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July 18, 2018

PUBLIC ACCOUNTS COMMITTEE

The

Committee met at 9:30 a.m. in the House of Assembly Chamber.

CHAIR (Brazil):

Okay, ladies and gentlemen – Ms. Rogers, if we could get started. We have

Hansard doing the recordings for us.

I want

to welcome everybody to the Public Accounts Committee hearing with Health and

Community Services on a number of topics, but the primary discussion at the

beginning of the hearing will around the road ambulance recommendations put

forth in the AG's report.

I'd

like to welcome everybody to this session which is taking place July 18, 2018 in

the House of Assembly. I would like to ask the Members of the Committee if they

would introduce themselves and then we'll ask the Auditor General's staff and

the staff from the Department of Health and Community Services also to introduce

themselves, then we need to swear in a couple of individuals who haven't been

sworn in, in previous hearings.

I'll

start with Mr. Reid, an introduction of who you are and your district, please.

MR. REID:

Scott Reid, MHA for St.

George's – Humber.

MR. KING:

Neil King, and I work for

the good people of the historic District of Bonavista.

SOME HON. MEMBERS:

Hear, hear!

MR. KING:

I am stealing your line,

Gerry.

MS. ROGERS:

You stole my line. That's

good. It means I am having an influence; I like that.

MS. P. PARSONS:

Pam Parsons, the District of

Harbour Grace – Port de Grave.

MS. ROGERS:

Gerry Rogers, and I work for

the good people of St. John's Centre, and anybody else who call me.

MR. FINN:

John Finn, Stephenville –

Port au Port.

MR. PETTEN:

Barry Petten, MHA for CBS.

CHAIR:

I'm David Brazil, Chair of

Public Accounts and Member for the District of Conception Bay East – Bell

Island.

I'll

ask the Auditor General.

MS. MULLALEY:

Julia Mullaley, Auditor General.

MS. RUSSELL:

Sandra Russell, Deputy Auditor General.

CHAIR:

Oh, and I go to the ADM – or

the DM, sorry.

MR. ABBOTT:

It's John Abbott, Deputy Minister of the Department of Health and Community

Services.

MS. HANRAHAN:

Heather Hanrahan, ADM, Regional Services.

MR. HARVEY:

Michael Harvey, ADM, Policy Planning and Performance Monitoring.

MR. CAMPBELL:

Cameron Campbell, Director of Primary Health Care.

CHAIR:

Welcome to everybody. We

have three individuals that need to be sworn in: Ms. Mullaley, Mr. Harvey and

Mr. Campbell.

I'm

going to ask our Deputy Clerk if she'd do the swearing in, please.

Swearing of Witnesses

Ms.

Mullaley

Mr.

Harvey

Mr.

Campbell

CHAIR:

Thank you, Elizabeth.

Now

I'll explain the formal process that we'll use here. I'll ask the deputy

minister to first do a synopsis or an overview of particularly the road

ambulance recommendations or the findings and the response from the department

as to the action plans that are in play. Then I'll start with Mr. Reid, giving

each Member 10 minutes to ask questions relevant to that particular topic. They

don't have to use the whole 10 minutes as we go through it.

If a

Member feels the questions have been answered that they had, they can skip. Then

afterwards, if the road ambulance process has been completed and the Committee

are happy with the findings or at least the information that's been requested,

we can move to any other issues around the AG's report for the Department of

Health and Community Services.

So I'll

ask Mr. Abbott to start for us, please.

MR. ABBOTT:

Thank you, Mr. Brazil.

Since

the release of the Auditor General's report on the Road Ambulance Services in

November 2016, work has been ongoing to implement the recommendations. The

department, along with the regional health authorities, recognize the importance

of optimizing the ambulance program. We have made significant strides in

improving the monitoring of ambulance operations, ambulance professional skill

development, internal communications and policy and procedure development.

address recent concerns over ambulance staffing and response times, Western

Health, on behalf of the four health authorities, engaged Grant Thornton to

carry out a staffing and payroll review of the 48 private and community

ambulance operators. The report was made public. The review's findings raised

concerns over insufficient staffing of ambulances and the operators' use of

funds provided by government.

As a

result, the department is continuing to contract with Grant Thornton to carry

out forensic audits of several operations. The firm has also been contracted to

establish a monthly staffing and payroll reporting system to ensure operators

are meeting their contractual commitments.

Eastern

Health has constructed and moved into a new ambulance dispatch centre. The

Eastern Health authority is in the process of customizing, testing and training

dispatchers on computer dispatch software. Once the centre is fully operational

in October of this fall, Eastern Health will have the most up-to-date technology

to dispatch and monitor its ambulance operations.

The

department continues to develop options for the establishment of a central

medical dispatch centre for the province that would allow for a province-wide

ambulance dispatch system and oversight. The department and the four regional

health authorities are reviewing a proposal to acquire electronic patient care

records, referred to as an ePCR system, as part of a larger acquisition of new

defibrillator monitors for road ambulances. The ePCR system will not only

improve quality assurance for patient care, but will also track ambulance

staffing.

The

department has hired an advanced care paramedic within the department to aid us

in better defining appropriate attendant skill levels and to begin planning for

the introduction of advanced care paramedics in rural regions of the province.

The department and the four RHA paramedicine departments have formalized a

communications process to ensure the department's performance objective and

information needs are communicated to the RHAs –

CHAIR:

Excuse me –

MR. ABBOTT:

Yes.

MS. ROGERS:

(Inaudible.)

MR. ABBOTT:

Oh, I'm sorry. Yes.

MS. ROGERS:

Great. It's such good

information; I don't want to miss it.

MR. ABBOTT:

Okay. I can provide this

later for sure.

The

department and the RHA paramedicine departments have formalized a communications

process to ensure the department's performance objective and information needs

are communicated to the RHAs and through the Provincial Medical Oversight

office. The department and the four RHAs have revised the ambulance program

policies and procedures and standards manual, and the revisions will be

implemented as part of the new service agreement with the operators.

Finally, on the 12 recommendations from the Auditor General, one has been fully

implemented to date, 10 are partially implemented and one has not been

implemented to date. That's our

summary right now, Sir.

CHAIR:

Okay.

Thank

you, Mr. Abbott. I appreciate that.

I'll go

right to Mr. Reid and we can start with your questioning.

MR. REID:

Okay.

Thank

you for your update and the information there. I have some questions as I go

along. Some are sort of general to get some more information so that I better

understand how the system works and things like that. It's more of a general

sort of knowledge that I want to get about how it works and, as we go on, we may

get into more specific sort of things.

But in

terms of the training for ambulance operators, that was one of the things that

came up in the AG's report, can you tell me a little bit about the training

requirements, where the training is done, who offers the training, those sort of

things, how extensive it is and how we compare with other provinces in terms of

training?

MR. ABBOTT:

Okay. I'm just going to lead on that, Mr. Reid, and then maybe I'll ask Cameron

Campbell to also add to that.

One of

the things, as a general sort of overview comment, is we realize that we need to

enhance training right across the board. So we have the ambulance attendants, as

it were, and we have the paramedics and the advanced paramedics. Our intent is

to expand training for paramedics so that there are more ambulances right across

the province. So we're engaging both public and private training facilities to,

in fact, do that and to up our skills.

One of

the things we have done is bringing an advanced paramedic into the department to

help us define those training needs with more certainty. We're also engaging

with the paramedics and the attendants in terms of how we should move towards

regulation of that occupation. Again, that will help us increase and improve

standards, and part of that would be to expand training.

Right

now, the operators are really responsible whether they are private, community or

hospital-based. Operators are responsible for making sure the training is

provided and/or the attendants are, in fact, trained. We've seen that as a bit

of a challenge for them and we recognize that, but at the same time the public's

expectation is those who are on our ambulances are meeting the basic skill sets

that are needed.

With

that, I'm going to ask Cameron if there's anything specific he wants to add.

MR. CAMPBELL:

Sure.

John

had touched on the fact that we've brought some advanced care paramedics to the

department that are working with us, and with a group across the regional health

authority where we've first targeted that, to look at how we would go about

spreading the advanced care paramedic model across the province. It's currently

concentrated in a couple of areas, primarily, in and around the St. John's area.

Of course, advanced care paramedics are able to work at a higher scope of

practice. We're looking at how we spread that in the rural areas where it could

be quite a valuable care tool for people.

I think

as well, kind of speaking specific to your question around where does training

happen and how does that compare to other areas of the country, locally we train

what we call EMRs, or emergency medical responders, and primary care paramedics.

Primary care paramedics are trained at the college level. That happens both in

our public and private college systems. The EMRs, or emergency medical

responders, is a shorter training stint. Those are the individuals who are

referred to as our ambulance attendants. They are not paramedics and do have a

much smaller scope and are often utilized in areas where it can be hard to

retain primary care paramedics.

Recently, the department has been working with the community paramedicine

operators association. They've paired up with a company called Training Works to

look at how we upscale existing EMRs that are working primarily in our rural

communities so that they have the opportunity to become primary care paramedics,

while still working and ideally doing that remotely. That's one of the major

initiatives that's been moving forward, and we're certainly paying a lot of

attention to, because of the ability there to potentially upscale a number of

our current attendants.

We've

also been working as of late with our Provincial Medical Oversight office, which

is housed within Eastern Health, to update the process of registration for

paramedics. In particular, linking back to the AG's report, we're looking at how

we ensure that we have adequate continuing education and ensuring that we update

the number of hours required to maintain licensure in the province. I think

that's an important step to make sure that we are increasing the level of

oversight and ensuring that appropriate education is available and required for

those currently working in the profession.

I'd

also note that in terms of how we compare across the country, our paramedics

have to complete what we call a COPR exam which is an exam that's organized at a

national level. It allows for labour mobility across provinces, but it also

ensures that we have paramedics that are on par with those in other regions of

the country.

MR. REID:

In terms of the recent study

that came out, the Grant Thornton study, that focuses mostly on sort of

financial accounting matters and how the money is spent. So in the future you

plan to do more of an assessment of what training people have to get a better –

is that the plan moving forward?

MR. ABBOTT:

So going forward, the Grant Thornton report lays out a number of recommendations

and, on top of that, we will be negotiating with the operators in terms of,

again, how we how we skill up and make sure that those who are on the ambulances

are meeting the standards and then we make sure that we have the supports in

place to do that.

that's all to happen relatively shortly because the agreements expire in

September and we have to engage them very shortly around that.

MR. REID:

Yeah, so that's an

opportunity there in terms of the contracts and when they expire.

MR. ABBOTT:

Yes.

MR. REID:

In terms of requiring additional training and having a plan as to how to achieve

it.

MR. ABBOTT:

Yes, and we're doing that, both using that as that opportunity to really bring

more attention to it, but also, as Cameron Campbell said, to continue to plan

and put the supports in place. We've been talking to the regulator as well in

terms of how to move forward to bring our EMRs and our paramedics into a

regulatory regime so that we can enforce the standards as well.

MR. REID:

Yeah.

You

mentioned the professional association. In some cases, I think the professional

associations for some other medical professions play a large in developing the

training and developing the certification.

Is that

the case with the association for people –?

MR. ABBOTT:

Yes, they're fully engaged. Again, they're evolving as an association. There's

new leadership, so again we're back at the table with them to help them to help

their members.

Part of

the challenge is not all those that are in the practice, shall we say, are

seeing the benefit of more training, regulation and those kinds of things. It's

a learning process, as well, for everybody.

MR. REID:

Yeah.

The

report, I think, showed that a lot of the – in terms of the way people were

paid, they weren't paid the required amount, I think 32 per cent or something

like that in Grant Thornton.

MR. ABBOTT:

Yes.

MR. REID:

Is that related to training? These

people weren't able to find someone who didn't have the training to justify a

certain pay level? Or why is that?

MR. ABBOTT:

Not in and of itself. I think part of

this is there was a negotiated agreement; monies were put in to really help the

operators attract and retain the attendants and paramedics. The question then or

the issue, obviously, that Grant Thornton has found is that some of that money

has not gone where it should have.

MR. REID:

Yeah.

MR. ABBOTT:

We realized we have to do more work on

that. Part of it is an administrative function within each of those operations.

There have been

some complaints made by different individuals and that's helped us focus where

we should get Grant Thornton and others to focus their efforts. But in and of

itself, we would disconnect the two.

MR. REID:

Yeah.

Okay, I think my

10 minutes are close to being up there.

CHAIR:

Okay. Thank you, Mr. Reid.

I'll move to Mr.

Petten now, if you want to ask some questions to the witnesses, please.

MR. PETTEN:

I might be repetitive because I'm

having a lot of trouble hearing most of the questions. I don't have an earpiece

either.

MS. ROGERS:

(Inaudible.)

MR. PETTEN:

I don't even think I have one there,

actually.

In 2015 the

province had 769 registered ambulance attendants. What is that number today?

MR. CAMPBELL:

Right now it would be just shy of 800.

I'd have to confirm the exact number because it does change on a day-to-day

basis.

MR. PETTEN:

Right, so that's pretty close to being

that same ballpark.

At the time when

the AG report – Eastern Health operated an ambulance service in St. John's and

Carbonear and provided oversight for another 15 private operators and six

community care operators. The AG report examined the skill levels, response

times and oversight of the RHA and other ambulance services.

Would you say the

department has made sufficient progress in each of these areas?

MR. ABBOTT: Mr. Petten, I

would say we are making significant progress but we know there are still gaps

that we are needing to address, and that's been the focus literally since the

AG's report has been out. As late as, literally, this week we are continuing to

focus on improving the quality of the services, making sure we have more

paramedics on our ambulances, that they are meeting the training standards

required by the program and working closely with the oversight office to make

sure that they are supported and have the skills there to move that whole

service forward.

We think, certainly, central dispatch is going to be a

critical part of that so we know where the ambulances are, who are on those

ambulances both in terms of staff and obviously in terms of patients, and that

we provide really sort of a national-class service for the residents.

That's where we are and we'll be continuing to discuss

those issues with the various associations, as well as in the department with

the health authorities, obviously, making sure we can get the funding to meet

the needs that we're finding as we go forward.

MR. PETTEN:

Recently, I know it was in the news, the Southern Shore region, Bay Bulls to

Bauline region, their issue was response times for ambulance service in their

region and apparently a new ambulance operator was approved. So has that worked

out yet? Again, about response times, is that issue still ongoing or is there

any resolution?

MR. ABBOTT:

We've been having discussions, obviously, with the proponent and with Eastern

Health. Our data would suggest that the response times are not the issue that's

been made public. That's why we are reviewing all of that data to make sure, in

fact, that the services are meeting the needs. It has not been, for us or

through Eastern Health, the issue that has been out in the public at this point.

MR. PETTEN: So,

just to be clear, the department questions those response times that have been

made public, the numbers that the public spoke of.

MR. ABBOTT:

Yeah.

PETTEN: You

don't agree with those numbers?

MR. ABBOTT:

Well, we're reviewing them. They brought that data forward. Again, it wasn't

coinciding with the data we had, so we were obviously going to review that. We

obviously owe that to the

communities involved to do that.

MR. PETTEN:

Okay.

Also in

the report the Canadian industry, the best practice for training – and I don't

know if this question was already asked by my colleague, Scott, there. Has the

department skill level standard been raised to match the Canadian industry best

practice?

MR. ABBOTT:

That's where we want to go. We're

working with the operators and with those staffing them to, in fact, move there.

As Cameron Campbell said, in terms of the paramedics, they are tested and

licensed based on national certification and testing. We would want to bring all

our attendants, their skill level, up as well.

MR. PETTEN:

Okay.

And the same then,

will the same thing will be expected of the private operators as well? It's not

MR. ABBOTT:

Oh yes, absolutely.

We don't make a

distinction between community, private and those operated by the RHAs directly,

so we want to make sure the whole system is meeting national service levels.

MR. PETTEN:

But that's where the gap appeared to

happen because from our base hospital it seemed to be running – their record is

much improved, St. John's and Carbonear, as opposed to our private and community

operations there. That's where the big gap seemed to – it seemed to be almost a

three-tier system when you look at …

MR. ABBOTT:

Yeah and some have described it that

way. We're trying to make sure it's as level as we can. The hospital-based

services, it's easier to attract skill, the paramedics. They are directly

funded, obviously, by government. They have the latest technology and we need to

bring everybody up to that level.

MR. PETTEN:

Also, in the AG report they found that

Eastern Health's own operators in St. John's are not meeting the response time

benchmarks. Has this issue been dealt with or is it being dealt with or is it

approved?

MR. ABBOTT:

Again, that's going to be just an

ongoing issue that we have to address with Eastern Health or any of the

operators, is to meet the response times. Part of that, again without getting

too technical, is sort of the immediate response time which we call the chute

time. The time the call comes in to the time the ambulance is on the road should

be 10 minutes max and then the question is 10 minutes or longer to get,

obviously, to the point where the pickup, shall we say, takes place

and we monitor those response times. We have the technology now to know where

each ambulance is and their response times. We monitor those very closely.

So if

you recall last year, there was a significant issue up in Labrador, in the Happy

Valley-Goose Bay area, and the operator was having trouble, repeatedly, meeting

both the chute time and then the response times. So through that review, we

determined that operator was not going to be able to provide the service we felt

was needed. So we then had the health authority take over that service so that,

in fact, we could meet those response times.

That's

how we monitor each of the services across the province. If there's an issue or

complaint made, we'll investigate. We'll work with the operators, whether it's

the hospital – because, again, the same thing applies. We've reviewed all of

their operations as well. We don't have double or triple standards here. We try

to have one for the province. But, as you can appreciate, a rural area, it's

going to take a little bit longer to actually get to the scene than in an urban

centre. But urban centres are matched against other urban centres across the

country so that the level of service is comparable.

MR. PETTEN:

Okay.

The AG

also found that the department wasn't providing effective oversight. Has there

been any changes made within the department now to improve upon that or –?

MR. ABBOTT:

Well, we have, in terms of – the simple answer is yes. We've provided more

support, resources to that. We have our director here, Mr. Cameron Campbell, to

oversee that work. We have brought in, as I said, an advanced care paramedic to

work with us on training. We have ongoing and regular meetings now with each of

the RHAs and ongoing meetings and discussions with each of the operators and

certainly their associations.

So we

are monitoring much closer the activity out in each of the regions and the lines

of communications have certainly been improved so that we can get – and

technology has allowed us to know where the ambulances are. So we are able to,

in real time, know where the ambulances are and that certainly helped us in

terms of any discussions we've had with both the public when complaints come

forward, certainly with the RHAs and then the operators themselves as to meeting

the standards expected of them.

MR. PETTEN:

Okay.

CHAIR:

Thank you, Mr. Petten.

I'm

going to go to Mr. King next.

MR. KING:

Mr. Abbott, you talked

about, when you did your introduction, you had a number of the recommendations

implemented partially and not. Can you go through which are done, which are

partially, which are not and the reasons why?

MR. ABBOTT:

Okay.

The first

recommendation was: “The Department of Health and Community Services should

evaluate its basis for road ambulance attendant skill level policy, which is

below Canadian industry best practice, and determine whether it is sufficient to

ensure quality care.”

We feel right now

that's partially implemented. Since we reported last year – and I'll give the

update as of March 2018 and then this month, so it will give you some sequence

of activity – we continue to work with the training institutions and industry in

an effort to address the primary care paramedic supply issues.

The department and

representatives from the RHAs and industry are developing a strategy to place

advanced care paramedics in rural regions of the province. As late as this

month, as I've said, we've seconded an advanced care paramedic from Eastern

Health to work with the department to better define appropriate attendant skill

levels, and aid us in planning for the potential placement of advanced care

paramedics to rural areas of the province. That work will continue. We don't

have a specific end point at this point.

In terms of the

second recommendation, that the Eastern regional health authority should ensure

that the road ambulance services provided by private and community-based

operators for the region meets the skill levels required by the department – and

it continues on – based on where we were in March from when we last reported,

the department and the four RHAs have developed a strategy to address best

efforts, issues and are waiting for the new service agreements to discuss a

change in the best efforts clause with the ambulance industry.

We are currently

planning for – again, we replaced some of the ambulance operator service

agreements that expire in September and we intend to address this issue in these

new agreements. That's in terms of the operators making sure that they have

those that are skilled to meet when there is a shortage.

The third

recommendation: The department should ensure that

its policies and procedures and the Ambulance Operations Standards Manual are up

to date, are being enforced, et cetera. Again, they updated in March. The

proposed changes to the policy and procedures manual have both operational and

financial impact on ambulance operations, which have to be discussed with them.

We'll be discussing that through the renegotiation of the service agreements. We

are also waiting to move forward on those with them. We've been developing the

changes, internally, but we now have to sit down and negotiate some of those

with the operators.

The

issue before us – and we approached Cabinet on this – is that we feel that we

really need to have new emergency service legislation for the province and that

these operating standards, in fact, then become either statutory or regulatory

and that they're really not a negotiated item, as we do in other areas. So

Cabinet has approved us moving forward with drafting legislation. We will be

doing consultations this summer and into the fall to develop that legislation.

The

next recommendation was that we should evaluate its basis for dispatcher

training and determine whether it's sufficient to ensure quality care. That one

has not been implemented and we are waiting on the results of Eastern Health's

central dispatch and how we can learn from that and move that service right

across the province.

We felt

it would be, sort of – I wouldn't say wasted effort, but we felt that once we

knew what we were doing in terms of central dispatch because we want them

focused on the training for those dispatchers than for looking at this dispersed

across the province.

The

next recommendation is the department should set ambulance response time

targets, giving consideration to Canadian industry best practice for response

times. Again, partially implemented, and I sort of referred to that in some of

my previous answers.

We have

now automated vehicle locator system in each of the ambulances so we, in fact,

know where each one is at any point in time, when it's either parked or on the

road. This has allowed us to gain better information and it's used by the

paramedicine staff and ambulance operators to track and audit ambulance

operations so we know then what response times are and then we can monitor

those.

As a

result of that, we've been able to figure out if there needs to be any change in

both location and response times.

MR. KING:

Sorry, just a quick question on that one: Is that on private ambulances as well?

MR. ABBOTT:

Yes.

MR. KING:

And to be cognizant of the

time –

MR. ABBOTT:

Yes.

MR. KING:

– just go through the Health

and Community Services. I know there are a lot of recommendations.

MR. ABBOTT:

Yes, the next one in terms of the department ensuring it is providing effective

oversight of the road ambulance program; as mentioned, we believe that is fully

implemented based on some of the responses I've given earlier.

The

next one: The department should ensure that contracts with the private and

community operators are negotiated and renewed in a timely manner. Again, we are

at the point now and we will be sitting down with the operators very shortly to

look at the future of those agreements, and we're looking at the options for how

to renegotiate those. We think there's sufficient funding in the system to allow

us to move and make the changes we need to see happen.

The

next one is the department should monitor the road ambulance program to ensure

intended results are achieved. Again, that's ongoing work so we say it's

partially implemented. And the Grant Thornton report was a major piece of work

we did this year to really get a better handle on what is happening out there in

terms of the system, who is delivery what and who is getting paid for what.

The

next –

MR. KING:

Oh, that's why those – I was just looking through the Health and Community

Services, what you folks have been doing –

MR. ABBOTT:

Okay.

MR. KING:

– I know each health

authority would be based on what you guys would dictate to them.

MR. ABBOTT:

Yeah.

MR. KING:

Just getting back to the

third recommendation here about Health and Community Services ensure that

policies and procedures and the Ambulance Operations Standards Manual –

MR. ABBOTT:

Yeah.

MR. KING:

You talked about emergency

service legislation in consultations. What type of consultations will you guys

be looking at?

MR. ABBOTT:

Again, we'll be going out to the communities across the province. We'll be

meeting with, obviously, the operators and their associations. We'll be meeting

with municipal leaders and the public if they're so inclined, so interested. We

will then be pulling all of that together and going forward in the fall to

Cabinet.

MR. KING:

Thank you, Mr. Abbott.

CHAIR:

Ms. Rogers.

MS. ROGERS:

Thank you very much.

This

may seem like an odd question, but if we were to sit down and have a beer, John

MR. ABBOTT:

Who pays?

MS. ROGERS:

I'll pay.

MR. ABBOTT:

Okay.

MS. ROGERS:

I'll pick up the tab for that.

If you were to

just tell me in a nutshell – these are the real challenges for our ambulance

services in the province – to sort of give us a global picture of what's

working, what's not working and what are the challenges. What we're doing is

we're looking at some of the very specific issues, but if we get sort of a

global picture of what you're really up against.

MR. ABBOTT:

I think from the department – and as we

look at these issues on a regular basis and as we sit down and address the

challenges – for us we think we, collectively, can still better manage the

ambulance service in the province. We look at what's happening across the

country and we see no reason why we can't have similar standards and quality.

It's getting

acceptance by all players, the operators, the staff and government, to agree

that, one, we want to improve the quality of the service. In doing that, we need

to provide better management; we believe a central dispatch so that we, whether

it's on a regional or provincial basis, can improve response times. Then, within

that, we need to make sure we have, on the ambulances, the appropriate

professionals to provide the standard of care.

If that is done

properly, obviously, the quality of care and survival rates, particularly in

severe incidents, is improved. It allows those paramedics to work to their full

scope of practice, and they become active as opposed to passive in terms of

supplying care.

We know all those

elements and we now just need to bring those together. We believe there's

sufficient funding in the system to allow us to do that. Again, on the whole, we

get complaints but we don't get a lot. I think both community and private

operators are doing a very good job in responding. We have, as I said, those

chute times. They have to meet those 90 per cent of the time and they generally

are.

When

we do see a problem, I think

the department, with the RHAs, are then in a position to move because we

understand the business and we know what is acceptable and what isn't. I think

the government wants to make sure wherever there's a gap that we're going to

fill that in. On a go-forward basis, we'll sit down with the operators to work

through, then, the detail as to how that gets done.

MS. ROGERS:

What you've talked about is

really where we'd like to see the service elevated to, but what are some of the

challenges of getting there? When I look at it, the dispersion of our people,

the geographic situation where population is widely dispersed, seniors, money –

one of the things we hear about is from people out in rural areas, in either

community or private operations, is the disparity of work-life balance and

payment for staff, people who are staffing the ambulances. What are some of the

challenges to get to where you really want to go?

MR. ABBOTT:

Looking at the dispersed population –

so, again, the call on the system is not significant. In some cases, an

ambulance may not move for a day or two, so retaining and attracting skilled

paramedics for that service is going to be challenge, both – well, in the first

instance will somebody want to work on that service and, then, will they stay,

and will they be able to work to their full scope of practice and remain

proficient in that. That's going to be – as we speak and going forward – our

biggest challenge. We want to skill up. Then, in doing that, it's going to be –

that's our biggest challenge.

The money, we say,

is there and will be there to meet that. We can do better. We can be more

efficient around some of the services so that we can make sure their response

times are a bit better and the dollars are better spent. Technology is there and

we need to apply that and use that regularly.

If I was to flip

it around, I think the expectation of, say, our urban centres, whether it's the

greater Northeast Avalon, which is a metropolis, and the standard of service and

expectation there is

high and we have to meet that. So we have to be comparable to whether it's

Halifax or Moncton or what have you in both the quality of care and response

times and things like that. They're probably under as much pressure, if not

more, than some of our rural operations.

The

other aspect is around the operators, generally, and certainly the community

operators. Many of those are still relying on volunteers.

MS. ROGERS:

Yes.

MR. ABBOTT:

We know that in rural Newfoundland that's going to be a challenge based on just

availability of volunteers. So we're going to have to look and monitor that very

closely. The default then is either a private operator and/or a RHA-run service

will be the result.

we'll be looking at that closely, but that's going to be the biggest challenge,

I think, for the community operators. We know they're very active and embedded

in their communities, in their regions and we support that, but we have to make

sure they can also provide the service that people expect.

MS. ROGERS:

What about an aging

demographic, how does that affect the operation of ambulance services?

MR. ABBOTT:

Today, or in the short-medium term, we're not seeing that from the supply side,

but it's the demand on the system and that's why we want to see paramedics and

advanced care paramedics in the service because then they can support seniors in

their homes, in the communities, in their personal care homes so that we don't

have to bring those citizens into the acute care system when they can be

serviced at home.

We are

working now on the West Coast in having an advanced care paramedic program

embedded in the community so that, in fact, the so-called ambulance service is

actually going to provide care in the community.

MS. ROGERS:

That's great.

Cameron

was talking about upscaling and training. So how do you see that being done

particularly in rural areas? My understanding – I don't know if these numbers

are correct or not – Eastern Health employees get about $26 or $27 an hour.

They're on call 12 hours a day. Private operators get about $21 an hour. They're

on call 24 hours a day, a number of days in a row.

How do

we address the disparity that we see, for the workers themselves, in rural and

urban? If we want to upscale – I love this idea of again using that full scope

of practice – how do you operationalize that when we see such a disparity in

payments and hours? How do you make that attractive? How do you make that

possible without it just being on the backs of the individual workers?

MR. ABBOTT:

Well, part of what we do is we scan right across the province and certainly

across the country to make sure we are going to be competitive in what we pay.

MS. ROGERS:

Uh-huh.

MR. ABBOTT:

That's a given and we work then through the negotiations with the operators to

make sure that what we negotiate – and this is the whole basis of the Grant

Thornton report, is we negotiated agreements, we put money in to address the

exact issues that you're referring to, but we found that some of those monies

weren't going to where they should go.

MS. ROGERS:

Okay.

MR. ABBOTT:

So that's really the basis of the Grant Thornton report. That's why I think we

feel confident and we say look, we think there's money in the system to allow

and to bring both the salaries up and, in doing that, we also want to make sure

we bring the skill levels up. If we have to pay more, we're prepared to pay more

to meet – and that there aren't the gaps that you refer to.

believe as a department, and I think within talking to the paramedics and others

themselves, that professionalizing that service, professionalizing the work they

do as a regulated occupation is something that we support. That way the

standards can be enforced and it doesn't become optional. Operator A can say

yes; the operator B says maybe. No, everybody has to operate at the one level.

that's the course we're on. As well, we just had a meeting this past week with

the licensing authority to talk about that and how we get to the next step.

That's going to require some development with the paramedics and the EMRs to

make sure we can get them to that stage, whether it'll be within a year or two

but that's where we'll make the biggest difference, we think, going forward.

MS. ROGERS:

Great.

My time

is out. I have more questions, but I guess I'll have to wait.

CHAIR:

Okay, when you come back.

Ms.

Parsons.

MS. P. PARSONS:

Good morning.

question is in regard to the response time benchmarks. As outlined in the

Auditor General's report, the Eastern Regional Health Authority has established

a 10-minute ambulance response time benchmark for its own ambulance operations

in the metro St. John's area. However, it has not established a response time

benchmark for its Carbonear operations.

This is

of particular regard and interest with the people I represent in the District of

Harbour Grace – Port de Grave.

MR. ABBOTT:

Yes.

MS. P. PARSONS:

Also, the Department of

Health and Community Services and the Eastern Regional Health Authority have not

set any ambulance response time targets for ambulance services outside of the

metro St. John's region.

guess, why is that and what is the latest and the status with regard to, I would

say, fixing this or improving this?

MR. ABBOTT:

Okay, just one second.

I'm

going to ask Cameron Campbell to respond to that.

MS. P. PARSONS:

Okay.

MR. CAMPBELL: We

have looked nationally at what benchmark targets do exist and whether or not

there's an ability to apply those. So I think there are kind of two key parts to

the question here: One is that in order for us to even monitor our benchmarks,

we knew that we needed to have technology in place that would allow that to

occur. So up until the point of this review, we would not have had any of the

automatic GPS-based systems that would actually allow us to monitor any

benchmarks that are set, with the exception of Eastern Health actually being an

initial earlier doctor of that technology, which has allowed them – particularly

in the urban setting – to try to establish those targets.

We can say at this point what we have done is put in place

a system across the province – and we spoke about this earlier – around

automatic vehicle locator. That allows us to start to trend and track what our

timing is currently. I think, to be fair, before we get to a point where we're

willing to set a benchmark, we need to make sure that's not arbitrary and that

it does fall within the realm of what is realistic within the current

configuration of the system.

Over the last year or so, we've begun to collect that data.

In addition, Eastern Health has led the way in now establishing its own central

dispatch. The department has been working quite closely with them. As part of

that, we are putting in place what is called a computerated dispatch system.

That will serve all of the Eastern Health current assets,

including those outside of St. John's and the Carbonear ambulances. That

computerated dispatch system is designed to automatically provide the best

possible routes, but also select the ambulances that make the most sense, and to

keep our ambulances in a state of – what we call – dynamitic positioning where

when an ambulance is responding to one call maybe on the eastern side of a zone,

those on the western side of that zone would begin to shift over to make sure

that we still retain ultimate coverage across the region.

I think back to the question around the benchmarks in

particular, it has certainly been more challenging for us to determine how we

would go about setting response benchmarks in rural and remote areas of the

province. And in some ways ,

we are not comparable to many areas of the country because of our very dispersed

population. If we look at other areas, the road networks are not nearly as long

and the distance between homes are not nearly as long. We will have to account

for that and I would think that may change our actual response times going

forward.

What we

can control at this point is that piece around our chute times, which is making

sure that when a call comes in that ambulance is leaving as soon as possible.

The deputy, John, had referenced that we currently aim for a 10-minute chute

time within 90 per cent of the time.

MS. P. PARSONS:

Okay.

It has

been made known to me of an incident, in particular, a year ago, February past.

It was obviously the winter and road conditions perhaps played a factor in this.

A call was made. The patient died, unfortunately, not because of – I don't think

the response time in this case, but it was made known that the response time, by

the time the ambulance got there, was significantly long. That was a major

concern by family.

happened in the community of Spaniard's Bay and Ridge Road in particular. I

would think this would be covered by Moore's Ambulance Service there. Just to

make that known to you.

Also, I

want to move now with regard to the contract. Moore's contract is said to be

operating on the 2008-2012 contract. Is this a fact? Why is this happening? When

can employees in this particular area expect that the contract will be signed in

the 2014-17 contract? What can you tell us about that?

MR. ABBOTT:

The contract is with the lawyers now to

finalize; we've gone back and forth. We've been hoping that this could be

resolved any day and it's taken a bit longer between the lawyers for both

government and the operator. We think we have pretty well all the terms sorted

out but yet to be signed.

MS. P. PARSONS:

Yet to be signed. Okay.

Also, employees

have raised concern about the retro pay.

MR. ABBOTT:

Yes.

MS. P. PARSONS:

I guess that would be all part of that.

I often get asked that question to look into this on behalf of them. When can –

a ballpark – employees expect to receive that retro pay?

MR. ABBOTT:

I think we're familiar with those cases

and we're monitoring that. Once things are signed, then we can make sure those

funds are paid out.

MS. P. PARSONS:

Okay.

In closing now, as

you're aware of course, there was a $5-million announcement recently down at

Carbonear hospital. Probably about a month ago – well, in June there and

that's to include a new ambulatory service to be operated out of Carbonear

General Hospital.

So can

you just shed some light on that and just give some details on exactly what that

means?

MR. CAMPBELL:

If I'm not mistaken, you're referring to the infrastructure that would be

updated at the Carbonear site?

MS. P. PARSONS:

Right.

MR. CAMPBELL:

So I don't have a whole lot of detail on that, but I do understand that part of

that infrastructure funding was to update the ambulance bays that would be

located at the hospital to bring them into a more modern stage. It's part of a

broader infrastructure redevelopment that has an impact on the emergency

department there. So it's one of many sites where we've been continuing to do

that over the last number of years.

So when

we've been making those updates at sites, we're making sure that, if there is an

ambulance base there, it is appropriately placed, it's close to the emergency

department and that allows us to do a couple of different things, including to

better utilize our paramedicine staff. So if they're not waiting to respond to a

call, they could be inside of the hospital helping to provide care services as

well.

MS. P. PARSONS:

So we can expect, of course,

for services to be enhanced and improved, obviously based on this. Right? Okay,

thank you.

That's

all for me for now.

CHAIR:

Mr. Finn.

What

we'll do after Mr. Finn, we'll take a short 10-minute break, if anybody needs to

go to the washroom or make a phone call.

Mr.

Finn.

MR. FINN:

Excellent. Thank you.

Good

morning, folks, my colleagues – I guess the benefit of going last – have done an

excellent job in terms of being very thorough, as you have with your responses.

So I just have one question and you just hit on it, Mr. Abbott, and this was

around the piece on the West Coast with some training and trying to have the

paramedics provide more services in the community.

I've

had conversations with the minister previously and, I believe, yourself. So it's

certainly something very exciting. So in addition to having made significant

progress, I believe, on your recommendations, I'm just really curious about that

one particular piece.

MR. ABBOTT:

Well, we're anticipating an

announcement on that shortly and, again, it grew out of the community coming

forward to say we think we can do this. Working with the Western Health

Authority and the department, the pieces have come together to allow the

ambulance/paramedic service then to engage in providing further services in the

community.

It's

based on what has been happening across the country, in Nova Scotia, in

particular, and we've been monitoring that. I'm not going to say we're using

this as a pilot in the sense of what we want to do is learn from this and then

how we expand that across the province.

It's

certainly suited for this province in terms of the rural nature, the isolated

nature and where we have an ambulance service, it can then add to the primary

care service in that region. The paramedics, if we have them work to their full

scope of practice, then they can be as qualified then to provide initial

response and care.

To Ms.

Rogers's point, for seniors in the community, they then can go in and help – get

diagnosed and be first responders in providing service, and through technology,

going back to the dispatch to the hospital to say with the state of this

particular patient, what else can we do to maintain this patient in her home

and/or community.

We also

want to bring that in to our personal care homes. We are seeing that we have

seniors who are leaving the personal care home to come by ambulance to an

emergency room only to be told: Yeah, here, and now you can go back. We're

saying we want to bring that service in to the personal care home sector as

well. We're going to learn from what we do out on the West Coast and then apply

that across the province. But the fact that the community wants to do that has

been the critical part here. We haven't imposed it.

MR. FINN:

Excellent, looking forward

to it.

That's

all for me. Thank you very much.

CHAIR:

Okay, if we want to take a

quick 10-minute break. Then, if we head back here at 10:45, it would be good.

It's a bit different on your phones; I think it's three or four minutes, so say

10:50 by your phone. We're all on 10:38 now. We're good?

Recess

CHAIR:

Okay, ladies and gentleman,

we're going to reconvene again.

I'm

going to go to Mr. Reid to continue the question process.

MR. REID:

We'll start again.

I'm

going to continue with some questions on the road ambulance. Again, I have a few

general questions. Part of it is to get some background and to get a sense of

where the department is going in the future and where you see the problems.

I'm

just wondering about the urban-rural challenges in each of these areas. You

mentioned the pilot project on the West Coast, how that could work and what

information that might provide. I'm just wondering: Has the department looked at

other possibilities in rural areas, especially co-operating with fire

departments or things like that, in terms of road ambulance service. Are those

models used in other provinces and other jurisdictions? Is the department

exploring options in that regard?

MR. ABBOTT:

What we are looking at is, from a principle review is, obviously, how we can

improve the service, make it more effective and be more cost effective in doing

that. An example of what we're looking at, and it started basically on the West

Coast, is we're providing the same ambulance and attendants on the ambulance if

it was – quote – an emergency or if it was inter-facility transfers, those kinds

of things.

We are

reviewing, with the health authorities, what is most appropriate there. Western

Health had started that a little over a year ago and has found that they can

provide more responsive service, a more cost-effective service by changing the

nature of the ambulance in responding to those different types of calls. One is

an emergency call, fair enough; the other is a call made between a facility,

say, in Corner Brook, Western Memorial, and up in one of our facilities on the

West Coast if we're moving patients between facilities.

We can

schedule those and what have you. We've looked at that. We're then seeing how

other health authorities can do that because it takes pressure off in the true

emergency and the ambulance service, so that then we can be more responsive and

have better wait times.

That's

an example of where we're looking at. The other thing is around central

dispatch. Eastern Health now is just putting their centre down in the Miller

Centre because they had some space that they could use in that facility. That

will be operational in October. I think we will learn from there the central

dispatch for all of their assets and how we can get better information, better

response times and better coordination.

We have

the automated vehicle locator now on all – again, that's relatively new – our

ambulances; get better data on how we manage those. The intent there is that

data then can go into a central dispatch to know if you are actually returning

from a call – and, particularly, we have a lot of calls that are ambulances

coming from rural into urban. We have ambulances coming from the Bonavista

Peninsula in to St. John's or from the Southern Avalon coming in to St. John's.

They're going back. If there's a call, can they be redeployed?

would make sense, have faster response times and, certainly, better utilization

of their vehicles. It then becomes more cost effective. So we're looking at all

of those possibilities as we move forward. The industry is, I think, supportive

of that. We just need to make sure we have more conversations in how we do that

and how they get compensated appropriately.

MR. REID:

In terms of the rural-urban

issues, are there more challenges in terms of rural areas of the province in

terms of keeping trained people in those areas? One of the recommendations

relate to monitoring the system and things like that. Do you have a sense of how

things are going in rural?

MR. ABBOTT:

Yeah, I mean it is a challenge, as I

said earlier, about recruiting and retaining the emergency ambulance attendants

and, in particular, when we want to move up to paramedics. Dare I say that's a

challenge in all our health services; the further we're away from a regional

centre, then the more difficult that is becoming for us.

It's the

attraction part of that and then it's just the availability, in the first

instance, of young people really wanting – are they there and do they want to

come in to this service. It's incumbent upon us to make it as attractive as

possible. We think having it as a regulated profession will give them more sense

of professional identity and support as they go into this.

It's going to be

an ongoing challenge for us, there's no doubt about that. We see that in other

services. In other

areas we're putting bursaries, we're putting return to service agreements, those

kinds of things. We haven't done that in this particular area yet, but I can see

that's going to be something we may have to turn our attention to as well.

distance, obviously, in the response times and things like that, we're providing

the physical vehicle and the equipment. That's the easy part. The training

that's going to be required, we're committed to, but it's going to be the

recruitment – it's just the HR issues that we face in health care, generally,

are going to probably play out quite significantly in the ambulance side of

things.

that's why we want to come up with new models to make it more attractive. Again,

as we're doing on the West Coast, on the Port au Port Peninsula, is that we can

make that more wholesome, sort of, experience as a paramedic, and not only are

you going to be on the ambulance, you are also going to go into people's homes

to help them provide care. That, we think, will be part of the solution.

MR. REID:

Yeah, and you mentioned

legislation and how that relates to professionalization and the, sort of,

statutory requirements. So there's no legislation now in terms of –

MR. ABBOTT:

No.

MR. REID:

– that establish those

things?

MR. ABBOTT:

No.

we're really the only province, I think, that hasn't gone down that road. We've

talked about it for some time. So this spring we did go to Cabinet to say: We

think time is – we're overdue on this. That was accepted and we're out

consulting.

I guess

the benefit of being the last in here is that we can look at best practices

right across the country, which we're doing, to support the legislation when it

comes forward.

MR. REID:

Yes.

Okay, I

think that's all I have on the ambulance stuff. I may have something else later

on.

CHAIR:

Okay, perfect.

Mr.

Petten.

MR. PETTEN:

Thank you.

Back to

the skill level. I know the AG found the department skill level policy was

outdated. I know we've talked about various improvements being made and things

being worked on. I guess my question is more of a broader question from the

common sense point of view that we all live in this province, we know the

dynamics we deal with.

I said

it earlier when I spoke first – and I want to go back to it – the three-tier

system. I'm not saying there's a three-tier system, maybe there is, but it's a

job to deny that there appears to be a different level of service. My community

operates under private ambulances, but I'm fully familiar with the community

system as well.

If I go

to the Health Sciences Centre, ambulance operations at the Health Sciences

Centre are first class compared to what I've seen. That's not diminishing the

other private and community care – or community. But it's obvious to anyone –

the common sense point of view when you look at it – there is a stark difference

in the professionalism and the equipment they have. Everything about the

operation is totally different

I'm

going to ask a really broad question: How does the department deal – I know it's

nice to say in theory and it sounds good publicly to say we offer the same

service to a rural community to the urban centre. That would play well. Being in

politics, I get that totally.

reality, how does the department – how can you tackle that issue? Training the

proper number of paramedics, skill levels, you name it, the geography,

everything, to bring this to an acceptable service for all involved – because I

don't think we'll ever meet across the board standard, as hard as we may try. I

don't know if you have any commentary on that.

MR. ABBOTT:

If you look at the options – and,

obviously, we've had lots of conversations in the department to the questions

you ask. In the way the service has evolved, it really started, in many cases,

in the community; it wasn't a top-down kind of a service. The community

responded. That's why we have the community operators and there are volunteers.

We will ensure

they have the equipment they need, but then staffing and training. Unless it

becomes – and until it becomes – mandatory, you're going to see variations. So

we would like to move to making sure the skill sets that are mandatory – you

won't be able to operate an ambulance unless you have the right people on the

ambulance and that are fully skilled to the level.

We want to make

sure there are paramedics, ideally, on each of the ambulances. That's going to

take some time but that will raise the standard. That's where you will see the

difference because the technology now – we have to know where the vehicles are,

how quickly they respond and make sure we have electronic patient records, all

of that tied in.

Until we get a

mandate and get to that level – so legislation will help us, regulating the

profession will help us. That will be the key drivers to get that equilibrium

across the province.

If you

look at the dedication and the commitment in the community side – and,

certainly, even on the private side – we have a lot to work with in moving

forward. As the population changes within the province we'll probably see more

concentration and more pressure on our urban services, certainly on the

Northeast Avalon, out in Grand Falls and Gander and Corner Brook and Happy

Valley-Goose Bay, to make sure that those services are probably even at a – I'll

call that an urban standard. Fundamentally, it's response times and the quality

and skill of the people on the ambulance. Those we have a fair bit of control

over.

MR. PETTEN:

In keeping with that, rules

can be in place for whatever and in government there are lots of rules. But

enforcement is probably just as important as the rule.

How do

you police this? How do you ensure those community ambulance operations and

private are up to scratch? Do you have regular inspections? I know you make

things mandatory, but unless you see something happening sometimes you'll never

know it occurred.

MR. ABBOTT:

Again, the health authorities are pivotal to that because they have a role to

oversee each of those ambulance operators and the contracts and service they

provide. We rely on them to do that, again, I think when we get to making sure

we have the legislative standards.

Right

now we negotiate these elements. I'll say, you violated – no, I didn't, and you

get into that kind of conversation. But if we have legislation and regulations,

which are definitive, then either you did or you didn't and there's no

discussion around that. I think that will be very helpful to all of us, both us

as overseers of the service and then for those who are actually delivering.

We work

closely with the health authorities, and through the associations, for the

operators to make sure we are moving the standard forward and that the quality

of the service is moving forward. We do get complaints around response times. If

we do get an issue, generally, in terms of a complaint, it's around the response

times.

Right

now, at least we have the systems in place to track the ambulance, where it was

and where it wasn't, so it's not debatable anymore. That has improved our

ability to respond to when there are problems. Ms. Parsons mentioned an example.

We're able to go back and track and have that discussion. If there's an issue

with that operator, as we found out in Happy Valley-Goose Bay, then working with

the health authority we are able to go in, intercede and either fix it or we

have to replace you.

The

minister has been very firm on that. With that resolution, we're able to then

improve all the services going forward. Part of that is making sure our

oversight is – we, in fact, do our part. That's what we're certainly committed

to doing.

MR. PETTEN:

Thank you.

One

other point to that, too, is in rural Newfoundland sometimes you're increasing

the rules and regulations, you're tightening, you restrict. We call it cracking

down, enforcing, making sure things are keeping a proper standard. Sometimes the

pool will shrink for qualified or interested people that are in that small

geographic area that's willing or capable of carrying out the service as

mandated by the department. I guess that will be something that will be a

challenge.

MR. ABBOTT:

Yeah, there are definitely those considerations. We definitely want to work with

the operators that are there, but they have to have both the willingness and

capacity to improve what they're doing. If they can't or they won't, then we

obviously have to have a separate conversation of how we deal with that.

Again,

using the Happy Valley-Goose Bay scenario, we had conversations but we felt we

had to move. I think we will do that and you will see some changes going forward

– nothing specific at this point – where larger operators may take over smaller

operators, or the health authority may have to take over some operators or

operations if they can't meet their requirements.

We've

got that from a contingency point of view. Now, of course, the sector is

becoming unionized. Fair enough. Then if there's withdrawal of services and

those kinds of things, we have to have backup plans and contingencies there.

We're always trying to keep an eye on what is happening on the ground. We have a

very good information basis to help manage any of the scenarios that are likely

to happen over the next five to 10 years.

MR. PETTEN:

I have a final one before my

time wraps up.

The AG

referenced the patient care reports. A lot weren't completed. There was some

post – after the patient was transported. They were altered after the fact. Has

the department figured out what happened there? Are there any mitigating things

put in place to prevent this from being a regular thing?

MR. ABBOTT:

Well, what we find if we're

using manual systems, then we're going to run into those problems. They're not

acceptable but they're a fact of what is happening. We will be now moving to

automated reporting. That then will take out that challenge or that gap in

service. Then it becomes automatic, the reports are logged in electronically and

they follow the patient into the hospital.

As we move in with

our electronic medical record system and other electronic systems, then it will

be all integrated. That will be one less challenge going forward. The bottom

line here – and I think some of them I answered – technology is really helping

us and will help us with a lot of these operational issues that we've had in the

past.

MR. PETTEN:

Thanks.

CHAIR:

Thank you, Mr. Petten.

Mr. King.

MR. KING:

Thank you for the detailed overview

here this morning. Great questions by my colleagues; it's pretty much covered

off everything that I've had marked down.

Thank you.

CHAIR:

Thank you.

Ms. Rogers.

MS. ROGERS:

Great. Thank you very much.

Central dispatch

in Eastern Health, we're going to see that fully operational by October?

MR. ABBOTT:

Yes.

MS. ROGERS:

When will we see a central dispatch

that will cover the province?

MR. ABBOTT:

We're looking at a couple of options

there. Right now, we are going to see how Eastern Health's plays out. We're

going to monitor that very closely and then one of the options is whether or not

we can bring that system or equivalent across the province. Then it would be

either a public-operated system either out of Eastern Health or however we

manage that.

Some jurisdictions

have a private provider for a central dispatch, so we've had discussions there.

That's an option. Or we can continue to rely on a mixed system here, both public

and private. Some of the private operators obviously have their own dispatch and

we can work more closely with them. I think the Eastern Health piece will help

us determine, over the next number of months, which way we should go.

MS. ROGERS:

Do you mean that if – oh, it is 11:11 –

Central Health's experience, then you would have more than one central dispatch

then? Eastern Health will have theirs and then are you –

MR. ABBOTT:

Yes. So we're looking at Eastern Health

having theirs. Do we expand that model and that system then across the province?

MS. ROGERS:

Yes.

MR. ABBOTT:

That's one option. The other is do we

have – quote, unquote

– three or four for each of the health authorities having their own. Do we go

contract with a private operator to have it province wide, which is done in Nova

Scotia and New Brunswick, or do we just built on with the private operators in

the province right now that have their own – quote, unquote – dispatch? Do we

try to enhance that and tie it into, say, each of the health authorities?

We're

trying to figure out which of those options we think makes the most sense for us

going forward.

MS. ROGERS:

You would even explore a

private operator province wide.

MR. ABBOTT:

Yes.

MS. ROGERS:

Then they would take over Eastern

Health as well.

MR. ABBOTT:

Yes.

MS. ROGERS:

Are you in negotiations or discussions

about that now?

MR. ABBOTT:

No, we just did some fact-finding,

based on we knew what was happening in those two provinces, but that's as far as

we've gone on that.

MS. ROGERS:

Okay.

Do you have a

timeline for that, John, in terms of …?

MR. ABBOTT:

We were hoping to have something by

now. Because Eastern Health was working with their model, we've slowed down a

provincial one until we see how theirs works, how they plan to deliver, and then

can we leverage that for the rest of the province rather than have to reinvent a

new system.

MS. ROGERS:

So you don't really have –

MR. ABBOTT:

No, and we think what they have – in

terms of the infrastructure they put in place, it probably can meet with some

additional staffing for the province as a whole.

MS. ROGERS:

Have you looked at what are the

benefits or challenges with a private versus public dispatch system?

MR. ABBOTT:

One is just the experience, really, was

what we saw in New Brunswick and Nova Scotia. Medavie provides the service

there, so they have the experience. It's certainly state of the art.

That was one of

the options. If we could contract through a public proposal process, somebody

could come in and put that in place literally right away, as opposed to us

building it piece by piece. That was really the attractiveness of looking at

that particular option.

MS. ROGERS:

Okay.

The automated

vehicle tracking system, is that province wide?

MR. ABBOTT:

Yes.

MS. ROGERS:

Okay.

So you

have new data, then, on response times?

MR. ABBOTT:

Yes.

MS. ROGERS:

Can we have that?

MR. ABBOTT:

Yeah, we can look at any particular period and …

MS. ROGERS:

Great.

MR. ABBOTT:

Yes.

MS. ROGERS:

Okay, because I think that's

something that has really been identified, like the Fitch report and that. It

would be great to see what you folks have solved with that.

MR. ABBOTT:

If I may, then we can have a conversation with your office as to what period you

would be interested in or …

MS. ROGERS:

How long has it been effect?

MR. ABBOTT:

Cameron?

MR. CAMPBELL:

It came into effect about a year ago. Although some of the data would have been

not so clean in the very beginning, in terms of needing to narrow down a

specific request; one issue that we would still have. There is a fair bit of

work involved in looking at specific response times.

We need

to then pair that with 911 data. Then, of course, there are still some gaps in

cases where a private or community operator is contacted directly. So it makes

it difficult for us to know what the contact time was versus the movement of the

vehicle.

MS. ROGERS:

Right.

MR. CAMPBELL:

We have all of the movement

data. It's just when you're looking at a certain period how do you then pair

that up with your 911 or your call data.

MS. ROGERS:

Yeah.

I would

think it wouldn't be just my office, I would think the Public Accounts Committee

would really like to see what has happened again, because that's been identified

as such an issue with the Fitch report and then what we hear anecdotally as

well.

I would

think that to be able to get some of that information – what have you found

yourselves now? Have you got a bit of a picture? Since you've been able to do

some of that tracking, has it told you anything?

MR. ABBOTT:

The general finding is that we are being responsive within what we've targeted

as reasonable response times. So we're looking at a 30-minute max kind of thing

for most regions in terms of where the ambulances are located. There are

variations in some regions just because of geography.

haven't seen any significant issues outside the issues that arose in Happy

Valley-Goose Bay. Then to have conversations with specific operators when we see

and hear, or a complaint of a specific delayed response as it were, we'll look

at that. Now we have the data. Again, it's done in real time and we can monitor

that as we speak.

What

we'll do is we'll develop a report for the Committee and table that here.

MS. ROGERS:

Okay.

Thank

you very much. That would be great.

With

the Grant Thornton audit, some operators have reviewed the latest audit and are

telling us there are many mistakes with numbers off, the issue of not being able

to replace staff because of the requirement for different levels of training.

They find there's a major problem with some of the calculations.

I'm

just wondering, have you been getting that kind of feedback from operators where

they feel it really hasn't accurately reflected the challenges they have been

dealing with?

MR. ABBOTT:

I mean we have heard some criticism. As

a matter of fact, probably not as much as we probably thought we might because,

again, the report finds significant issues around use of funds, payment and what

have you. That's why we ask an independent auditor to do that because that's

their business. Each of the operators are then free to have that conversation

with the auditor and correct, if there are things to be corrected. At the end of

the day, we have to stand behind whatever that auditor finds and then go from

there.

Part of that is

just going to be some conversations. We're being careful going to the next

stage, based on the recommendations of the auditor where we need to do further

audits. The numbers are significant where there's a variation of 25 per cent,

which is, you could argue, a high threshold. Because of some of the reasons, we

know it's not a perfect system there. We will then do further audits of those

operators and see what needs to happen on those.

That's the basis

of the audit. Not everybody would agree, but as we say, the facts are the facts

as we know them. They had done a fair bit of time – we thought this audit would

take a couple of months; it's taken longer than that for some of those reasons.

Some of the operators did not keep good records. They weren't as compliant in

the first instance, those kinds of things. So they really had to work hard to

get in to get access to that data.

MS. ROGERS:

I wonder if I could ask for leave.

CHAIR:

Oh yeah, go ahead.

MS. ROGERS:

I only have two more questions left on

this, on ambulance.

CHAIR:

That's fine.

Mr. Finn, yeah,

and Ms. Parsons.

MS. ROGERS:

Some operators are telling us – and I

don't know how accurate this is – that the minister said he's not renewing their

contracts, there's no meeting scheduled to start the negotiations and many

operators and their staff are kind of unsure of their future. I'm just wondering

what the department is doing to quell those fears?

MR. ABBOTT:

We will be continuing to provide road

ambulance service after September. The audit piece was – because it was slightly

delayed (inaudible) results. We wanted to wait for that before we went to the

next stage with them. We will be conversing with them very shortly as to what

the next stage of the negotiations will be for those agreements.

MS. ROGERS:

Okay. So you are going to meet with

them and –?

MR. ABBOTT:

Yeah. We don't see, obviously, in a

short period that there's going to be any significant change here, but we need

to work through that now with this report in hand.

MS. ROGERS:

My last question. I know there have

been some real challenges around folks who may have a mental health crisis who

need transportation to a facility. How is that going? What has been done about

some of those issues?

MR. ABBOTT:

We are working with the health

authorities to make sure how we respond to any emergency is done in a more

appropriate and sensitive fashion. This area we haven't really explored a lot

yet and it's something we know we need to do. That's something we have on our

work to do further on that, working with the paramedics and the operators to

make sure that those issues are fully recognized and addressed, as you put it.

MS. ROGERS:

Yeah, and because I know the RCMP in

some rural areas have said they're not going to do that transportation.

MR. ABBOTT:

Yeah, we have not had that. Again,

we're working with the RNC and the RCMP on that.

For them, it is

training and making sure the right people are in those situations. It's not

perfect, certainly, as we know it, but as we've seen with the mobile response

with the RNC, they have stepped up significantly. They've set a higher bar for

the province and we, the RCMP, the ambulance operators and everybody else will

have to move in that direction.

MS. ROGERS:

Okay.

Thank you very

much.

CHAIR:

Thank you, Ms. Rogers.

Ms. Parsons.

MS. P. PARSONS:

No, that's everything for me.

Thank you.

CHAIR:

Perfect.

Mr. Finn.

MR. FINN:

Yeah, just one actually.

Mr. Abbott, you

mentioned once or twice that you felt there were sufficient funds in the

department for some of the implementation of a variety of the recommendations.

With respect to the Grant Thornton report, were there any cost savings realized

or any areas where you could –?

MR. ABBOTT:

Well, I'm taking the report at face

value, and based on that, if you – because they just looked at one quarter. If

you pro-rated that

across the system on an annualized basis, there's over $2 million to be

addressed. That's a significant amount of money within that program. That gives

us some comfort to say all right, we need to figure out how we redeploy those

dollars. But we do need to sit down with the operators to figure out how we do

that.

It's

going to be a potentially heated type of conversation because that money that

was intended for a very specific purpose hasn't happened. We need to know why

and we need to know why on an individual operator basis how they're going to

change that going forward.

MR. FINN:

Okay, excellent.

Thank

you.

CHAIR:

I'll go through again to see

if there are any further questions.

Mr.

Reid.

MR. REID:

On the road ambulance –

CHAIR:

Road ambulance, yes.

MR. REID:

(Inaudible) the Fitch

ambulance review, there were recommendations related – medium- and long-term

recommendations. I'm not familiar with that report. I think it was done a number

of years ago.

MR. ABBOTT:

Yes.

MR. REID:

What were these

recommendations and where are you in terms of those?

MR. ABBOTT:

It was done under the previous administration. It was really looking at the road

ambulance program in its entirety. There were a series of recommendations but it

really focused on how to improve quality, skills training, central dispatch and

those kinds of things, things that the Auditor General has also hit on in the

report.

MR. REID:

Yeah.

MR. ABBOTT:

We have taken that report

and are working with industry to make sure we can implement those as quickly as

possible; central dispatch was certainly a significant one, the need for

legislation and those kinds of things. We're looking in tandem with the Auditor

General's recommendations to implement those.

It was

a very well-done report and I don't think anybody had any fault with it. Part of

it then was making sure we got consensus with the all the operators as we start

to move forward with implementing those recommendations.

MR. REID:

Yeah.

When

was that report, just so I can locate –?

MR. ABBOTT:

CHAIR:

MR. REID:

2013, okay.

MR. ABBOTT:

Yeah, because that's five years.

MR. REID:

I should have a look at that because it

still seems to be some of the same issues, maybe, that you're dealing with now.

MR. ABBOTT:

Yes.

MR. REID:

Okay, that's it for me.

CHAIR:

Thank you.

Mr. Petten,

anything further?

MR. PETTEN:

No, I'm good. Thanks.

CHAIR:

You're good?

Mr. King, you're

good?

Ms. Rogers, you're

good?

MS. ROGERS:

(Inaudible.)

CHAIR:

Ms. Parsons and Mr. Finn.

I'll just have a

few concluding remarks on that one. I do thank and appreciate everybody. It's

been a very thorough discussion.

It did, from my

perspective and, obviously, the Committee will have more discussions later on

about – appeasing is probably not the right word, but at least relieving some of

the concerns we had. That's why we called for a second hearing on this one.

In comparison to

some of the other responses that we had received from the department, there was

less of an uptake on ensuring that compliance was adhered to in this case, and I

do realize for a number of factors: you have a three-tiered or three-approach

system here when it comes to road ambulances and how you provide the service;

you have regional health authorities who may do things differently and you have

a different hierarchy or bureaucracy that has to be followed; and different

geographic challenges, no doubt. Knowing that the Grant Thornton was one part of

a report that was in play may have played a

part in waiting to see where that is

and what impact it may have on certain things there.

The discussion

here from my perspective – and I think from the response from the Committee –

seems to alleviate some of the concerns we have. No doubt we'll have an

opportunity, after we review discussions and we start to formulate our report

for the fall, we may have some recommendations around how you move that forward.

One of the big

concerns by all on the Committee was time frames because, obviously, your

ambulance service is your primary first responder call that anybody relies on.

Particularly, how do you provide those services in remote and rural areas? How

do you provide an adequate service in heavy-demand areas like the Northeast

Avalon and urban centres?

I do give credit,

you've outlined at least a plan is in play to make that work and there are going

to be contingents that may have to change along the way. Obviously, the biggest

concern that we've had over a period of time is always asking if it's resourced

properly. I know even from Grant Thornton, being able to look at the finances is

one side of it, the training is the second side and the implementation process

is the third component.

I'm happy to say

from my perspective that there's a plan in each one of those. Some may take a

bit longer than others; some might actually literally have to change the process

of moving resources to make it happen. It may have to change being a little bit

more creative on the model that gets implemented in a particular area. I do

appreciate that and representing a district that's urban from Paradise, Portugal

Cove-St. Philip's and then having the challenges on the ambulance service on

Bell Island, I can appreciate the uniqueness. So do my colleagues here who come

from rural and represent rural and remote and

city-oriented districts that

there are different challenges there.

I will

say, and I apologize in advance, I say it tongue-in-cheek, but I have to ask you

a question I asked eight years ago in Public Accounts to a deputy minister from

a different department but in a similar circumstance. At the time it was with

the Department of Education. We had different school boards and I asked would it

be easier, more fluent and more consistent if there was one authority that

oversaw the whole process from a department point of view.

Being a

former bureaucrat here in the building, I know sometimes when you're trying to

juggle how one works where, and you've got 10 components coming at you versus

having to deal with regional health authorities – and I'm not putting you on the

spot –

MR. ABBOTT:

No.

CHAIR:

– but I do recognize the

challenges, and we did in Education at the time. I'm hopeful that the new plan

in education has to be fluent and has been working with the one school district

because we seem to have an even flow of access to particular services in various

regions, even with some of the challenges.

So I'll

just throw that out to you. You don't have to answer, but I would appreciate if

you'd just say, or just your concept, it would be easier if there was one or a

set policy that was umbrella for everybody.

MR. ABBOTT:

Well, I think for us in the department and we've accepted – we have the four

health authorities and for the reasons they were set up I think they're still

valid. As I say, trying to respond to a health issue or whatever in Labrador

from St. John's –

CHAIR:

Becomes a challenge.

MR. ABBOTT:

– is a big, big challenge.

So that

health authority, as an example, are able to deal with their issues, I think,

quite effectively. What we are doing as a department is that we want to ensure

that we have provincial standards and legislation to back that up if need be,

but certainly provincial standards and policies that then are to be consistently

applied across the province no matter where you are, reflecting that there are

going to be some contacts there. Obviously, road ambulance in Labrador is going

to be slightly different than road ambulance on the Northeast Avalon.

That's

really where we are, whether it's ambulance service, cardiac, speech language,

we want to make sure we have provincial policies and that we're not just relying

on four individual sets of policies, or even more, around the province. So the

same with ambulance, we've really focused on making sure we have consistent

policies across the province and then on a go-forward basis with the legislation

and new agreements, I think we'll get closer to that ideal.

CHAIR:

Good.

So do

you feel you've got good co-operation between the four regional health

authorities when it comes to road ambulance particularly?

MR. ABBOTT:

Yes, absolutely.

CHAIR:

Okay.

They

bought into rectifying, improving and finding the models that work and

supporting it?

MR. ABBOTT:

Yes.

CHAIR:

Perfect. Okay.

The

norm at the end of part of a session before – and we want to continue in

to some of the health ones. I'll get a

little time frame here and we'll have a little chat about that in a second.

I would like to

ask the Auditor General, after sitting here – and I know it's a report to your

predecessor, but you're very in depth into this report after discussions that

we've had in meetings. From what you've heard, do you feel that they're

adequately approaching and addressing the recommendations to your review in a

year or so, that you'll be confident that they're compliant to a point where

they've improved exactly what the standard of ambulance services should be for

the people of the province?

MS. MULLALEY:

I guess I certainly can comment that

I'm encouraged to hear the progress that's happened over the last few years. I'm

certainly encouraged of some of the initiatives that are underway.

From our office's

perspective, we monitor reports three years after the issuance. This particular

report would have been issued in the 2016 time frame, so we will actually do

some formal monitoring next year to the House of Assembly and the public on a

further status update on that. I think that will also beneficial because I think

many of the initiatives we heard here today will be further implemented in that

regard. I think that will be an appropriate time frame then to update the House

of Assembly and the public on progress.

CHAIR:

Okay. Perfect. Thank you.

Mr. Abbott, I just

ask that if we have some follow-up questions down the road when the Committee

gets together, that we can send an email to you and you can respond with

information. I know, as Ms. Rogers had noted, some information, but if you could

share any information that you shared with either one of the Committee Members,

you share it general, to everybody. You can either send it to myself or

Elizabeth and we'll ensure that it gets part of people's packages.

As you know in

hearings, we're taking notes and that, but there may be something that we may

think we have an alarm out. You may have already answered it and got the detail,

or it may be something that we neglected to ask that may be pertinent to when we

put together our recommendations. We do ask that if you share with one Member of

the Committee, you share with all.

MR. ABBOTT:

Sure.

CHAIR:

Because then that's pertinent to our

discussions when we complete our report for the fall.

I thank you on

this part of it. As we noted, we wanted to take advantage while we had you guys

here, rather than call other hearings in this. This was one that warranted it

because of the fact that compliance wasn't at the level that we had thought it

was.

We had agreed as a

Committee that we'd probably spend an hour or so – and we'll probably have to

take a break for lunch at 12 p.m., for a quick break, and then we'd come back.

My plan would be that we'd have everybody out of here between 1:30 and 2 p.m.

I know everybody

has busy schedules as part of that, but there are some general ones there, I

know, going back over what was in the AG's report. Particularly, I have a couple

later on, on the personal home care. A lot of information you had shared with us

and we had the debate and the discussion last year. But as part of just

follow-ups, rather than us have to go through a whole hearing process again, we

may be able to knock

that off today and not have to worry about this and have it in our report of the

fall.

I'll

start with Mr. Reid. We're going to continue. Around five to 12 we'll break for

lunch for half an hour, and then we'll come back and try to conclude. So I do

ask – there may be a couple there. We don't want to get generally into the same

thing we did last year, but because there's been a lapse of a year, there may be

a couple of things that have popped up; I know a couple on some of the policy

changes in personal care home approaches there.

There

may be something that we can knock-off, have done, and then when we do our

report we'll have a more fluent, thorough report for the House of Assembly in

September. I think we're all happy with that.

Dose

that work for your time frames?

MR. ABBOTT:

Yes.

CHAIR:

Yes, we'll plan to get

everybody out between 1:30 and 2 p.m. for sure. We'll give you a break for half

an hour at lunchtime at 12 to go make a call, get something to eat, these types

of things.

I'll

start with Mr. Reid, if you have a few health-related questions.

MR. REID:

Yeah.

Are we

going to start with any particular area or just general?

CHAIR:

No, no, if that's okay with Mr. Abbott.

MR. ABBOTT:

Sure.

MR. REID:

Yes, okay.

CHAIR:

All the ones relevant to the

AG's report that you responded to eight months ago.

MR. REID:

Okay, I'll just ask a

general question first about the nutrition in long-term care facilities. There

were some issues raised about that in the AG's report. I'm just wondering how

the implementation of those recommendations are going?

MR. ABBOTT:

As you know, the AG provided 10 recommendations; two specific to the department

and the remaining eight to the regional health authorities.

terms of the two that apply to the department directly, they've been partially

implemented. I can just speak to those in a moment here. One second.

terms of “The Department should conduct a formal review of the Operational

Standards for Long Term Care Facilities in Newfoundland and Labrador,” we have a

working group from the health authorities, as well as ourselves, to review and

revise the standards. That's ongoing.

date, approximately 90 per cent of the standards have been drafted. To get the

full implementation, the working group needs to complete the remaining

standards, begin a review process with the stakeholders and gain approval of the

manual. That's sort of standard process. When we do that kind of work we want to

ensure in this case, obviously, the health authorities, the nursing homes and

others are fully engaged in the final approval. Our plan right now is to have

all this work done, completed and implemented this fall. That's where we are on

that particular one.

Then

Recommendation 10: “The Department and the RHAs should establish benchmarks for

performance indicators, review and monitor actual financial and statistical

data,” et cetera. The department has identified financial and statistical

indicators. We've done that work. We're in the process of validating those with

the regional health authorities. Again, we are consulting with them and the

Centre for Health Information on the benchmarks.

Through

our system we have different operations, different delivery models, size of

facilities, et cetera. So we have to take that into consideration. We're

comparing those against national comparators where we can find them. There are

not as many there as one would think.

We hope

to have that work fully implemented by the end of the summer. In essence, give

it another month or so and we should have that work completed. The RHAs – for

those that I'm aware of – are in the same mode in terms of implementing or

partially implementing the recommendations specific to them. I have some updates

on those as well.

MR. REID:

Yeah.

Okay, I

think that's good for me for now.

CHAIR:

Okay.

MR. ABBOTT:

If I may, just on that.

MR. REID:

Yeah.

MR. ABBOTT:

What this AG report has

highlighted is an area that really was sort of under the radar; we were talking

about it. It's really brought heightened attention by the department and the

health authority. So it's been very helpful, us honing in on that particular

area.

There

are industry standards, there are comparators that we know we should be and

could be using. That's been very helpful in focusing the work.

CHAIR:

Okay.

Mr.

Petten.

MR. PETTEN:

Thank you.

The

AG's report on the personal care home regulations; I know myself and my

colleague, actually too, for Ferryland, have a fair number of personal care

homes in our districts. I know I do, as well as himself – community care homes.

I've

come back to this report, actually, when I've had questions and talked to the

different home care operators. It appears to be inconsistent, and I know Keith

is finding it in his district as well. It's gone from we're working with you and

there's a bit of give and take – and they're not slack, but they were used to a

certain level. Now we've gone from one end of the spectrum to the other. They're

finding themselves going to non-compliance or getting sanctioned or getting

warnings for almost any infraction out there.

We've

gone from probably being a bit too easy on these homes, for want of a better

word, to now – it's gone from one extreme to the other. This is home owners in

two different districts altogether, two unrelated groups. We've gotten the same

message.

question is being that I know the department, obviously, tightened up on a lot

of this with the regulations and I have no problem with that, but how much has

the department done in consulting with these home owners? A lot of the home

owners find they're getting very little consultation. They're being told there

are changes coming, these are the expectations, we need this and we expect this.

Then someone is coming in, walking in unexpectedly – which is fine, a surprise

inspection – and they're getting wrote up.

I had

one home, one person and they had a resident. They had everything prepared and

the resident was on their way. In mid-transport it was cancelled due to some

infraction. They pushed back, kicked up and questioned it and at the end of the

day it turned out to be a non-issue and it was solved. They feel they're

constantly under siege now as opposed to before, they probably weren't under

siege enough, if you know what I'm saying, but trying to find that balance.

there a concerted effort? I know there must be but has the department given any

consideration to probably being more collaborative with the home owners to try

to bring them in to compliance and to bring them to the new age. I understand.

There are 13 in my district and there are all levels from there to there. I

agree with improving but I'd like to see more of a …

MR. ABBOTT:

I hear you. So just a couple

of things, if I may.

terms of inspections and then conditional licensing; there are two components

of, I'll call, an inspection. Service NL will go in to look at the physical

premises and preparation of food, those things. That falls within their mandate

based on current legislation and regulations. Then they can issue a report and a

conditional licence, or pull a licence if it's not safe. Then we have the health

authorities that go in obviously to monitor care in the facilities and depending

on what they find, can provide conditions on the licence.

It's

not done lightly and it is done based on standards, protocols and best

practices, what have you, that the operators are fully knowledgeable about.

Harking back to our conversation earlier about road ambulance, once we go to the

regulatory side, and if a standard is set, then they must meet that standard.

They are funded to meet that standard.

terms then of consultation, we have a working committee with the personal care

home operators. We meet on a regular basis. We are reviewing, currently, the new

operating standards and we are going page by page with the operators to make

sure they understand and can support those changes.

The

working relationship with the home operators has generally been good. There have

been issues at times where things might not have gone as well as both parties

would have liked but, certainly, under the current minister we are working quite

closely and meeting on a regular basis, including myself, as needed and the

minister also, as needed.

think the working relationship is quite good, but as the standards change and

the expectation – and the expectation of residents is changing – then the

operators are sometimes finding that a bit of a challenge. The market has

changed and what have you. For them to – quote, unquote – keep up, will require

them to invest and invest in the training and what have you.

That's

where we're finding, at times – and it's not happening on a regular basis but

there are, and I suspect I could probably guess who some of those operators

might be – that they're having a difficulty to keep in with the change in

business practice and expectation. There's really nothing we can do, other than

have more conversations with them.

know, in particular, the small home operators – say with 25 beds or less as a

case in point – some of them have been around for quite a while. We are working

and have committed to working with them on their finances and what have you,

because in certain locations they need to be there. We need them there because

they're the only operator in a large geographic area. We will work and are

working closely with them as well.

That's

sort of where we are on that as we speak. There is a table for them to bring any

and all issues and our doors are definitely open to hearing those.

MR. PETTEN:

I guess it goes back to with

those – because I do have a pretty good knowledge. I know all the operators; I

know a lot of their issues. They've been around for a long time.

MR. ABBOTT:

Yeah.

MR. PETTEN:

I know a lot of those homes

were operating under some form of a committee as opposed to individuals. There

was a committee, a personal care and community care home group that dealt with

the department or their RHA on different issues.

MR. ABBOTT:

Yes.

MR. PETTEN:

I'll go back again to say

that there seems to be a lot of confusion. I know that the department are

probably trying to work with these home owners. This confusion doesn't seem to

be – I'm just wondering is there a better way the department could address this

issue? It's not like one issue here or there, I've gotten it pretty well from

right across the board and I know Keith has in his district as well. He met with

groups in the last week.

No one

is saying we're opposed to change. It's just the expectations and they're

overwhelmed. The expectations have gone from there to there and they feel they

have no support. I know I've talked to several home owners and they feel

helpless. I mean one I was trying to – I'm waiting to hear back, actually. I

tried to set up some sort of meeting with the department to go in and have a

face-to-face because they were struggling. There was a lot of stress on them, a

lot of financial responsibility because most of the homes in my district are the

20-25 beds or less.

MR. ABBOTT:

Yeah.

MR. PETTEN:

They're the small operators

that have been around forever. I'm speaking on behalf of a lot of people in my

district and these are real concerns – and Keith's district as well and I'm sure

others.

You may

not realize because they're dealing with the RHA, but this is a lot of stress to

those home owners. They're not opposed to doing change, but they want more help

and more guidance in helping them attain the proper change. It's a lot of

investment for these small homes. It's a lot of financial to keep up with the

criteria, but it's their livelihood as well. They obviously don't just run the

homes, they work there. It's part of who they are. They're family operations

that have gone on for a long time.

MR. ABBOTT:

Yes, and I think, Mr.

Petten, certainly with some of the homes that are in your district, they operate

slightly different in that they really work under the RHA, the Eastern Health

Community Supports Program, usually for persons with mental health and other

challenges.

We have

been just talking recently around how we to need to re-engage with those

operators with the focus on how we support the residents in there and,

consequently, the operators to meet that. We're committed to engage further with

them and with Eastern Health.

We may

need to have a separate conversation with you and some of those operators if

their voice isn't being heard to the degree you've enunciated that. But we have

flagged that in the department as a specific issue as late as this past week

that we need to do along the lines that you've set.

MR. PETTEN:

Okay.

Thank

you very much.

CHAIR:

Okay, just looking now that

it is 11:52, if we could break for lunch just to give people an opportunity to

get lunch and make some calls. Then we'll come back at 12:30 and spend an hour.

It gives each to the five who haven't – their 10-minute opportunity to ask a few

questions. Then we can be out of here by 1:30 or so.

Is that

good for everybody?

Okay,

back here at 12:30 sharp, please.

We're

out in the Speaker's Boardroom. Yeah, we are. We can have a chat on a few

things.

Recess

CHAIR:

Okay, I want to welcome everybody back, and as we committed to, we'll try to

conclude this within the hour. We've asked people to – any questions that are

outstanding or something new that's changed, particularly around health care,

while we have the officials here that we could have a little discussion around

that.

Okay.

Mr. King, you're next.

MR. KING:

Okay. The only question I

have is related to communities, environmental care facilities (inaudible).

Around this time last year when we met we had just rolled out the new system for

food. I forget the name of the –

WITNESS:

Steamplicity.

MR. KING:

Steamplicity; I just want to

know how that's working out. Has it improved food quality, and are patients

happy?

MR. ABBOTT:

It's been operational now for – give or take – four to six months, fully

operational in Eastern Health. The initial response has been positive. The

quality of the food is better, timeliness and what have you. They're monitoring

and will be reporting to us on those issues as we go forward. We'll be sort of

monitoring that approach and whether or not then we should obviously roll that

out to other hospitals down the road.

MR. KING:

Yeah.

MR. ABBOTT:

It is early days. The

promise is of a better system, so we're now going to monitor for that.

MR. KING:

Yeah. From what I've heard

of it, it's been very positively received. Is this in long-term care facilities

here locally as well?

MR. ABBOTT:

No, just in the hospital.

MR. KING:

In the hospital, okay.

You're evaluating it right now and you're looking at possibly moving it out,

too.

MR. ABBOTT:

Yes.

MR. KING:

Okay.

Thank

you.

CHAIR:

You're good?

MR. KING:

Yeah.

CHAIR:

Thank you, Sir.

Ms.

Rogers.

MS. ROGERS:

I'd like to ask a few

questions about acute care bed management. It's still such a big problem, hey.

Can you

give us an update on the state of the art of what's happening? There are so many

recommendations here for different regional health authorities. I know there are

working groups, program team looking at the lean process, improvements, patient

flow, task force priorities.

Can you

just give us an update on what's happening with acute care bed management?

MR. ABBOTT:

In terms of the 16

recommendations – and they apply obviously across all the health authorities –

10 of those have been fully implemented and six are partially.

We have

a working group in place. They've taken these recommendations quite seriously.

We know we have beds that are underutilized or – quote, unquote – over utilized

in the sense that there are people in them, patients in them that really should

be discharged earlier, discharged home or discharged to long-term care or

personal care or what have you. We've been looking at that.

I just

want to give you – I won't say it's an anecdote because it's, in fact, the case.

In recent months in Central Health, we've had 17 cases where people have been in

long-term care and we were able to move them actually back home.

MS. ROGERS:

Oh, great.

MR. ABBOTT:

All of this sort of ties in,

when we look at what we call the alternate level of care beds, as people who

clinically can be discharged but have nowhere in the first instance to go. They

will obviously remain in the hospital bed. We're really focused on bringing

those occupancy levels down considerably.

We have

adopted a Home First approach, which basically looks at those, and said: What do

we need to do? What supports to we need to put in place in addition to our

existing programs and policies? We have home support, we have this, we have

that, but is it working for that particular client? It is an individualized

approach at the end of the day. We're finding a lot of success with that and

we've only really been rolling that out over, literally, the past year.

That's

been the focus. That will help us with the management of the acute-care beds.

The working committee involves the department that's overseeing that with the

four health authorities. They have a work plan that's in place and we are

striving to meet and implement all of these recommendations. Given the nature of

the work involved, they're meeting on a monthly basis to drive that work.

MS. ROGERS:

Is that just Eastern Health

or is that province wide.

MR. ABBOTT:

No, that's the province as a whole.

They're

taken and they're going through each of those recommendations, as well as

looking at some other issues that need to be addressed as we go forward.

One

thing that will be addressed in recommendations is what's the policy or plans to

support any of the changes we need to make. We're developing the performance

indicators to make sure they make sense and monitor those. There's a lot of good

national data that we can use. We're applying those to the Newfoundland and

Labrador context.

We are

looking at, obviously, early discharge planning. So when you come to the

hospital there's to be, at that point, a discharge plan already developed for

you. Based on your case and your acutely, et cetera, it should take three days,

four days, five days, what have you. A discharge plan is put in place and then

you're monitored against that. That's to help manage the patient as well as the

resources.

There's

a whole series of those initiatives that the RHAs are working on and monitoring

for that, comparing results against the benchmarks and then making the changes

that are necessary. Obviously, it requires the full co-operation of the nursing

staff and the physicians that are involved in the care, but sometimes it's

simply down to making sure that when a patient leaves the bed, that the support

staff that are put in place are available to make sure that bed and that room is

cleaned appropriately to admit somebody shortly thereafter.

We hear

of backlogs in the emergency room to get up to the floors. Again, that all ties

in to that. If you look at the number of beds we have on a per capita basis,

relative to the other jurisdictions we're again on the high side. Part of it is

geography but part of that is that we need to utilize those beds a lot better.

MS. ROGERS:

The work plan, is that a

public document?

MR. ABBOTT:

It's just a document that's used by the committee itself.

MS. ROGERS:

Is that available to us?

MR. ABBOTT:

I think that can be made available, yes.

MS. ROGERS:

Oh, that would be great.

Thank

you very much.

What

are some of the blocks and barriers, because I think there's still – is there?

Has it changed in terms of the amount of people who are medically discharged,

but still in acute-care beds, the data around that? Has that changed the

numbers?

MR. ABBOTT:

It is improving.

MS. ROGERS:

Yeah.

MR. ABBOTT:

It's still higher than we

would like, but we needed to have a response to that. The Home First approach;

we knew the issue, we knew what some of the solutions were, but we weren't

making the changes because we were dealing with established policies and

processes.

What

we've done now is set teams up in each of the health authorities so that it will

not only have somebody from the Community Supports Program but from the nursing

program, the OT and what have you, to say for this particular patient, for him

or her to now go home, we need to make sure we have these things in place. Now

they have a process to address those. It's a collaborative team approach there.

Again, a very simple concept but it wasn't happening.

MS. ROGERS:

Yeah.

MR. ABBOTT:

Now we have put that in

place. We've allocated some additional dollars to fill in the gaps. The federal

money from last year's Accord was targeted to support that.

MS. ROGERS:

What do you see as some of

the main blocks, barriers and challenges to get people out of those beds?

MR. ABBOTT:

Part of it will be, maybe, needing some more additional home support hours

upfront. From a process point of view we were waiting to do the financial

assessment before we allocate the hours. We're saying that can be done in

tandem. The need is there, put the service in place and we'll address the

financial assessment so, again, an example.

But I

think providing home nursing hours, if needed, and adding those where it's

needed, making sure there's either OT or PT services in place, connecting back

to the family physician and those kinds of things – so, as I said, it's

case-specific and each case has had a different solution .

MS. ROGERS:

John, where are we with the

financial assessments in terms of eligibility, ceilings and what we ask people

to pay in relation to the rest of the country?

MR. ABBOTT:

Yes, again, our Home Support Program, in terms of the level of subsidy we

provide, is probably one of the more generous in the country. We have looked at

that, but, again, how we can improve because there are still people who are not

getting access.

We have

gone recently to Cabinet to look at some changes and they have been approved and

will be announced in short order; again, to get at some of the barriers that we

see there, particularly for the liquid assets issue and then adults with

disabilities who are working. We recognize there are sort of two areas that we

can improve on and we can make it more administratively – we can simplify the

process.

The

income ceilings, I know we're not in a position to change those because we're

not in the overall fiscal situation to change those at present.

MS. ROGERS:

But in a number of provinces

there is no means test. People don't pay out of pocket for home care, right?

MR. ABBOTT:

Yes, but we won't be changing that certainly in the foreseeable future.

MS. ROGERS:

Okay.

Are we

still facing wait-lists for long-term care beds?

MR. ABBOTT:

We do have wait-lists waiting for beds. Again, we've added capacity. We just

opened up the beds in Carbonear; that will relieve pressure. We've expanded –

MS. ROGERS:

Is that full now –

Carbonear?

MR. ABBOTT:

Yes, it should be, or if not we're just phasing that in over a couple of weeks'

time. We've expanded – again, through Home First some home support hours were

needed, so that's taken some of the pressure off. The numbers haven't increased

significantly. I should say they've actually improved and we monitor those on a

monthly basis.

CHAIR:

Okay.

Ms.

Rogers, I'm going to go to Mr. Finn.

MR. FINN:

Actually, I'm fine now. I

was curious about the acute-care bed management. I know there are a few nuances

there and I think you've addressed what Ms. Rogers was referring to. Obviously,

we want to get people out of the beds and into long-term care or back home with

a level of care. I know that's a constant challenge, so that's really all I had,

Mr. Chair.

Thank

you.

CHAIR:

Okay, thank you.

Mr.

Reid, anything further?

MR. REID:

Yes, I just had a couple of

questions. I guess I'll ask them both at the same time. One is related to the

Newfoundland and Labrador Prescription Drug Program and I just want to get a

sense of how that's working out and if there are any changes in practice. Are

there any savings based on the implementation of the program?

MR. ABBOTT:

Sure.

The

provincial Prescription Drug Program, we have roughly 130,000 people registered

for that program. In any one year we may have between 105,000 and 110,000 people

who actually use the program. It's administered out of our Stephenville office.

Administratively it's, I think, fairly simple in terms of access.

continue to add new drugs to the formulary based on Health Canada and the

Canadian Agency for Drugs and Technologies assessment and then we negotiate a

pricing agreement with, say, the generics or others. We're relatively fairly

current on that.

The

biggest challenge we have right now administratively is the special

authorization. Some drugs need that to be authorized by our pharmacists in the

department. Because of increased demand and some staffing issues, we're having a

few challenges there, but we think we're close to catching up on that.

The

income ceilings are such, in the way the program is structured, that there are

more people looking for assistance than we can provide access. We are optimistic

that the national discussions on pharmacare with the federal government will be

a solution to that particular problem.

The

other challenge is – and all governments are facing and anybody in the business

– that the new drugs and therapies that are coming on are quite expensive. It's

not uncommon now to hear that based on a new therapy developed by a

pharmaceutical company that's gone through the approval processes that you're

talking at $400,000, $500,000, $600,000, $700,000, $800,000 per patient.

That's

going to be the biggest challenge we face going forward, just from a cost point

of view. That's why we think the pharmacare discussions are going to be very

instrumental in allowing us and all other provinces to deal with that.

Technology and science are really going to be our biggest challenge going

forward.

CHAIR:

Are you good?

MR. REID:

Yeah, that's good.

CHAIR:

Okay.

Mr.

Petten, follow-up questions?

MR. PETTEN:

I don't have much else

either. I'm just kind of curious overall with the AG report – we want a chart of

what's been implemented partially, fully and not implemented at all on all the

recommendations. I know that the Prescription Drug Program, according to us,

most of the recommendations are 100 per cent done, but where are we with the

other ones?

I know

that acute-care bed management, nutrition in long-term care and salaried

physicians we're probably a little over half fully implemented – the

recommendations. What is the goal of the department to reach – where do you

figure it will be to max out in completion percentages or where are you with

those things?

MR. ABBOTT:

If I may, just as a whole, we are working diligently on all the recommendations

for all those areas and we anticipate – for those that are remaining to be fully

implemented, like in terms of the physician's one, for example, over the next

number of months we should have those in place, the same with acute-care

management. So we've got working committees and processes in place to get us

there. We don't feel substantively that we're very far off in meeting the intent

and spirit of those recommendations.

Now,

there's one in the Drug Program in terms of a technical piece that we can't put

that in place. It's cost prohibitive and it really is not going to solve the

problem. It's not for the sake of looking at that seriously and in terms of

trying to get close to what the recommendation was trying to get at.

Where

it is at all feasible, we are striving to get these recommendations in place.

MR. PETTEN:

Okay.

That's

all I have to ask, Mr. Chair.

CHAIR:

Okay.

Mr.

King.

MR. KING:

I'm good.

CHAIR:

You're good?

Ms.

Rogers.

MS. ROGERS:

Yes.

Back to

acute-care bed management, because I know it is very complex – what are the

recommendations? Is that work ongoing to ensure that policies are in place

throughout all areas to support acute-care bed management? Can we see those

policies? Would it be possible to see those policies?

MR. ABBOTT:

Yes.

MS. ROGERS:

And I know it's all very,

very complicated and I know that a number of facilities do have people in

acute-care beds that need to move on but that it's difficult.

And so

we see that Labrador-Grenfell Health has not implemented yet, in this last

report that we had an update – “Regional health authorities should identify

and/or establish performance indicators related to acute-care bed management and

ensure national benchmarks are identified or hospital targets are established

for each performance indicator.”

The

last update we had was that Labrador-Grenfell Health has not implemented this to

date but are arranging for a group to commence this work within the next several

weeks. Has that happened?

MR. ABBOTT:

Yes.

MS. ROGERS:

Okay, great.

MR. ABBOTT: Of

those indicators, they have five in place and four they're working on. We also

now have a new CEO in place who will be driving that change.

MS. ROGERS: And

that's happening in all the regional health authorities, is it?

MR. ABBOTT:

Yes.

MS. ROGERS:

Okay.

MR. ABBOTT:

Heather's telling me that all the others are fully implemented.

MS. ROGERS:

Okay, great. Great.

For the

provincial Prescription Drug Program, the ceilings for eligibility, have they

changed at all? If not, how long has it been since they've changed?

MR. ABBOTT:

Those, Ms. Rogers, were put in, roughly in, I think, 2006.

MS. ROGERS:

Okay.

MR. ABBOTT:

And we, I don't think, have changed those for that period.

MS. ROGERS:

Yes, because I'll tell you

why – 2006. I hear from so many people, particularly seniors, whose income, OAS

and GIS, has really not changed; yet, their cost of living has skyrocketed,

particularly rent. And how many seniors come to us saying: I can't afford my

drugs – who may not be right at, you know, they may just be above the

eligibility rate.

I'm

hearing also from doctors. I'm hearing from people in emergency departments

about people coming, particularly again seniors, who are not taking their meds.

It's anecdotal, but it's real.

MR. ABBOTT:

Mm-hmm.

MS. ROGERS:

Or cutting their meds in

half, taking them only every second day, which I think probably ends up being a

cost down the road to our health care system. It's a problem.

MR. ABBOTT:

Yes. I think certainly the department and the government recognizes that. Right

now, because of our government's fiscal situation, not really able to move to

expand as much as I think people would like. But that's part of the argument and

rationale moving towards national pharmacare so that there is a level playing

field right across the country, and access to the expensive drugs as well.

That's where I think we're pushing with Ottawa to move this forward.

MS. ROGERS:

I don't want to argue with

you, except I believe that probably the cost down the road is greater if people

are not able to take their medication as prescribed.

MR. ABBOTT:

Mm-hmm.

MS. ROGERS:

Have we really come to the

point in our history