The Nova Scotia Legislature

The House resumed on:
September 21, 2017.

Public Accounts -- Wed., June 7, 2000

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8:00 A.M.


Mr. John Holm

MR. CHAIRMAN: Good morning. For the benefit of our guests, my name is John Holm, and I am the Chairman for today. Our witnesses today, from the Department of Health, are Dr. Thomas Ward, Deputy Minister; Mr. Byron Rafuse, Chief Financial Officer; and tied up in traffic but will be joining us is Ms. Barbara Hall, Executive Director of Health Services. I can sympathize with her trying to get through the traffic at this time of the day. Also with us today, of course, as usual, is Mr. Roy Salmon, Auditor General, and Ms. Elaine Morash, Assistant Auditor General. Joining us now is Ms. Barbara Hall. Before we begin, I would ask the committee members, if they wouldn't mind, to briefly introduce themselves.

[The committee members introduced themselves.]

MR. CHAIRMAN: I understand that Dr. Ward has up to about 20 minutes in terms of opening remarks. With that, I will turn the floor over to Dr. Ward.

DR. THOMAS WARD: Mr. Chairman, I thought, as an introduction to the following events, I might just review a bit about what has been happening in health care across Canada in the last 10 years or so, relate that to Nova Scotia, then look forward a little bit to the challenges that lie before any publicly-funded system, and then talk a bit about those challenges with respect to Nova Scotia.

My own personal background is that I am a physician, I was in practice for about 20 years doing newborn and pediatric intensive care. I subsequently moved into hospital and medical administration, and then I became much more interested in systems and future and impacts of technology and changes. I have done a fair bit of consulting work, both in the public sector and public sector, not only in Canada but around the world. The last couple of years I have been working with the World Bank in the Balkans.


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If you look back at what has happened in the last 10 or 20 years with respect to health care, there have probably been three or four very fundamental changes that have really changed the face of what most of us grew up with. The first thing is that the impact of technology and new diagnostic procedures and new pharmaceuticals, we have really seen the disappearance of the bulk of acute diseases that really caused much hospitalization. The great epidemics of infection, particularly in the pediatric world, of gastroenteritis, pneumonias and other things, have really disappeared to a great extent. If you look at large children's hospitals, they have really changed remarkably. When I trained at the children's hospital in Toronto we had 1,200 beds serving metropolitan Toronto, back in the late 1960's; it is now down to about 300 beds, serving a population of close to 12 million. It has really been the impact of the changes of technology.

The second thing that has happened is that as the acute components of disease have changed, we are really into an era in which the biggest challenges before us are chronic diseases. There is chronic atherosclerosis leading to heart disease; renal failure; it is diabetes; it is chronic lung disease; whether it is asthma or as a result of smoking, with emphysema, or those types of conditions. Really, we need to begin to think about managing on a chronic basis as the acute episodic history has been changing.

I think the third biggest change has been a change in the workforce and workforce expectations, and that is particularly true for physicians. When I was in practice, it was not uncommon for many solo general practitioners to be established in small communities. I as a practising neonatologist, practised alone for four years before I ended up getting a partner. The physician workforce of the current time is changing remarkably. They actually think that a 40 or 50 hour work week is pretty reasonable, instead of 100 hours. One of the things we are seeing is that it is now very difficult to recruit and keep physicians where there are intense demands for their off-hour time. They like to be out with their kids, they like to have their weekends off.

If you look at the situation where you would really like to have medical coverage on a 24-hour basis, in-house, you are really talking, at the current time, about requiring 6 physicians to do that. When you begin to plan and look at a system for the future, you really have to begin to think about the potential impacts of the medical manpower piece. If you want an emergency room running with a doctor there 24 hours a day, you are really going to have to have 6 doctors available to do that, to cover all the hours. That has changed remarkably, the patterns of practice and the expectations.

The impact of the technology piece of it, we have really seen a change from the in-patient bed utilization piece. There remains a perception at the current time that somehow the presence of hospital beds equates to good health care. I don't think that is necessarily so. I think the bulk of disease is managed in the community or on an ambulatory basis, and the presence or absence of a large number of hospital beds is not a reflection of the overall health or health care provided in the community.

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The move to ambulatory care, day hospitals, medical daycare, home care, specialized treatment programs has really significantly seen a change in the acute care mix and use of beds across the country. In that we have suddenly begun to realize that there is another issue called alternate levels of care. That is really the fact that for an acute care bed to be adequately utilized, you really need the back-up of radiologists, labs, nurses and physicians. If you can't have that available around the clock, then it is really questionable as to whether or not you should have an acute care bed in a particular site or facility. That is not to say there shouldn't be beds there for observation, for overnight stay, for recovery, convalescence, rehabilitation, respite for families who are caring for members who are chronically ill or for palliative care.

If you look at the utilization of services in Nova Scotia on the acute care side, one of the interesting things is that Nova Scotia remains in excess of about 900 days per 1,000 population for the acute care piece. That is compared to a national average of about 600. I don't believe the population of Nova Scotia is 50 per cent sicker than anywhere else. I think it has simply been a history, that is what has been, that is how it has been in the province, and there really has not been a good solid look at that. I think, as we are beginning to understand the system, we are really talking about trying to define what is a reasonable utilization in terms of acute care days, and recognizing that we really have to begin to focus on the alternate level of care issues.

That is sort of where we are currently in terms of the system here. Most other jurisdictions have gone through some pretty rigorous programs in terms of looking at acute care utilization. In some of the larger metropolitan centres, particularly an area like Vancouver, acute care utilization is down to about 400 days per 1,000 population, with good back-up for day hospitals, day surgery programs, alternate level of care and other programs. As you begin to look at the continuum of care and type of care, you really have to be able to segment out what is acute care versus an alternate level of need, and are there other or more effective opportunities to be providing care to people.

If you begin to then look out as to what the current pressures in the system are, they are absolutely no different in Canada than they are in any other publicly-funded system across the country. Professor John Wyn Owen spoke to us last Thursday at a meeting in Toronto, and he is currently the senior researcher in the Nuffield Trust in Great Britain about what the common issues are as we are looking forward in terms of health care systems across the world.

There are really six important things. The first one, very clearly, is rising expectations. The rising expectations piece is simply that in a publicly-funded system, the public seems to be expecting more all the time. I think it is certainly fuelled in an environment which if you watch CNN you see the latest technology, people assume that it is going to work, it should be here and there are questions as to why we can't have it. That has to be balanced off against whether or not those treatments may or may not be effective.

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The second piece clearly are the questions of demographics and ageing. We are beginning to understand that certain community groups may have higher incidents of diseases. Very clearly in the Chinese and Indo-Canadian communities in British Columbia, there is a very high incidence of diabetes, about a four times incidence of renal failure in that particular population. As that population expands, there are different requirements in the system.

The second piece is the ageing piece. One of the impacts of improvements in medical care has been an increasing length of life. At the current time in Canada, life expectation is over 80. We just need to look back 25 years ago, geriatrics was becoming a specialty in medicine and at that point in time geriatrics was talking about anybody over the age of 65. At the current time, if you talk to most geriatricians, the real issue that they have is probably seniors with lots of product diseases and a population called the frail elderly, who are individuals over the age of 85 who do become very dependent in the sense of a need for personal services and other things. That population is expanding very rapidly.

The third piece in all of this is really the question of technologies and the assessment of technologies. Science is wonderful and we have done a lot of good things in terms of medical technologies, but many of them are very costly. At the current time, there are new medications coming out virtually every day that may or may not have some potential to improve life or control disease, but they come with very high costs.

An interesting phenomenon that many people comment about is the fact that all of those technologies are marketed towards individuals, but they tend to be paid from either public or private insurers. They are really not seen elsewhere in the world. Open heart surgery is not seen in Africa, but it is seen in North America and in other economically developed countries. The pressures will continue if there is a belief that the public can pay.

Information, knowledge and management again is a huge issue. At the current time, it is very difficult to do any long-term longitudinal studies to understand the impact and changes brought on by technology, to be able to monitor and follow patients and to make assumptions that there are opportunities for improvement.

The fifth big piece in all of it simply is the workforce and education piece. I talked earlier a bit about the workforce, in terms of physicians, but the same is true for nursing and many other health care professionals. As technology and pharmaceuticals come on to the market place and are brought into hospitals, there is a need to continually upgrade and educate the workforce, but at the same time, we need to understand the bulk of the workforce are in fact, baby boomers and in 10 or 15 years they will be retiring. Fifteen or twenty years out from now, there are some really fundamental questions about who is going to be providing care in the system.

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The last piece in all of this is that there are always issues about the system and its performance. I would simply say that medical systems tend to be individually focused. We are really talking about care for the individual, but, at the end of the day, what people are interested in as much is a health system focused on the community and organized around the community. I guess the challenge in any planning process or change process or looking at the system is really to find a balance in all of those issues.

In Nova Scotia, in terms of changes in the system or changes in the strategic direction, I think very clearly, there are probably a number of issues. Access is clearly one of them. It is a very geographic population. There are certainly areas that are isolated with small populations and whatever plan or direction it is going, you would like the system to try to treat everybody fairly, but everybody should have at least the same access to a basic core level of services.

We also need to understand that there are some quality issues, issues around safety, expertise, outcomes and accountability. That is simply to say that in managing patients, you need to see a population of patients to keep the skills up. If you were given a choice between going to a heart surgeon who is doing 250 open hearts a year versus somebody who is doing one every 5 years, I don't think any of us would have a problem about making the choice. There are certain things around volumes and expertise that are absolutely important in all of this. That is true for the whole team - whether it be physicians or nurses, respiratory technicians, lab technicians or any other diagnostic piece.

The third piece in all of it, very clearly, is some questions around the affordability side of it. The pressures and demands across the system at the current time are absolutely inordinate. Even if we were able to get a sense of control around it, I think most people in health care at the senior level at the current time are beginning to understand that the growth rate is probably going to be twice GDP, if not three times. That is in a well controlled situation. I don't think there is an economy in the world that can stand that kind of growth in one sector, at least drawing money out of the system and so, whatever we do in terms of managing and moving ahead with the system, we need to understand that.

The direction that I see for this province in terms of the system in the future, is really a continued move to an integrated community-based system. When I talk about that, I am talking about a system that I personally think should be an all-in system which includes the community level or rolled up in a district. Access to long-term care, home care, mental health, addiction, family physician services, social services, but hopefully through a single entry, through a single site in a community, where somebody can go to access those services, that in fact we do have a smooth continuum. That is a big challenge in itself.

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That is what the public has said to us. The public has certainly said that across the country and in the review done by the Provincial Health Council, the message from the people to the Provincial Health Council was for access to a broad range of services at the community level.

At the same point in time in the past few years, there has been an increasing emphasis put on the issue of accountability; $1.7 billion a year of the public's money is being spent on medical care or health care or some combination thereof. At some point in time we need to understand where the money is going and we need to understand what the impact of those dollars has been.

In the process that I see going forward, we really need to begin to think about the system as an integrated model. We really need to begin to look at the various components and see how we can put them together. That is certainly my wish for the system, that is certainly the direction I am trying to provide within the department and to the industry at the current time.

It is not going to be without challenge. Again, there will always be financial pressures. One of the speakers at the meeting last week, who was with the World Health Organization, described it as perpetual austerity with respect to health care, which is really to say that you will probably never have enough money to provide all the services that everybody thinks they need at any given point in time. Somehow or other we are going to have to go through a process of balancing off some sense of fairness, access, quality and affordability for all the public in a manner that is fair within the resources that any particular government has at any point in time.

MR. CHAIRMAN: Thank you very much, Dr. Ward. We will now turn it over to the question period, rounds of 20 minutes each to begin with, and this week it is the turn of the New Democrats to begin the questioning. Mr. Dexter.

MR. DARRELL DEXTER: Thank you and good morning. Dr. Ward, when you were hired, I had an opportunity to look at your résumé at that time and, in fact, I went looking for it, but it is down off the site these days. At that time you were shopping for business and these days you are fully employed, so it is not there anymore at least.

What struck me about your experience was that there was a lot of it with respect to mergers and consolidations. In fact, I think your résumé talked a lot about your past involvement in merging and consolidating services in various institutions. So I wanted to start with that because it occurs to me that that is what the clinical services review is all about, isn't it?

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DR. WARD: No. I think the clinical services review is really a process that is designed to look at one portion of a system. We really have been looking at the use of hospitals as we currently understand it and hospital beds, and we are looking at it from two perspectives. We are not only looking at what is available in communities and we are really talking about the bed, the physical plant, a very important piece called the health human resource piece which is physicians, nurses and other professional staff, as well as the equipment needed to support activities, the presence of things like CAT scanners, operating rooms, those types of things.

At the same point in time we do recognize that in our publicly funded system, one of the very unique things is that people have a right to choose where they receive services. For many people who live outside the metropolitan area and come to work in the metropolitan area, they may choose to have a physician in Halifax rather than their own community. They may choose to come here to receive services and whatever we do in terms of this, we really need to look at the flow of patients and what they think their requirements are across the system and try to meet that and balance that out across the province.

At the same point in time as we are looking at the various types of utilization, we are also trying to understand what opportunities there are to provide some efficiencies or find some efficiencies in the system. We are really looking at the issue of best practices. One of the things we have been able to do is to look at activities by a thing called case mixed groups, which is really an opportunity to define a certain disease or set of procedures by a hospital or by a physician and look at who has good length of stay and that sort of good activities compared to somebody else and then say if we got everybody in the province to that level, what would be the impact in terms of utilization.

The second piece in terms of the clinical services review and where we are going on all of it, we really need to look at both the demographics that I have talked about. If you have a population that has a higher percentage of elderly, you will need to be in the position to support those requirements. The elderly are higher users of the system. You also need to pay attention to geography. We are also very clear that given the current demands from physicians, that really they don't work more than one in four or one in five; we are really talking about trying to put together a set of services where they are going to be comfortable in practising. If you are going to have four internists, they are going to have to have some resource base and that is probably going to be a district hospital. Those are the kinds of things we are doing at the current time with that.

MR. DEXTER: Well, that is interesting and I hear part of what you are saying in terms of the review end of it, but every time the Minister of Health opens his mouth he talks about shared services. He talks about programs being offered in a different form in a different place. Now, shared services so far as I am concerned, unless you tell me otherwise, is nothing more than a euphemism for consolidation and merger. I think that is anybody's fair analysis of what the Minister of Health continues to say, and what that means by extension is that those services that are consolidated are not going to be available in local communities. They

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are not going to be available in Queens County, they are not going to be available in Shelburne and they are not going to be available in other parts of the province.

I think it is a fair question to ask, if this is the focus of the clinical review, what is that going to mean to the individuals locally, specifically in rural communities, because what we hear is it means increased wait times, longer travel times; some fairly serious implications for rural communities.

DR. WARD: I guess that is probably an issue that I have not done quite as good a job as I should have in terms of talking about the shared services piece. For the people who are involved in health care, when we talk about shared services, we are talking about the support services side. We are not talking about clinical care or clinical programs at all. The shared services model basically is, do you have a centralized laundry and are there cost savings from doing that rather than having every hospital with a laundry? The same thing as purchasing; health human resources; biomedical technology, in the sense of who fixes radiology machines; those kinds of things.

The push for shared services is really to integrate those kinds of things as well as integrating the administrative side to find cost-efficiencies on that piece; at least for those of us in the department and in the field when we talk about shared services, that is what we are talking about. We are not talking about the clinical programs piece at all. Clinical programs is entirely separate from that. We are really talking about the delivery of care to people and we are really talking about underpinning that as a framework of support for HR, the diagnostic pieces, labs and those types of things. So there are two different things.

MR. DEXTER: So are you saying that the provision of clinical services in communities across this province is not going to change in the upcoming year?

DR. WARD: There is going to be some role change in some hospitals. Is it going to change dramatically? No, I don't think so.

MR. DEXTER: The focus of the initiatives from this government, at least when it came to power, was on the question of administrative savings. They said, we think that we can find money within the administrative budget. So I am going to ask you as plainly as I can, is there $83 million in administrative savings that can be found in the system that is not going to affect the delivery of programs?

DR. WARD: At the current time our general sense is yes. The difficulty is going to be to find those savings. It is not a one year issue. The move to a shared services program, where we believe there are very significant savings, is a minimum of a two year effort. So any results of that process we are not going to be seeing for a year or so. I think the second piece very clearly is that when we begin to look at the administrative side, it is really issues about the number of HR departments and support staff and information technology people, that if

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we begin to get sort of a critical mass together in a more centralized fashion that, yes, in fact, there are savings there.

MR. DEXTER: This seems to be, in my mind at least, very contradictory because you have a system where you had four regional health boards, you had four administrations. You are now moving to nine district health authorities which apparently are going to have their own administrations in some form or other, nine district health authorities that are going to have to support numerous community health boards with administrative support, with enough funding to carry out what is an exhaustive list of undertakings under the Health Authorities Bill. Where are the administrative savings going to come from?

DR. WARD: At the level of the community health boards, the community health boards, in fact, are responsible for developing community health plans and for integrating activities at the community level. The community health boards themselves basically are not going to be in the business of managing anything. That is really the responsibility of district health authorities to meet the requirements under community health board plans.

At the level of the DHAs, or the district health authorities, very clearly we will have the opportunity to assist in prescribing what the administrative structure should look like. I do believe that we should be moving to a province-wide purchasing system. I do believe that we need to have a province-wide HR department on a strategy to manage all of those things and that the number of people you will require at the level of the DHA should be significantly less than we would currently be seeing in the regional health board piece.

MR. DEXTER: I am not sure that that answers my question entirely, but you said that you think that over a couple of years you might be able to find this much administrative savings. The reality is that $83 million is coming out of the system this year. So, if you don't find it this year, then my assumption is that it has to come out of the service delivery budget.

DR. WARD: The change we are seeing at the current time in the system is really a change from 8 organizations to 10. If you include the previous NDOs and the move to provincial health care centres, really the change is relatively minimal in that. The savings this year that we are looking at in the system really, a huge amount of that is administrative savings in that process of primarily the capital district of getting together with single administration, in the next little while. The bulk of those savings we have put into this year's business plan.

[8:30 a.m.]

MR. DEXTER: I guess you can appreciate that that is not what we are hearing. That is not what we are hearing from institutions. When you see dramatic results, like the cancellation of the Nutritional Support Program at the IWK-Grace; when you see the closing of the Well Woman's Clinic; when Mental Health Services in this province, which quite

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frankly have been underfunded for a long time, being hit because of the budget considerations, that is not administration. That is front-line care, that is health care workers who have a direct hand in the delivery of services to the people of this city and of this province.

I don't know what kind of a read the government is getting on it, but I can tell you right now that the read that is coming into my office every day is that people aren't happy about it. No amount of sitting here and wringing your hands and saying, we are going to be able to get this kind of savings over two years, is going to make people happy with these kinds of what, quite frankly, are Draconian cuts.

DR. WARD: In terms of the specifics that you brought forward, about the Nutritional Support Program, the Well Woman's Clinic, and the Mental Health Services portion of it, the Nutritional Support Program at the IWK-Grace - as you are aware the business plans have not been finalized or approved, and we are still in discussions with them - that is no longer an issue; that has been resolved; that has been taken off the table.

The Well Woman's Clinic is a primary care activity. It is being moved back to the community, and is being picked up in the Central Region by the Central Regional Health Board. The last issue, in terms of the mental health piece, we have received the mental health review. We are in the process of having a look at it, and I am sure that it will be released in the next little while. In it, there are a number of things, particularly around, again, integration, that we will be dealing with to try to improve services in that area.

MR. DEXTER: Let me start by saying that if you are saying that the Nutritional Support Program has been reinstituted - what you have said is that it was taken off the table, I assume that means one of two things. It means either the department has refused to allow that cut to go ahead or the alternative is what I heard yesterday, which was that some of those children who are going to lose that service were going to be admitted so that they wouldn't lose the service because they would be in-hospital. In my view, it is a terribly inefficient thing to do. Perhaps you can expand on what you meant by that.

DR. WARD: When I say it has been taken off the table, the discussion we have had with the IWK-Grace, we have come to an agreement that they are not going to be dropping the program.

MR. DEXTER: I said at the very beginning that my hope was that we could shame the government into making that happen, and I am pleased to see that that is the case. Quite frankly, I was amazed that the Minister of Health didn't stand on the day that that was announced, and say that he wasn't going to allow it to happen. I think it is a sad commentary on the minister's performance that that didn't happen at the time.

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You have said that the business plans have not yet been approved. I remember when this government was in Opposition, most of the players who are in Cabinet now sat in these seats less than one year ago. They said at the time that it was reasonable for budgets to be approved by February. We are into June, and the budgets have still not been approved. I would like to ask your opinion on it, is it reasonable to ask the health boards to carry out a proper planning exercise and then not deliver their budget until a quarter of their year is over?

DR. WARD: I guess my response would be, I think it is very reasonable to ask health boards to carry out a proper planning process. I would rather we carry out a proper planning process and delay meeting some deadline, than to arbitrarily say, here is the deadline, here is the budget. I would say, from my own experience in terms of this, one of the things we have done in the past year is that the department has worked very hard with its counterparts in the industry to talk about the whole budget-planning process, not only with respect to the health boards and the acute care piece, but really trying to look at the system, trying to understand that if we change something within the hospital sector, it will obviously have an impact. Do we need more long-term care beds, more home care to deal with it that way? That is a very interactive process.

The regional health boards and the current NDOs have brought forward their sense of what a business plan is. The department has been sitting down with those individuals, with people in the department to look at how that fits for the services across the province. It is not to arbitrarily say that there are various segments, here is a budget and go and do what you believe is appropriate. I think it has been a very positive process; I think it has been inordinately interactive; and I think that given my previous experience elsewhere I have been very pleased with that. My understanding is that in the past those types of activities didn't happen.

I think the fact that we are at least having a broad discussion and dialogue, not only with the acute-care providers but with long-term care, home care and others, is a very important and positive step in this. I believe we are all committed to doing it right, rather than just doing it.

MR. DEXTER: What you are saying sounds reasonable on first blush; in fact, dare I be so bold as to say they sound like self-evident truths? But in order to back that up there has to be some investment. You talked about some of the cost drivers in the system. You talked about the latest technology, new drugs, ageing population, length of life, there are others in this province changing diets, which have become less healthy, changes in active lifestyles, which in fact among men in this province, I understand, have actually declined rather than increased, and all of these things lead to increases in costs.

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So we know in advance that the costs are increasing. If you are taking money out of the system at the same time, then the system is suffering under both strains, increasing costs and decreasing budgets. How can you provide the level of service that is required under those circumstances?

DR. WARD: The department's responsibility in that is that we are provided an allocation from government. We need to work with the industry and the providers to come up with the best plan to use those resources effectively at the current time.

MR. DEXTER: That is a very different response than meeting the needs based on the actual situation that exists in health care in this province.

I know I only have a couple of minutes, but I want to pursue down this line. In other provinces there have been reviews of services. They went in and there have been consolidations, there have been mergers, and there have been hospital closures. But what they did is they went into the communities and they said the amount of money that is going to be allocated in your district is not going to decrease, if services come out of your community we are going to leave the money there and allow you to invest it in wellness promotion, in recreation services, in all of the ways that affect the determinants of health. That doesn't seem to be on the table here; if it is, I would like you to tell us, because that is certainly not the approach we have seen here.

DR. WARD: In fact, the sense that the approach across the country has been what I would describe as somewhat egalitarian, in the sense of going to communities and saying we are going to change your services but we are not going to touch the money, is absolutely wrong. Every jurisdiction in this country that has gone through a process of looking carefully at its system and restructuring it, changing the face of hospitals and others, much of it has been financially driven. The Capital Health Authority in Edmonton - when it moved to the Capital Health Authority - the first thing they did was take $200 million out.

At the current time, the types and level of services, in the last three or four years, it has improved significantly with that process. The issue about getting to integration, getting to a single board, to improving community based programs, and to pushing organizations to more community care and beginning to deal with the wellness and lifestyle things has, in fact, been effective in that area. But in fact the money was taken out, it was no different in British Columbia when we went through the process there, and it has been no different in Saskatchewan or Ontario or anywhere else.

MR. DEXTER: Well, I . . .

MR. CHAIRMAN: We are going to have to come back to that line of questioning, because the time for your first round has expired. We will now go to the Liberal caucus.

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The honourable member for Dartmouth East.

DR. JAMES SMITH: Mr. Chairman, deputy minister, Ms. Hall, Mr. Rafuse, usually when the past deputy minister came before the committee, it was at the request of the Opposition; this time it was at the request of the government. What do you see as your role here this morning, deputy, representing the administration of the Department of Health? Did you have discussions with the Premier and other members of the Premier's office prior to coming here, as to what the message might be? Who was your contact in the Premier's office, the representative of the Premier, prior to coming for this meeting this morning?

DR. WARD: I have not spoken with the Premier about being at Public Accounts prior to coming here.

DR. SMITH: Who is your contact in the Premier's Office, who would you work with, who is the deputy of the deputy you would be working with or do you answer to yourself alone? Who do you answer to, who do you see as your boss?

DR. WARD: I guess my reporting relationship is probably twofold. One of them is very clearly to the minister.

DR. SMITH: Pardon?

DR. WARD: One aspect of my reporting relationship very clearly is to the minister. I guess within the circle of deputies, I am in a working relationship, or a reporting relationship with, as you describe it, the deputy of deputies, and that is Dr. Ripley.

DR. SMITH: The business plans have been sort of mentioned here. Were they reviewed yesterday morning or any time yesterday by Cabinet that you are aware of, or in the last day or so, since Monday, by Cabinet, the business plans for what we used to call the regional health boards that don't exist now, they have been disbanded, but where the control has come back? The reason I want to be clear on this is because, as was mentioned, the regional health boards have been disbanded and so the governance of the health care system rests in your office and you are the person responsible for that. The status of the business plans, there has been some discussion. Have you made that presentation for the finalization of the business plans to P & P and/or the Cabinet within the last 24 to 48 hours?

DR. WARD: We provided Priorities and Planning with an update of where we are in the process yesterday morning.

DR. SMITH: Did you have any approval of those, any indication?


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DR. SMITH: They were sent back for further work?

DR. WARD: No. As we indicated at that point in time, we are in the final review ourselves. There are still issues for discussion with the various regions and NDOs with respect to aspects of the business plan. As I spoke to earlier, we view this very much as an iterative process and which is bilateral discussions as we are moving forward.

DR. SMITH: Would you say they are 99.9 per cent finished at this juncture?


DR. SMITH: About what percentage would they be if you could put a . . .

DR. WARD: I would think we are approximately 90 per cent to 95 per cent.

DR. SMITH: And does that involve the downsizing of any hospitals, as we know hospitals, into health centres, community centres, whatever? We heard a lot of words yesterday in the House during Question Period, a lot of vague terms being used but, for instance, you see the Lunenburg Hospital being downsized to a community centre with one or two beds floating around, as you mentioned, for observation or whatever. Do the plans at this juncture involve that?

DR. WARD: At the current time we are not anticipating the closure of any facilities.

DR. SMITH: With the downsizing from a hospital to a health centre, or whatever, those terms the government might choose to use, and I mentioned Roseway and Lunenburg mainly because I guess they are both on the South Shore in the western region, are there major changes in that hospital that would involve bed closures?

DR. WARD: We are not anticipating the closure of any facilities at the current time.

DR. SMITH: No, you are saying facilities, I am saying beds.

DR. WARD: You are saying beds, I am saying that we are still in the process of reviewing the business plans and until such time that the government, or the Cabinet, gives us approval one way or the other, I cannot . . .

DR. SMITH: Will you be briefing the Tory caucus or members of your staff in the next few hours today, tomorrow, in the next day or so, or have you briefed the Tory caucus on these business plans?

DR. WARD: Have I? No.

[Page 15]

DR. SMITH: Any members of your staff?

DR. WARD: I think members of our staff . . .

DR. SMITH: Or are they due to brief them within the next short while, the next day or so, or next few hours?

DR. WARD: Yes, I think they are in the process of discussing at a general level what the general sense of the business plans are and following this meeting I am going to the caucus to discuss the whole issue about what integrated community-based services is.

DR. SMITH: Okay, and that means different things to different people. Would there be the same number of nurses employed in the province in the acute care system following the business plans as there are right today? Do you see an increase, a decrease or status quo of nursing positions?

DR. WARD: We see no change in the nursing workforce in the province.

DR. SMITH: There will be no change, okay.

DR. WARD: I think, in fact, there will be opportunities for more nurses.

DR. SMITH: You are aware that during the election the now Premier said that the health care system was broken. It could be fixed for $46 million. This could all come out of administration and there would be no new money. Do you feel that is so, that you are able to do this out of administration without direct impact on patient care? I don't want to get into the formula thing because I know that can be fixed pretty easily, but the big problems are the system changes.

DR. WARD: To begin with, I am not aware that the Premier made any comments about $46 million.

DR. SMITH: I thought that travelled and that was national news, I thought that won an election.

DR. WARD: Well, it certainly did not make the other side of the country.

DR. SMITH: Well, we know how they are out there sometimes. Speaking of administration, there has been some concern about your office and even yourself. I don't want to make this personal, but we have to deal with the issues when there are statements like that. We see you do have an associate deputy minister. What is the salary of that person?

DR. WARD: I think it is about $110,000 a year.

[Page 16]

DR. SMITH: It is $110,000 for an associate deputy minister?

DR. WARD: Yes.

DR. SMITH: And then you have an assistant deputy?

DR. WARD: Bill Lahey has been with the department for a couple of years.

DR. SMITH: He certainly has and I am quite aware of Mr. Lahey. He is a good person. Is there any additional staff, like a coordinator or anything, coming into your office, or the minister's office?


DR. SMITH: There is no one like that coming in?


DR. SMITH: When do you think that the business plans might be finalized, deputy? We are two and one-half months now into the new year. I know you were a bit critical that the system had not worked before. I would accept that to some extent, but I think there were efforts in the last while to improve that where the caregivers and the decision makers had input. I support your moves toward that. When would the business plans be complete and when do you see this process coming to completion?

DR. WARD: We would like to be in the position of having our final sense of what they should be like, hopefully, by the end of this week or the start of next week.

DR. SMITH: Some people feel that this is being held up because the Legislative Assembly is in session. Have you had any discussions with anyone regarding that, about the timing of the release relative to the House of Assembly or is that just rumours that are so rampant throughout Nova Scotia sometimes?

DR. WARD: Rumours tend to be rampant in most places. With respect to the business plans I will go back to saying I am absolutely committed to making sure that, in fact, we do have a good final dialogue with the industry to make sure that we are all comfortable with the business plans. I think that that is absolutely important. I recognize the timing issues are very sensitive, but I will go back to say what I said earlier, it is absolutely important that we do it right rather than worry about meeting some type of an artificial deadline.

DR. SMITH: I would suggest that two and one-half months into the year is more than an artificial deadline. It might be really deadlines determined by someone else's agenda.

[Page 17]

There has been some concern in the Department of Health about the absentee rate. Have you had any discussion recently on that with regard to the staff itself, within the department? Has anybody brought anything like that to your attention?

DR. WARD: No, and in fact I am really quite puzzled by that.

DR. SMITH: I am just wondering . . .

DR. WARD: No, and in a quick conversation with our human resources people in-house, in fact, we don't understand what the comment is about but that is . . .

DR. SMITH: I am just asking because it is a very stressful job, these are very difficult times and we know, for instance, in the hospitals particularly, not necessarily in the Department of Health, it is a major issue. We continually hear this from the nurses, it is one of the real cost drivers within the system.

In regard to staff within the department, is that pretty well settled now or do you see any changes in the numbers of staff? We were talking about your office expanding, what about the staff at other levels within the Department of Health, are there any changes there? We have heard from other deputies who felt they were probably under-served or that the numbers were not adequate. Are there any changes coming within your department within the business plans of the department itself?

DR. WARD: In the sense of how the department is organized or aligned, I view that over the next while we will continue to realign some aspects of it very clearly, as we start to look at the department. Do I see any major changes in it? No, I think there is only one outstanding position and that is one, I believe, that is an absolute requirement and we are in the process of trying to find a chief information officer. I think one of the things you are well aware of from your time in practice, certainly as I am, is that the whole question about information, how it is managed in the system, is a huge problem. We really do need to have a strategy in the province to manage information and health care. We are in the process of trying to find some individual to provide us some leadership and direction in that area, but those individuals are inordinately rare across the country at the current time.

DR. SMITH: At the QE II, the waiting times in cardiac surgery, for instance, are they the same as they were or has there been improvement? What is the status of the waiting times in cardiac surgery in the last couple of months?

DR. WARD: At the current time they are at the lowest they have been in the last couple of years.

[Page 18]

DR. SMITH: So the waiting time for procedures is shorter, is that correct? If I hear someone is normally waiting six weeks for something that would normally take two weeks, that is just something within the system?

DR. WARD: I don't think you can generalize from one particular aspect of it. For cardiac surgery it is down. It may well be in some areas, depending on the availability of physician services, they may vacillate up and down.

DR. SMITH: I don't want to dwell on the issue of beds but we, as government, received quite a bit of criticism originally. Of course, as you mentioned in your comments, the beds per population were very high in this province relative to the rest of Canada, and still a reasonable average. There are some hospitals like Dartmouth, for instance, what do you see is the role of the Dartmouth General Hospital? Are you free to comment on that this morning? Are you prepared to mention any bed cutting or limitation of services that you see there?

DR. WARD: I can't really comment at the current time. I would say that really the issue within the metropolitan area is to get some smooth integration of all the facilities and the beds to provide optimal utilization.

DR. SMITH: Yesterday, the Leader of our Party spoke in the House and did not get an answer on the changing roles, and I am not sure if we got an answer here this morning. Are you saying there will be no closure of any hospitals, as we know them as hospitals, in the province as a result of the business plans? Did I understand you to have said that?

DR. WARD: What I said is that there will be no closure of any facilities in the province.

DR. SMITH: Will there be a change of role of hospitals as we know them - with beds - down to community centres? The role changing from a hospital - like the NDP did in Saskatchewan with 52 hospitals - changed down to community health centres?

DR. WARD: At the current time, business plans haven't been finalized and I am really not in the position to comment.

DR. SMITH: So you are not prepared to come here and be honest with us this morning?

DR. WARD: Quite frankly, Dr. Smith, until the government approves the business plan or until I am given an okay, I am not in a position to say yes or no.

DR. SMITH: I guess that goes back to my first comments about what you saw as your role here this morning because we do believe that things have been finalized and have been approved by government. We know pretty well, even with 90 per cent, what it is going

[Page 19]

to look like and we think there have been some dramatic changes. Have you, yourself, recommended these changes to government? Do you agree if there are five or six hospitals, as we know them, in rural coastal Nova Scotia communities and they are going to go down to community health centres, is that your recommendation? Are you the one who made the recommendation to government to do that? Do you stand by that, that is the way to go?

I realize you are a civil servant and you have responsibilities to your government, but it is your responsibility to come here this morning and put a good face on something that is going to be really very disruptive to these members going back to their communities on this weekend? And if you can't be open and honest with us, I understand that. This is not going to change from one day to the next. All of a sudden, it is something out there that is a piece of paper and then the next day it is reality.

DR. WARD: I guess from my sense of what you are saying is that I am not sure that you don't have a couple of things somehow or other intermingled. The business plans came forward from the regions and from the NDOs. They made the recommendations to the department, that is the process we are currently involved in, is having a look at what they say.

The second piece in all of this is the clinical footprint piece which everybody believes is a fait accompli somehow or other, is a process under way to look at the distribution of services across the province. It is a planning process, it is in process and absolutely no decision . . .

DR. SMITH: Did they all have access to the clinical services plan - to the footprint plan? Did people in the community have access to that or did these business plans keep going back and forth and saying, you are not conforming to the clinical services plan so you have to take this out or change this? Did they have complete access to what the department demands of them?

DR. WARD: No, two separate processes. The business planning process is the aspect of coming forward from the regions with how they would like to spend their money in the coming year. The clinical planning process is entirely separate from that.

DR. SMITH: Well, it is and it isn't. It is coming together very shortly and I think Nova Scotians should be aware of that and our concern is that it is out there, it is being delayed artificially and I was hoping by you coming here this morning and the government wanting you to come here that you would be the spokesperson and you would tell us what it will look like in this province. You can talk about integrated systems and Dr. Owen and all the others, but at the end of the day, Nova Scotians want to know what it is going to look like. Right now, there is a lot of fear and apprehension in the system. A lot of your CEOs that you have lectured to are not happy. It is a very unsettling time and it is two and one-half months into the new year. I realize that you don't have the freedom to be open with two and one-half

[Page 20]

months into the new year, but I realize that you can't come here and divulge these if the government decides to be secretive about it and I will end my questioning on that.

DR. WARD: My response to that is the business planning process, we are in the process of doing that. The clinical footprint piece, we are only partway through that and that is a very evidence-based, long-term process and once we begin to get some sort of a data base built, certainly that will be shared with everybody.

[9:00 a.m.]

MR. CHAIRMAN: We will turn things over now to the PC caucus.

To begin the questioning, the member for Kings South.

MR. DAVID MORSE: Mr. Chairman, I welcome Dr. Ward, Mr. Rafuse and Ms. Hall. I guess there was some insinuation that government had asked to have this put on the agenda. I was the one. I am very concerned about the sustainability of health care, education and everything in the province. I have witnessed for quite some number of years in Nova Scotia that government has not always seemed to be driven by a great sense of fiscal vision in the way that they roll out programs. In fact, I would say quite often, particularly in health care, things have been sort of willy-nilly. A department comes up with a suggestion or maybe there is someone particularly able out in a hospital or a region and they come up with a suggestion and the next thing you know it gets incorporated into the plan. Could you just comment as to how that fits in to the overall vision? Is this your perspective of what has gone on previously?

DR. WARD: In many ways, I think those are fair comments. One of the things I have seen in most health care systems across the country has been really that many of the decisions have been politically driven, in terms of distribution of resources and other activities. I think the biggest challenges I see at the current time are that everybody currently believes that the historical distribution somehow or other has been fair, appropriate, and right, when, in fact, in many cases if it was not evidence based or evidence driven but driven by some other thing, there may be huge inequities in the system, in the absence of having some formal analytical review of it.

The second thing I would say in all of it is that somehow or other there is a belief in all of this that every cent spent on health care is absolutely 100 per cent effective. Yet if we look at the literature around the world, very clearly, there are always opportunities to improve operating efficiencies and to make more effective use of those resources. There are things such as clinical practice guidelines, disease management programs focused at the community level, keeping patients out of hospital, and as Mr. Dexter pointed out, really beginning to deal with the determinants of health and the community-based issues.

[Page 21]

One of the really remarkable things about the system in this country is that we all understand what the determinants of health are. Departments of Health are always held accountable for them but the Departments of Health fund absolutely none of them. The issues of health around education, the economy, social housing, community policing, safety, all of those things, the infrastructure pieces, Health Departments don't control any of that.

The problem or the challenge for us as a department is that we really need to manage the resource piece that we currently have some responsibilities for but at the same point in time, engage all of the other partners in government to begin to deal with those things. Very clearly if we had safe communities and we had high standards of education and a very robust economy, one would assume that the general health of the population would be better. Those things aren't, unfortunately, in the purview of the Department of Health, so we will deal with the pieces we have.

Getting back to your original question about how resources do get distributed, I think really the clinical footprint planning process that we are currently undergoing is really an effort to try to get some absolute, firm evidence, good, solid data and come back out with some sense of what a reasonable distribution of those resources are across the province. I guess as an individual and in all the communities I have been to, listened to, and attended town hall meetings about, everybody has an anecdote about the fact that they don't have enough but somebody down the road has too much. I guess my response in those situations is, what happens if we take the resources from down the road and move them to your community? Does that mean the nurses have to come, do the doctors have to come?

I think rather than dealing with anecdotes and changing the system based on that, I think we really need to begin to look at the fundamentals of the structure of the system and it is not just hospital beds, as I have said before, it is the whole distribution of equipment, the health human resources piece - physicians, nurses and others across the system - but more importantly, it is access to ambulatory care programs, home care, long-term care beds, the whole alternate level of care piece, integration at the community level. Certainly the department in pushing forward with the single entry access piece, I think that is part of it, to help us deal with that, and that is really to begin to get a single entry for seniors into both long-term care and home care so that we have some coordination of that, but it is an inordinately complex system, absolutely inordinately complex, but we really are in the process I think of trying to get some solid sense of what the system looks like and then to begin to make some sense in terms of changing directions or strategies and dealing with it based on evidence and not anecdote.

MR. MORSE: I want to say that I look to you as the lead person in the department under the minister to bring some of that stability which has been so sorely missing from the Department of Health, by far and away the largest service that is provided by the provincial government. Getting back to my opening comment about why I brought this to the agenda, I should clarify that while I am a member of the PC caucus, I am not a member of Cabinet

[Page 22]

and, therefore, technically I am not part of the government-making body of Cabinet, but I am from Kings County and I want to tell you that under the previous government, I am not sure whether we had an inordinate disproportional amount of health care in Kings County before the previous government took power or we had, we will just say, a greatly reduced amount of health care in Kings County because back in 1993 at the change of government we had three hospitals. Shortly thereafter we had one.

I am not saying that one is not the right number or it is the right number, but I am concerned with the process and what greatly concerns me is that, as you have been speaking on today and as the minister has many times before, there is some sort of equitable way of distributing scarce health care resources. I am not looking for Kings County, and I am speaking parochially here now, to have any more than any other part of the province, I just want it to be driven in some sort of equitable fashion and to that regard we get into the question of sustainability. From there we get into business plans and I understand that this business planning process is something that is new to the province and that I would like you to take a little time to go through how these business plans are generated from the community health boards, or will be generated from the community health boards through the district health authorities, and then ultimately the Department of Health and the back and forth because this is critical to the community having input into the formation of their health care services, but also in making sure that we are able to sustain them. Could you give us your thoughts on that topic?

DR. WARD: I guess my response really needs to focus on three aspects and that is what was historically, or at least my understanding of the history in the province, what the process is currently today and what we see as being the future process. My sense of the past has been that previously business plans were sent in by RHBs and NDOs, taken into the department. The department made some decisions and just sent a letter back out saying, fine, here, do this.

This time out I am very aware that we are really talking about a system and I think that it is only appropriate that all the players in the system have an opportunity to participate in the budgeting or business planning process. To that end we really started earlier this year in January meeting with the CEOs from regional health boards, the NDOs, as well as inviting people in from long-term care and home care, both private providers and others, to sit down and talk about the process of business planning, that we really needed to have a thoughtful, integrated approach because very clearly some change in the acute care sector could impact the other. Those types of things were not really discussed in the past. Certainly in that process the CEOs and people from the various sectors I think were very pleased at having the opportunity to actually participate in the process. It was something they had not seen in the past and it was a big change.

[Page 23]

For me it is important, we are all in the system for the same reason and that is to try to provide the best services to the public within the resources we have available. I guess the issue is where are we going to be next year and where are we going to be when we are in a new system of DHAs and community health boards. My current sense of how that should really be working is that we do need to deal with the accountability piece in all of this. The DHAs will be receiving from community health boards a community health plan, what the community expects it needs in terms of services, and we are going to be asking the DHAs to try to meet all of those needs within the resources they are going to be provided.

At the same point in time within the department we will have access to those community health plans and to the DHAs' plans so that in some sense the DHA is accountable back to the community for the provision of services, but is also accountable to the department so that we understand that those services are going to be met. The biggest difficulty or the biggest challenge we are going to have in all of that is really coming to some sense of funding the DHAs over the next little while.

If we were in an absolutely good system, we would have in fact some sort of per capita funding methodology that was weighted for the burden of illness in a community; in fact, it was reflective of the burden of illness in the community and the population so that, in fact, there was a fair and equitable distribution of resources. We don't have that at the current time. That is where I would like to be. That is certainly where I would like to see us in about three or four years from now.

The issues about changing or altering the system, or revitalizing it, or transforming it, or whatever you want to do, it is not like this. It is a long process. It is a three, or four, or five year process. When I took this particular job - and I know I have sort of been thrashed a little bit, unfortunately, I was not here when I was first being thrashed about - one of the things I was very clear on is that if I took on the responsibility of providing some direction in the system, that it was really a five year job. It was not a one year job. One of the biggest problems in the system across the country is the lack of continuity in anything and that is particularly true in Health Departments and in terms of the leadership in departments.

As you are aware, in the department here, I am sort of the latest in a fairly long line of deputies over the last number of years but, more remarkably, when I joined the national corps of deputies at the first part of November, I was at the bottom of the seniority list. I am now seven months into the job, and out of 13, I am number four in terms of seniority as of today. That, quite frankly, does not speak well of the view of the system and at least its leadership through departments and Ministries of Health across the country. I think stability is absolutely important in all of this. I think some sense of a vision about what the system needs to look like in order to assure sustainability and to provide services to the public is an absolute must and I really think that that is what my job is most of all in all of this. It is really to provide that direction and that leadership and to try to get people to understand what all

[Page 24]

that is about. I was not brought in to manage hospitals or to manage clinics or do any of that stuff. I really believe my role and responsibility is to provide that leadership.

MR. MORSE: Dr. Ward, I was hoping you were going to touch on your commitment for the five years and given the number of Health Deputy Ministers that we have gone through in Nova Scotia over the past six years, it is no surprise that there has been no cohesive integrated decision-making system that is trying to bring some semblance of fiscal sanity to our largest provincial program and I agree that it is absolutely critical to have that stability in order to secure the future delivery of sustainable health care and that is not only critical in the health care field, but it is critical for all the provincial programs we deliver because health care consumes such a disproportionate amount of the budget. Your talk of a future funding formula which is based on evidence is certainly welcome news to me and I would think that it should be welcome news to Nova Scotians. With that I am going to ask to pass over to Mr. Barnet.

MR. CHAIRMAN: The honourable member for Sackville-Beaver Bank, you have just a little over five minutes.

MR. BARRY BARNET: Five minutes left, that will actually change the direction that I want to go. To shift gears to some extent, let me be a little bit parochial. I want to ask a question surrounding the Cobequid Multi-Service Centre. As you may or may not be aware, the Cobequid Multi-Service Centre is undergoing the planning process for new construction for replacement of that facility. There is a site selection process that has begun. There has been some community involvement. The Cobequid Multi-Service Centre, albeit not a hospital, it provides medical services such as diagnostic, emergency care, clinics, those types of things; it doesn't have beds, but it does provide well-needed and well-used medical services. Dr. Ward, could you tell this committee where that process is and when we can expect, in the communities surrounding the Cobequid Multi-Service Centre, to see that new facility up and running and operational to provide the services that are needed?

DR. WARD: I think that you are aware the site selection and planning process is currently under way. The department has $2.5 million set aside for the continuation of that process; the capital construction costs are in our long-range capital planning piece. We are really looking forward to seeing the development of the new site. I think that particular centre for me as a centre is really the type of centre that I would like to see elsewhere in the metropolitan area. I think, as we are aware, one of the issues that really seems to come out from the public is the whole issue of emergency departments and waits.

The system at the current time - I am going to come back to the health human resource piece and physicians - many family practitioners choose to run regular office hours, 9:00 a.m. to 5:00 p.m., five days a week, and choose not to provide after-hours services and everybody ends up in the emergency departments. Emergency departments are meant to treat emergencies. We really need some other resource to meet the needs of the public in the off-

[Page 25]

hours, be it evenings or weekends, and centres such as the Cobequid Multi-Service Centre, for me, are the answer to that. They are community based, they are community focused, and they provide access to diagnosis and treatment on an ambulatory basis, an absolutely wonderful site to run long-term ambulatory care programs and disease focus programs. I was really excited about the diabetic management program at the Cobequid site. I think that is just a fantastic process and I really think that is the type of integration that we need to be seeing across the system in every community.

The centre is also very important in that it is the focus or the entry site to the system. Very clearly, if somebody needs additional diagnostic treatment or care or access to a hospital bed or a surgeon or a referral, it is done through that; the same is true for addiction or mental health. I really think that conceptually for me is really a pièce de résistance in the system in Nova Scotia.

MR. BARNET: That is good news; I am pleased to hear that. I think that quite frankly the approach that the Cobequid Multi-Service Centre uses - and I am sure the Chair would agree - is the kind of approach that would benefit the entire Province of Nova Scotia.

I am going to shift gears one more time. My next question is concerning nurse practitioners. We have pilot projects under way in this province, and I have been approached by members of the nursing profession who have indicated to me that they feel this is the kind of direction that the province should be going in terms of how we expand our valuable health dollars. My question to you is, the progress of this particular pilot project, how is that proceeding, and when can we see this move into actual health care provision for other areas in the Province of Nova Scotia?

DR. WARD: At the current time there are four pilot projects funded in the province by the Health Transition Fund to look at the role of nurse practitioners in community based care. Those programs should be up and running this fall. That is a three-year period with assessment at the end of it. Jumping ahead, I think you will see a move across the country to expanding the numbers and roles of nurse practitioners in many settings in the next year or two.

MR. CHAIRMAN: Maybe stop there and come back. We have enough time for 12-minute rounds, if that is suitable for everybody. Okay, to the NDP caucus, for 12 minutes.

MR. DEXTER: Thank you, Mr. Chairman. I just very briefly want to remind the member for Kings South that he indeed is a member of the government. If he hasn't dusted off his civics textbooks since Grade 10, maybe he should have another look at it. His vote in favour of the budget counted every bit as much as the vote of the Minister of Health and he should remember that. I would remind him as well, and if Dr. Ward hasn't heard this before, the member for Kings South said that they would be building scaffolds in front of the local hospital once they had an opportunity to look at what was going to happen in health care in

[Page 26]

his community. I guess my question is, are you meeting with the Tory caucus to tell them just how high the scaffolds are going to be?


MR. DEXTER: I say that tongue-in-cheek, but I must say it does astound me that you or your staff are taking the time to meet with the Conservative caucus at an in camera meeting. You said it was to brief them on integrated community - you want me to stop there?

DR. WARD: Quite frankly, I think the entire issue of the system and understanding where the demand is, which is really at the community interface level, with agreement with the minister, my plan is to speak to the PC caucus about that. I have also asked for the opportunity to speak to both your caucus and the Liberal caucus. I don't think there should be any secrets about this. We are really talking about the system of the future. It is a system which, in every publicly-funded system across the world, is really moving to the concept of integration at the community level and management at the community level. I think it is only fair that everybody who has a role to play in this, that includes yourself and others, understand that, and understands what I am talking about and where I think the system is going. I don't think there is any secret about it.

MR. DEXTER: That was exactly my next question. What is it that you or your staff are going to tell the PC caucus that the people of Nova Scotia can't know?

DR. WARD: I don't think anything.

MR. DEXTER: You are not intending to brief them on the existing business plans or the decisions of the government with respect to the business plans of the health boards and NDOs.

DR. WARD: Am I? No.

MR. DEXTER: Or staff?

DR. WARD: The staff are reviewing the current status of the business plans.

MR. DEXTER: Is that the information you are going to be giving to the PC caucus?


MR. DEXTER: Your staff?

DR. WARD: The current status of the business plans, the same response as to Dr. Smith, where are we at? Yes.

[Page 27]

MR. DEXTER: I don't want to put too fine a point on this, but this is our only opportunity, and you said you weren't here when you were being thrashed, initially. Well you are here now, and not to put too fine a point on it, but I think, really, this is our first opportunity to have an interaction with you, and I say to you in all good faith that your credibility is something we are all going to be examining, as are the people of Nova Scotia. If we can't get a straight answer out of you about something as simple as the reason why you are meeting with the PC caucus and whether or not you are going to be divulging to them the results of your review of the business plans of the various health authorities, then I suggest to you that your credibility is going to take quite a thrashing. Are you not prepared to say whether or not you are going to be divulging the results of the business plans of the NDOs?

DR. WARD: I will go back to say what I said originally, Mr. Dexter. The current process is for the staff to brief the PC caucus on the current status of the business-planning process.

MR. DEXTER: Earlier on you used what I think is quite an unfortunate example, you used the Edmonton example. What we have seen happening in Alberta over the last number of years, in fact, is an undermining of the public system to a degree that is not seen elsewhere in this country. You have private clinics, you now have provisions under Bill No. 11 for private hospitals. To say the very least, it is at the forefront of privatization initiatives in this country. Is that what you foresee for Nova Scotia?

DR. WARD: Absolutely not. I would just point out that there are a couple of processes involved separately in terms of your comments. The first one is the move to an integrated Capital Health Authority in Edmonton, the results have been very spectacular in terms of the programs. There are some programs that are now being recognized around the world as being on the leading edge in terms of the delivery of services. The recent health care survey in Macleans Magazine ranks Edmonton number one, ahead of everybody else.

The Bill No. 11 piece, for me and for most of us, is really much more a political piece. That is a government that is really trying to get the attention of the federal government around an issue. I think there is the issue nationally, at the current time, about how to engage the federal government in responding to the growing issue around the sustainability of the system and the need for the federal government to get back to the table to become a full partner in it again.

The issue about moving to two-tiered or private clinics, or any of that stuff, the answer is absolutely not.

MR. DEXTER: You have said that those issues were the political piece. Isn't the decision to move from regional health boards to district health authorities just a political piece?

[Page 28]

DR. WARD: The decision to move from regional health boards to district health authorities is a decision to move to a different organizational structure.

MR. DEXTER: That was a political decision, right?

DR. WARD: It was a decision made by the government.

MR. DEXTER: You can say yes. It is okay.

DR. WARD: Yes, it was a decision made by the current government.

MR. DEXTER: One of the things that we have been watching and trying to figure out over the past eight months is just exactly what the commitment of this government was to community-based decision making in health care. I brought up to you earlier the whole question of community health boards, and you said, well, it is not our intention that community health boards would manage anything or administer anything, but the provisions within this Act have a long list, including the construction of a community profile. It is going to take people, volunteers and I suggest to you they are going to require administrative support to do that. They are there to manage or assist in the management of community development grants on behalf of the minister or the district health authority. There is quite an exhaustive list of what it is that these community health boards are supposed to be doing. I don't think you can suggest that there isn't going to be a cost involved with running the community health boards. Is that fair?

DR. WARD: That is fair.

MR. DEXTER: There is a cost involved in the running each of the nine district health authorities.

DR. WARD: Yes.

MR. DEXTER: Where, in an administrative sense, are the savings coming in administration, when you have set up this kind of a system? You have gone from four to nine.

DR. WARD: We have gone from four regions to nine DHAs. We have gone from four NDOs down to two. There have been some other structural changes. At the community health level, I am going to come back and talk about the fact that if you look at that exhaustive list, it really involves many of the other departments of government and is around determinants of health. There are opportunities within that for other government departments and staff to participate in the support at the community level. It is really the integration of many activities of various government departments and agencies.

[Page 29]

The second piece is that much of the data sets or information required for community health boards will be provided by the Department of Health from information we currently have. The third piece is that direct support for community health boards is part of our expectations of each DHA.

MR. DEXTER: I am not exactly sure how much time I have left, so I am going to ask a couple of short-snapper questions.

DR. WARD: Short snappers, do I get 100 points for each one?

MR. DEXTER: The new Associate Deputy Minister of Health, where is she from?

DR. WARD: Her previous site of employment was in British Columbia; prior to that she was in regional health in St. John's.

MR. DEXTER: Can you tell us very briefly what qualifications she has?

DR. WARD: She has been in the industry or in the business for a long time. She originally graduated as a nurse, worked her way up through senior management positions, and was the Director of Planning and Operations in St. John's for that particular region for a number of years. She then moved from that point to be the Chief Operating Officer in the South Fraser District for an area called Surrey; again, it was an all-in program, public health, long-term care, home care, acute care, all in one package.

MR. DEXTER: Did you work with her in B.C.?

DR. WARD: No, our paths had never crossed.

MR. DEXTER: It was a logical question. What is it that she is going to do?

DR. WARD: She has been brought in primarily to oversee the clinical aspects of the department in the sense of the clinical programming piece and it is really the issue for the clinical service activities, the integration of long-term care, home care, how public health, addiction services and mental health, will roll out under the DHAs.

[9:30 a.m.]

MR. DEXTER: I was just handed a note here and it says that so far as our caucus staff is concerned there have been no requests to our caucus for you to meet with us, at least at this point. Can you confirm whether or not, in fact, a request has been made to our caucus to meet with us?

[Page 30]

DR. WARD: I will look at the person who I had asked to do that. It is either this or this. It has not happened as yet. I would love to come and talk . . .

MR. DEXTER: The mental health review is finished?

DR. WARD: Yes.

MR. DEXTER: Why is it not being released?

DR. WARD: At the current time it has been provided to the minister. We are in the process of reviewing the recommendations. I look forward to the release in the next few days.

MR. DEXTER: Any reason why it could not be released today?

DR. WARD: The biggest issue is to get enough copies printed in the next little while.

MR. DEXTER: Well, you give it to us and we will copy them.

MR. CHAIRMAN: I will turn it over now to the Liberal caucus.

MR. RUSSELL MACKINNON: Dr. Ward, I noticed during budget deliberations you were not in attendance at any point in time. Was there any particular reason?

DR. WARD: Very simply, from my viewpoint, the important aspects of that particular process relate to finances. That would be Mr. Rafuse and specific questions about small communities and other things, having been in the province for only three or four months, I really did not have the knowledge base where I thought I could be effective in contributing and supporting the minister in that.

MR. MACKINNON: So you did not see a need to participate in the budget deliberations, is that what you are telling us?

DR. WARD: No. What I said was that in that process there are two support people allowed to sit beside the minister, to support him in that process. After discussing it, the agreement was the best two people to provide him that support were Mr. Rafuse and Ms. Hall.

MR. MACKINNON: What did you do during that particular point in time?

DR. WARD: What did I do?

MR. MACKINNON: As an employee of the department?

[Page 31]

DR. WARD: I carried on with my regular activities with my cell phone in my pocket.

MR. MACKINNON: In province?

DR. WARD: I believe I was away for some parts of it.

MR. MACKINNON: Parts, how many trips have you taken out of province since you became deputy minister?

DR. WARD: There have been a number related to federal-provincial . . .

MR. MACKINNON: If you can give me numbers, how many?

DR. WARD: Four or five.

MR. MACKINNON: I see, and were they all related specifically to health care in Nova Scotia or was it kind of an integrated approach, health care, as you indicated, to your positioning on the national level?

DR. WARD: By far all of them have been related to health care.

MR. MACKINNON: I see. When my colleague, Dr. Smith, asked you about the business plans and your recommendation to Cabinet being complete, you said they were not complete. He indicated, was it true that they were 99.9 per cent complete and you indicated, no, they were 99.5 per cent complete. Essentially everything is completed. You have brought it before P & P and the issue also that he raised in terms of rolling this out and making it public, you did not really answer the question. Is there any reason that this has not been released to date before the House rises?

DR. WARD: A bit of a correction, what I had said to Dr. Smith was the business plans were some place between 90 per cent to 95 per cent complete, not 99.5 per cent. We are still in discussion with at least two organizations with respect to their business plans.

MR. MACKINNON: I guess, quite pointedly, and you still did not answer the question to either of my two colleagues, what is your recommendation? Is it your recommendation that these particular hospitals, such as Lunenburg, Roseway, Shelburne, Tatamagouche, Pugwash, Parrsboro, Sherbrooke and Canso be downgraded to community health centres?


MR. MACKINNON: Is it a recommendation from anybody within the Department of Health?

[Page 32]


MR. WILLIAM LANGILLE: Mr. Chairman, on a point of order. Public Accounts Committee is for value for dollar. He is going completely into the future on this and I would ask that he get back to what we are discussing.

MR. CHAIRMAN: I will, in fact, rule that that is a point of order that is valid because we are supposed to be dealing with expenditures. So I would ask the member to please come back to that.

MR. MACKINNON: Thank you, Mr. Chairman, that helps me even more because it goes back to the budget which is past tense because it has been approved in that context. If somebody were to suggest to you, Dr. Ward, that they could correct the problems in health care by eliminating $46 million of waste in administration and directing that into patient care, would you agree with that assessment based on your knowledge of the department and health care?

DR. WARD: Could you repeat . . .

MR. MACKINNON: If somebody were to suggest to you that they could eliminate $46 million of waste in the department and correct the problems in health care, would you agree with that assessment as it stands today, a simple yes or no?

DR. WARD: It is not a question that can be answered with a simple yes or no. You are really talking about whether there are opportunities to identify operating efficiencies in the system and redirect resources towards patient care. The answer is yes. That is true for every system.

MR. MACKINNON: Well, let's be clear. We have seen somewhere in excess of $80 million reduction in the budget this year that was approved earlier in this session of the House. That would suggest that that $46 million figure was not accurate, am I correct?

DR. WARD: Within that is that number, again, I will come back to the $46 million that seems to be floating up from some place, I really have not . . .

MR. MACKINNON: Regardless of where it came from, never mind the source, $46 million versus $80 million or $87 million, which would be a more accurate figure to reflect upon in addressing the problems in health care?

DR. WARD: With respect to the changes in the current budgetary cycle, very clearly there were significant savings of one-time costs around Y2K which were approximately $50 million. There are other operating efficiencies within the system that we believe we can find.

[Page 33]

MR. MACKINNON: But you have not answered my question.

DR. WARD: Is it specifically $46 million?


DR. WARD: I cannot answer that.

MR. MACKINNON: So you don't know if a $46 million additional injection of revenue into the Department of Health by changing things around and making things better in administration, more cost-effective and so on, would address the needs in health care. Is that what you are telling us?

DR. WARD: It will it address some of the needs . . .

MR. MACKINNON: But not all of them?

DR. WARD: . . . but there are other operating efficiencies to be found, I think it is very much . . .

MR. MACKINNON: On a percentage basis, Dr. Ward, how would you assess that $46 million from what you know of the department to date?

DR. WARD: Is it possible? Absolutely.

MR. MACKINNON: Forty-six million dollars of additional revenue would correct the problems in health care?

DR. WARD: Will it correct the problems in health care?

MR. MACKINNON: The major problems?


MR. MACKINNON: No, okay.

DR. WARD: I think that when you say major problems, I should probably respond by saying I think there are two or three things in that. One of them very clearly is the issue of a capital deficit and that is simply issues about replacement of buildings in the long term, replacement of equipment and stuff, that is a national problem. I think there are other issues in terms of changing some patterns of practice. It is developing and supporting information systems so that we can, in fact, . . .

[Page 34]

MR. MACKINNON: Excuse me, doctor, if I may, through you, Mr. Chairman, I don't want to get off on rabbit tracks. I am talking directly about dollars that are going into administration versus what can be put directly into the front lines for patient care. That is what I was referring to. Your indication is, no, that wouldn't necessarily address the problem. There would have to be other factors.

MR. WARD: Yes.

MR. MACKINNON: The community health boards, you indicated, there seems to be a bit of a misunderstanding as to a community health board versus the regional health board. Under the present legislation providing for regional health boards, there is a provision in that Act that allows for community health boards, you are aware of that?

DR. WARD: Yes.

MR. MACKINNON: What would be the significant difference between that Act and the proposed piece of legislation in terms of autonomy at the community level? Would you be able to determine various health care issues in terms of finance, administration, capital and so on? If you can give us a thumbnail sketch of that.

DR. WARD: At the current time, the community health boards really are autonomous but do not have any sense of influence I think in the system. I don't think there is any clear sense of accountability related to the communities. My sense of the new Act that is being put in place is that we are beginning to deal with the accountability piece and that is done on a twofold basis. One of them is that the system has to respond to the issues and needs of the community. There is in the Act the opportunity for every community health board to elect or appoint a member to the district health authority board of governance. That in fact they will have a voice at that level.

The second piece we have talked about very clearly is that the district health authority must look at the community health board plans . . .

MR. MACKINNON: The major issue, Dr. Ward is the issue of financial accountability. Those decisions are made at your level, is that not correct? Under the new proposal?

DR. WARD: The decisions for the communities? No, they will be made at the level of DHA.

MR. MACKINNON: Well then I guess we are reading the legislation a little differently than you are, but at this point, I will pass it over to my colleague.

MR. CHAIRMAN: Okay, just slightly over a minute.

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DR. SMITH: I will be very brief. A couple of questions. We talked about the $46 million promised that the deputy wasn't aware of, but were you aware of any of the other Tory Party promises during the last election, deputy? Were you aware of any of the other Tory Party promises during the election on health care?

DR. WARD: Were or am I? Before I came, no. When I got here, yes.

DR. SMITH: After?

DR. WARD: Yes.

DR. SMITH: Okay. The facilities review report that we had and you spoke about and continue to hear from your minister that all of this is good for us, it is in the best interest of everyone to go through these business plans and what we perceive will be major changes, but how do you see the continuum of care being met in the community, particularly with what is probably a 10 per cent cutback in home care? Is that part of your vision and is that your recommendation?

MR. CHAIRMAN: Okay, there is only 15 seconds.

DR. WARD: Very quickly, the facilities review process, you talked about the need for alternate types of care in the community. A 10 per cent cutback on home care, we are currently in discussion with the VON with a view to significantly altering our relationship, but with very much an increased opportunity for productivity. More services for the same amount of money.

MR. CHAIRMAN: Thank you very much. Now I will turn it over to the PC caucus. The member for Preston for 12 minutes.

MR. DAVID HENDSBEE: First, I wish to make a comment about the Opposition's incredulous speculations of this so-called deliberate delaying of the business plans. They are nothing more than asinine assumptions, making the accusation that we are keeping a secret from the House I think is ludicrous. If you look at the document, Future Direction of the Health Care System provided eight months ago, November 1st, it says right there on Page 12 on what the preparation of budgets and business plans, that the transition teams develop business plans, starting in April and finishing July 1st.

I think we are pretty well on target there within three weeks of that target date. The preliminary budgets for DHAs will be July 1st. I would think that we are right on target, regardless of the time-frames and I think that the department and the deputy minister should be congratulated for staying on that time-frame.

[Page 36]

You stated earlier, if you fail to plan then you plan to fail. I think you are right about making sure we get off on the right foot with these things.

I would like to further the questioning that the honourable member for Cape Breton West started. My experience from being on the Dartmouth General Hospital Board and seeing what happened to the local hospitals - be it the Cobequid Multi-Service Centre; the Twin Oaks Memorial Hospital in Sheet Harbour, the Eastern Shore Memorial Hospital - over the last few years, after the regional health boards came in, those operations were traditionally running on budget, without any deficits, or if they were, very marginal, but they ran up significant deficits. What happened during that time-frame and how is this legislation going to be fundamentally different than that?

DR. WARD: I think the biggest piece in all of that, is that we are really setting out very clearly that we expect the DHAs to live within their budgets. In the past, certainly my sense of it is that organizations have run up deficits, that no measures were taken to either look at the organizations or operations and deal with that. I think the Auditor General has made it clear in his comments in the past that we really do need to get to some sense of financial accountability. That really means asking organizations to live within the resources they have.

MR. HENDSBEE: Also to follow up on the comments about the Auditor General's Report, I know quite a few recommendations that he had in his 1999 report appear to be included within our legislation. Could you make some further comment about the accountability and the fiscal control that this new district health authority is going to have over the local facilities?

DR. WARD: I think as we are going through this evolution and transition to district health authorities, a couple of things are very clear in this. The integration and discussions around business plans and the process between the department and current RHBs and the new DHAs is important. The legislation very clearly sets out the issues around financial accountability in the sense of living within your resources. Any organization, as a result of a transition or a change in process, that may need to deficit for a year, it must be approved by the department, with a clear understanding it will be made up within the next year. We are not going to get into the process of having organizations continually running up deficits on a regular basis, and in fact to acquire a fairly large debt. You just can't do that in the system.

MR. MACKINNON: On a point of order, I think what applies to one member really should apply to other members of the committee, and that is that if I am precluded from dealing with future matters before the committee, I would suspect that is the same issue for members of the Conservative caucus.

MR. CHAIRMAN: My understanding, unless I heard it incorrectly, was that the question certainly started off, at least, dealing with past practices and in terms of past

[Page 37]

expenditures, although the answer was not necessarily. Maybe we will go back to the member for Preston, keeping in mind there has been a little bit of latitude given to all questioners so far on that issue.

MR. HENDSBEE: At least I don't have staff coming in and passing me notes and whispering in my ear about certain questions.

MR. CHAIRMAN: We will talk about that later, too.

MR. HENDSBEE: Thank you very much. With the delivery of services here in the metro region or the central capital region, this is the only territorial area that has not been adjusted in its boundaries, from the regional health boards to the district health authorities. Could you relate how the outer facilities, outside downtown Halifax, how they are going to be able to operate within this new jurisdiction, this new floor plan versus what they had done or not done in the regional plan?

MR. CHAIRMAN: Can you rephrase that in a manner that is within the mandate of the committee?

MR. HENDSBEE: Why weren't the facilities outside of metro able to be a part of the overall health delivery systems under the regional health authority? Why wasn't there any integration under the previous legislation?

DR. WARD: I guess the biggest challenge in all of that was very simple. Within the capital district there was not only the capital regional health board but also three independent organizations providing both primary and secondary care services. The fundamental issue was the integration of all of those entities into a single thing.

One of the things we are trying to do under the new legislation is really to try to get some sense of integration at least at a senior level by moving toward a single board of governance for at least three of those organizations. That is really from our viewpoint, the opportunity to ask that board as part of its mandate to really deal with the issue of the integration of all of those organizations so that there is some sense of flow across the continuum of care, whether it is from the outlying communities such as Musquodoboit Harbour or any of those other areas, as well as issues within the metropolitan area, particularly for areas such as the Dartmouth General and the QE II with respect to integration of services.

MR. HENDSBEE: I would like to pass the remainder of my time to my colleague, the honourable member for Sackville-Beaver Bank.

MR. BARNET: Mr. Chairman, do the presenters have the same briefing book that we have? (Interruption) Okay.

[Page 38]

In the briefing book there was a page that actually intrigued me, I should say interested me greatly, and probably would interest most Nova Scotians. It was Nova Scotia's listing of the National Health Expenditure database. Quite frankly, I was a little bit surprised - I shouldn't say completely surprised but a little bit surprised - at some of the figures on this page. What this does is it actually breaks down the expenditures of health care in different categories from 1975 right through to 1999. This particular piece of information shows that incrementally, year after year, from 1975 right through to 1999, we have seen increases in health care expenditures - 15.4 percent, 6.1 per cent, 10.0 per cent, 10.9 per cent, and it goes on and on.

I guess my question is that it seems evident to me from stories we have heard in this House, from stories I have heard from constituents that, although we have increased expenditures in health care, year after year for at least 25 years - and who knows what we did before that - the people of Nova Scotia don't feel or don't believe that they are getting healthier or getting a better health care system. We have heard stories here as recently as a couple of days ago. My question is, how can this business planning process and the development of a clinical footprint, improve value for dollars and improve the health care system in the Province of Nova Scotia?

DR. WARD: The current business planning process I think really is the beginning step of an integration of the services and the funding across the system. It is really the beginning of the dialogue between the providers of long-term care, home care, and the acute care sector, in sitting down together to figure out how we can thoughtfully provide better services and access to the citizens of Nova Scotia within the resources available. As we move forward in the planning process, it is really again, gathering evidence so that we can make some thoughtful decisions about the distribution of services across the province to ensure there is fair and equitable access for Nova Scotians to core services, and that in fact we are improving the value for dollars.

The important piece in all of that really is that we can deal with some of the other issues that Mr. Dexter raised, and that is really to begin to deal with the wellness piece of it. Very clearly, we do need to emphasize that. Nova Scotians have a very high incidence of tobacco use. We need to get out in front of those types of problems. We do need to deal with the issues of lifestyle and get people more active. It really has to be a multi-pronged approach across the system. I think the other important piece in all of it in terms of looking towards the future is that every year that we are required to put more and more funding into the system, we are really, in fact, losing opportunities elsewhere. The more dollars that are really required to go into the health care system are dollars that could potentially go into infrastructure, education and other areas. I guess the biggest challenge for any government is to try to find a balance across that to deal with those issues.

[Page 39]

MR. BARNET: I am going to shift base just a little bit. Recently the government made a decision to realign ministerial responsibilities into the future. One of the decisions they made was to put the sport and recreation commission responsibility with the Minister of Health, and do you see that as a positive step?

MR. CHAIRMAN: With the committee's approval, I certainly am prepared to allow it to stand because it is going into the future, others have done the same thing. Go ahead.

MR. BARNET: That is the question. Do you see it as a positive step?

DR. WARD: Do I think it is a very important piece? Again, we are getting back to the wellness lifestyle issues that we talked about previously. The integration of those activities within the department, looking at community lifestyles and health promotion are absolutely a very positive step from our viewpoint.

MR. CHAIRMAN: The time has expired. On behalf of the committee I would like to thank Dr. Ward, Mr. Rafuse and Ms. Hall for the presentation here today. Thank you very much. Before we adjourn, there are a couple of things, briefly. The member for Kings South.

MR. MORSE: Mr. Chairman, I see that the Pharmacare Program is down for next week. After discussing, previously to this meeting with my caucus colleagues, we would like, in view of the fact that the House is likely soon going to rise and in view of the fact that a lot of us have some time we would like to spend back in our constituencies, to put this off for a couple of weeks and thereafter that will be the last Public Accounts Committee session until after the summer and in so doing, I would move all this and that we delete all the other topics that have been approved for the agenda. We could discuss that as we come closer to resuming the sessions.

MR. CHAIRMAN: If I could and just to interject, first of all there are a couple of meetings planned right now. There is the meeting on Pharmacare, and there is going to need to be one more meeting to discuss the conference this fall. That one is tentatively planned for two weeks from today, the one to plan the conference. I thought it was the understanding or the agreement of the committee when we had our session in dealing with planning, we itemized a whole series of individuals and groups we wanted to bring in and that we had at that time agreed to proceed with these and then to hold the others off until the fall. Not to cancel, but the meetings would then resume again in the fall, and that we had a list of topics and presenters for the fall session. The member for Dartmouth-Cole Harbour has his hand up as well to respond.

MR. DEXTER: Well, just to say that I am opposed to this motion. This meeting has been set, witnesses have been contacted. The history of the Public Accounts Committee, at least as long as I have been on it which is since I was elected in March 1998, was that we met regularly. In fact last time we met through the summer, we all have obligations in our

[Page 40]

constituencies, but the Public Accounts Committee is, I would dare say, one of the most important committees that this House has. It is one of the few opportunities we have to examine programs and program initiatives and to ferret out the information that comes before the public, and I really think it would be hugely inappropriate at this point to cancel the Public Accounts Committee for next week.

MR. CHAIRMAN: Maybe it is inappropriate for the Chairman to make the observation, but I guess my observation would be twofold. One is that I understood that the committee had previously decided that in July and August the committee would not be meeting, that we would hold some meetings in June. We have contacted people and we have had confirmations for next week's meeting. It might be possible, for example, to move the meeting a little bit later in the day from 8:00 a.m., if it would be more convenient, to 9:00 a.m. or even 10:00 a.m. That has been done before. I have reservations, expressing my own opinion, about cancelling witnesses who have already been contacted and agreed to appear.

The member for Sackville-Beaver Bank.

MR. BARNET: As a new member, I am obviously not completely aware of what goes on in this committee, but I would suggest that there is no hidden agenda or anything like that. We do want to talk about and discuss the Pharmacare issue. What we have proposed here is that we meet in two weeks time, it gives members an opportunity to take a little bit of a break. At the same time, at the same meeting, we talk about the conference issue. I am not certain as to what that is about, but the member put forward a motion, it is in order, and I would ask that the motion be called.

MR. CHAIRMAN: The member for Cape Breton West.

[10:00 a.m.]

MR. MACKINNON: Well, Mr. Chairman, this is probably one of the most unprecedented acts that we have seen come before this committee, where the committee has approved to invite particular witnesses to come before the committee. The witnesses have agreed to appear before the committee, the scheduling has taken place with the coordination and assistance from our staff. There is absolutely no logical reason to delay this particular issue before Public Accounts, unless there is another agenda that has not being spoken of. There is no logical reason to delay it.

The honourable member, it is his first time. He seems quite anxious to fulfil some mandate that is unbeknownst to the committee and that is fair ball if they want to be political. But realizing also it is the first time that the committee will not be meeting throughout the summer months. We have extended some considerable latitude to the Conservative caucus in accommodating all the concerns about doing constituency work and so on and so forth. I have never seen anything like it. What are they hiding? That is the question.

[Page 41]

MR. CHAIRMAN: The vote has been called for. Are we ready for the question? All those in favour of the motion as put, please say Aye. Contrary minded, Nay. The Ayes have it five to four. (Interruption) We can have a recorded vote if it is a wish? (Interruption) We are still in the process, and we can briefly call roll call. We don't ring the bells or anything.

The honourable member for Kings South.

MR. MORSE: Is it the normal practice for a recorded vote after the vote has already been taken?

MR. CHAIRMAN: It was still in the process, but if there are people who are questioning what the vote actually was, that is quite common. It is done quite regularly. We could get the recorded vote done faster than we could talking about it. Maybe we can have a roll call vote. I will ask the Clerk to call.

[The Clerk calls the roll.]


Mr. Morse Mr. MacKinnon

Mrs. Baillie Dr. Smith

Mr. Hendsbee Mr. Dexter

Mr. Barnet Mr. Holm

Mr. Langille

THE CLERK: The vote is 5 to 4 in favour of the motion.

The motion is therefore approved.

MR. CHAIRMAN: Before we adjourn, a couple of other things. I take it that, based on that motion, we are going to have to have another planning session early in the fall because I believe that motion wiped everybody off, unless I misheard it, everybody off the list that we had prepared. The session we had previously, and I think we had eight groups, seven or eight groups that we had requested witnesses to come before this committee. We are starting off now with a clean slate of nobody. (Interruption) That was the way the motion was worded.

MR. MACKINNON: Mr. Chairman, on a local matter, one of our research staff did enter the Chamber door during deliberations.

MR. CHAIRMAN: Can I just stop this because we are past our time. I just want to make this observation. Not one, but two researchers had entered. I would just make the request that in future, and this is for all caucuses, that a message can be sent in and ask a caucus member to step outside to have the conversation.

[10:05 a.m. The committee adjourned.]

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