May 4, 1992

SOCIAL SERVICES ESTIMATES COMMITTEE - HEALTH

Pursuant to Standing Order 87, Mr. Larry Short,

M.H.A., (St. George'

s) substitutes for Mr. Bill Ramsay, M.H.A., (LaPoile); Mr.

Melvin Penney, M.H.A., (Lewisporte) substitutes for Mr. John Efford, M.H.A.,

(Port de Grave); and Mr. Norman Doyle, M.H.A. (Harbour Main) substitutes for Mr.

Garfield Warren, M.H.A., (Torngat Mountains).

The Committee met at 7:05 p.m. in the House of

Assembly.

MR. W. NOEL: Order, please!

It is now about five past seven, so everybody is

all set. I guess we can start.

I am Walter Noel. This is Mr. John Noel, who I

think should take over proceedings from here as the Clerk of the House. Should

you, Mr. Noel?

MR. J. NOEL: Yes. Our first item of business is

the formal election of the Chairperson of the Committee, so do I hear

nominations for Chairperson?

MR. WALSH: I nominate Walter Noel.

AN HON. MEMBER: I will second that.

MR. J. NOEL: Mr. Noel?

MR. NOEL: I will accept.

The next order, I believe, is to elect the

Vice-Chair of the Committee.

MR. WALSH: I move the Member for Humber East.

MR. CHAIRMAN (W. Noel): Seconder? Mr. Doyle.

Ms. Verge accepts?

MS. VERGE: Yes I do.

MR. CHAIRMAN: Thank you.

Tonight we have the Department of Health with us,

and we have a reporter from The Evening Telegram, Mr. Bennett I believe. I have

not seen any other reporters around.

The procedure is that normally the minister makes

an opening statement of fifteen minutes or so, and the first speaker from the

opposition responds for about the same time frame. Then we try and limit

questions to about ten minutes per interjector.

Does anybody have any problems with that, or

suggestions?

MS. VERGE: No, that sounds good to me.

MR. CHAIRMAN: Any number of interjections, and

we go on until everybody is happy.

MR. J. NOEL: So the Department of Health had an

expenditure subhead 1.1.01.

MR. CHAIRMAN: Excuse me, if I might, I never

did introduce the other members of the committee.

Ms. Verge, who is the Member for Humber East.

MR. HARRIS: You should do it now for the

minutes. Last year I know we had debates of great length before the health

committee, and primarily before the social services committee, about how the

time was allocated and whether the ten minute allocation or the fifteen minute

allocation includes questions and answers, or whether the person just has the

ten minutes assigned to them.

This minister is very good, in the House I know, of

giving very long answers to very short questions. You might have a two minute

question and an eight minute answer. I am not suggesting he would do that here,

but that could use up the ten minutes of a member. So perhaps we should have a

ruling or a consensus amongst the committee as to how that should be treated

here.

MR. CHAIRMAN: I would not propose to be too

strict on the time, as long as everybody was comfortable. I would think we would

consider them ten minute slots, whether it is a question or an answer taking up

the time. There is no limit on the number of questions you can ask, and we would

just keep going round. We can stay all night if people want to stay; but if we

get into trying to keep track of the questioner and the answerer, that makes

life more complicated. I do not have a stopwatch, and I do not propose to get

one unless we get complicated.

Mr. Walsh?

MR. WALSH: Mr. Chairman, to that point, I tend

to agree with you that there is a good chance the committee will flow just fine.

I do not think that we are going to be nipping at the bit over a few minutes one

way or the other, but I would not want to see a situation where the floor is

being dominated. By following the ten minutes through, it gives us all a chance

to at least ask some questions rather than just simply sitting and listening.

I know for myself, I will not interject if we

should go over into ten or fifteen minutes, just as long as everybody realizes

that we are looking and working on ten minute time slots; that we are all

cognizant that there are other people in the room tonight. If we go along with

that, I think we will be fine.

MR. CHAIRMAN: I would hope we will not have too

many difficulties. If we start getting into problems, then we will get stricter,

I would suggest.

If I might proceed with the other introductions:

Mr. Doyle, who is the Member for Harbour Main; Mr. Harris, second from the left,

the Member for St. John's East; Mr. Walsh, the Member for Mount Scio; Mr. Short,

the Member for St. George's, who is substituting for Mr. Ramsay tonight, who is

unable to be here; and Mr. Efford is missing this evening, so far.

Perhaps if the minister would like to introduce the

officials with him, and he is ready to proceed, we can begin.

MR. DECKER: Thank you, Mr. Chairman.

In previous years when I have attended these

things, the minister usually had a long drawn out speech and I don't think that

is the intent of these committees. We are dealing with $880 million in this

particular department and I think it would be a waste of time for me to take up

even fifteen minutes, as there are far too many issues which have to be dealt

with, so if it is okay with the committee, I would just as soon not give an

opening speech.

I will introduce the officials with me. This

department we deal with on two levels, there are a lot of policy issues and

there are a lot of very technical issues which none of us can answer in-depth I

am sure, the depth to which the questions go from this committee, so I would

like to have permission with your consent to have the officials deal with

technical questions. If it is of a policy nature I will attempt to answer it on

behalf of government.

I have with me the deputy minister whom many of you

know, Dr. Bob Williams; I have the assistant deputy minister for Planning and

Programs, Jerry White who has been here before; I have the new deputy minister

who has only been with us for a short time, Joan Dawe and she is assistant

deputy minister for Community Health, and we also have another new deputy

minister since we last met here, Primrose Bishop. She is the assistant deputy

minister for Institutions and Primrose was promoted when Brian Lemon left the

department as assistant deputy minister. I should point out that two-thirds of

the assistant deputies in the Department of Health are female which is not too

bad.

We have the Executive Director of Administrative

Services, Mr. Cecil Templeman who is also here tonight, and hopefully to join us

a little later, will be the Director of Hospital Services, who is acting, the

position is now vacant, Mr. Roy Manuel, and he will be joining us later on. Now,

Mr. Chairman, having said that, I won't waste any more of the committee's time

but if we can get right into the proceedings of the evening.

MR. CHAIRMAN: Thank you, Mr. Minister.

Mr. Walsh.

MR. WALSH: Reflecting on some of the rules last

year - and Jack just jogged my memory on it - as in the House if a question is

asked and the officials themselves just do not have the answer off the tops of

their heads, they have the right to take questions under advisement and come

back to the committee; they are not expected to know all the answers. Is that

normally the way?

AN HON. MEMBER: That is normal.

MR. WALSH: Okay, thank you. So the officials

with the minister would have the right to take questions under advisement. I

just wanted to be sure.

MR. CHAIRMAN: Thank you.

Who wants to begin the questioning? Mr. Doyle.

MR. DOYLE: Thank you, Mr. Chairman.

First of all, let me say I am quite pleased that

the minister did not get into a long dissertation on his department and I will

pretty well follow suit on that but I cannot resist making a few observations

before I go into questioning, because I do have some difficulty as a member of

the Opposition and as the health critic as well, in understanding some of the

statements that one hears from time to time here in the House of Assembly. On

opening day I heard the Premier say that the health care system in Newfoundland

is doing very well. You know that is something that I find a little bit

difficult to understand when you get down to it, because over the last couple of

months we have certainly given the impression, rightly or wrongly, that

government seems to be whistling pass the graveyard in a lot of instances with

regard to the condition of the health care system in our Province, and it was

borne out of course, by statements that we are hearing doctors and nurses and

people within the health care system make.

Just recently, we have heard some prominent doctors

say that the situation is now so bad in hospitals that doctors are called upon

to determine who lives or who dies based on who can get the next hospital bed.

These are not my words, they are published in the local media and sound very,

very serious to say the least. We can all, I suppose, quote our own individual

horror stories that we are hearing from day to day from health care

professionals, people who are directly working in the system in the hospitals,

on the wards, looking after patients in the operating rooms. They are pretty

well saying that the health care system in Newfoundland and Labrador is in a

shambles, it is at a breaking point.

Nurses we see over the last number of months have

been taking out full page ads in the Evening Telegram. That would indicate to me

that something is wrong. So I guess my first observation has to be: are all

those people wrong? These are sound, sane, rational human beings who are working

in the health care system, and they are qualified health care professionals. Are

they all wrong? Are they crying wolf when they shouldn't be? That is the first

thing I want to get the minister's opinion on when he answers. You know, I want

to know how the minister can square some of the comments that he has been making

and the Premier has been making on the condition of the health care system in

the Province with some of the comments that we are hearing from doctors and

nurses, as I said, who are taking out full page ads in the Evening Telegram to

express their concern. The minister, I am sure, has seen all the public

statements.

We have a number of hospitals in the Province that

have been downgraded. We have brutal cuts in virtually every sector of the

health care system. I believe 800 or 900 positions have been eliminated over the

last couple of years, 300 nurses gone. Even last year we had a $25 million to a

$30 million shortfall in the 91-92 budget. We have hundreds of acute care beds

closed. Patients are now being charged in certain instances fees for services.

Line ups are horrendous we are hearing, especially in the area of heart surgery

and this type of operation. But still, you know, we continue to hear statements

from government that the health care system is in fairly good shape. It is in as

good a shape as it has ever been. Well probably the minister didn't say that,

that it is in as good a shape as it has ever been, but I am just surprised that

on opening day I heard the Premier make the statements that he made with regard

to the health care system in Newfoundland.

So I guess I will get down to some individual

questions that I want to ask the minister. First of all, the changes that have

been made to the transplant policy, organ transplants. I would like the minister

to give us a rundown on that and to tell us how organ transplants have been

affected. What is the formula that the government is using for the transplant

patients, especially the people who have to leave the Province to go to the

mainland for transplants? What is it going to mean for these people? Obviously

they now have to pay. That is the first question. There is no point, I believe,

in asking a whole number of questions. Maybe I will just let the minister

respond to that question first. I want to find out from him or his officials

what changes have been made to the transportation policy with regard to organ

transplants and how it is going to in particular affect those people who have to

get transplants on the mainland to have to go by air probably taking up two or

three seats in an aircraft on a stretcher. How would these people be affected,

and what are they going to have to pay now?

MR. CHAIRMAN: Mr. Decker.

MR. DECKER: Thank you, Mr. Chairman. As regards

the

preamble to the hon. member's questions, I will just have to say I do not

particularly share the same observations. But I am sure you will find as many

people who disagree as do agree. I suppose it is a matter of perception.

The transplant program - as we announced in the

Budget, there is a program in the Department of Health which helps pay the cost

of transportation for people who have to go away from where they live in order

to receive the services of health care, whether it be from St. Anthony to St.

John's or from Goose Bay to Corner Brook, or from St. John's to Ottawa, or

wherever. Before the program was changed anyone who had to pay more than $500 in

travel, after the person went beyond $500, every dollar from then on was paid in

half by the government. So if a person had a $1,000 ticket out of the Province

or wherever, he would have to pay $750 out of his own pocket, $250 would be

refunded.

Now the exception to that was that people who went

out of the Province for heart transplants, or for any transplant, the whole shot

was paid. The change which we made was that from now on, whether you pay more

than $500 for a heart transplant or for a kidney transplant, or whatever, we

treat all the people the same. Instead of treating the disease we treat the

patient. So now, if a person has to - for some reason, I do not know how it

could ever happen - but supposing someone had to go to Montreal to have a tooth

removed. We would pay in excess of, after $500, we would pay half of it back,

for whatever the reason is. So that is the only difference.

But there is something which I think hon. members

should know. The cost associated with transplants, a very minute part of that

cost, is travel. A person, for example, who goes for a heart transplant outside

this Province, the average cost is $111,350, which the Province picks up. A

heart-lung transplant is $152,320. A liver transplant is $105,730. A bone marrow

transplant is $105,895. A paediatric adult kidney transplant is $42,405.

Government would love to be able to pay the whole shot, pay everything. We can't

do that. Money has to come from somewhere. So you try to make your changes in

the places where they do not hurt too much.

We thought that it would be less harmful, cause

less hurt to our people, if we could pick-up a savings there of half a million

dollars by treating everyone the same. I believe it is really a fair way to

treat people. Mind you, we would rather have paid the full shot, treat everybody

the way we are treating the people who are receiving transplants, and pay the

whole shot. That would be the perfect way to do it.

But living in a real world we thought: if we are

going to pick up the savings, this was the equal way to do it, bearing in mind

that there is already a tremendous cost to Medicare and to the people of the

Province when a person has to leave the Province for a transplant.

MR. CHAIRMAN: Thank you. Mr. Doyle.

MR. DOYLE: I am not absolutely sure that I

understand what the minister just told me. So I will get him to approach it from

a different angle. What would it cost an individual before this Budget was

brought down, say to go to Toronto for a heart transplant? In terms of

transportation alone, what would he pay?

MR. CHAIRMAN: Mr. Decker.

MR. DECKER: Before the change, a person who had

to go to, say Toronto, for a liver transplant - I think liver transplants, I'm

not sure they were done in Toronto. They were done in Halifax, were they?

AN HON. MEMBER: Some were done in Halifax.

MR. DECKER: Yes. It would not have cost the

person the fare, the transportation.

MR. DOYLE: It would have cost them -

MR. DECKER: It would not have.

MR. DOYLE: Oh, would not have, okay.

MR. DECKER: Okay? Today it will cost him,

first, $500. If the ticket is $1,000 he pays the $500, then every dollar beyond

the $500, government refunds half. So if the ticket was $1,000 it will now be

$750. But prior to this, the person who received the transplant would not have

had to pay anything for transportation. So if the ticket was $1,000 it will now

be $750; but prior to this, the person who received the transplant would not

have had to pay anything for transportation. Now if there was board and lodging

involved and that sort of thing -

MR. DOYLE: What if he takes up three seats on

an aircraft?

MR. DECKER: If he takes up ten seats, that does

not matter.

MR. DOYLE: It does not matter?

MR. DECKER: It does not really matter. The $500

he pays himself, or herself, whatever the case might be.

MR. DOYLE: And that is the entire cost to him?

MR. DECKER: No, after that he pays half.

MR. DOYLE: After that he will pay half of the

cost again? So if it costs another $500 he will pay $250 of it?

MR. DECKER: That is correct.

MR. DOYLE: So it is possible then, if he was on

a stretcher, say, and he was taking up three seats on an aircraft -

MR. DECKER: Most likely if it was a stretcher

case we would send them up by the King Air, which is the hospital ambulance.

MR. DOYLE: Okay.

Could the minister outline for us what areas have

been cut in the children's dental program?

MR. DECKER: We have allocated $5 million in

this year's Budget to buy some services from the dentists. That is the way we

are putting it. We want to maintain a basic service. Now you might say, what is

basic? That is what we are working out between the dental association and the

department, the director responsible for that.

So I cannot say to you today, with absolute, total

certainty, what we will be delivering and what we will not be delivering. We

will be delivering a program for $5 million. Certain basic things we are

suggesting will be kept in there - fillings, cleanings and these sorts of things

will be kept in there. The details of that are being worked out in close

cooperation with The Newfoundland Dental Association and the appropriate

director of the Department of Health.

MR. DOYLE: So the department does not really

know yet what areas are going to be cut?

MR. DECKER: No, all we do know is that there

are certain components we want to keep there; as I say, cleanings, general

maintenance, extractions, fillings, and a whole lot of things which we will be

keeping there.

MR. DOYLE: What did the minister say was the

total cut in that program, two and one-half -

MR. DECKER: It was a $7 million program. Now in

this particular year it is going to be $5 million. Then we are hoping to bring

the program down to about $4 million in this year's dollars.

AN HON. MEMBER: Is it four?

AN HON. MEMBER: (Inaudible).

MR. DECKER: Okay, my deputy corrected me. It is

$5 million. The program, we are hoping, will level off at about $5 million.

MR. DOYLE: I asked the minister some questions

about a week or so ago on the cases of meningitis that we have in the Province.

I did not get a chance to ask him how many meningitis cases have been reported

to the Department of Health this year, and at what point - or is there is a

point - at which the department will introduce a Province wide immunization

program? Is there some point that you reach where the department would be

looking seriously at introducing an immunization program Province wide?

MR. DECKER: Now I have to take my advice on

that from the professionals in the field. I can tell you it would be unique, I

suppose, to vaccinate the whole Province.

I would like to ask Ms. Dawe to explain this, with

your permission Mr. Chairman. I think there were only seven or eight cases this

year, but she will explain that, and then the professional reason as to why you

would or would not vaccinate a number of people.

MR. CHAIRMAN: Ms. Dawe.

MS. DAWE: Thank you, Mr. Chairman.

If I could, in 1991 there were sixteen cases

reported in Newfoundland, and up to the current date there were seven cases

reported.

With respect to immunization, there is an advisory

committee of appropriate professionals from around the Island who are called

into play when there are cases of meningitis, and they provide a considerable

amount of advice to the department.

In the most recent case, with the death in

Labrador, not only was there professional advice from within the Province, but

also across the country, because of the experience that Prince Edward Island and

Quebec and Ontario had around Christmas time. So it was based on extensive

consultation with professionals that it was decided to vaccinate in Labrador

over the past two weeks.

Because of the target group who were affected over

the last three months, it was decided to vaccinate individuals from the age of

two to twenty-two. That program will conclude this week with about 4,000

vaccinated.

With respect to the overall vaccination program for

the Province, it really has to be dealt with over time because it is very

difficult unless there are sound medical reasons to vaccinate, and then to

vaccinate specific target groups. You don't automatically vaccinate between the

ages of two and twenty-two or thirty or whatever. So it is based on a

considerable amount of professional advice at the time and then monitored over

time.

Again, as you may be aware, the disease is more

prevalent in March and May, then October, November and December of the year. But

I think suffice it to say that this year the incidents to date are seven

whereas

the total cases in 1991 were sixteen.

MR. CHAIRMAN: Thank you, Ms. Dawe. Mr. Doyle,

your fifteen minutes are up. Do you have something quick or shall I go on to

another member.

MR. DOYLE: I was just going to ask a fast

question on that. As a matter of curiosity, why would the Province of PEI do a

full immunization program? They did do a full province wide immunization didn't

they? Why would they do that? I know they are a whole lot smaller to begin with.

MS. DAWE: I don't have all the information at

my fingertips, but I guess it is based on their experience and the number of

cases at the time the decision was made. I don't have the number of cases ready

and available to me on Prince Edward Island at the time of the outbreak around

Christmas time.

MR. DOYLE: Okay, I will get back a little bit

latter on.

MR. CHAIRMAN: The floor is open. Ms. Verge.

MS. VERGE: I was just going to say the Chair

and I had a brief conversation a bit earlier about the order of questioning, and

we both agreed it would probably be fair to rotate between Opposition and

government members, but since Mr. Harris had his hand up first it would be quite

in order to recognize him next.

MR. WALSH: On rare occasions I have granted him

leave in the House to speak, so I see no reason not to let him go for a few

minutes now.

MR. CHAIRMAN: Mr. Harris.

MR. HARRIS: I speak as a right I hope, and not

by leave of my hon. colleague here. I know there are occasions when even the

Speaker in the House asks for leave when leave is not required. Nevertheless,

Mr. Decker, I have a number of questions. Rather than philosophize about things

perhaps I could ask a few questions of a specific nature, jumping around of

course from various lines in the budget.

I see in line 4.2.01 on page 206 of the Estimates,

some $16 million allocated for services outside the Province. Now that would

include some of these transplant operations you were discussing with Mr. Doyle.

There seems to be a $500,000 increase allocated over last years estimates and

actual. Is there any significant portion of that related to out-of-Province

expenses for people who actually reside out of the Province for large portions

of the year? I know the Ontario government had a look at what they call their

snowbirds issue where large numbers of people spend five or six months wintering

in Florida or other places, and asked the Ontario government to pay American

style health care costs for them under the medicare budget. I was just wondering

if you were aware of what portion of that is the kind of services that would be

-- you need an operation in Toronto because of a particular emergency, or

transplant, or a particular specialist might be available. What proportion of

that is that kind of special service, and what kind would be services for people

who are on vacation or extended vacation type of thing?

MR. CHAIRMAN: Mr. Decker.

MR. DECKER: Primrose is going to take that. As

regards the snowbirds, as you refer to them, we do have some expense for people

who go south or go on vacation, but we made a change to the government policy a

couple of years ago whereby we only pay the Newfoundland rate. You would have a

procedure done in Newfoundland which would cost you $300 and if you are

vacationing south, the same procedure could cost $3,000 and we used to pay the

American rate, we do not do that anymore, we only pay -

AN HON. MEMBER: While they were on vacations?

MR. DECKER: That is correct. We only pay the

Newfoundland rate now. Within the country we have a different agreement with all

the provinces where, we would pay -

AN HON. MEMBER: (Inaudible).

MR. DECKER: Yes, what is it called?

AN HON. MEMBER: Reciprocal billing.

MR. CHAIRMAN: Mrs. Bishop.

MRS. BISHOP: Thank you, Mr. Chairman. With

respect to services outside the Province, we have in place what we call a

reciprocal billing arrangement between all the provinces and territories, and

under the Canada Health Act you are entitled to access health services in Canada

and we would pay for the charges that were required for your hospitalization or

your care.

Out of that $16 million, just under $4 million has

been spent for these transplants, on an average, that are going out. A very

small amount is to the US because of the fact that we changed our policy last

year, and these would be people who had to access emergency type treatment; if

you went down and broke your leg or broke your arm, we only would pay the

equivalent as a visit to an out-patients department that we would pay in Canada.

The remainder is for people who are in other provinces and take sick; if you are

in Ontario and your gall bladder gives you trouble and you have to have it

removed, you do not get a bill, you can go in the hospital and we pay for it

here on a reciprocal arrangement.

MR. DECKER: I would also point out, Mr.

Chairman, that in 1990-1991, outside the country, we paid for 104 people who

were treated as inpatients and 434 who were paid as outpatients. Now that was

done by Newfoundland rates I understand, wasn't it?

DR. WILLIAMS: 1990-1991, perhaps, not.

MR. DECKER: Okay, 1991 might have been paid at

their own rates, we can check back, but in the same year, within Canada under

the reciprocal billing Mrs. Bishop talked about, we paid for 1,771 inpatients,

some transplants and some other treatments, and we paid for 15,764 outpatients

visits outside the Province.

Now I should point out, Mr. Chairman, that, a

considerable number of them were down in Blanc Sablon in Labrador, where the

borders are so close, quite a few patients go from Eagle River across to Blanc

Sablon at Long Point and we have quite a number of billings there. Now what

about the other border up in Labrador?

AN HON. MEMBER: I think it flows the other way

into the hospital (inaudible).

MR. DECKER: Yes, most of them come from

Labrador into Newfoundland.

MR. HARRIS: Thank you very much. The second

issue I wanted to question about was the next line in fact in the Budget,

4.2.0.2. - health care centres. How many health care centres are covered under

that vote?

MR. DECKER: Which one is that?

MR. HARRIS: Page 206 we are on.

MR. DECKER: Okay, there are ten paid for there.

MR. HARRIS: So ten are covered by that and

there is a drop in the Budget for these centres of $1 million, from an actual

expenditure of $31.6 million in 1991-1992, to a projected expenditure of $30.4

million, that is a considerable amount of money and looks like approximately a 4

per cent decrease, a million dollars for ten centres. What is the consequence of

that $1 million removal of funds for these centres and can you explain what

services will be removed?

MR. DECKER: Yes. Mr. Harris will remember that

last year we changed the roles of a lot of these institutions. We changed the

roles in Bonavista, Bonne Bay, Burgeo, Placentia and Springdale. As a result of

changing the role and going more with long-term care in these institutions, that

is the explanation for the savings. These were some of the bed closures.

In 1991, for example, in these ten institutions

there were 153 acute care beds. In this year's budget, 1991-1992, we were down

to sixty-seven. Now in 1991-1992 there was a phase-down. We just could not stop,

you had to phase it down. But we are down to sixty-seven acute care beds in this

year and that explains the savings.

MR. HARRIS: Can I ask that again? Last year you

decreased the number of beds from 153 to ninety-one, yet you spent an additional

$600,000 over your budget. Now you are decreasing it to sixty-seven for

1992-1993. You drop a million from what you spent last year?

MR. DECKER: Yes.

MR. HARRIS: Why did it go up?

MR. DECKER: There were severance packages which

had to be put in place. You just can't stop and shut your door. You have to

phase-down. Were there some other reasons there as to why, Ms. Primrose?

MS. PRIMROSE: No, there was fairly significant

severance pay for people who chose to retire.

MR. DECKER: That all had to be factored in. We

didn't -

MR. HARRIS: I'm sorry. Is Ms. Bishop responding

or just giving you information? Because I did not hear what she said.

MR. DECKER: Okay. Ms. Bishop.

MS. BISHOP: Mr. Chairman, there was a

significant number of people who received severance pay who were resigning and

retiring.

MR. HARRIS: Do you have any numbers of people?

In the ten health care centres, what were the numbers overall? Is that

available?

MR. DECKER: Dr. Williams will address that

issue.

MR. CHAIRMAN: Dr. Williams.

DR. WILLIAMS: In the original budget there was

an increase of $574,200 over what was initially budgeted for. This is due to a

new salary contract with the Association of Allied Health Professionals which

had some retroactivity to it, increases in employer contribution rates for

Workers' Compensation, and the Canada Pension Plan. I understand that these are

the three factors that went into that increase.

MR. HARRIS: These are now factored into the

cost for this year -

DR. WILLIAMS: These will be factored into the

cost for this year.

MR. HARRIS: - less the cost of reducing the

number of beds.

DR. WILLIAMS: Yes. Last year as well in our

budget, as the minister said, there was provision for severance pay that is not

in this year's budget. So that is why there is a reduction.

MR. HARRIS: The figure that I have heard in the

medical establishment I guess is terms of cost per day of a hospital bed, acute

care bed. The figure that has been thrown around for the past few years is a

figure of $400. Is that still a figure that makes sense? Four hundred dollars

per day is the cost of having someone in an acute care bed, or having an acute

care bed open?

DR. WILLIAMS: I will let Ms. Bishop give you

the exact figures that we now use. We have different rates for different types

of hospitals. For a community hospital we have one rate, and for our tertiary

care centres we use a different rate. Ms. Primrose, do you have those rates?

MS. PRIMROSE: Yes, Mr. Chairman. The inpatient

per diem rates, which are effective April 1, 1991, for instance at the Health

Sciences, the insured rate is $730 a day. That is a tertiary facility. The James

Paton in Gander, $572 per day. These are just examples. Sir Thomas Roddick

Hospital, Stephenville, $470 per day. St. Clare's, $428 per day. Burin, $600 per

day. Carbonear, $500 per day. These are the per diem rates.

MR. CHAIRMAN: Thank you, Ms. Bishop. That's

your time, Mr. Harris.

MR. HARRIS: I will get another chance, no

doubt.

MR. CHAIRMAN: Ms. Verge.

MS. VERGE: Thank you.

MR. CHAIRMAN: Were you asking to intervene, Mr.

Walsh?

MR. WALSH: I was going to, seeing as how I gave

my time to Jack.

MR. CHAIRMAN: Okay, go ahead.

MS. VERGE: You go ahead.

MR. WALSH: Okay, thanks.

MS. VERGE: I just didn't want people to think

that I wasn't eager and willing.

MR. WALSH: Actually, I thought you would have

gone with the Chair and the Vice-Chair first, but I like the way you are doing

it, letting us go first.

Staying with the same particular page actually,

206, there are some very positive things that I see there. I am just wondering

if you can elaborate to some degree on them for me.

We were talking about 4.2.01. Services outside

province are going up by almost a million dollars, and that is services outside

province - well approximately half a million dollars. What would that cover,

because you are saying that you trimmed somewhat in terms of what you are

looking to do, people going south of the border and so on?

MR. DECKER: Which one are you in now, Mr.

Walsh?

MR. WALSH: I am in 4.2.01.

MR. DECKER: Yes, services outside province. You

are asking what services -

MR. WALSH: You have gone up by half a million

dollars, yet you were saying earlier that there were areas where you are looking

to trim and cut. Why would you see an increase there? What would you be looking

to look after?

DR. WILLIAMS: These services outside a province

could be the same package of service that we provided for in the previous year,

but because of cost and inflationary increases in other provinces then the cost

of providing those services have gone up. As we bill other provinces, we bill

other provinces for service provided.

Say somebody from Ontario is visiting and had to go

in hospital, we use our per diem rates in hospital and our cost of outpatient

services in this Province to bill them. They in turn, if one of the residents of

Newfoundland is in one of their provinces, they use their basic rate structure

to bill us. So some of this might be for the same type of package, but it might

be inflationary increases that would account for the large portion of this.

MR. WALSH: Under the same heading, Grants to

Hospitals, would that also allocate or rationalize why we have gone from $418

million to $423 million? There is about a $7 million increase. Is that just

normal increases in operating?

DR. WILLIAMS: Primrose, do you want to go into

some detail on that? Do you want some detail, Mr. Walsh?

MR. WALSH: Yes, I would not mind having a

little detail there as to what would include that amount - five and a half

million.

MR. CHAIRMAN: Mr. Decker.

MR. DECKER: Contrary to the perception, Mr.

Walsh, we have not frozen the hospital budget this year. As we have gone over

last year's we found there were some budgets we had to increase a bit. So what

you see there is the increase to most - I suppose most of the hospitals did

receive some level of increase, did they not, this year?

MS. BISHOP: Yes.

MR. DECKER: Ms. Bishop can explain the exact

amounts. She has them there.

MR. CHAIRMAN: Ms. Bishop.

MS. BISHOP: Thank you Mr. Chairman and Mr.

Minister.

Last year our revised amounts that we gave to the

hospitals was in the order of $469 million. This year the amount that has been

allocated is in the order of $483 million.

We have given increases to The Cancer Foundation,

Western Memorial, St. Clare's, Sir Thomas Roddick, The Janeway, James Paton

Memorial, the nursing stations, Melville Hospital, The Miller Centre, The Health

Sciences Centre, The Grace, Central Newfoundland -

MR. WALSH: So there has been about $5 million

allocated across the Province to those various facilities?

MR. DECKER: Bearing in mind that we have a wage

freeze, 75 per cent to 80 per cent of the hospital budget is salaries anyway.

MR. WALSH: How much did you say?

MR. DECKER: Seventy to seventy five per cent of

the money that we spend in the hospitals is really salaries. So this $5 million

extra is going directly into patient services as you can appreciate.

MR. WALSH: Still, that is quite a number.

One other area that I see increases in, and I am

not sure if this ties directly to the changes in terms of chronic care. I know

that in my own district there were some major changes made to our hospital on

Bell Island. It is something that has been quite accepted. As a matter of fact I

think a committee on Bell Island made recommendations as to what they thought

the future of that hospital should be. Government agreed with it and went along

with it.

I am seeing there in terms of 4.3.01 - long term

care facilities. First off, what are those facilities, and before I am corrected

again we are looking at about $2.5 million I think in an increase there.

MR. DECKER: Yes.

MR. WALSH: What are we covering in terms of

those areas?

MR. DECKER: They are basically the nursing

homes throughout the Province. A lot of them are run by interfaith groups. Some

of them are government owned, for example, the Harbour Lodge in Carbonear, which

we own. I have a list. The Agnes Pratt in St. John's which is church owned, the

A.M. Guy Memorial, the Bay St. George, the Blue Crest, the Bonnews Lodge,

Carmelite House, Corner Brook, the Hugh Twomey Centre, the O'Connell Centre, the

Glenbrook Lodge. These are basically nursing homes throughout the Province, and

once again in them we also have to give an increase.

MR. WALSH: Now I understand that you have

opened I think some floors at Western Memorial, the sixth floor has been

re-opened. Is that being termed chronic care as well, and would some of that

approximately $2 million have gone to them for that purpose?

MR. DECKER: Yes. Primrose, would you talk about

Corner Brook and the Agnes Pratt and the Twomey Centre in which we are going to

open some more beds.

MS. BISHOP: Thank you, Mr. Chairman. In the

Western Memorial region the sixth floor is going to be converted now for an

additional thirty long-term care beds. We have put in money to open up the

remaining twenty-eight beds at the Agnes Pratt Home, and money is in the budget

for the remaining sixteen beds at the Dr. Hugh Twomey Centre in Botwood.

MR. DECKER: We also have Baie Verte coming on

stream.

MS. BISHOP: Yes, Baie Verte is undergoing

renovations for changing the focus more in line with long-term care. It will now

have eight short-term acute-care beds and nineteen long-term-care beds. That

renovation should be completed by mid-summer.

MR. WALSH: Am I to assume again, based on the

minister's previous comments about the amount of funds that are wrapped up in

salaries, approximately that entire $2 million has gone into the facilities, and

it would not have gone into labour as well in terms of cost?

MR. DECKER: No, not exactly. For example in

Baie Verte we never had a long term facility there before, and the Twomey

Centre, we have to take on extra people. In Corner Brook we have to take on

extra people. As a matter of fact Corner Brook will have nineteen more.

AN HON. MEMBER: Nineteen more employees.

MR. DECKER: Is that now, or when they open?

AN HON. MEMBER: They will when they open up the

first of June.

MR. DECKER: Yes, when Corner Brook opens their

beds the first of June they will have nineteen more employees than they did last

year.

MR. WALSH: So there has been some hiring done

because of this change.

MR. DECKER: That is correct.

MR. CHAIRMAN: That is fine for me for now. Ms.

Verge.

MS. VERGE: Thank you. I have several questions

which I know I won't get through in the first ten minutes. To give you some idea

of the major topics I will indicate headings at the outset. I would like to get

the minister's views, 1) on the general direction in which he thinks our health

care system is headed or should be headed; 2) institutions; 3) MCP; 4) drugs; 5)

public health.

In terms of the direction presently and for many

years, the health care system in this Province as in most of the western world,

has been heavily oriented around institutional care. These estimates provide for

total spending by the Department of Health of $848 million, the bulk of that is

to be spent on institutions, hospitals, health care centres, long-term care

facilities; according to my rough calculations, about $580 million of the $848

million total is to be spent on institutions.

The next single biggest category is MCP, $144

million. That involves of course under our present system, fees, for not all

health care professionals but just physicians and to some extent dentists and

optometrists. Other health care professionals such as nurses, midwives,

chiropractors, nutritionists are not covered by MCP. If they provide services

directly to the public, the public have to pay, there is no provision for public

funding through MCP.

A third relatively large category is drugs, $30

million for drugs, so while the department is called the Department of Health,

actually, most of the effort goes into treating illnesses; a relatively small

amount of the Budget goes into preventing illnesses through education or other

programs. In fact this year, the same as last year we have the perverted heading

on - let me see if I can find the page, the one page of the Budget which is

called Health Prevention.

There is a health prevention label on the

relatively small amount of effort that involves presumably, not the prevention

of health but the prevention of illness, through education programs and

counselling. That is what has been called by some academics and analysts, The

Western Medical Model. We have reached the point in the western world, as many

of us see it, of thinking that this model is not the best model in terms of the

results, and regardless of our views on the results, many people are realizing

that we cannot afford the model.

The cost of maintaining this model has grown at a

faster pace than the economy has grown so we are faced with the inevitability of

change, it is just a question of what kind of change; are we going to try to

cling to the old model and lop off sections and parts or, are we going to face

the challenge of improving the model, of changing the model, of reforming the

model? I would like the minister's views on those comments before I move into

the next heading which is: Institutions.

MR. CHAIRMAN: Mr. Decker.

MR. DECKER: Mrs. Verge raises some excellent

points and I share her views on a lot of the points. If you were to look at the

money we are spending on health you could almost call us the Department of

Sickness. I would not deny that and I agree that if you look at what has

happened to the western world, you would find that we prevent tuberculosis, we

prevent polio, we are trying to prevent cancer. You know, if we could ban

smoking for example, the impact that would have on cancer would be unbelievable

in a few years.

I would suggest that housing has done more to

prevent sickness than some of the immunization vaccinations which we give. I

would suggest that water and sewer in the western world has done more to stop

disease than a lot of things we have done; the western world is trying to clean

up our environment, the impact of mining and all this, so I have no problem with

saying that we are committed to prevention. I believe that one of the key areas

where we are trying to reorganize the Department of Health is in those community

health care boards which we are putting place, which will be putting a

tremendous amount on prevention. We are trying to work that area.

This is Ms. Dawe's areas, one of the reasons we

appointed Ms. Dawe to this particular position within the Department was we knew

her expertise in this field. One of her major assignments is to develop those

community health care boards. There is a considerable amount of prevention in

that. Maybe, Ms. Dawe, if you could address that issue, just to let the

Committee know some of the directions that we are heading into.

MS. DAWE: Thank you, Mr. Chairman, Mr.

Minister. I would as well encourage support for many of the comments that you

have made about the redirection of the system. I think it is fair to say, if you

look at what is happening in the country, in many respects Newfoundland is

taking the lead in its efforts to redirect health services to the community.

Since January part of the major mandate that I have is indeed with the

reorganization of community health services and the establishment of community

health boards, bringing together many of the community services that are

currently provided by a number of organizations.

The first grouping being the public health

services, which are provided directly by the health units, administered through

the Department of Health. These four units across the Province will, over the

next year, become the responsibility of community health boards. In addition

there is quite an array of continuing care and home care services that are

provided by various organizations, which as well will become the mandate. The

process that is in place now to see the realization of the establishment of

community health boards is one which involves extensive consultation again with

varying departments of government - Health, Social Services, and so on -, quite

a number of individuals representing health care providers across the Province,

and an individual representing the public at large.

So that we have a provincial task force which is

now providing advice and direction through the Department on the reorganization

and the need precisely to focus on some of the aspects that you have identified

in terms of more time and public attention on health promotion and health

protection services, as well as redirecting care, which can be provided safely

and appropriately in the home, as opposed to in an institution setting.

So our major focus is really to encourage more

independence and to provide care in the most appropriate settings, obviously

with quality as a criterion there. I personally, as a newcomer to the

Department, am most encouraged with the level of support and commitment that we

have not only across the Province but across the country in the initiatives that

we are undertaking. It is very much at an early stage. We started this process

in January. With the consultation that is required it will take over the next

year before we have the boards established. At this stage it appears that our

plans are still on

schedule to have the first board in place in western

Newfoundland in the Fall, before the end of 1992, and as quickly as possible

thereafter the boards in central Newfoundland, then St. John's and then eastern.

So if we would, for the moment, consider that

northern is under the Grenfell Association, although there has to be some

re-organization there as well, on the island part of the Province there will be

four community health boards with regional representation on these boards, as

well as provider and consumer input. So that the decisions with respect to

community services in the whole array of - and I think you may have copies of

the conceptual model....

MS. VERGE: No, we don't.

MS. DAWE: Well, these are here to be

circulated.

MS. VERGE: Okay, thank you. Where will the four

island regional health care boards be headquartered?

MS. DAWE: That decision has not been finalized

yet. As far as we are at this stage is that there will be four. One in western,

central, eastern, and St. John's.

MS. VERGE: Have you decided where the western

board will be based?

MS. DAWE: No.

MR. DECKER: The board itself will have some

input into that. We will not be dictating from St. John's that it must be Corner

Brook or Port aux Basques. The board itself will make that decision.

MR. CHAIRMAN: Now we have gone through another

ten minutes. Does anybody else want to intervene at this point?

Ms. Verge, would you like to continue?

MS. VERGE: Yes, I would, if nobody else does.

MR. CHAIRMAN: Mr. Harris?

MR. HARRIS: (Inaudible).

MR. CHAIRMAN: Okay, well why don't you go now,

please?

MR. HARRIS: The next area in which I was

interested is basically a follow-up to the question on the per diems. Can the

minister tell us how many patients in - well let's just take the three large St.

John's hospitals, not counting the Janeway - how many patients do we have in the

Health Sciences, St. Clare's and Grace, in each of those hospitals, who have in

fact been medically discharged and are still in the hospital because there is

nowhere for them to go?

MR. DECKER: A quick answer. We have about 10

per cent of our beds, I think, in the Province occupied by medically discharged.

The actual institutions - do we have that figure readily available?

MR. HARRIS: Acute care beds, I guess -

MR. DECKER: I beg your pardon?

AN HON. MEMBER: Seventy-four patients.

MR. DECKER: In where?

AN HON. MEMBER: St. John's.

MR. DECKER: In St. John's we have seventy-four

patients who are medically discharged.

MR. DOYLE: And who are still in hospital?

MR. DECKER: Yes, they are in acute care beds in

hospitals.

MR. HARRIS: What is the average length of stay

of these people after they have been medically discharged?

AN HON. MEMBER: Do you have an average?

MR. HARRIS: Maybe somebody could give us some

more information as to what all that means. You could have seventy-four people

now; they could be all discharged tomorrow. In order to determine the extent of

the problem, I guess, a more realistic question might be: What is the average

length of stay of these medically discharged people? Are there people that have

been there for six, eight and ten months? Can you give us more information about

that problem?

MR. DECKER: Well we are trying. You see, there

are a whole lot of problems, and it could take longer than I am sure the

committee would be prepared to let me go on.

In this Province, according to The Royal Commission

Report which was done, we should have, I think it is 2,896 long-term care beds -

chronic care beds?

AN HON. MEMBER: (Inaudible).

MR. DECKER: Well 2,900 we should have for

chronically ill, for level two and three. In actual fact we have 3,453 long-term

care beds in the Province. So you say we should have lots of room for our

medically discharged people; but you will find that a lot of these long-term

care beds where, for various reasons, some of them are already occupied by level

ones - people who should not be in long-term care institutions, or if they

should it should be in a personal care home.

You find in The Agnes Pratt and St. Patrick's and

all those institutions there are people who really could in some cases cope at

home, with some home care, or certainly in the personal care home. Now there are

many reasons for that. One of the most obvious reasons is that when those

institutions were built, especially the newer ones, they were built under Canada

Mortgage and Housing money, and they were built as hostels. They were built for

healthy seniors; but over the years the people have aged, and some of them went

in there as level ones and now have become level twos and level threes.

We have made a policy to only admit from hereon

level twos and threes, but you obviously cannot put people on the roads. If we

had proper placement in our chronic care homes, we would have plenty of beds. It

would not be necessary to have those medically discharged people in the

hospitals, because we would have about five, six, seven hundred more beds than

we are supposed to have, according to The Royal Commission, and we tend to take

their advice.

I have said publicly before that in the interim we

are going to have to have more beds than we actually need, and we do. We have

more beds, but to solve the problem we have to get at admissions to the homes.

Those boards which Ms. Dawe talks about, one of

their roles will be dealing with what we call the single point of entry, where

government now, or each board, will have some say as to what level of care gets

into a particular home.

For example, the interfaith home in Corner Brook

has quite a number of level ones in it. It was designed for that in the

beginning. We are in the process of bringing that home up to a level two, level

three. Then, only levels two and three will be admitted. The home itself will no

longer have the right, once this board goes in place, to say: we are going to

take this patient and not that one. The home will only say that after this board

has determined that Mrs. Doe or Mr. Smith is approved to enter into a facility.

So it is not a simple matter of saying: why don't

you build more long-term care beds and take them out? We have enough long-term

care beds, but we have a problem with organization. They are inappropriately

filled. It is just as wrong to put a level one into a level three facility as it

is to put a level three person into an acute care bed.

MR. HARRIS: Did I hear you right when you said

10 per cent of our acute care beds are occupied by medically discharged people?

MR. DECKER: In the Province that is about the

number, yes.

MR. HARRIS: Can you tell us what the cost of

that is? I am trying to find a way to get a handle on this. We hear

seventy-four, and then we hear the other reasons for it. But I would like to

know what the cost to the Province is of having - the cost of having these

medically discharged people in hospitals. Can anyone answer that question?

Whether we are dealing with the seventy-four beds in St. John's, what is the

cost to the system of that? Or what is the cost to the system of having 10 per

cent of the acute care beds being not used for medical purposes at all?

MR. DECKER: If you are coming at it from cost

really there are no savings. If you are just looking at in simple terms of cost

really there are no savings. Our concern is not so much with cost as the

appropriate care we are delivering. Whether the bed is filled by a chronic care

person or an acute care person, the bed in a hospital is going to be filled. But

our concern in the Department is that it is inappropriate for a person to be in

an acute care facility, a person who is medically discharged. He or she would be

much more appropriately cared for in a long-term care institution. That is one

of the reasons we are trying, where we did some role changes in the last few

years, we are trying to get appropriate placement for people who are medically

discharged.

MR. HARRIS: Well, Mr. Minister, it is of great

concern to somebody who is trying to get into a hospital and needs a treatment,

or is being kept in an emergency situation for longer than they should be, or an

emergency ward as opposed to in a bed, as to whether that bed is occupied and

whether the health care funding is being essentially wasted. There would be no

saving to the system, yes, if you took one person out of an acute care bed and

put someone who needed an acute care bed into it. But you would have one person

getting the care that they needed. That is important too. But it is important to

know how much of our health care budget is being spent to accommodate this

problem. I wonder whether you can answer this question.

MR. DECKER: Mr. Chairman, first the member

comes at it from a point of view of cost. Well, I explained, the cost does not

mean a hill of beans whether that bed is occupied by a chronically ill person or

an acutely ill person. The cost is not the factor. But for the person who is

waiting to get into an institution, yes, we totally share that, that is a major

concern of the Department. That is why when we made some changes last year we

tried to free up some chronic care beds so we could take some of those people

who were medically discharged out.

There was some criticism this year that we did not

open any new acute care beds. The reality is we opened eighty-odd acute care

beds this year. By opening up Agnes Pratt and Hugh Twomey, and by opening up

Baie Verte and by opening up beds for the chronically ill, we could take the

acute care beds that were occupied by medically discharged people and put them

into those institutions. We did the same thing the year before with the

Springdale situation, where we took people out of Grand Falls and put them in.

So we do not directly build new acute care beds, we have plenty. We have

ninety-three more than we require. Acute care beds. But the inappropriate use of

these beds is our problem.

MR. HARRIS: The same question has to be asked

again. My understanding is that one of the roles of an estimates committee is to

examine government expenditure and see whether it is being spent properly or

whether it is being wasted. Maybe I should put it this way. How much of our

health care dollar in terms of millions or hundreds of thousands, and it must be

hundreds of thousands even on a weekly basis, is being wasted in maintaining -

and what the solution might be is a different question - people in acute care

beds who are not required to be there?

MR. DECKER: Mr. Chairman, I hate to use the

word "wasted" because these people are sick. They are medically discharged. That

means that there is no longer anything that we can do for them in an acute care

facility. But I would hardly think that the relatives of those people would

consider it a waste to keep those people in hospital beds.

MR. HARRIS: If you had them sitting in

operating rooms, Mr. Minister, you would be able to call that a waste, wouldn't

you?

MR. DECKER: I would hardly think it is a waste,

Mr. Chairman, when you are talking about human beings here who are in a bed.

Whether they are old and frail and medically discharged, we still have to care

for them.

SOME HON. MEMBERS: (Inaudible).

MR. DECKER: The reality is that when those

people are medically discharged, there is nothing else we can do for them, from

the point of view of curing their illness.

MR. HARRIS: How much is it costing?

MR. DECKER: They would belong in a long-term

care facility. The reality is, as I pointed out earlier, we have some

inappropriate placements in our long-term care facilities as well. The Province

is trying, as rapidly as it can, to address the problem of the chronically ill.

If we can address the problem with the long-term care patient we can free up the

beds because the reality is, we only need in this Province about 2,300 acute

care beds. About 2,300?

AN HON. MEMBER: Twenty-two.

MR. DECKER: Twenty-two, and we have more than

we need. But 10 per centre of them are inappropriately filled. That is the

problem. We are trying to deal with that over the term. But we certainly do not

look at it as a waste of money. People are sick, they are sick, whether it be a

result of old age or what have you.

MR. CHAIRMAN: Okay, Mr. Harris, we're through

another ten minutes.

MR. HARRIS: I will want to be back again.

MR. CHAIRMAN: Oh yes, we will all be back

again, as long as we want to be.

Mr. Short.

MR. SHORT: Mr. Minister, you are talking about

acute care, and chronic care and so on. The Minister of Municipal Affairs last

fall, or just I guess before Christmas perhaps, announced a facility for

Stephenville Crossing, a pilot project, in congregate housing. Is that the kind

of thing that is going to alleviate some of the problems, especially with level

one care, which I guess is a real problem for people trying to get into the

home? They are not really well enough to be in cottages or whatever, but they

are also not sick enough to be in the home itself.

MR. DECKER: The policy of the Department and of

government is that the best place for a senior citizen to be is in his or her

own home. That is the philosophy. That philosophy is shared by the Senior

Citizens Federation, and by most senior citizens themselves. They would rather

be in their own home. So wherever possible, with some home care, some home

support, we keep people in their own homes.

Now, there are exceptions to every single statement

which you come up with. Sometimes for social reasons a person has to have a

little extra care. A lot of problems in Newfoundland, both in outports and in

the city, is that people do not have adequate housing. So between the nursing

home and their own homes, sometimes there are certain levels of care required.

Congregate housing is a concept which is quite

common in the States. It is basically an apartment building with about ten to

twenty people living in it. The building has one central dining room. Then it

will have eight, ten, twenty little apartments. They are more like bed-sitting

rooms. There is a kitchenette, there is a private bath, and there is a sleeping

area and a living area. One meal a day is prepared and served in the central

dining room. The breakfast and the lunch, whether it is midday or evening or

whatever, is taken in their own little residence. Services are available. There

is snow in this Province, this would be important, snow is shovelled. A little

bit of shopping is done.

Visits would be arranged then. The public health

nurse would make the appropriate visit the same as if it were a private

dwelling. The community health care worker, or whatever the case might be, would

go in as is needed.

That is an experiment which we are now trying in

St. George's, and we have found a considerable amount of interest throughout the

Province for other such similar homes, but we are not rushing it. We want to see

just how it is going to work in the St. George's area first. It is very common

in the States. I do not know if it is used much in Canada or not. Is it, Dr.

Williams? Can you help me on that?

DR. WILLIAMS: I think congregate housing is

something that is utilized throughout the system across the country.

MR. DECKER: Across the country. We are the last

ones to get in on it.

MR. SHORT: I have a question, or maybe a

comment first of all. Last year, I guess, there was a lot of fuss with our

budget and so on, and the freezing of budgets and so on. Last Monday I was

driving across the Province, myself and Mr. Ramsay, and I happened to pick up

The Globe and Mail. There was an

article there talking about basically, I guess,

the fact that a lot of other provinces wish they were now where we are in terms

of, I guess, restructuring the health care system.

I was wondering if you would like to comment on

that, because even though there has been a lot of fuss, as I said, when you read

the

article it seems as though what is happening in Ontario and Saskatchewan and

so on, we are probably going to have the best budget in terms of the results, I

guess.

MR. DECKER: Yes, Mr. Chairman, I did skim the

article. I did not pay much attention to it. I just skimmed the first few lines

and threw it in the garbage. I believe I did draw it to the attention of the

health critic. Rightly or wrongly - well it has proven to be right - we realized

early in the game that in order to save - I think Sister Elizabeth Davis made

the best quotation in that

article where she talks about where they gave up

their obstetrics, where we brought the two obstetrics together into The Grace

Hospital. She talks about how their hospital was founded on obstetrics, and it

was quite a sacrifice to give it up; but she says it was not that difficult a

decision to make when you consider we are trying to save medicare.

This administration is totally, absolutely,

committed to universal medicare; but we know that if you pay for everything that

people want, then you would end up spending 100 per cent of your budget on

health care. Well if you spend 100 per cent of your budget on health care, you

have no transportation to get them to hospital; you have nobody working, except

in the health care system, so it is totally unrealistic.

We managed to restructure our health care system,

and I can tell you that we are getting calls on a weekly basis from other

provinces asking for our advice and asking how you can restructure. When the

ministers met in Ontario the last time, they had our officials go aside and

discuss how we were reorganizing. We try our best to give them some advice.

Naturally all the people in the department are very

proud over the

article which was done by The Globe and Mail, and I believe it is

fair.

I should say for the benefit of Jack Harris that

his former leader became aware of this over a year ago, of the steps that we

were making in health care in Newfoundland. He did an excellent

article which

was similar to the one which was done by The Globe and Mail, because in order to

save medicare we have to reorganize the system. I would rather pay $500 to go to

Toronto to have a heart transplant than to have to pay the $152,000 to do it,

which would put me bankrupt.

We have to make sure that this country never gets

to the point where you can go bankrupt because you are sick and cannot afford to

pay the shot; but if we try to supply every want, every time that an interest

group, or every time someone shouts and screams, if we are going to try to run

and meet that, for political gains or whatever, we will see the end of medicare.

If that happens, I think we are going to be in a lot worse position than we are

by doing a little bit of restructuring and making a few role changes.

MR. CHAIRMAN: Ms. Verge.

MS. VERGE: Thank you. I would like to come back

to my first topic which is the direction in which our health care system is

heading or should be heading. I listened with interest to Miss Dawe's remarks

about the proposed community health boards. What I am hearing is that there is

some tinkering being done but there really is not, fundamentally, a redirection

shaping up. The community health boards, basically involve a shuffling of

existing services and personnel.

The proposed organizational chart which I was just

handed, indicates that five areas of responsibility which are now carried out by

personnel of the department and agencies funded by the department will be

combined and run regionally by five community health care boards and that may

have merits, it is a bit too early for me to comment on that, but one of the

five areas of responsibility indicated is alcohol and drug dependency

prevention, treatment, rehabilitation and research, the functions that are now

carried out by the Alcohol and Drug Dependency Commission.

The Budget estimates indicate a drastic reduction

in provincial government funding for the ADDC, approximating 25 per cent

reduction, I am wondering whether under this restructuring the community health

boards will have as much wherewithal as the current services that are delivered

as I mentioned presumably by the department directly or by department funded

agencies.

MR. DECKER: By putting the ADDC under the

boards we are going to save, in this year, $400,000.

MS. VERGE: But, how can that be, if I might

interject?

MR. DECKER: That is the kind of thing that the

Globe and Mail talks about, I believe. It is really amazing. We will be

delivering the same service, maybe a better service, as a result of this. It is

amazing.

MS. VERGE: I would like to interject.

MR. DECKER: If the hon. member would listen.

MS. VERGE: No. I would like to -

MR. CHAIRMAN: Perhaps you would let the

minister finish.

MS. VERGE: No. I would just like to interject

to ask the minister to explain that, because we have heard statements, glib

statements, to the effect that more is being done with less, but yet the results

indicate otherwise. In the case of the Alcohol and Drug Dependency Commission,

there have been regional offices. In the case of the Department of Health, there

are regional offices of the public health branch. I can speak about the western

region, about the services based in Corner Brook. The ADDC, the Humberwood

Center operated by the ADDC and the public health branch of the Department of

Health seem to work fairly closely together.

Now, how can you expect more to be done if you cut

the staff and reduce the funding?

MR. DECKER: Now, Mr. Chairman, is that all the

question? So, I can assume I am going to be allowed to answer.

MR. CHAIRMAN: Yes, Sir.

MR. DECKER: We are going to save $400,000 on

the ADDC and we are going to deliver the same service or probably a better

service. Not a single counsellor will be laid off. None of the hands-on

services, none of the people who deal with the people who need it, not a soul,

will be laid off. The Humberwood in the member's district will not be downsized

one iota. Everything is going to be done better. But by bringing the

administration together, we can knock out payroll costs, we can knock out - how

many people are we laying off, twelve or fourteen?

MS. DAWE: Eleven.

MR. DECKER: Eleven full-time positions will

disappear and one or two part-time positions will disappear, people who had

nothing to do whatever with services. It is within the administration. Lots of

time you hear the criticism, coming from the unions especially, how some of our

institutions have too much top weight on them. In this particular case we are

going to do away with the administration, but we are going to keep the personnel

under these services.

Ms. Dawe, is there something you can add to that?

MS. DAWE: Mr. Chairman, Mr. Minister, I would

like to go back, maybe, to the earlier comment first. The plan that I have

distributed, the model, is not intended to just bring together current services,

because you are correct, some of these services, if you look at health

promotion, health protection, these services are currently offered by the public

health units, some of the continuing care services, some home care provided by

public health units, and others by other organizations in the community. Mental

health is very weak from a community perspective now. So continuing care and

mental health are two areas for further development, as well as health

promotion. So this is seen as a restructuring of community health services with

a longer range plan to put more emphasis on the community for many of these

components. So I just needed to clarify, it is not only just bringing together

the current and the status quo, it is planning for the future.

With respect to the Alcohol and Drug Dependency

services, as the minister has stated, there will be absolutely no impact on the

direct services provided across the Province. The provincial office which houses

the administration and the accounting personnel functions, will be incorporated

into the Department of Health. As we now have a division of mental health, for

example, under community health, so will there become a division of drug

dependency. So it will have its own entity. That is the only component of the

ADDC which will be impacted. The services provided in St. John's directly and

across the Province will not, in any way, be reduced.

When the regional boards are appointed, starting in

the fall with western, the services in western will then become incorporated

under the regional board. At that time, as the minister has indicated, the

service will be enhanced, because there will be a greater array of professional

support services to assist with drug dependency.

MS. VERGE: That sounds good. Two questions

about the details. What eleven people will be taken out of the system...eleven

full-time, or part-time? How can this plan, worthy as it sounds, work, with more

functions being taken on and better services being provided? Where will the

resources and personnel come from to achieve these objectives?

MS. DAWE: The individuals whose positions are

being declared redundant are part of the provincial office and they are in

accounting, personnel manager and clerical positions. Because these functions

will be incorporated into the Department of Health.

MS. VERGE: So when you say provincial office

you mean the provincial office of the Alcohol and Drug Dependency Commission.

MS. DAWE: ADDC, yes.

MS. VERGE: So you mean they have eleven

administrative people at the head office?

MS. DAWE: No, but there is a claims officer,

and various clerks, because they have their own structure. So they have

twenty-two people now organizing the provincial services. Because it is

independent, it is an entity.

MS. VERGE: Yes, I understand.

MS. DAWE: Okay.

MS. VERGE: But how many staff will be

eliminated because of the absorption of the ADDC into the Department?

MS. DAWE: Eleven positions will be declared

redundant.

MS. VERGE: So all of those will come out of

ADDC.

MS. DAWE: Yes, of the provincial offices.

MS. VERGE: Okay. Now where will the staff and

resources come from to provide better mental health services?

MS. DAWE: At the moment, as I said, it is

bringing - the plan this year is to get the structure in place. So as is

indicated in the estimates, there is $179,000 allocated for restructuring the

system and putting the boards in place in western, central and St. John's.

MS. VERGE: But we will have to wait until after

the next election to see what happens.

MS. DAWE: No, well I think in fairness, the

mandate this year is to get the structure in place and coordinate existing

services so as to avoid duplication of effort and provide a broader base of

professionals to support one another in the service. As I had indicated, this is

really intended to be a longer range plan. It is not a quick fix this year.

MS. VERGE: Okay. Getting back to the question

of the need for redirection, a very big portion of the budget now goes to MCP to

pay those health care professionals who are covered by MCP. Basically physicians

and for some services - dentists and optometrists. Does the minister agree with

continuing to restrict public funding through MCP of just those professionals?

Does the minister see that the public purse is funding physicians, the most

expensive of the health care professionals, to do a great deal of work which can

be done quite well - in some instances, better - by lower priced professionals,

such as nurse practitioners, nutritionists, midwives, chiropractors?

MR. DECKER: Mr. Chairman, these are topics that

we do discuss from time to time. Now you will know the MCP budget has been

frozen for two years in a row except for the normal, the increase in

utilization. I think last year it was 2.8 per cent, and this year, what is our

increase in utilization, Gerry? One point nine per cent we've factored in? So we

have practically frozen that budget for a couple of years in a row.

In consultation with the other ministers across the

country we are looking at the contribution that other professionals can make. In

the whole northern region of course we do have the nursing professional. This

year we had planned to go with an experiment with midwives to assist in

deliveries. However, that is being done in St. Anthony at this moment. Anyone

who goes to St. Anthony to have a delivery most likely a midwife will do it. But

I think the way they phrase it, the obstetrician is in sight, is it? There's

usually an obstetrician within calling distance.

The Association of Registered Nurses, albeit they

are committed to

the midwife playing a bigger role, it is generally

accepted that the obstetrician at least be available in the event that something

goes wrong and in 15 per cent to 20 per cent of the cases something can go

wrong, but we are looking, we have a committee in place with the Newfoundland

Medical Association in which these things are being discussed.

MS. VERGE: But the medical association has a

vested interest in maintaining doctors monopoly, why wouldn't you broaden that

committee to include the other health care professionals who are now shut out of

medicare?

MR. DECKER: We have various committees

throughout the Province where we discuss with all the people, Mr. Chairman, but

I do not think it would be very smart, if we tried to do this without consulting

with the Newfoundland Medical Association. I think we would be leaving ourselves

open for probably valid criticism if we tried to ride roughshod over the

doctors. Even last year when we froze their budget, I know members of the

Opposition, I am not sure if the hon. member herself made it, but there was a

lot of accusations flying across that doctors are going to leave the Province

and all this sort of thing, so you just cannot go ahead and do these things

without consultation with the professionals so we have to consult with them.

MS. VERGE: Of course -

MR. CHAIRMAN: We are through another ten

minutes. Now I propose that we take about a ten minute coffee break until about

8:45; if people are interested in doing that and nobody has objections ?

MR. DECKER: Only if there is tea.

MR. CHAIRMAN: Pardon?

MR. DECKER: Only if there is tea available?

MR. CHAIRMAN: There is some coffee available in

the caucus room of the government just across the hallway there.

Recess

MR. CHAIRMAN: Are we ready to resume?

MS. VERGE: Okay.

MR. CHAIRMAN: Who would like the floor?

MS. VERGE: I have more questions here.

MR. CHAIRMAN: Pardon me?

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: Yes, she did. Yes, I am going to

recognize you, if you want.

MS. VERGE: Yes. I think what the Chair is saying

is that I had used up ten minutes when we started the break -

MR. HARRIS: You had used them up?

MS. VERGE: Yes. I am ready to go again -

MR. HARRIS: Well so am I -

MS. VERGE: Okay, well you go ahead.

MR. HARRIS: Just like your new questions in the

House, I guess eh?

MR. CHAIRMAN: Listen, who is Chairman here? Mr.

Harris.

MR. HARRIS: Thank you, Mr. Chairman. I want to go

back to the interesting question that I was asking before, which, as of yet I

have not had an answer, and I guess the minister does not like the word 'waste',

when I talk about the amount of money that the Department of Health spends on

services that are not required, so I will have to rephrase it.

Can the minister tell us how much money is spent

providing these acute care beds which are filled with people who do not need

those beds?

MR. CHAIRMAN: Mr. Decker.

MR. DECKER: Mr. Chairman, to get an exact number,

as the hon. member knows, we would have to say there are ten in the General at

$790. There are five in St. Clare's at whatever, but the best estimate I could

give, and I could take the question under advisement to give the real number, we

can put someone on that, but the best estimate is we are spending approximately

$600 million in the hospital services, 10 per cent of that is in discharge, so

10 per cent of $600 million is what... $60 million? That is about as close as

you would come to it in round figures. Now, it might be $58 million or it might

be $62 million, but we would have to break it down per hospital because as Mrs.

Bishop pointed out, the General costs more than a bed say in, Labrador West, but

we will get the answer to that but it is somewhere in the vicinity of $60

million.

MR. HARRIS: Okay. Thank you. The reason I want the

number is because we are looking at a very substantial number, a very

substantial amount of dollars spent this year and presumably last year and next

year, on this misuse of health facilities and with a substantial amount of money

like that, my point is that there could be alternatives devised with that money,

and some of that $60 million would obviously be used to look after the people

who need the acute care that those beds are unable to provide right now, and

maybe more need to be there, I don't know. Obviously some of that money should

be used to provide alternative types of care for the individuals who are now

there. So what I want to know is: Can the minister tell us what alternatives to

keeping on spending that $60 million, and I am assuming that - is that 10 per

cent figure something that has been constant for a few years?

MR. DECKER: It is not only constant for a few

years; it is constant throughout the country. About 10 per cent of the beds in

the whole nation are occupied. That is the reality of the health care system.

Yes, it has been constant for what - five or six years?

MS. DAWE: Well for the last ten to twelve years.

MR. DECKER: The last ten to twelve years there has

been 10 per cent occupancy.

MR. HARRIS: I regard that as a considerable waste

of money. You have told us that we have a problem in the other end of it as

well. What other solutions have been considered by the government instead of

wasting that kind of money?

MR. DECKER: Mr. Chairman, I agree. I am not sure

it is waste. It is inappropriate spending. For the person who is waiting to get

into an acute care bed it is a problem. For the person who is in that bed it is

a problem. I share the hon. member's opinion. It is really inappropriate to have

it.

Now look at some of the things we have been doing and

are doing. Last year we changed the role of some acute care facilities in the

Province which were underutilized. One was in my own district of St. Anthony,

which had 52 per cent occupancy. Fifty-two per cent of the acute beds were being

used for acute care. The others were underutilized, so we took a space - we took

a whole wing - and we are in the process of putting an extra twenty people, I

believe, into chronic - people who are medically discharged, we have redesigned

a wing in the hospital for long-term care.

Now for long-term care you have to have bigger rooms.

You have to have the access to the bathroom made different. You have to have

more lounges. It is a different level of care, as the hon. member knows. That is

what we did last year with St. Anthony.

Everywhere we changed the role was to address this

particular problem. In Bonavista we did it. In Bonne Bay we did it. In St.

Lawrence we are in the process of doing it. Where else did we do it?

AN HON. MEMBER: Burgeo.

AN HON. MEMBER: Port Saunders.

MR. DECKER: In Burgeo and Port Saunders we have

institutions which are presently being constructed to deal with this issue. One

of the ways we are trying to deal with this issue of the medically discharged is

to make available more chronic care space. Another way that we are trying to

deal with it is with the home care program. This very day in Newfoundland, I

would bet you that there were some people who had as many as five visits from

some level of home care. The public health nurse could have gone in. A Red Cross

representative could have gone in. Someone from social services could have gone

in. That is the reality you will find in certain parts of this Province today.

In other parts of the Province you will find that

there has never ever been any home care available. So we are trying to deal with

that issue with our community health care boards. One of the components is

addressed to home care so that we can have people taken out of the institutions

to stay in their own homes.

There are a whole lot of things which we are doing to

try to get those beds freed up; but I have to say, Mr. Harris, that history has

shown that no matter what we do there will always be some people in the acute

care centres who are medically discharged. I think 10 per cent is a figure that

we do not want to live with, but it is going to be extremely difficult to have

everybody out.

Now people will not be in there for months and months

and months on end, but in some cases people who are medically discharged are

only there two or three days. In other cases they have to wait two or three

months; but we do not have any cases where people are actually medically

discharged and staying in hospital for a year at a time. Basically they are

there until we can get a placement for them in a long-term care facility.

So we are trying to address it. We are not addressing

it as fast as we would like, because when you start changing roles you get an

awful lot of opposition. You know what happened in Baie Verte, and you know what

happened in Placentia where we tried to deal with the issue. We had people

marching on the Confederation Building. So it is not an easy thing to do, but we

have to do it.

I do not disagree with you at all. It is inappropriate

use to have medically discharged in acute care beds.

MR. HARRIS: Thank you, in terms of home care,

perhaps Ms. Dawe can deal with this, what is the best way of measuring the level

of service provided in terms of home care? I know you can talk about areas in

the Province where it is offered, you can talk about the number of different

services that are offered. Is there a way of quantifying what progress we are

making in terms of developing home care facilities?

MS. DAWE: In terms of this year there are

additional monies going into community based services to improve home care

services, but that is certainly not going to be addressing the full need. As I

had indicated earlier, the emphasis this year is to get the structure in place

and to co-ordinate, bring together appropriate organizations to avoid any

duplication of effort, and then build on the delivery of community based

services.

MR. HARRIS: So your money is not going into

delivery yet.

MS. DAWE: There are some monies, yes, going into

the delivery of services this year, some that have been directed around the

Province, and some to St. John's home care. Additional funding for home care

services are being provided for this fiscal year.

MR. HARRIS: Can you give us, for example, what

change has been made in the allocation to St. John's home care?

MS. DAWE: Yes I can. For example last year,

1991-92, our budget for the St. John's home care formed community based

services, that is one component, was $900,000. This year it is $1,027,000. That

is just out of the community based service vote. There is an increase as well

coming from the institutional budget for home care in St. John's. So this is

just an indication of what is coming out of one component of the budget for

direct services.

MR. HARRIS: This is direct services by St. John's

home care. When you say institutional budget, what -

MS. DAWE: That is Ms. Bishop's area.

MR. HARRIS: That is health care services provided

through the hospital, and -

MR. DECKER: A nursing home, for example, would

have a meals on wheels program.

MR. HARRIS: Here and there.

MR. DECKER: Yes, in the institution in Springdale,

for example, they have a meals on wheels, and some have wheels to meals where

they bring senior citizens into the institution. So this is what I am talking

about when I say it is almost ad hoc what has been going on. That is one of the

reasons for trying to bring it together under those central boards where we

allocate $10 million or $5 million or whatever we can afford to the board to

deliver the service rather than have this ad hoc system which we have now.

MR. CHAIRMAN: Thank you, Mr. Harris, until we go

around again.

MR. HARRIS: Thank you.

MR. CHAIRMAN: Mr. Doyle.

MR. DOYLE: Thank you, Mr. Chairman. I have a

couple of questions on MCP. Over the last number of weeks the report on MCP has

come out and a number of recommendations have been made. I believe twenty-five

or thirty recommendations to tighten up security at MCP. Have any of these

recommendations been implemented so far? I mean what is government doing with

these recommendations? Is there any time frame to have these completed?

MR. DECKER: Most of them I understand have been

dealt with. Now obviously we have not moved to a new building. We are looking at

whether or not it would be wise. I think the report was that we build a new

building, well I doubt very much we will build a building, but we could

conceivably rent a new building. So we don't want to go full scale with putting

in this electronic security only to discover within six months we move to a new

location. So that hasn't been done. But the recommendations about shredding, the

recommendations about cleaning after hours, I think the vast majority of them

have been dealt with. I don't know, Mr. White, if you could answer.

MR. CHAIRMAN: Mr. White.

MR. DECKER: That is under your area isn't it.

MR. WHITE: It is my understanding that MCP has

moved to implement a number of the recommendations. I am not sure exactly of the

specific recommendations they have moved to implement, but a number of them they

tell me have been implemented already. Some of them are fairly major, as you

said with respect to a new building and that sort of thing.

MR. DOYLE: There is a great deal of concern, as

the minister knows, about the current method of auditing physicians because of

the confidentiality thing that has been going on for the last couple of years,

really. Physicians, I think it is fair to say, are quite concerned about it.

Will the government be changing in any way, will they be making any adjustments

to the current auditing system that they have? For instance, why wouldn't the

government, since there is a such a great deal of concern about doctors having

to mail in xeroxed copies of their patients files, why wouldn't the government

for instance allow the Newfoundland Medical Association, in consultation with

MCP or a representative from MCP, to get involved in the auditing process or to

have a joint team there who would visit -

MS. VERGE: Require the patient's consent.

MR. DOYLE: Yes. Visit physicians and do the

auditing like that in consultation with the Newfoundland Medical Association.

Why can't you move somewhere in that direction to get the confidence of the

physicians back again? And the patients as well.

MR. DECKER: It is the official position of the

Newfoundland Medical Association and the official position of government that

there has to be an audit. I do not think there is any disagreement on that. We

have had some physicians who have gone public and we have had a court case and

so on, and of course the court case made it perfectly clear that the Province

does have a right to demand the audit. So I think it is pretty well accepted. I

believe the member himself would agree that there should be an audit.

MR. DOYLE: Yes, yes.

MR. DECKER: The process whereby that audit is

carried out has caused some problem. Now mind you, the majority of the doctors

are not against it. The official position of the Newfoundland Medical

Association is that the audit is acceptable. We have put in place a committee

made up of representations from Medicare and the Newfoundland Medical

Association who at this very minute, for the last six weeks, have been examining

the whole audit process. So what you are asking is already being done. We have

involved the Newfoundland Medical Association. Now at the end of the day, they

might come up and say: there is no better way to do it, or this is the way. But

we are waiting for their report. We will not give up our right to audit.

MR. DOYLE: No, and I do not believe government

should give up its right to audit. But I mean, there is an awful lot of concern,

especially from the patients themselves. I think an awful lot of people would

agree, certainly members of the medical profession, and the minister would have

to agree, given the statements that have been made by the medical profession

publicly, that there have been breaches of confidentiality long before the

dumpster type of thing.

MR. DECKER: The accusations have been made and as

a result of that I have put this committee in place made up of the doctors and

the medical -

MR. DOYLE: So it is possible that the procedure

could be changed in some way?

MR. DECKER: Yes, it is possible. Depending on what

(Inaudible).

MR. DOYLE: To satisfy both the physician and the

patient?

MR. DECKER: Yes. Dr. Williams, have you anything

to add to this particular committee on this?

MS. VERGE: Who's representing the patients on the

committee?

MR. DOYLE: Yes, that's a good question. Who is

representing the patients on the committee?

MR. DECKER: The Medicare Commission is a board

which is appointed by government. The majority of the members on that are really

representing the consumers. The chairman of that board is Roger Crosbie, who I

guess the hon. member would know. He was chairman of the board when we took

office and we re-appointed him. There is representation from every region of the

Province. There is I believe a Labrador representative on the committee so the

Commission itself is basically managed by consumers.

MR. DOYLE: Yes. It just seems to me that it would

be very appropriate, if you are going to continue the auditing procedures that

you have, it would be more than appropriate to have somebody there from the

Newfoundland Medical Association -

MR. DECKER: That's exactly what we have.

MR. DOYLE: - in consultation with MCP, doing these

audits. Probably visiting physicians instead of having the patients files coming

through the mail, and copies flirting about here -

MR. DECKER: Well these are the matters which this

committee is dealing with. I think Dr. Williams might have something to add to

that.

DR. WILLIAMS: Yes, there is a committee set up at

the minister's request, of the Medicare Commission and the Medical Association

to review the practice of audit, how it is conducted, and they are to report to

the minister on their recommendations on what modifications might need to be

made. So we are waiting for that report to come in.

As well at the Medicare Commission there has been for

quite a number of years a consultants committee with representation on it,

majority representation from practising physicians in the Province who advise

MCP on certain matters relating to physician profiles and the need for audit,

and advise, I guess, the Medicare Commission on all matters pertaining to this.

As well the commission has a physician whose only role

at the commission is to deal with the audit issue and to provide a medical input

to the audit procedure from the Medicare Commission as well. So that person, Dr.

Al Mercer, joined the commission perhaps within the last year to make sure that

there is a good medical input into the whole process. So there are those sort of

checks and balances on the system.

Right now, I guess, the minister is waiting for

feedback from the joint committee of medicare and the medical profession to see

if there are any adjustments that need to be made to make the process more

reasonable if there is a method, or what the recommendations might be. So we are

waiting for that.

MR. DOYLE: People say you should know the answer

to a question before you ask it, but I certainly don't know this one. Do we have

authority under our current Newfoundland Medical Act to be doing these audits

the way we are doing them? Because I think there was a controversy recently in

Ontario.

MR. DECKER: You will recall that Dr. Delaney took

us to court.

MR. DOYLE: Yes, I know that, and the supreme court

said yes.

MR. DECKER: Yes, we have the authority to do it.

MR. DOYLE: So under our current medical act, we

do?

MR. DECKER: You will recall that the commission

went ahead and did the audit, I think they had to have my signature for some

things.

DR. WILLIAMS: There is a procedure they have to

follow to recover funds.

MR. DECKER: Yes, and there was some question as to

whether or not they actually followed the procedure properly. The admonition

from the judge was there was a procedure not followed to the letter of the law.

But there is no doubt either with our Supreme Court or the Supreme Court of

Canada that provinces do indeed have the right to audit. Yes.

MR. DOYLE: Just getting along to another topic

here: heart surgery. What is the current situation with respect to the waiting

time for heart surgery in our hospitals in Newfoundland. I mean I read the

Fraser -

AN HON. MEMBER: That is the one that the Premier

misinterpreted.

MR. DOYLE: Yes, the Fraser Report or the Fraser

Institute.

And it seems - not seems, it is proved that we are

running way behind in that area in regard to waiting time and what have you.

What is the current situation in our Newfoundland hospitals with regard to heart

surgery? I have gotten two calls since yesterday from two individuals who are in

hospital and have been in there now for a month or so and still don't have

surgery scheduled. The doctors keep saying they have an adequate number of

surgeons to do the operation, but they just don't have the operating rooms. They

don't have the facilities to do it. So what is the problem anyway? Could you

shed some light on it for us?

MR. DECKER: Yes, the issue came to the forefront

in recent weeks, and the Fraser Forum Report was one of the things. The

Opposition addressed it in the House, as you are aware. I have had meetings with

the General Hospital, who do open heart surgery in the Province, and we have put

a procedure in place hopefully that we can deal with. Now Dr. Williams, I am

going to ask you because you attended the meeting with me and your memory tends

to be better than mine on some of these things. So maybe if you could address

the issue.

DR. WILLIAMS: Some years ago we would target it

based upon the population in the Province and the needs in the Province to

achieve about 300 procedures per year and that includes all open heart

surgeries, coronary artery bypass grafting is just one form but that represents

the majority of cases. There is also open heart surgery for people with valvular

disease that probably represents about forty or fifty cases a year but of a 300

case profile about 250 would be the coronary artery bypass grafting. For a

number of years they achieved a number of about 250 or less.

Several years ago, four extra beds were added to the

intensive care unit at the hospital to enable them to increase their throughput;

they went from ten beds to fourteen beds, all the patients who have open heart

surgery have to spend up to forty-eight hours in the intensive care unit after

the surgery, given the type of surgery done, so there had been some delays there

in the post-op area, the need for more beds in that area as well as there was

some additional equipment provided for monitors and that type of thing to

accommodate those extra four beds.

Last year, the number of cases done was over 300, I

think 313 to be exact. We are targeting this year to achieve a load of at least

300, hopefully a few more. There has been a backlog and it accumulated in the

years when we did less cases. We are presently waiting to hear back from the

General Hospital about how they might be able to achieve an additional number of

cases to try to clear up the backlog. The target we had set had been around 300

cases which we achieved last year but that is the first year we had achieved it.

MR. CHAIRMAN: Mr. Doyle.

MR. DOYLE: So in order to achieve that, to clear

up the backlog, how many cases will we have to perform and for how long?

DR. WILLIAMS: Well, we are hoping that with

achieving about 300 or just over 300 cases a year, we can start to make some

dents in the backlog and maintain the status quo into the future and be able to

respond in a reasonable period of time. I read an

article recently, and I can

get that for you from one of the Canadian Medical Associations Journals or some

such journal. This compared the waits in Newfoundland with other areas so it

depends on what you read, depending on whether you read the Fraser Journal, the

report or this other article, how we compare with other areas of Canada.

Then there is a whole issue that's a very grey area in

the health care system and that is the issue of needs versus procedures done. If

you look at the US, their rate for coronary artery bypass grafting is probably

twice as high as that in Canada; does that represent a different approach to the

patient with a cardiac problem or not? These are some of the grey areas that you

have to look at in health care.

Each patient is different, physicians have to decide

what approach is justified; people with coronary artery disease, obviously some

of the surgery that is done has a long-term impact on survival and mortality.

Other cases are done for relief of symptoms and are more of an elective nature;

you know, we rely on the physicians obviously who are treating the case. One of

the areas where we are putting some emphasis on in this Province now is the

whole area of continuous quality improvement in health care and is something

that is coming to the forefront; it has been I guess, in the business world for

some time. It is not a new principle and we are looking at, with the General

Hospital, and in fact, I think the committee has approached them Joan, to look

at the cardiac program in the Province to supply some of the techniques there to

see if there is a way that we can make the whole operation more efficient.

Obviously it deals with the availability of intensive

care unit beds, OR time - we actually opened an extra OR I think last year, the

seventh OR in the hospital to accommodate this area and it needs to be

co-ordinated with the beds available, the ICU time, the anaesthetist

availability in the OR, so what I am trying to say it is not a very simple

problem and easily solved, and we are working with the General Hospital to

improve the situation for patients in the Province.

MR. DECKER: Also, Mr. Chairman, I just want to

interject that in addition to the open-heart surgery, they are also doing

angioplasty. When angioplasty was introduced - what year did they start that in

the Province?

DR. WILLIAMS: It started probably in the early

eighties down in Boston - probably about eighty-four or eight-five in the

Province.

MR. DECKER: Well the logical assumption was that

as you did this procedure then the open-heart surgery should have gone down, but

in actual fact that has not happened in this Province. So we are doing 160 or

so?

DR. WILLIAMS: We are doing over 200 angioplasties

now.

MR. DECKER: Over 200 angioplasties, and we are

also doing over 300 open-heart surgery procedures, so it has to be looked at.

The angioplasty in effect has become an add-on. It was supposed to replace it,

but it is certainly not replacing it.

MR. CHAIRMAN: Are we ready to move along?

Mr. Short?

MR. SHORT: I have a few questions for the

minister. It is mentioned in the budget about reducing the number of hospital

boards from twenty-five, or whatever the number is now, down to possibly five.

How do you plan to go about this? What is the plan? Or is it only in the

planning stages?

MR. DECKER: It is pretty well accepted in the

Province, Mr. Chairman, that we have too many hospital boards. Now to save money

in the hospital system you can lay off people. Alright, do you lay off your

nurses? Do you lay off your support people, or what do you do?

Obviously you cannot lay off a whole lot more nurses.

You cannot lay off many more support staff. You cannot lay off too many of the

specialists. So it seems that the last place we can find some real savings

without hurting delivery of the care would be in the administrations. The only

way you are going to cut down the cost of administrations is to bring some

boards together.

Now if there was an unfortunate figure in the budget,

it was five. We are not married to the figure five. We have twenty-five and we

are going to bring that number down to a reasonable number. There are some

boards in the Province which I do not think anybody would doubt. I am not going

to say them, because I am sure - let people interpret it as they will. But what

we propose to do is to take on a facilitator, a person who is going to spend the

next six, eight, ten months, whatever it takes, meeting with every single

hospital board and some of the administrations, some of the users, the consumers

of the systems, to try to determine how many boards we should have in the

Province and where we should have them.

In addition to that, I am putting in place an advisory

committee made up of representation from the general public, from the

Association of Registered Nurses, the Newfoundland Hospital Association, the

Newfoundland Medical Association, every single group which is involved in

delivering health care in the Province. I am going to ask for representation in

the form of an advisory committee. Of that advisory committee there will be an

executive to work with the facilitator. Over the next number of months we are

hoping that the facilitator, after getting all this input and all this advice

from the different people in the system, will then bring a recommendation to

government as to how many boards we should have, and where they should be -

where the headquarters should be and that sort of thing.

The figure five is probably a little bit unfortunate.

There is a sort of a bit of a breakdown there, but it might be four; it might be

three. I would think it is probably going to be more like eight or ten, but at

the end of the next eighteen months or whatever we will know where we are going

on that one.

MR. CHAIRMAN: Thank you, Mr. Short.

Ms. Verge.

MS. VERGE: Thank you. It sounds like the minister

is going to avoid the consolidation of hospital boards until after the next

election. Of course then we will see who is in government.

I have a lot of questions, and I do not think I am

going to be able to ask them all before we adjourn tonight. I will move to the

heading of Institutions which, as has been pointed out, consume the bulk of the

Department of Health budget, some $600 million.

I wonder if the minister would table for the

committee, an institution by institution breakdown of the global amount set out

in the estimates, for each hospital, for each health care centre, for each

long-term care facility. What is the allocation for the current budget year?

What was actually spent last year? What was originally estimated for last year?

What is the number of beds forecast to be operated in an institution this year?

What was the number of beds operated last year? And what was the number of beds

in use and funded the year before that?

I don't want to use up the very short amount of time

that we have left talking about that, because there are many institutions, but

Ms. Bishop seems to have all this on paper and I wonder if copies would be made

available to each member of the committee.

Next I would like to move to the subject of AIDS. In

our Province -

MR. DECKER: You asked me to table something. I can

table it.

MS. VERGE: Good. Thank you.

On the subject of AIDS, relatively little is being

done by the provincial Department of Health, but we do have a federally funded

community based organization called the Newfoundland and Labrador AIDS

Committee. We have all learned through the news media that misfortune has struck

that organization recently with a large amount of money having been stolen. The

AIDS Committee is providing public education designed to prevent the spread of

HIV and AIDS. They have been carrying out education programs for groups of

students in schools and for public audiences all around the Province. They have

been providing support for people who are infected with the virus and people who

have AIDS, and they have been serving as advocates for people who are infected.

From what I have seen, they have been doing an extremely good job.

Because of the theft, the AIDS Committee is now unable

to continue to pay its staff. As of last Friday, they were taken off the

payroll. Most of them have continued to work on a voluntary basis. Some of them

qualify for unemployment insurance, some do not and will have no alternative but

to resort to social assistance.

I understand that the provincial Department of Health

has provided very little financial assistance to the Newfoundland and Labrador

AIDS Committee. I would like the minister to tell us exactly what financial

assistance and other support the Province has been providing. More to the point,

what will the provincial government do for the Newfoundland and Labrador AIDS

Committee now in its hour of need?

We all realize the need to restrain spending, but

surely the officials here will appreciate that it is much better to spend a

small amount on prevention today than to have to spend a small fortune on

treatment of people with AIDS in eight or ten years time. Surely today it is

better to spend money employing people, through a Department of Employment and

Labour Relations employment program or through a Department of Social Services

employment program, than it is to pay out more in social assistance.

So will the Department of Health consider interim

financing, an emergency allocation, for the Newfoundland and Labrador AIDS

Committee. Will the Department of Health recommend to other departments of

government that funding be provided to the Newfoundland and Labrador AIDS

Committee for an employment project to allow the committee to continue to employ

people to do the very worthwhile work of educating and preventing as well as

supporting people who are infected? Will the Department of Health immediately

take over the cost of the toll free AIDS information and assistance telephone

line that the provincial AIDS committee operates? Will the provincial government

provide additional support to the Newfoundland and Labrador AIDS committee?

MR. WALSH: I don't mean to interrupt but I counted

eighteen questions so far. I wonder if maybe the minister could start answering

some and then we can go on with some others. But we could just finish the night

on the eighteen questions that were just asked. They are relevant questions and

I know they have need to be asked, but can we get some answers? I would like to

hear some of the answers before we forget what the questions were.

MS. VERGE: Mr. Walsh, I had just finished, and

with respect all my questions were on the same subject. I don't think the

minister had any trouble following. Your attention span might be short, but the

minister seemed quite able to follow my line of questioning.

MR. WALSH: The reason that I had difficulty

understanding is that there were some good questions and I don't want to miss

any of the answers. I am up to eighteen questions, and yes I am having

difficulty following them. You may have an advantage in that you have them

written down. The minister and his staff may have an advantage because they were

writing them down, but I didn't write until number seven.

MR. CHAIRMAN: Thank you, Mr. Walsh. Mr. Decker.

MR. DECKER: Mr. Chairman, there are two levels of

the number of questions. The details I am going to ask Ms. Dawe to deal with,

the policy issue of whether or not we will pay for it I will address afterwards.

I will ask Ms. Dawe remembering now that we are dealing with the HIV problem not

only through the AIDS committee. Our public health area and the drugs which the

Province provides, a whole lot of areas, but Ms. Dawe if you could just walk the

committee members through that and then leave the policy issue for the $40,000,

I will try to deal with that one afterwards.

MS. DAWE: Thank you, Mr. Chairman, Mr. Minister.

There are two individuals in the community health branch of the department whose

almost full time is dedicated to AIDS prevention and AIDS education.

MS. VERGE: Who are they?

MS. DAWE: Ethel Heald who is an education

consultant, and a considerable amount of her time is working with community

groups including the AIDS committee, but a considerable amount of her time as

well is working with professional groups across the Province and the public

health unit staff in AIDS education and promotion. Joanne McKinnon is the

reproductive health consultant. A considerable amount of her time over this past

year and currently as well is associated with dealing with AIDS initiatives.

For the record I would be happy to provide you - there

are a list of four pages of initiative that are under way dealing with the AIDS

question and health promotion.

MS. VERGE: I have been involved extensively as a

volunteer in the Corner Brook area in talking to professionals in health and

education about efforts under way to educate people about AIDS, to try to

prevent the spread of the infection. Every single one of them says without

hesitation that they are just not doing nearly enough. These are all well

motivated, extremely well qualified people, but they have many responsibilities,

and with respect these two people are in St. John's. We have a large Province,

and Joanne McKinnon's responsibilities cover the whole area of reproductive

health. Another area which we are not doing nearly enough in is preventing

unwanted pregnancies. Planned Parenthood for years now has been operating

without one cent from the provincial government.

MS. DAWE: I guess if I could, Mr. Chairman, to go

back to the AIDS issue, my point was that we have two individuals in the

department. A considerable amount of their time is spent in providing consulting

services to a number of groups. I agree that there are many other people across

the Province who are involved. The role of these individuals is to provide

consulting services and try to facilitate AIDS education in a number of

different forums. As well to say there are many initiatives currently under way.

These two staff members are working with the regional public health offices

across the Province currently to develop strategies so that the staff in the

areas will be appropriately prepared to work with community groups as well.

MS. VERGE: I would like the minister to answer my

questions about the inclination and preparedness of the government to provide

assistance to The Newfoundland and Labrador AIDS Committee in what I call their

hour of need. Prefacing that, would the minister tell us what the government is

doing presently, before this recent crisis, to assist the Newfoundland and

Labrador AIDS Committee, and is the government willing to - even on just an

emergency interim basis - give additional support to The Newfoundland and

Labrador Aids Committee?

MR. CHAIRMAN: Mr. Decker.

MR. DECKER: Mr. Chairman, since I have been

minister the department has been working very closely with the AIDS Committee.

Doctor Ian Bowmer is Chairman of that committee, and we meet on quite a number

of occasions. He advises government on it.

Members will recall the television ads last year which

were carried by the AIDS Committee. They were paid for directly by the

Department of Health, and they were delivered by the AIDS Committee.

We were involved in the toll free line when it was set

up. I think we are paying for a considerable amount of that, are we not?

MS. VERGE: No, I am told that the toll free line

operated by The Newfoundland and Labrador AIDS Committee is paid for entirely by

the committee with federal funding, and that the Province is not contributing to

the cost of operating that toll free telephone service.

MR. DECKER: Well let's get the truth. What is the

truth of it, Ms. Dawe?

MS. DAWE: The AIDS Committee has asked this year

for funding to provide a second 1-800-line. That is under consideration at the

moment.

MS. VERGE: Who is paying for the existing line?

MS. DAWE: My understanding is that is coming from

other sources. It is not the department.

MS. VERGE: Yes, that is my understanding.

MS. DAWE: It is a federal grant.

MR. DECKER: It is a federal grant.

MS. DAWE: But they have asked us to provide

support for a second 1-800-line.

MR. DECKER: Now, as to whether or not -

MS. VERGE: If I might interject, obviously their

ability to continue to pay for the existing line is now in doubt because a large

sum of money was stolen from them. They have no money left now.

AN HON. MEMBER: (Inaudible).

MS. VERGE: They took everyone off the payroll last

Friday, and they have debt. They have $25,000 debt.

MR. CHAIRMAN: Now that is the conclusion of the

time for this period, but perhaps the minister will respond to the rest of that

question before we change.

MR. DECKER: Yes, Mr. Chairman, I think this

request would be better if it came from the AIDS Committee. At this moment they

have not asked government for any assistance on this particular issue. If and

when they do, we will sit down and discuss the matter with them. I am not going

to commit tonight that we are going to give them $40,000 or $5,000. I am not

going to say we will not. If and when the committee comes to us, and we discuss

the matter, if there is something we can do, depending on the means within the

department and the need and all this sort of thing, we will deal with that

matter. It would be inappropriate for me to prejudge what we will say.

MS. VERGE: Yes, I appreciate that.

I wonder -

MR. CHAIRMAN: No, that is the conclusion of that

period.

Mr. Penney, the Member for Lewisporte, has joined us

as a member of the committee for this evening, replacing Mr. Efford who has not

been able to attend.

It is now almost 9:45. Ms. Verge raised the question

of time. Does anybody want to say anything about the question of time? You have

indicated that you do not expect to conclude say by 10:30 or something like

that?

MS. VERGE: Well it depends on the committee as a

whole, but I have several more questions that I would like to ask. I do not know

about anyone else.

MR. CHAIRMAN: Does anybody want to suggest that we

consider a time to conclude for this evening, or that we continue until we

exhaust the questions?

Mr. Walsh?

MR. WALSH: I am really curious. I want to come

back to a comment that the minister made. I am willing to carry on. Let's go as

far as we can to wrap this up tonight. I would just as soon be here until 12:00

tonight as to try to reschedule for another night.

MR. CHAIRMAN: Mr. Doyle.

MR. DOYLE: Not me. It is my understanding we

generally go until 10:00 and then it is cut off if it is not finished. I can't

stay beyond 10:00.

MR. CHAIRMAN: I don't think there is any rule to

govern us. I think we can go all night if the committee chooses to. That is my

understanding. There doesn't seem to be much consensus about what to do so I

would propose that we continue as we are. If at some point somebody wishes to

make a motion we will deal with that.

Mr. Harris.

MR. HARRIS: If my voice could be added to the

consensus I don't think we are going to conclude by 10:00, which normally is the

time that committees conclude. It would be my suggestion that 10:00 at night is

a reasonable time and to set it over for another day. So it would be my

suggestion that we go until 10:00 unless we think we can finish by 10:15 or

something like that, which I don't think we can, Ms. Verge has a number of

questions and there are a number of areas that I haven't gotten into yet as

well. So I would propose that we finish at 10:00 and come back another time.

MS. VERGE: Personally I wouldn't mind staying

until midnight, but there are other people who have to drive an hour or more to

get home for the night, staff who probably made plans to finish at 10:00. I

concur with Mr. Harris, I think we should adjourn at 10:00. If we haven't

exhausted our questions by then we will have to

schedule a second hearing for

the Department of Health.

MR. CHAIRMAN: Let's wait until 10:00 to deal with

it or when somebody wishes to make