing home. Sometimes that is

caused because the level of care for one may be a level III, and the level of

care required for the other may not even be a nursing home level, it may be

level I, you know, so these things unfortunately happen.

The area where I get most commentary now is the

Clarenville area because they feel that generally in that area, there should be

more spaces but if you take it as a region, we have vacancies, say, in St.

Lawrence and Bonavista and people do not take well to having to even hear the

suggestion that they may have to access these beds before we build more beds and

have more vacant space.

MR. H. HODDER: (Inaudible) visits to St.

Lawrence and to Grand Bank. My roots are on the Burin Peninsula, as some people

would know, and I have talked to people there from, say, the Clarenville area

who sometimes do not have a great deal of choice. Are there other areas of the

Province like Clarenville now where we have significant concern about the

availability, because the people in Clarenville have been very much concerned

about, or unhappy with, the alternatives placed before them?

MR. MATTHEWS: I am not aware, off the top of my

head, of anywhere where there is -

MR. H. HODDER: There are no other regions like

that?

MR. MATTHEWS: Most of the regions of the

Province, most of the people of the Province have long-term care space available

to them within a reasonable radius from where they live. If you started in St.

Anthony and worked your way around the Province down to St. Lawrence, you will

find, like St. Anthony, Port Saunders, Bonne Bay, Corner Brook, Bay St. George,

Burgeo, all have good, long-term care facilities. If you come across the Island,

you know, you will find in every significant area, there are good, long-term

care facilities. So long-term care, I have to tell you, is not an area where we

are under-resourced in terms of beds or under-resourced in terms of funding.

Simply put, it is not a pressure point in the system, but you will always find

somebody in some community who may, in fact, have had to go beyond what he would

consider a reasonable distance to get a relative into a long-term care space.

Clarenville, would be the only area, off the top of

my head, where I can think we are getting a sort of continual pressure - and not

a lot of pressure except from, let us say, the politicians and town councils and

people who have relatives in the area, because we put fourteen beds in there

last year, and the bed study that we are working on said that we may need up to

forty-four there you know, if you were going with the maximum. So we have done

some things there, even, to address the concerns, and it has helped.

MR. G. REID: Minister, what has happened with

the demand for chronic care in the Province?

MR. MATTHEWS: What has happened?

MR. G. REID: Yes, I mean, ten years ago there

was an outcry out there for more beds for chronic care. A lot of the studies

showed it prior to say, 1989 that, there was a need for more.

MR. MATTHEWS: The Orsborn Royal Commission in

1086-1987 recommended that by the year 1995, ten years out, they thought we

should be working towards about 2,700 long-term care beds in the system. For

some reason, we have gone well beyond that. We have 3,000 to 3,100. So that is

what has happened. We have made provision for as many spaces as was recommended,

and probably some more.

We do have an aging population, which would

normally say there is an increased demand, but the other side of that is we have

made substantial strides in home support programs which allows people to stay in

their communities and in their own homes as long as they can. In the last two or

three years, I guess, with more and more rural Newfoundlanders probably being

out of work because of the fishery crisis, there may be, to some degree, seniors

staying at home a little longer with their families. All of these factors have

put us in pretty good shape with long-term care, no question about that.

There is a facility in your area, the Notre Dame -

Twillingate area, and I am not aware of any waiting list or any pressure on the

waiting list in that area. There is space available when somebody needs to get

in.

MR. G. REID: But we have not built a lot of

these facilities since 1989, have we? What have we done - just added on to the

existing ones?

MR. MATTHEWS: We have done a bit of both. I

guess we built some facilities - most prior to my arrival. I think we have done

some things in -

WITNESS: St. Lawrence, (inaudible).

MR. MATTHEWS: St. Lawrence, Burgeo, and Port

Saunders were three facilities we built recently.

WITNESS: And one facility in St. Anthony.

MR. MATTHEWS: St. Anthony is a new facility,

which replaces a current one with fewer beds. We have done things in Bonavista.

There is a fairly new facility there. We put the Bonnews Lodge in Brookfield,

the Hugh Twomey Centre in Botwood. We have added space to the Notre Dame Bay

Memorial Health Care Centre in your area. We have been doing it all over,

really.

MR. G. REID: A study in Central Newfoundland

recommends a decrease in the next eight years of some forty -

MR. MATTHEWS: They are projecting, yes. That is

based on a couple of things, I guess, Primarily on the fact that as the home

support side of the health care system continues to grow, allowing people to

stay in their homes longer, there will be less demand for -

MR. WHELAN: Second largest industry, I think,

in my district.

MR. MATTHEWS: Home support?

MR. WHELAN: Yes.

MR. MATTHEWS: Well, it has gone from the

well-known figure now of about $300,000 in 1987 to $30 million plus this year.

That should tell you something about how that home support program has grown,

and the effects of it on the pressure that was on long-term care.

MR. WHELAN: A year or so ago, you introduced a

change in policy with regard to personal care homes in that you allowed level II

patients to be admitted to the level II homes. How was that program looked upon

by the industry? Did they welcome it with open arms, did they partake in the

opportunity? Were there many level II people -

MR. MATTHEWS: Let me make a quick answer. I am

going to ask Eleanor Gardner who is charge of and is very much involved in that

area to answer it in more detail. Yes, I think they welcomed it roundly. They

wanted to see to what extent each of them individually could participate because

there were new standards. Probably Eleanor you can comment, if you would come to

the mike, please, and identify yourself, and give what I am anticipating will be

an excellent answer.

MS GARDNER: The personal care home industry was

made aware of the change in policy to allow level II clients to be admitted.

Fourteen of the personal care homes to date have indeed become licensed to admit

level II clients. Many others have applied, but the regulations regarding the

building in many cases needed improvements. We have perhaps another thirty that

are presently undergoing renovations in order to apply for the level II licence.

MR. MATTHEWS: Yes. The receptivity of it, or

how it was received by the industry, I think, was part of the question.

MS GARDNER: It was received very well. I think

for quite a while now there has been some concern within the industry about the

principle of aging in place. Whereby a client would be admitted to a personal

care home as a level I. Over time, over some years, they would begin to

associate the home as their family home, having grown attached, even, to some

other residents in the facility. When they became more frail, or at a level II,

they would be required to leave the facility. It was stressful not only for the

actual resident who would be asked to leave, but it was also stressful for the

home itself.

By and large, I never heard any negativity from any

of the seventy-two operators. I think some of them are disappointed, actually,

because the advice they have been given is that the cost to renovate would

exceed the margin of profit.

MR. WHELAN: Due to the fact that they have had

to make some fairly extensive renovations, I would assume, in certain cases, and

also considering the fact that the personal care homes are probably the best

bang for the buck that we have in health care in this Province, has there been

any consideration given to perhaps subsidizing the renovation that they may have

to make, or increasing the payment received for each individual guest in that

home, especially of their level II patients? Mr. Minister, probably you may be

the best one to answer.

MR. MATTHEWS: Well, yes. To the question of

assisting with renovations, no, that industry is purely totally private

sector-owned and driven, so we have no program to assist them with retrofitting.

We have set the standards for life, fire and safety purposes and let them meet

the standards.

In terms of paying them more for the residents

because they have higher levels of care, they have been, I guess, very fortunate

in the context of what government has been able to do generally for rate

increases for other people in health care and other areas. We have given them

two rate increases over the last year, which has moved them effectively from

$846 in the subsidized beds to $900 per month, as a result of the two increases

we have given them, the bigger one being in this budget of $34 I believe.

We recognize that it costs more to give a higher

level of care. There is not a big percentage yet of the residents at level II.

Most of them are still at level I, obviously because only thirteen homes are

suited up to take level II. We recognize it costs more to care for higher levels

of care, and we recognize the value of that industry in the health care sector,

and being probably, as you say, a very good value for money spent. They have

been the beneficiaries of a 7 per cent or 8 per cent rate increase basically

over the past six months, really. They have received that with gratefulness, but

with disappointment that it is not more, obviously.

MR. WHELAN: Considering the fact that nursing

homes - I am not sure exactly what the cost is per person, but I would say that

they are considerably more than the personal care homes. The money that would be

saved by a transference of x number of people from nursing homes to personal

care homes might warrant another look at whether you would subsidize the cost of

renovations, or indeed increase the amount of money paid per patient in the

nursing home. It may in the long run be quite beneficial to the Province

financially.

MR. MATTHEWS: We are moving towards our nursing

homes becoming - and we saw some protests again in the Corner Brook area over

this, our nursing homes becoming that, nursing homes, high levels of care. And

as we, on a go-forward basis admit people, we are admitting higher levels of

care. We are really getting out of a level I business, or levels I and II

business in the nursing homes, and we are concentrating on levels III and IV.

They are high cost nursing home beds, so we cannot

afford to be having people in there at level I. On the other hand, it is not

very easy - as a matter of fact, we would not, and I do not think you would want

us to, once we started doing it, if we did - start moving level I people out of

homes that they have been in for many years, such as the Glenbrook Lodge or St.

Luke's home or some other nursing home. Unfortunately, attrition will take of

all of us eventually, but it will take care of people in the nursing homes who

are level I as they age and pass on. We are not going to replace level I people

with current level I, but we are not in the process of moving people out. The

only way you really get the savings is if you close down a home. Because if you

took six out this home and eight out of that home you really are not gaining any

efficiencies of scale.

MR. WHELAN: There may be enough people coming

out of hospitals and coming out of private homes who would be considered level

IIs to increase the number of guests or patients, however you want to refer to

them, in these personal care homes.

MR. MATTHEWS: These people are placed through

the single entry system. If they are level Is, that is where they are directed

now, under the new concept, to personal care homes. We do not redirect level Is

or IIs on medical discharge from hospitals or from the community who are

applying to our nursing homes. We direct them to personal care homes through the

community health boards single-entry system. I think that is accurate, Eleanor?

MS GARDNER: Yes, that is correct, Sir, and

probably one of the reasons why we are running that 50 per cent level Is on our

waiting list currently in St. John's is because we are trying to encourage

people to go to the personal care home industry.

MR. WHELAN: Do you need a licence (inaudible)

facilities, or any facilities licensed in the past number of years? I understand

there was a freeze on. Is that just in particular areas or is that for the -

MR. MATTHEWS: There is no freeze on licences as

such. The licences are continuing.

MR. WHELAN: For subsidized homes?

MR. MATTHEWS: Oh, I am sorry. The licences for

our personal care homes, if somebody wants to start-up, it is issued based on

demonstrated need in their area. In terms of subsidized bed spaces, we have not

subsidized the bed spaces since 1991-1992, when we got out of approving new

licensed, subsidized homes.

MR. WHELAN: So you did not regulate the number

of homes?

MR. MATTHEWS: We used to regulate through the

WILB board: The Welfare Institutions Licensing Board but now, all that is done

by policy only through the community health boards and essentially now, if you

meet the standards for levels of care and for life-fire safety, you are free to

open up a home any time, anywhere you want. It is a laissez-faire free-market

enterprise system on which that operates.

WITNESS: Without subsidies?

MR. MATTHEWS: Without subsidies, yes. If you

want to go into the business, you can. It is not unlike any other type of

business you might want to get into, you know.

CHAIR: John?

MR. OTTENHEIMER: Going beyond that point, I am

just curious: Who makes that assessment if an individual is a level I, II, or

III? Because there are grey areas - there would have to be, and, who makes that

eventual determination?

MS GARDNER: Through single entry, there is a

provincial assessment tool which is used all over the Province and in Labrador.

The staff who use that assessment tool are all trained in that assessment

process, but there is also a provincial policy manual regarding how to use the

assessment tool. If an assessor feels that there is any grey area, you know, a

high level II or low level III, then the case is discussed on the weekly

clinical panel, which has a minimum of nurses and social workers on the panel.

So there are those two checkpoints, but we have admittedly found that the levels

of care need even more fine tuning and that is in process.

MR. G. REID: So, what would stop a senior or

the family of this individual, from putting a level III or level I care

individual into one of those private homes, or do you have to go out and do an

assessment of that individual?

MS GARDNER: The person cannot access the

personal care home without having the assessment if they are looking for

subsidy.

MR. G. REID: If they were willing to pay it all

themselves?

MS GARDNER: If a person were admitted to a

personal care home without going through the single entry and were a higher

level of care, he would be picked up when the nurses do the monitoring of the

personal care homes. They are visited regularly and the client would be

counselled that if he were level III, the facility would not meet the B2 codes

for the Fire Commissioner's safety standards and he would be counselled about

that. If he persisted in staying there, though, he would have the right to stay

there, but we would engage in counselling with the client and family for, not

only that client's safety but, if you are in a shared-care environment and you

were a level III, and it is really only staffed for levels 1 and II, and

something happened, like a fire, then the other clients, the other residents in

the facility would be put in jeopardy because there would be more stress on

staff regarding the level III.

MR. G. REID: But legally there is nothing to

prevent him from entering?

MS GARDNER: Not if he is private-paying.

CHAIR: Harvey?

MR. H. HODDER: How do you (inaudible) waiting

list in this area and how it is impacting on hospital space? We hear that, you

know, as you said before, there is a significant waiting list in the St. John's

region, and part of that is probably because more and more of the people are

moving out of rural Newfoundland, their children are probably living in this

area and sometimes they tend to come here. There are a whole lot of

circumstances.

We hear tell sometimes of people occupying beds in

hospitals and, in other words, they have been medically discharged. How many

people will we have, let us say, in the hospitals in St. John's today, who are

medically discharged, who are, in essence, waiting for a space in a nursing

home?

MR. MATTHEWS: Probably Deputy or Eleanor might

be able to answer that. I would only preface it by saying that it is a fact of

life that there will always be people on medical discharge in facilities waiting

for transition into a personal care home, back to their own home, or into a

nursing home. That is a fact of life, and our medical discharge patient

population, if you like, on average is certainly not abnormal. Having said that,

I think Dr. Pat Parfrey has done some work for us on that, and you might be able

to comment further to hopefully validate what I said.

MS GARDNER: Actually, I think that we are to be

very proud of our statistics there. We average only 4.2 per cent of our beds,

our acute care beds in St. John's, being occupied by a medically discharged

client. We have a system with single entry whereby we would not permit that

number to exceed 10 per cent. We would be able to control that by the clinical

panel which I mentioned earlier. In their admissions, they would start to rotate

the admissions from community and from the hospitals to prevent it from

exceeding that. The national norm of an acceptable range is 8 per cent to 10 per

cent, and we are currently running at 4.2 per cent.

MR. MATTHEWS: Thank you, Eleanor, I appreciate

that. She keeps me well-informed, I tell you.

MR. H. HODDER: I had no doubt that she would

have the precise information. On the same topic, following through on that, on

the waiting list, you mentioned that there is an attrition rate of about

twenty-five or thirty per month in this region. Of course, we have a waiting

list, you said, of about sixty to seventy, therefore, the waiting list is about

two months long. That waiting list, of course, is only two months long if you do

not have someone else who becomes more acute in the meantime.

Is there any data kept on people who are, shall we

say, on that waiting list but they are nearer to the eighty level, you might

say, than they are down to the - you know, the top twenty-five are going to get

in. But the same twenty-five who existed last week are not necessarily the same

twenty-five this week, because obviously things change. Because things happen

and people become ill, or in some cases they drop off again because of attrition

while they are waiting. Do you keep any stats on the people who are waiting

longer than that because they are not as ill as somebody else but they are still

in need of a nursing home, and therefore, the two months - two times thirty does

not necessarily mean that you will be covered in the top sixty.

MR. MATTHEWS: You are really asking us how well

do we manage the ongoing waiting list.

MR. H. HODDER: Yes.

MR. MATTHEWS: I would say that the statistics

on medical discharge at 4.2 per cent indicate that we are managing it very well,

for two reasons. Number one, we have the space becoming available fairly

quickly, and number two, we are conscious of the cost of hospital beds. Eleanor,

you may be able to add something else as to how well we are managing. I would

say we are managing very well.

MS GARDNER: I think so, yes. Betty Havens - she

is actually one of the experts in Canada for our national norms regarding

waiting lists - says that if your waiting list has a turnaround time of six

months then you are doing very well. Our longest turnaround time is three

months, but we turn around within three to six weeks as well. So the longest the

person would be on the waiting list now is three months.

One year ago, prior to single entry, where we are

running a situation as you are referring to, at that time the turnaround time to

placement could be as high as two years. In the past little while through single

entry we have reduced that well within the Canadian norm. The ones who are

highly prioritized as to higher need are turning around in a three, six, eight

week pattern. The longest of the pattern is the three months.

MR. MATTHEWS: Thank you, Eleanor. There is

clearly no really serious concern in those areas. I am glad you are dwelling on

them, because they are areas where we are doing a good job. I would suggest you

keep up your line of questioning.

SOME HON. MEMBERS: Hear, hear!

WITNESS: Stick with it, Harvey; they are

getting hammered on this one.

MR. H. HODDER: I am just here, you know,

looking after your best interest, John.

MR. OTTENHEIMER: On, I guess, the same topic, I

am curious as well; in acute situations, due to need or perhaps the family's

inability to do anything further, what sort of contingency plan does the

department have in place, or what policy presently exists, to deal with those

perhaps exceptional cases where admission is essential almost immediately?

MS GARDNER: We have an emergency response

program. For example, we had one lady who was sent home from hospital and the

situation was critical. The turnaround time to placement in that emergency

situation was twenty-four hours. In the meantime, while we were waiting for the

twenty-four-hour period, the single entry would mobilize home support in the

family's home around the clock for the emergency response.

The second type of response for an emergency

situation, especially if it is a spousal situation, is that we have emergency

beds which are always kept fluid so that if we cannot accommodate the person at

home, with relief through home support while we get a placement, then we can

admit to an emergency bed. We have also swing beds in every region in the

Province for that type of emergency response.

WITNESS: How good are you at all?

MS GARDNER: It is the people out in the

community health boards. I am only reporting.

MR. OTTENHEIMER: Thank you.

MR. H. HODDER: While John is looking for

another question there, on the issue of the waiting list for the Janeway,

particularly as it applies to adolescent, psychiatric services, two years ago we

had a tremendously big problem there. What is the current status for adolescent,

psychiatric services?

MR. MATTHEWS: I will ask Debbie Sue Martin to

answer that. I can only say, from where I sit on a daily basis, I have not had a

concern expressed to me directly on that issue for at least a year. A year ago,

or two or three years ago, there were some more concerns being expressed to me

directly. But, Debbie Sue, probably you can be more succinct and accurate.

MS MARTIN: I will try.

The waiting list has improved from the last two

years.

MR. H. HODDER: The 600 one.

MS MARTIN: Yes. If you recall, when we chatted

the last time it was around 800, I think, and people were waiting anywhere up to

a year. There has been some improvement in that, and that has resulted a lot

from the amalgamation of the Janeway through the St. John's Health Care

Corporation. One of their programs is now an adolescent health program.

MR. H. HODDER: Yes.

MS MARTIN: Again, at this particular point,

things are being planned and put in place; for example, the adolescent health

counselling service that is still on LeMarchant Road but had really not been

utilized to its full potential. There are discussions now between the community

health, St. John's region, and the institutional board to reactivate that and

put some extra staff there. One additional staff has just gone there at the

beginning of this fiscal year. So it is an area that we recognize really needs

some assistance.

One group that we are looking at, this adolescent

program that will be with the Health Care Corporation, will go up to the

twenty-first birthday, and that has been a real gap for those people, once they

get past the sixteen, and even past the eighteen, because you can do extended

wardship up to eighteen, and do services that way, but that gap is also being

looked at being filled as well. Things are moving along. We are in a better

position but we are not where we would like to be. We still have a fair bit of

work to do on that.

We also have the other regions as well looking at

adolescents and children's services. There is also, in the western region this

year - people might be aware of the opening of the Blomidon Centre there, which

is a children and adolescent mental health service. So that has taken a fair bit

of pressure off the Janeway unit, because for any kind of assessments, under

young offenders or anything like that, people had to come into St. John's to get

those assessments. The Blomidon Centre opened in May, I think, of last year, and

they are able to provide some service there within the region.

We are also in the best situation that we have been

in terms of child psychiatrists. We currently have five now at the Janeway, and

one of the new people who just came, Dr. Rhonda Vardy, is looking at doing some

outreach clinics to the rest of the Province. We are trying to negotiate with

some of the boards about that. There are a few things in place and I think we

are getting at the problem, but the nature of the business is, as you respond,

there is a lot of unmet need out there, and you are getting more demand for the

services as well, as people become aware of them.

The other initiative that is addressed, that older

adolescent group (inaudible), has been the mental health crisis centre here in

St. John's. A lot of people, again, who were falling through the cracks in that

eighteen, nineteen, twenty are able to at least get hooked up to the system

there. The crisis centre does not provide long-term counselling, but it at least

allows someone to get into the system and gets them hooked up with some other

services.

MR. H. HODDER: What would you say the waiting

time would be now for a child or a teenager who is, let us say, referred from

either a family doctor or has gone through the procedures, and whether they come

through the school counselling system or through the family doctor or whatever -

what would be the waiting time now?

MS MARTIN: In terms of seeing a psychiatrist or

just getting -

MR. H. HODDER: In terms of having their needs

addressed and seeing the psychiatrist.

MS MARTIN: Okay. Having your needs addressed is

one, and having seen the psychiatrist - because mostly what ends up happening is

that for the person who has mental health problems, we are trying to look at

that holistic - sort of look at the kid in all of the needs. There may be social

needs, maybe family problems, things like that. Waiting time for a psychiatrist

right now is about six to eight weeks, which is pretty reasonable.

The Janeway now offers a crisis program, not quite

as impressive as the single entry system, but there is a crisis program that is

able to see people within a week. That does not mean they are going to be kept

on and everything met with them, but they will get contact with a counsellor. It

may be indeed that there is some short-term intervention, and they can stay in

that program up to six to eight weeks. Mostly people should get some service in

a fairly timely fashion, but there is still - you know, if it is not a crisis,

you are still talking about a probably four- to six-month waiting list. Again,

it is down a bit. We would like to see it down around three months if we could,

but it is still fairly high.

MR. H. HODDER: The last time we were talking,

we had one doctor, I believe, in Newfoundland who was trained or able to work

with and identify fetal alcohol syndrome children. You are familiar with the

recent study done in British Columbia -

MS MARTIN: Yes.

MR. H. HODDER: - where they found that very

high numbers of teenagers who were in trouble with the law indeed were fetal

alcohol syndrome, something like 23 per cent.

MS MARTIN: I do not (inaudible).

MR. H. HODDER: I do have the

summary of the

stats in my office. In that kind of situation, where we know that there are

significant numbers of children in this Province who are probably victims of

fetal alcohol syndrome, what are we doing to identify it? We have one doctor at

the Janeway who was supposed to be able to do these things but, of course, he

has a full

schedule besides that. We have a whole population of teenagers out

there whom we should be doing something about and addressing the needs in the

school system, in the justice system, and also at the community level. What are

we doing for those children?

MS MARTIN: Okay, I will speak on behalf - fetal

alcohol syndrome really falls under addiction services. This year there was a

workshop put on for professionals, family members, who are interested in fetal

alcohol syndrome. I cannot remember exactly when it was. I think it was last

Fall sometime.

WITNESS: October.

MS MARTIN: Yes, October, I think it was. I

think there was over 100 people at that. You are right, in that there is a fair

amount of interest. Because the rate in the native or aboriginal population is

even higher than 23 per cent. I think it is somewhere over 50 per cent in some

populations.

MR. H. HODDER: Yes, it is a scary stat.

MS MARTIN: Yes. So that issue again, it is

really a target area for the aboriginal population, and also in terms of

diagnosing the problem, as you say. It is something that gets missed a lot of

times. I do not want to speak for them, but the Department of Social Services

ends up getting involved with a lot of children with that, and is interested in

trying to get some training for staff to identify that - also, doing some

training for parents who are fostering children with fetal alcohol syndrome.

There is some work being done on that, but I am not

sure what the follow-up of that workshop was. I know, as you say, that study in

B.C. really gave some impressive numbers to that. There was a lot of interest

around. I cannot remember the name but there is one person, as well, at the

Health Sciences Complex who is also involved in the diagnosis.

MR. H. HODDER: But, other than the

familiarization session that you had last October, we have not really addressed

that issue to any kind of a level that would even be remotely commendable, and

it is an issue that is very significant. It is a big issue for aboriginals; it

is a big issue in the general population, because what it says is that the

treatment we are giving these teenagers may be totally inappropriate and we may

be putting children in prison at Whitbourne for something that is physiological,

and in fact, we know that there are teenagers in Whitbourne who are there

because they were born with a fetal alcohol syndrome -

MS MARTIN: Which was not picked up.

MR. H. HODDER: - which had been totally missed.

I have said to the minister that this is an area that is very important to me as

a person and also as an advocate for children.

MR. MATTHEWS: I think it is recognized by

government and certainly by the department, because one of the areas where we

have deliberately said, and we are, in fact, putting more money every year, is

in the area of community services for our community health boards, and a lot of

these areas will continue to be addressed in a better fashion as we further

resource our community health boards to get out and do, not only education and

prevention, but also trying to pick-up by way of assessment, those situations

where we can probably offer some intervention as early as we can. But it is an

area where there is a big need - there is no question about that.

MR. H. HODDER: I would say to the minister that

the study done in British Columbia has called for messages for every province

and that is something that I think every educational system, legal system and

the medical system should be looking at. Because the stats are so much higher

than anybody expected them to be.

MR. MATTHEWS: They are overwhelming.

MR. H. HODDER: Yes, they are.

CHAIR: Thank you, Debbie Sue.

John.

MR. OTTENHEIMER: If I could just follow up on

this, because as I recall, I think the same issue came up last year when we were

talking about the psychiatric treatment of children at the Janeway. I remember

your saying last year that as a result of a probation order, or as a result of a

disposition by a judge, that waiting list is then circumvented and that young

person almost automatically has a direct route to such care. Is that still the

case?

MS MARTIN: Yes.

MR. OTTENHEIMER: It is?

MS MARTIN: Yes. The court- ordered assessments

do get a higher priority on the list.

MR. OTTENHEIMER: Because in a perverse way, you

know, a person who needs care and attention gets that care and attention by, in

fact, becoming involved with the criminal justice system.

MS MARTIN: Yes, and I think again that one of

the responses was the creation of that Blomidon Centre out on the West Coast,

because a lot of the demand being put on the Janeway psychiatric service was

coming through court-ordered assessments. And, as the minister mentioned, we are

trying much more to be pro-active and not wait until people get desperate for

service, trying to provide service so that, hopefully, they do not reach that

point. But it is true that the young offenders system - you know, most people

are in fear of judges, maybe not everyone. But, once the court-ordered

assessment is - there is something from the court, it is usually complied with

in a fairly timely manner.

MR. OTTENHEIMER: How is that done? Is there a

specific doctor at the Janeway who is dedicated to those who have been convicted

in the Young Offenders court?

MS MARTIN: No. What happens is, the judge would

put the order -the order would come, and usually the psychiatrist is named on

the order, and then that psychiatrist has to do the service. A lot of times, the

psychiatrists have had real problems with assessments being ordered within four

hours and things like that, but we have had some discussion with the judiciary

about the resource that we have available, the total impossibility - as well as

clinically, that is not a very reasonable way to do an assessment, so we have

been able to work out. Usually you get something within forty-eight hours or

seventy-two hours. And usually, what will happen is, if there needs to be a more

in-depth assessment, then that recommendation would go to the court, and that

may indeed take some longer time.

There are some additional services offered through

Whitbourne which you may be familiar with. They have a psychologist on site

there. They also have a psychiatrist who visits there on a weekly basis. In some

ways it is not sort of - it is probably not as much of a circumventing of the

system as there would have been last year, because there are a few other

services that are particularly directed towards justice. So it does not

circumvent, if my kid or your kid is on the list down there, keeping their place

in the line.

MR. OTTENHEIMER: Even though there is an

increase in the number of specialists available at the Janeway, is it also fair

to say that the number of individuals requiring such help has also increased?

MS MARTIN: I am not going on any concrete facts

with that, and I do not have them at my fingertips right now, but my feeling

would be, yes. As I mentioned, as you create a service, it sometimes creates a

demand for the service greater than one would have even thought there was. I

think also there has been a lot of work trying to break down some of the stigma

associated with psychiatry and mental health, and people are looking for the

service a little bit more than they would have in the past. They have seen it as

being not just sort of to go and find out that you are crazy and be put away

forever. I think people are seeing what counselling and mental health services

can offer a little bit more acceptable, so people are asking for that more.

In the consultations that the community health

boards have been doing, mental health continually comes to the forefront, as do

services for children - health services as well as mental health. Some of you

may be familiar with the interdepartmental model for services to children that

is being piloted now on the West Coast. Some of the people you talk about who

may have fetal alcohol syndrome or children with autism, some of those groups

who have a lot of needs but are small in numbers, that particular model will be

addressing those children who require more than one service.

We are hoping that once that model gets in place -

and, of course, it has bugs in it that are going to be worked out - but when

that gets in place we will be picking up a bigger portion of the kids that we

know are having problems and not waiting until, as you say, they end up as

teenagers in the justice system. Because that is a hard place for them to be,

often.

MR. H. HODDER: Could we perhaps move on to

another topic? I want to go to page 203 in your Budget document. It is on

Community Health, and health promotion. You have a total allocation there of

$1,741,000 and -

MR. MATTHEWS: Page 203?

MR. H. HODDER: Yes, page 203, 2.1.01. Talking

here about health promotion. How much extra money have we allocated into health

promotion this year as opposed to last year, if any?

MR. MATTHEWS: What line item are you looking

at?

MR. H. HODDER: I am looking in the whole area

here, because it is all put in together here now. You say: Community Health

Sector in areas of health promotion, disease control and epidemiology, nursing,

child health, and so on and so forth. You have a total here of the whole thing,

but in terms of promoting good health, nutrition, that kind of thing, it seems

that there is - it is always a battle to find dollars to go into health

promotion. We tend to have a sickness philosophy rather than a wellness

philosophy. What are we doing in terms of promoting better health practices to

the public, including nutrition, for example?

MR. MATTHEWS: To answer the question as to how

much more we are putting into it, we are putting into the community health side

of it, as the figures indicate, we have gone from $56 million to $59 million

total amount being voted there. In terms of how much more we are putting into

education and prevention - I think that is your question -

WITNESS: (Inaudible).

MR. MATTHEWS: Yes. I do not know how to answer

that, other than to say we are putting more. To break down what is actually

going into education and prevention, you would have to get into almost every

component of the programs delivered by the community health boards. Because

almost every program that the community health boards deliver has an element of

education involved in it, particularly as it relates to the children's side of

it, you know, when you are dealing with the - and not only the children's side

of it, as you are dealing with the adults as well, when you are dealing with

pre-natal programs, with nutrition programs, and with counselling and dietary

matters of certain specific segments of the population.

All of these have components of education and

prevention built into their programs. So, it is not a figure you can take out as

a line item. It permeates every program virtually that is targeted towards

health improvement areas.

MR. H. HODDER: Let me take a particular

example.

MR. MATTHEWS: Yes, okay.

MR. H. HODDER: A few years ago, Prince Edward

Island had the highest incidence of low birth weight babies in the countries.

The province began an aggressive policy to address that through promoting better

health to mothers and getting at the pre-natal, addressing the whole issues of

the people who were in their child-bearing years. It has been able to now go

from having the worst record in Canada to having the best record in Canada. What

has it done that lets it get that turnaround in its stats?

MR. MATTHEWS: From when to when did this

happen?

MR. H. HODDER: I think it is over about a

ten-year period. They have really addressed it, they have come to grips with it.

It was at about 4.5 per cent. No, they were up to 5.5 per cent. They are now

down to about 4.5 per cent, if the stats are right here. They have made

significant gains there. Newfoundland's record in low birth weight babies is

still one of the worst in the country.

MR. MATTHEWS: On the low end of it, yes. I am

going to ask the Deputy to speak on it. Unless they are drinking more Farmers

fresh milk or something. I mean, they are in a good area to get fresh milk and

fresh food in P.E.I. That would not hurt, but -

MR. G. REID: We are self-sufficient on milk

here in the Province.

MR. MATTHEWS: What?

MR. G. REID: We are self-sufficient on milk

here in the Province.

MR. MATTHEWS: Yes, Carnation.

MR. G. REID: No.

MR. MATTHEWS: We are. We are pretty good.

Deputy, can you take a go at that one?

DR. WILLIAMS: There are a number of programs -

unfortunately Lynn Vivian-Book, our parent and child health consultant, could

not be here tonight to give some details. The data I have is 1993 data, low

birth weight data in Canada, and P.E.I. is the lowest at 4 per cent. The

Canadian average is 5.7 per cent in 1993, and Newfoundland is at 5.7 per cent.

MR. MATTHEWS: We are at the Canadian average.

DR. WILLIAMS: Yes, we are right at the Canadian

average. We are not above, we are not below. Ontario, for instance, is 6.2 per

cent. The Canadian average, like I say, is 5.7 per cent. Some are above, some

are below, and some are right on the mark. We are at about average. Our latest

data for 1995 shows we are down to 5.4 per cent. They are small numbers and

small percentage changes. There are a lot of activities going on through our

public health units in terms of parenting skills for women and children through

the CAPC program. There is also Canadian nutrition program. Many of the things

that our public health nurses do are of a preventative nature.

Specifically how P.E.I. was able to get at theirs I

do not have at my fingertips, but we could certainly get for you a

summary of

what we are doing, to provide it to you in follow-up to this meeting, what

action we are taking. I will get Lynn to do that for you. The data that we have

heard recently is not correct. I think somebody was going around saying that our

low birth rate is worse than other provinces, but right now we are at the

Canadian average. We are waiting for the 1996 stats to come out before we make

any statement on that. It indicates that in 1993 we were at the average. In 1995

we are down to 5.4 per cent. I know that is small numbers, but you may inch

along.

P.E.I. is far and ahead the best in Canada. It may

be, too, that they are small, they are not scattered as much as we, so they may

have better access to some programs and services. I am not sure about that. They

are certainly different in other provinces.

MR. H. HODDER: Every low birth weight baby,

according the stats that come across my desk, will cost about $200,000 in

initial care. The stats I saw, say that every year, in this Province, we are

spending upwards to perhaps $14 million or $15 million in terms of trying to -

you know, that is cost of caring for low birth weight babies. I would suggest,

and, in fact, the stats said, that in the past four years we have spent $56

million trying to care for low birth weight babies. So everything we do in that

area and even if these stats are not quite 100 per cent on, everything we do in

that area is significant, because every dollar we put in there - For example, in

British Columbia, in every ladies' washroom, there are posters that talk about

low birth weight babies and the effect smoking has on them and all this kind of

thing and they are in every washroom that is there. I have not visited all of

them but I am told by my contacts out there that, they are very aggressive with

this because they -

MR. MATTHEWS: My question is that you visited

any of them.

MR. H. HODDER: I have not visited one, not a

single one. I take other people's word for it. But what I am saying is that

there is an aggressive promotion and I do not think that we have that kind of

aggressiveness to this particular issue.

Now, we took $100,000 and we did a t.v. spot or we

put some more information out there, brochures, we told doctors and they - I am

told that one of the things that worked on PEI was the medical community, to

make sure that doctors addressed this on the first visit and all that kind of

thing. There are a number of strategies that I am told they use. It is an area

where we can have real input, not only in terms of saving dollars, but we can

also have an input on long-term care because every child that is born of normal

weight, will have significantly, on average, fewer health care problems as its

life progresses.

MR. MATTHEWS: Agreed.

MR. H. HODDER: So what I am saying is, we have

to get more dollars in that area.

MR. MATTHEWS: I am sure the officials have

heard you and to the extent that we can bring more dollars -

MR. H. HODDER: Oh, we are not in the House of

Assembly now, Lloyd, that is the answer you give every day.

MR. MATTHEWS: No, no. I never said the

officials have heard you because I am not sure that they would waste their time

listening to us in the House; I would hope they all do not but, certainly -

MR. H. HODDER: It is a big issue and I know

that we have kind of treated it rather lightly here but -

MR. MATTHEWS: No, it is not. It is important,

Harvey.

MR. H. HODDER: I hope that it is not; it is a

very big issue and it says that health care starts long before pregnancy begins.

DR. WILLIAMS: It is really a prevention of

something that can have a life-long effect on somebody so it is very important.

In the last two years our rates are going down. We are hoping that our rates,

which will be available to us very shortly, will have three years down in a row.

I will get something for you from Lynn Book who is most familiar with this

problem about the approach we are taking. A lot of activities are going on at

the community level and with high-risk groups, to try to lower this rate, a lot

of activities, but I will get her to lay it out for you; and we are having some

success.

MR. H. HODDER: Okay. Maybe she could give me a

call and I could drop over to her office and have discussion with her. It is a

topic in which I have a great deal of interest.

DR. WILLIAMS: We had something prepared here,

not because we expected a question on it but just because we are getting ready

to do something publicly on it. So I just happen to have and that is why I have

the rates in front of me.

MR. H. HODDER: And you probably knew beforehand

that I would ask a question on that anyway.

DR. WILLIAMS: No, (inaudible) completely.

MR. H. HODDER: The answer this year is better

than the answer last year, all positive, and he will quote me on that in the

House one of these days.

MR. OTTENHEIMER: Certainly, we have heard a

number of rural doctors state publicly, and perhaps this has been an area that

the department has been giving attention to over the past number of years, but

it is this whole concept of the expanded role of nursing, And we hear the term,

I think, `nurse practitioners' for example, as a way to help deal with what

perhaps many would call very difficult circumstances as presently exist in rural

Newfoundland, so I guess, I am wondering, Mr. Minister, from a philosophical

point of view, if you could perhaps share with us what the direction is of the

department with respect to an expanded role for nurses in our Province and, how

you see their role changing in the future to deal with rural medicine in our

Province.

MR. MATTHEWS: The concept of using nurses more

and more in areas of primary care on the front lines is what we are dealing

with. Philosophically and unequivocally I support that concept. I have shared

that with the nurses of the Province through their associations, I have shared

it with the doctors of the Province in my meetings with them.

There are a number of things happening to try to

move that along. We have nurse practitioners to a limited degree now on the

Coast of Labrador and in Northern Newfoundland. They have been a historical part

of the Grenfell delivery of primary care, simply because doctors were harder to

get in previous years than they are now. Although you may not think that to hear

about the doctor issue. The fact of the matter is, we have just as many doctors

now as we had - more doctors than we had ten years. We have about 100 more

doctors.

MR. G. REID: How many do we have (inaudible)?

MR. MATTHEWS: I thought you would ask that

question. We have the information here. The comparison for 1983, we had 669

doctors in the Province.

MR. G. REID: Six hundred and sixty-nine in

MR. MATTHEWS: In 1983. Fourteen years later in

1997 we have 863, which is an increase of almost 200 doctors, 194 doctors I

believe that works out to.

MR. OTTENHEIMER: Does that include everybody?

MR. MATTHEWS: That includes specialists and

general practitioners.

MR. G. REID: With a declining population,

according to some.

MR. MATTHEWS: Yes.

MR. OTTENHEIMER: Is that practising specialists

and general practitioners?

MR. MATTHEWS: Four hundred and twenty-nine -

MR. OTTENHEIMER: But that includes the -

MR. MATTHEWS: - specialists, or general

practitioners, and 434 specialists. The percentages on that, because I memorized

them for you, is 49.7 per cent primary care, 50.3 per cent specialists.

MR. G. REID: What is the total salary for these

fellows? Or not fellows, individuals, I should say.

MR. MATTHEWS: We are spending close to $140

million in physician services, medical services, fee for services and salaries.

On average that works out to - well, you can work it out. The average billing

last year of a fee for service doctor in the Province was, I think, $162,000.

Now, that was a fee for service -

MR. G. REID: One hundred and sixty-two thousand

dollars?

MR. MATTHEWS: Yes. That was a fee for service,

family practice or general practitioner. A specialist, considerably higher than

that. Of course, there is a bunch of different arrangements under which we pay

doctors, particularly specialists, because some who are really hard to get we

have to guarantee certain minimums and that sort of thing.

To get back to your question about nurse

practitioners, yes, we believe there is an expanded role for them. The Health

Care Corporation is currently, I believe, working on a new model of more of a

continuum of health care delivery of services in the Ferryland area, where you

have doctors and nurse practitioners and other health care providers working in

more of a group setting, or more of a horizontal continuum of care. We may have

to do more and more of that in the Province.

The other part of it, of course, is education and

expectations. People in the Province who have always had a doctor in or near to

their community are very reluctant to hear talk of not having a doctor, and you

cannot quite replace a doctor with anybody else who meets the stature of a

doctor, with the greatest of respect for every other profession. You know,

people want a doctor at a certain point and nobody else will do, and

appropriately so, I suppose, depending on how sick they are.

I might also add that in the past couple of months

we made available to the School of Nursing through the Health Care Corporation

$130,000-odd of extraordinary funding to allow it to take advantage of some new

training that was taking place for training nurse practitioners at the

University of Toronto. We gave it some funding to send off some people to be

trained in the area of nurse practitioning so that they could essentially come

back and run more and better programs at our nursing schools. So it is sort of a

train-the-trainer type thing.

We are doing everything we can to encourage the

nurse practitioner concept. It is not something that is new to Newfoundland, but

it is not something that we use readily. The other thing you have to think about

in health care is that sometimes when you add a new service like that, you may

not necessarily displace a current service. So it is a question of when you are

adding one service to complement another, or augment another, as opposed to

adding it where you are actually adding a new level of service. We do not have

much money to be adding new levels of service to the health care system, but if

we can do as good a job with less money, and because we cannot get doctors,

provide nurse practitioners, we are prepared to entertain and go in that

direction, and we are encouraging it.

MR. G. REID: That 863 -

MR. MATTHEWS: I am sorry.

MR. G. REID: The 863 that we currently have,

they are actually out there now or are there some shortages?

MR. MATTHEWS: Well, when you talk about

shortages you are talking about places where you have had doctors or the numbers

you would optimally like to have. All of the numbers we hear about in terms of

shortages, whether it is sixty or eighty doctors, there are not necessarily that

many vacancies existing. Sometimes we have salaried physician doctors who quit

or move out of their salaried position spots and go over to fee-for-service, and

that is deemed to be a vacancy but sometimes that is really not the case.

Probably Dr. Hunt can comment on it. Dr. Ed Hunt is

fairly new with us. He came on this year as the medical consultant, and he has

been doing a fair bit of work in that area. One of the things he is involved in

is a medical services review, which is really a head counting of the actual

number of doctors we need and how many we have. Probably, Dr. Hunt, you can give

the Committee some comment on that.

MR. G. REID: I find it rather surprising, to

tell you the truth, that we have increased the number between 20 per cent and 25

per cent in the past fourteen years and yet we are in a crisis, or that is what

some would lead you to believe.

MR. MATTHEWS: Well, I think that is the

observation I made a couple of days ago to the deputy. We have more doctors than

ever, we have fewer people than ever, and we have more problems getting the

doctors' work done than ever. It does not readily add up. With that backdrop,

the good doctor, as opposed to the great doctor, can comment.

DR. HUNT: We do have 863 bodies on the ground

right now in Newfoundland.

MR. G. REID: But we have vacancies as well.

DR. HUNT: We have vacancies.

MR. G. REID: So what would the number be if you

(inaudible) them all?

DR. HUNT: It is difficult to get a handle on

exactly what a vacancy is, as the minister said, because you can pick pockets of

areas where there are vacancies but when vacancies are reported - for example,

if one area is reporting a salaried physician, a surgeon who is needed, and yet

a surgeon somewhere else is moving areas and also reports a surgeon who is

needed, so you have two vacancies when actually there is only one.

That kind of thing is happening, and the problem is

that we do not have a real good data base in place, which is what I am working

on now, trying to get a good data base so we can track this and see what is

going on all the time.

I suspect we have an oversupply in some areas of

the Province, and this is why we have all of these numbers. There is a problem

of distribution. If we could get the numbers that we have and put them in areas

of the Province where we need them, we probably would not have a shortage of

doctors today. We would not have any vacancies in the Province. We certainly

have vacancies.

MR. G. REID: So is distribution the problem,

Dr. Hunt?

DR. HUNT: The problem is distribution, yes,

Sir. What we are trying to do is address that and see if we can encourage

doctors to move into the rural areas where they are needed, and try to

discourage them from moving into areas where there is not such a great need.

The other point I would like to make is that the

biggest problem we are having now is with general practitioners. We do not have

a real problem with specialists. For example, although we have had an increase

in the total doctors, there is no difference in the number of GPs in the

Province now between 1991 and 1997. There was a peak in 1993, in which we went

from 429 to 460, and from that time the GPs dropped off, back to 429 again. That

is mainly because of the great demand in the international market place. The

United States, in particular, has been looking for a lot of doctors; and

northern Canada, northern Ontario, northern Alberta, even though they are rich

provinces, have an equal amount of trouble trying to attract doctors there as

well.

Because the United States is moving towards more of

a primary care model, that has created a surplus of specialists, so we are

starting to see the reverse now. Some of the specialists in the United States

are coming to Canada and we are having less of a problem getting specialists

here now than we used to, say, four or five years ago.

So our specialist problem is probably not going to

be a problem for a few years to come, if ever, but GP may be a problem for some

time to come. This is where we may have to look at other means of delivery, such

as nursing practitioners or physician assistants or whatever, to staff those

areas where we have a shortage right now, because there is definitely a shortage

in some parts of the Province. If you could get some way to mobilize the doctors

into those areas, that would be another alternative.

We are exploring all of these options to see what

we can do. Certainly, there are pockets of problems out there right now, but not

necessarily in the total supply of doctors to the Province.

MR. H. HODDER: How are we doing the

recruitment? I was listening the other evening and the minister was speaking

about some of the recruitment that was being done, I think. Then we had one of

the health care boards indicating they were doing recruitment. How do we address

the whole recruitment program involving the local health care board and also, of

course, having, I guess, a co-ordinator approach from the department as well?

How is that handled?

DR. HUNT: The boards have hired a professional

full-time recruiter who is working at the board site, and they are advertising

all over the country, plus all the universities, and they also have an internet

site which they are using. Some boards, in addition to that, are hiring what

they call head-hunters, professional people who search for doctors. There is no

up-front cost for that, but if the head-hunters are successful there is a cost

for finding a physician.

Again, the whole problem is supply. In terms of

family practice there is a general shortage of supply in Canada and in North

America. We used to depend fairly heavily on our international medical graduates

in the past, but I guess again because of the big demand for GPs all over the

world, that supply is drying up as well. However, in terms of trying to address

some of that problem, there are a number of international medical graduates in

Canada who come from universities about which we are not fully knowledgeable, so

they might be totally first-rate doctors but we have no way of judging whether

they are or not. They may not be good rated doctors, and we do not want to put

non-qualified people out in the field; so we are just now working with the

university and are going to set up what we call an assessment and enhancement

program, so that any doctors who may be in Canada, trained foreignly, will be

properly assessed and evaluated, and if they meet the standards of the Canadian

trained doctors, then they will be licensed to practice here. If they do not

meet the standards but are short in some small area - if they, for example, did

not do a lot of paediatrics in their country - we can give them upgrading for a

number of months to bring them up to our standard, and we think we may be able

to solve some of our supply in that way. We know of perhaps twenty or thirty

doctors out there now who may qualify if they had the assessment done.

MR. MATTHEWS: The deputy tells me that the

faculty council at the medical school recently has approved that program. There

is another program similarly running in Manitoba and one other province, I

believe, B.C., Dr. Hunt?

DR. HUNT: Manitoba have an assessment program

but they do not have the enhancement program. The assessment assesses the

doctors to see if they are qualified. The problem is, if they are not qualified

they are just dropped and they may be only marginally deficient in some things.

We are hoping this will be like an enhancement program so those who are marginal

will be able to get a chance to meet the mark.

MR. H. HODDER: So when these doctors arrive

they would write the Canadian Medical Association exams, or -

DR. HUNT: Yes, they have to write the

qualifying exam just to see if they have any knowledge of medicine, but that

does not mean they are competent in all of the areas we want them to be. This is

why we need an assessment, to find out for sure.

MR. H. HODDER: So if we were to identify a

doctor, let us say, from South Africa, which used to give us a lot of doctors

but not as many anymore -

DR. HUNT: And generally they were very well

qualified. We usually (inaudible).

MR. H. HODDER: They were well qualified. Well,

let us say, from some other country.

WITNESS: Say, from Russia because (inaudible).

MR. H. HODDER: Yes, from one of the Russian

republics, and they are not as well qualified, and you identify it, would you

people then pay the cost of that enhancement?

DR. HUNT: Usually what happens is the board

will search these people out, and if the board feels they are going to make the

mark it is something we will take a chance on, paying their money up front. It

depends on whether they are able to do it themselves. If there is a good chance

that they can get into the system, the board will often assist those doctors up

front, with a view that, if necessary, the doctors can reimburse the board at

some later date. Sometimes it is cheaper for the boards to do that than to spend

all kinds of money on recruitment.

MR. H. HODDER: In the interim period, let us

say, as you said, that you have a doctor whose skills in paediatrics may not be

as high as we would want. Would that doctor then be permitted to - you said he

has passed the Canadian medical exam. Would he be allowed to then practice with

that board, but not practice in the area where he was deficient, but be able to

practice in all the other areas, or would he just wait?

DR. HUNT: He would not be able to practice

until he passed (inaudible).

MR. H. HODDER: Until everything is done. You

cannot have those partial admissions, you might say, or that kind of thing.

DR. HUNT: No. If those doctors were to be so

deficient that it would take more than six months to upgrade them, it is not

worth the investment.

MR. H. HODDER: No.

DR. HUNT: They just drop them. The rule of

thumb is that they have to be well enough trained that you can bring them up to

standards within a six-month period. Otherwise, you might as well send them back

to university for a whole year.

MR. H. HODDER: Where would this upgrading be

done? At the medical school or -

DR. HUNT: At Memorial University.

MR. H. HODDER: In conjunction with -

MR. MATTHEWS: Done through our medical school.

WITNESS: This would be done in St. John's, but

it would have to be done in co-operation with the medical school to really meet

the standards.

DR. HUNT: Yes.

MR. MATTHEWS: There are some doctors, I guess -

some have come - I have had a few immigrants, Russian doctors, some brought in

by political colleagues, you know, who are here in St. John's, one or two of

them. One is here driving a taxi, another is here delivering pizzas. There are

these types of fellows who - they are from Russia, the last one or two I saw,

and there was a question of - they wanted to be able to be assessed, and we did

not have the (inaudible). Our medical school now has that program close to up

and running. That should help us a little bit. It is not to find marginal

doctors to put out there if they are not qualified. We cannot risk that. But if

there are those who are qualified but whose university standards we are not

familiar with, then we can pick them up this way. It may help us.

CHAIR: Perhaps, Don, you could have one

question and I propose we take a ten- or fifteen-minute break.

MR. WHELAN: Well, we can take the break. I can

ask the question after we come back, if you wish.

CHAIR: So we will take a ten or fifteen-minute

break. There is some coffee in the Opposition caucus room. I will keep a close

watch on fifteen minutes. We should be back here in about fifteen minutes.

Recess

CHAIR: Order, please!

Let us take up where we left off. Don.

MR. WHELAN: Basically, I think - I will certainly

forget the

preambles - I was wondering how many graduates do we have from

medical school each year? How many doctors are graduating?

MR. MATTHEWS: This year?

MR. WHELAN: Yes. Well, on an average, I guess.

MR. MATTHEWS: It depends. Because the ones who go

into family practice where we have the shortage, the general practitioners go

into the family practice program. There are twenty-five coming out this year. It

is like a political poll now. There are thirteen leaning or committed toward

working in Newfoundland. Committed or leaning. We know there are three going to

the U.S. Two of these are bursary students who took the bursaries and they are

paying them back. So we gained a great deal there by helping them out over the

years. Three are doing further training in ER and obstetrics, anaesthesia, and

there is one non-MUN grad expected to stay with us.

That would be thirteen, fourteen. It is a little over

50 per cent retention that we know of for sure. Our average is about the same as

the rest of the Canadian medical schools at about 45 per cent. That is the

retention rate.

MR. OTTENHEIMER: What is the present incentive

program, I guess, which exists at our medical school?

MR. MATTHEWS: The incentive to go there or to get

MR. OTTENHEIMER: No, incentive to stay in the

Province.

MR. MATTHEWS: Well, the incentive, I guess, is

apart from the - we used to have ten bursaries of $12,500 a year. We found out

the first year I was in Health, which was the last year we had the ten, we could

not even give away ten at $12,500 each, because students were not prepared to

take them and have the attached commitment of giving us return of service. So we

changed it two years ago to a $20,000 bursary, but we reduced the number to six,

which is more of a commitment if you took it, if you had to pay it off. I do not

know if we even gave away all the six of them last year, did we?

WITNESS: I think we did.

MR. MATTHEWS: I think we did. So the only

incentive to come to our medical school, I guess, is number one, it is one of

the best medical schools in the country by virtue of quality of education,

number two we have that bursary program. The only other incentive for them to

stay with us really is if they want to work in Newfoundland. Because in pure

dollars and cents, if they are just looking for the biggest bucks, chances are

they will find a place somewhere outside the Province, unfortunately.

MR. WHELAN: What is the cost to the Province to

educate these doctors and then to have them -

MR. MATTHEWS: The medical schools -

MR. WHELAN: Do they pay back the subsidization

that we provide in total or...?

MR. MATTHEWS: The medical school's budget is about

$16 million, $17 million a year.

MR. G. REID: (Inaudible), Lloyd?

MR. MATTHEWS: Pardon?

MR. G. REID: Is that just the salaries or

(inaudible)?

MR. MATTHEWS: That is the cost of running the

medical school. We can give you the breakout of the salary component of that,

you know, for the professors and the doctors. But say $17 million a year for the

medical school. We have at any given time in the medical school about 240

students, 260 students. We take in, on average, sixty a year. There is a

four-year program, and then they go into a residency program, depending on what

stream they want to go into for specialization or family practice. So there are

probably 240 students, 260 students here at any given time, it costs us $17

million a year to run the school, so if you want to divide that out you will

find out the cost. Almost, it would appear, on average, about $60,000-plus to

educate a student per year.

MR. OTTENHEIMER: Why is it showing a decrease of

approximately $750,000 from last year to this year's Estimates?

MR. MATTHEWS: That is the American students. We

have always had ten slots open for New Brunswick students because they used to

send their kids here. They do not have a medical school. Two years ago they

pulled out of the commitment to those ten spots, and we started selling them to

Americans at $30,000 a crack. Each year that is - the first year there was

$300,000, the next year it went to $600,000. We have fifteen there now, so -

DR. WILLIAMS: This year we took in fifteen and

last year we took in fifteen.

MR. MATTHEWS: Fifteen or ten? Well, we took in ten

Americans and some Malaysians, was it not?

DR. WILLIAMS: Yes. We took in some Malaysians. I

think the first year -

MR. MATTHEWS: Three or five Malaysians.

DR. WILLIAMS: - we took in five.

MR. MATTHEWS: Yes.

DR. WILLIAMS: And some Malaysians. Then we took in

- we now take in fifteen Americans.

MR. MATTHEWS: Yes, so the bottom line is that we

are generating revenue from selling those seats that we had there, and that is

why the budget is - we are taking it out of their budget.

MR. WHELAN: So it is ten or fifteen at $30,000 a

year?

MR. MATTHEWS: Yes.

MR. WHELAN: And it is costing $60,000 to educate

them.

MR. MATTHEWS: Essentially, yes.

MR. WHELAN: Are they here with the understanding

that they are going to have to stay here for awhile?

MR. MATTHEWS: No, there is no commitment, nor do

we have a commitment to provide speciality or residency training to them. We

basically do it as a revenue measure because we have the space available, and

$30,000 was about what the market could bear. In other words, if they had stayed

home in the U.S., it would cost them about what they are paying, the equivalent

of $30,000 Canadian to go to university in their own country.

MR. WHELAN: Would it be valid to say we are

subsidizing them and it is costing us $30,000, or would that $60,000 be an

expense to us anyway and they are alleviating the debt that we would ordinarily

have? Is that the case?

MR. MATTHEWS: Yes, you can evaluate it in either

way. If we did not fill the slots, you would not save the equivalent of not

having them there. In other words, the fixed costs are in place to run the

medical school. It is really that we are gaining by having them, although if you

average out the cost of the medical school over the number of students it would

work out to about $60,000.

MR. G. REID: What did you say your retention rate

again was in the Province?

MR. MATTHEWS: About 45 per cent to 50 per cent.

MR. G. REID: Forty-five per cent to 50 per cent.

MR. MATTHEWS: This year it looks like thirteen or

fourteen, maybe, out of twenty-five, so it may be a little better than 50 per

cent this year.

MR. G. REID: That is in the Province. Have you any

idea as to what percentage of those go to rural Newfoundland?

MR. MATTHEWS: All of them would basically go to

rural Newfoundland in family practice because in areas of - in the St. John's

metro area, you cannot come in here and set up unless you come for 50 per cent

of fee schedule. Nobody has been coming in for the last three or four years to

set up in over-serviced areas like St. John's. Now, I suppose they could

theoretically work in the St. John's area if they wanted to go salaried in an

emergency room.

DR. WILLIAMS: Only in emergency departments.

MR. MATTHEWS: Yes, which is where we have some

needs as well. But fee for service? No, they cannot come in, really, because no

one is going to come in at 50 per cent of what they would get, because they

could not make, you know.

MR. G. REID: Are there any stats on how long they

are staying?

MR. MATTHEWS: Who?

MR. G. REID: These doctors who are going to rural

Newfoundland.

MR. MATTHEWS: How long on average? I do not know

if we have any information on that - Doctor Ed?

DR. HUNT: (Inaudible).

MR. MATTHEWS: I do not think we do.

DR. HUNT: Two to four years.

MR. G. REID: Where do they go then - out of the

Province?

DR. HUNT: They either move around the Province or

(inaudible).

MR. G. REID: Alright.

MR. MATTHEWS: Or they go back for speciality

training. They go in all kinds of areas. What we have found is that the bonus we

introduced two years ago has slowed up doctors leaving. Interestingly enough,

John Peddle from the Hospital and Nursing Home Association indicated to me over

the weekend - we were in doing some work - that the new salary package we have

announced, the $2.6 million we put in, they seem to be getting more enquiries

even in the last month or so as a result of that. I think that is going to help

us, I think that is going to be a significant help to us. But it is not going to

happen overnight. Doctors who are with us will certainly be more interested in

staying. Doctors who would be interested in coming for the old salary will

certainly be more attracted by the new one.

MR. OTTENHEIMER: What are the local students

paying approximately, say, for annual tuition at Memorial?

MR. MATTHEWS: Sixty-two hundred and fifty dollars.

MR. OTTENHEIMER: Sixty-two hundred.

MR. MATTHEWS: Tuition. Well, it is at, per year,

$2,700.

MR. OTTENHEIMER: That is per year for, what, about

three, four years, is it?

DR. WILLIAMS: Four years.

MR. OTTENHEIMER: Four years.

MR. MATTHEWS: Four years. It was $2,700 for the

first couple of years, and then it went to $3,500. I know, when I went into the

department, I proposed an $8,000 fee. The University Senate gave me $6,250.

MR. G. REID: Go for $15,000 next year.

MR. MATTHEWS: Don't tempt me, Gerry.

CHAIR: I think (inaudible) is a good number.

MR. MATTHEWS: Sixty-two hundred and fifty dollars.

CHAIR: My daughter is going to be applying in a

couple of years so keep it at that number.

MR. G. REID: But if you look at the 50 per cent

retention rate, we are paying $120,000 a year basically to keep that open, per

student.

MR. MATTHEWS: No, not $120,000 per year, but -

MR. G. REID: No, $60,000 per year per student now,

and considering only 50 per cent of them stay in the Province, for the 50 per

cent who are staying we are paying roughly $120,000 a year now.

MR. MATTHEWS: No, some of the rest stay after, but

they go into specialty training and go into areas of specialty care. This is the

primary care, the family doctor, the front-line fellow we are having trouble

getting, you know.

MR. G. REID: A four-year program, is it?

MR. MATTHEWS: Four years, yes.

WITNESS: Plus two years as a minimum to train as a

general practitioner, and four to five years as a specialist after the basic

four-year undergraduate program. So it is six to eight years.

MR. MATTHEWS: That is plus the four years they

spend in MUN, we will say, to get their undergraduate degree. It is a ten-year

program to train to be a GP, let us say.

MR. OTTENHEIMER: What do they have to return to

the Province if they accept the bursary? The commitment is for how many years?

MR. MATTHEWS: A year for a year. It is three

years, at the moment.

MR. OTTENHEIMER: A year for a year, I see. I am

just wondering. I know a number of years ago the Department of Justice had a

program whereby magistrates were sent to law schools throughout Canada, tuition

paid by the department, and in return there had to be, I believe, a five-year

commitment to continue practising as a magistrate - well, now called provincial

court judges. Has the department ever considered that, or in terms of a

completely free tuition program, as an incentive for perhaps even a longer

period of commitment to medicine in this Province?

MR. MATTHEWS: You have probably heard me

pontificate quite a bit lately about the whole concept of every student getting

into medical school having to come with a condition attached that they give us

at least two years return of service. That is the direction in which we are

moving and government is on for that, once we can work out some details probably

as to how you would implement such a program. The difficulty with it, I suppose,

is that if you implemented it and every student who came in agreed they had to

have two years of service or pay more tuition, and you didn't need them all when

they graduated, you have to have a process in place to determine to who gets

picked or who we select or who stays. Free tuition?

MR. G. REID: You are giving them (inaudible)

$20,000 now.

MR. MATTHEWS: The fact of the matter is that we

could not give away the ten at $12,500. We upped it to six at $20,000, and the

uptake now is not great, is it?

WITNESS: At ten it certainly was not. We are

getting six now.

MR. MATTHEWS: Ten was not. We are getting six now,

yes. But, you see, if somebody comes up from the U.S. and says: We will pay off

your $60,000 or $100,000 as a signing bonus to come down with us and work, and

this is happening, you cannot fight it, I guess, Gerry, is the simplest way to

put it.

MR. G. REID: The Canadian military fights it.

MR. MATTHEWS: The military does fight it, and

short of operating as the military operates, we cannot fight it. That is the

difficulty, yes. It is frustrating to have a first-class facility -

MR. H. HODDER: But there is something ethically

wrong with making a commitment and then not delivering on it. There is something

wrong with the morality of that.

MR. MATTHEWS: Yes, it is, and it is interesting.

The Deputy put a copy of a letter on my desk yesterday from a parent of a

student who wrote Chris Decker in 1990 complaining about his son not being able,

being a rural Newfoundlander, to get into medical school. He eventually got in,

took the bursary, and the shagger decided last month he was going down to the

States and pay off his bursary. I am thinking about writing his father and I

will ask him if it worked - his concept of getting his son in was a good one,

but it did not work well - if he has any other suggestions.

WITNESS: You should.

MR. OTTENHEIMER: What we are talking about, and

what we were talking about earlier, still unfortunately does not deal with, I

guess, what are in certain parts of Newfoundland today real problems in terms of

doctor shortages. It is a distribution issue, I guess, as Dr. Hunt mentioned. I

guess the challenge, Dr. Hunt, and Mr. Minister, is to somehow find a way to

ensure that those communities in need have the required medical attention. It is

a tough challenge, but I guess it is one that has to be continually sought

after. I mean, we keep hearing stories like - why do we hear about Port Saunders

and why do we hear about Corner Brook?

WITNESS: Port aux Basques.

MR. OTTENHEIMER: Just two examples recently. I

guess, in terms of a question, what are we doing specifically to deal with

examples like that?

MR. MATTHEWS: You are quite aware of what we are

doing basically. We are trying to massage all the leverage of the levers we

have. The medical school - we have to get a better return out of that, and a

return of service commitment is something we are working feverishly on. It does

not have much acceptance or have any favour at the medical school amongst the

academia over there. They believe in such purity that this would taint it, you

know? It is a difficult chore with them, but we are working on that.

We have put the bonusing system in place, we have put

the enhanced salary package in place recently. We have a central recruiter in

place, working on behalf of all the boards, trying to attract people. We are

asking communities and town councils to advertise their community, and when they

get a doctor to be as user-friendly as they can to the doctor to make sure that

his family and he are comfortable when they come. That all helps a bit.

Beyond that, I am not sure how much more we can do. I

asked that question last week in Port aux Basques to Dr. Shandra who was leaving

to go back to New Brunswick. It was not a money issue with him. He decided to

come for two years, that was his commitment, he was going, so I do not think any

amount of money would keep him. Which may be an exception. I asked him what

could he suggest. He said: Look, minister, it is the $1 million question. I do

not know what the answer is. If it were simply money, then I guess it would be

simply to say, when we can get ourselves up to the average of what the rest of

the country is paying, we should get the job done, but there is no guarantee of

that.

There are a number of initiatives we have to take and

we are working on all of them. I do not know, Dr. Hunt, if we can do much more

than we are doing, only fight the good fight.

DR. HUNT: We are still working. We have a

committee within the department here that is negotiating now with the Medical

Association with regard to the MCP funds and so on, to see how we can best

manage that. Because I would like to think they are as interested as we are in

trying to get the problem solved. We are working within this department also to

come up with new ideas, new concepts, to see how we can best manage the system.

We are exploring all of these and we are trying to leave no stone unturned. I

have only been here now for a short while so I have to get some time to

formulate these ideas. Hopefully, in a short while we will get some more

thoughts and more goodies on the table to make the system work. It is in

everyone's best interest that we do.

MR. MATTHEWS: I guess the only other thing I could

suggest we do, if it is doable, is to restore to the young doctors now

graduating more of a missionary spirit that was resonant in the Deputy when he

graduated in 1969, was it? as a `townie' and went to rural Newfoundland and

spent his time until he came to the department. I do not know if that is an

injectable quantity or not, the missionary spirit.

DR. WILLIAMS: I doubt whether it was the

missionary spirit, but we had a commitment back then. The government of the day

- because there was no medical school in Newfoundland, most residents of this

Province went to Dalhousie. Some went off to McGill or other universities. We

were given $2,000 a year, I think it was, or $2,500 a year. Of the four years

for which we had funding, we had to spend at least two years in rural

Newfoundland, and then we could spend two years as a resident at the General

Hospital. Because they had trouble then at the General even getting residents

and interns to cover the hospital.

Pretty well all of us at our class went out and spent

- I went out for two years and stayed for ten. Most people fulfilled their

commitment. In 1969 MCP came in place, and in 1970 a lot of the doctors started

reneging on their commitment. In 1972, I think, government canned the bursary

program because a lot of doctors were not fulfilling their commitment. We have

only started it up in recent times again, but we are still plagued by the same

thing. What we have now is recruiting firms coming up. The Americans do not

invest one cent in training here.

We train the people here, we put the money up - the

taxpayers, sorry, put the money up - and the Americans do not spend one cent on

training people. Then they can come up and offer them the big dollars because

they have not put any investment in these people, and they take them south of

the border. Because they want to increase, as Dr. Hunt has said, from an 80 per

cent mix of specialists and 20 per cent primary care physicians to a 50-50 mix

as we do in Canada. It will take them six or seven years to gear their

post-graduate training programs up enough to switch from sub-speciality programs

and specialist programs to good primary care programs down there, family

practitioners. This will be a fact of life for the next six or seven years.

The question is: Do you make the financial penalty so

great that people will stay in the Province in return for having their financial

penalty forgiven? I mean, that is the dilemma we are in, I guess, something like

that, in order to match those kinds of dollars. Because we cannot match them in

any pure sense. We cannot match $150,000 a year U.S. with a $50,000 signing

bonus. We cannot match it. That is U.S. dollars. It is a pretty big dilemma, and

it is a dilemma in pretty well every province in Canada, even in Ontario and

Saskatchewan. I think somebody coming over tonight, there was just something on

the wire that they have announced, a $25,000 signing bonus.

MR. MATTHEWS: I saw it on Friday night, actually,

on Channel 4.

DR. WILLIAMS: So all the provinces are involved in

that. I do not know - most medical schools in Canada, I do not think provinces

or governments are looking at a solution within their own medical school,

because in every other province but Newfoundland the medical school is funded by

the department of education. In Newfoundland, we are the only medical school

that is funded by Health. So we have a closer relationship, and we are more

aware, I guess, of our medical school than other provinces.

But really, we have not looked at that as a solution

across the country. We are trying to come up with a made-in-Canada solution that

is uniform, through our medical schools, recognizing again that it does cost a

lot to train a physician. You have to have a good competent staff, there are

certain accreditation standards to meet, and unless you meet those, you cannot

train them; the facility will not be accredited. So it is an expensive business

we are in, and it is a fair investment of taxpayers' dollars, and it is, I

guess, not very appropriate when the system right now can go south of the

border. At least if they stayed in Canada that is one thing, but if they are

going outside the country it is another thing.

MR. OTTENHEIMER: What is it that the state, or the

institution in the state, is paying the student to go to the States? Is there a

bonus? Are they paying off just their student loan, or...?

DR. WILLIAMS: They are giving them a fixed amount,

whatever deal they can negotiate, I guess. It might be a $50,000 or $60,000

U.S., one-shot deal up front; if you will sign a contract you come down here for

a year or two years. And, by the way, when you come here we will guarantee you

this package.

MR. MATTHEWS: You see, the health care system in

the States is a private enterprise, so everybody who wants to come up and

recruit into Canada, they can do whatever they want. They are just hiring you to

go to work in a business.

DR. WILLIAMS: Some of these are HMO's; they are in

it for profit. They are in a for profit business.

MR. OTTENHEIMER: Could there not be some sort of a

term whereby a student, say, a local student who attends our medical school,

would sign an understanding or a commitment that if, in fact, upon graduation

they leave and go to another jurisdiction, the U.S., for example, the commitment

from that signing institution would, in fact, be to make sure there is full

compensation - full compensation - for the cost of education, and in that case

the university or the Department of Health would be reimbursed; so really there

is an incentive and, in fact, a legal obligation on that student, if he wishes

to enter into negotiations with a state or an institution, that that

compensation be sufficient to fully reimburse for the total cost of that

education. Has that been considered?

MR. MATTHEWS: That is basically my program. I am

very deeply into that type of trying to pull that off now. The only way it seems

it can work, really, is to have a student come in and sign an understanding, or

a contract or whatever, that you pay the normal tuition of $6,250 but if you

leave, your tuition will be, essentially, $30,000 or $60,000 - pick a number

that you think is right to work with - whether it is full-cost recovery or not.

I have to tell you that there is such a vociferous and

ardent and almost obstructionist view of that concept held by the NLMA, the

rural doctors, the people who run the medical school, the society of medical

school students, it is -

MR. OTTENHEIMER: (Inaudible) Charter of Rights.

MR. MATTHEWS: Well, the Charter comes into it to a

point. The Charter would come into it, John, in your concept, you know, you sort

of - you cannot negotiate with this crowd unless you pay us. I mean, it is a job

to enforce that. It seems that the only way you can enforce it is to have them

come in and say: Here is your tuition, $30,000 or $60,000 - pick a number - and

that is deferred and forgivable upon a return of service; otherwise, it is fully

payable if you do not stay with us.

That is the approach we are taking, quite frankly, but

sorting it out is a struggle. It is a dog's breakfast. If you could write the

contract - and I am sure you would do it free of cost for the taxpayers of the

Province - we would be happy to examine it and see it if it is enforceable,

Deputy? ...for the greater good, John.

MR. OTTENHEIMER: It seems to me, it is the kind of

situation that where there is a will there is a way.

MR. MATTHEWS: I accept that as being a fair

statement, because I support your concept wholeheartedly, or you are supporting

mine - I am not sure which - but I think we are -

WITNESS: Otherwise, we would be just as well

taking our $60,000 per student and giving it to South Africa, and train doctors

to come here.

MR. MATTHEWS: Either that or take the $60,000 and

add it on to a salary package so that you could compete in raw dollars and

cents.

WITNESS: Yes, okay.

MR. MATTHEWS: But I think it also has to be

recognized that the medical school has great value beyond training doctors. If

you did not have the medical school you would not have the specialists coming

here. It seems like all of them come here because they have an opportunity to

teach, do research, and also be involved in practice. And there is a fairly

significant research industry developed over the medical school in terms of

attracting research funding for research work. So there is a lot of value to

having a medical school, beyond training doctors, but the primary policy purpose

for which it was put there twenty-five years ago, was to resource ourselves in

doctors. So there are a lot of issues around the medical school beyond training

doctors but we have to use it to get doctors in the first instance, that is the

bottom line.

DR. HUNT: Yes, and that explains that we are

probably a victim of our success there because other provinces in Canada are

actively seeking doctors from Newfoundland. I know that Northern Ontario targets

Newfoundland for their supply.

MR. MATTHEWS: As a matter of fact, their new

recruiter is a former Newfoundlander, I understand, in Northern Ontario -

DR.HUNT: Yes, that is right.

MR. MATTHEWS: - and he gets 25 per cent of his

recruits from Newfoundland.

MR. G. REID: Oh my, oh my; you talk about a

traitor, eh? We talked about education earlier, but I found the biggest problem

in the area I represent is that, we get a doctor out there, some of them are

worked to death because a lot of them are on salary and others have very little

to do because the constituents or the residents of the area pick a certain

doctor and they think that he is far better than anyone who may come in there,

thus you see one who cannot get a weekend off because they are calling his house

or calling the clinic looking for him, but then you have another fellow who is

really not working full time and I can see why some of them pull out of the area

because they cannot get a weekend off or they cannot get a night off and I

think, basically, we are going to have to educate people and I think this fellow

Peddle was talking about something about this on tv last week, about people

coming into an emergency room at seven or eight o'clock in the evening when they

can really wait to go and see a GP the next day in a private clinic. It is a

real problem, I know, in my district.

MR. MATTHEWS: Well, there is a certain amount of

consumer education needed to educate the people about how to use medical

services. If you use the medical services right, there would not be as many

people in emergency over at the Health Sciences Complex or in your area, you

know. In terms of directing patients to specific doctors, if you are on salary

and working in an institution, I guess you are paid regardless of how many come,

to a point, although doctors like to have a decent workload to keep their skills

up, and they need that. So it is not a question of doctors being prepared to

take the money and run or do nothing, doctors need a workload to keep their

skills sharp. But these are all issues that will take all of our efforts I

believe, not the least of which is politicians, to tell it like it is and adjust

expectations and try to get people to understand that the world of the 1970s

even is not the world we are dealing with now.

MR. G. REID: No, it goes back to what you said

earlier, a town taking some role in ensuring that a doctor has a certain amount

of comfort.

MR. MATTHEWS: Yes. Sure, if they like the people

and like the town and like what is there for their lifestyle purposes, they

would be more likely to stay. That is clear, you know, and quite obvious.

MR. H. HODDER: I just cannot believe it has been

fifteen minutes and I have not said a word.

MR. MATTHEWS: (Inaudible), you asked enough

questions last year, this time.

MR. H. HODDER: That is okay. I just have one

question or two really. This thing about double-doctoring and why we cannot

control it. What efforts are we making to be able to have better access through

the - I see Information Technology here at millions of dollars and, why does it

take so long for us to realize that a particular person is seeing, you know,

multiple doctors, and is there any way in which we can have that information

shared without being in conflict with the Charter of Rights or you know,

breaking confidentiality or whatever? What strategies are we developing to

control that?

MR. MATTHEWS: The double-doctoring issue is one

that is audited and monitored by MCP and they are having some success in terms

of identifying, on a usage basis and a visit basis. Now, the prescription drug

thing is a separate issue from double-doctoring in and of itself.

MR. H. HODDER: Okay. I was putting the two

together.

MR. MATTHEWS: Yes, and we are now involved in a

triplicate prescription, drug program that is being worked through the Nova

Scotia program because they have had it up and running for awhile, and we are

wanting to see how it is going to work.

I guess probably the deputy can comment on it, but my

understanding is that where they have had these triplicate drug prescription

programs in place, they have not really had a great deal of value in terms of

cutting down the cost. People find other ways around, and they go to other

substances. It is alleged, the police will tell you, that crime increases

because there are more break-ins, and that sort of thing, for people to get

their drugs. They have other ways of doing it, so it does not control cost as

much as one would think. That is why we are working with the Nova Scotia model

before we go into a full-blown program of our own.

In terms of how else we can do the audits of doctors,

double-doctoring visits, deputy, beyond the MCP audit program, I am not sure

there is much more you can do, other than through the triplicate prescription

program.

DR. WILLIAMS: Minister, MCP has a program in place

and, Mr. Hodder, I can get you some data on their initial findings, and some of

the things they have taken. They can identify people who see multiple doctors.

They have done that, and they have written the physicians and written the

patients, and they have seen a fairly significant drop in physician utilization

after they put that in place, and they are continuing with that. That is one

approach.

The other approach we have a problem with is the abuse

of prescription drugs - not misuse but abuse - and we have a number of people

who go around to different doctors abusing certain drugs, and one doctor does

not know they are seeing the other doctor so they will write a prescription.

As the minister said, before we jumped in head first,

everybody was saying that these programs are great, you should have one of

those, and it sounds good on the surface. We had Dr. Parfrey's group at the

medical school research the triplicate prescription programs in place in Canada

and the U.S. just to see, in fact, what the outcomes were, and a lot of them are

not well evaluated. They were implemented on good faith, but they have not been

well evaluated, and in those that have been evaluated there are indications that

the drugs you put on the list - and it depends on how big you are going to put

the list; are you going to put it just to narcotics, which are prone to abuse?

Are you going to put it on benzodiazepines, which is a much broader category of

drugs for anxiety and this type of thing, that are probably overused and abused?

What they found out is that the drugs you put on, the

incidents rate usage goes down, but other drugs that are not on go up. What is a

little bit more disturbing is that the rate of crime and break-ins to pharmacies

go up because they cannot get them - they are getting them not legitimately but

they are getting them from physicians; they are duping physicians. Now, with the

triplicate prescription program, the physicians are notified: Look, you have a

problem. This person is getting multiple drugs. So that stops the patient from

getting the drugs, but now there are more pharmacy break-ins in some of those

jurisdictions and more crime. What is even more disturbing is that it drives

some people to maybe harder drugs, some of the street drugs that are not on

prescription but some of the LSDs - those kinds of drugs - that are probably

even more -

WITNESS: Damaging.

DR. WILLIAMS: Yes, in the long term, I guess.

So what we have done is, we have gotten permission to

move forward with a pilot project based on that study. Nova Scotia has a

triplicate prescription program in place for a number of years. We are going to

do this as a pilot. We are setting it up so that we can have the medical school

evaluate the results for us, and rather than duplicate the program and try to

start up our own, we are going to have a joint program with Nova Scotia. It will

cut down on our costs, and if we find out after a couple of years that, in fact,

the benefits outweigh the downsides, then we will probably repatriate it to the

Province and continue it here. We want to evaluate it first, and we are setting

it up in consultation with the medical school. They are on the steering

committee, along with the Newfoundland Medical Board, which will operate the

program for the Province, the Medical Association, the Pharmacy Association, and

the dentists because there are going to be dental drugs as well; the dentists

can write some of these drugs. So we are going to do it jointly and then

evaluate it; it is going to be set up on that basis.

MR. H. HODDER: I have no further questions, Mr.

Chair.

CHAIR: Thank you, Mr. Hodder.

John?

MR. OTTENHEIMER: No further questions. Thank you,

Mr. Chair.

MR. G. REID: Before I make a motion that we accept

the - I would like to say that I gained a lot of knowledge here tonight and I

was very impressed with the knowledge and the positive attitude that you and