STANDING COMMITTEE ON PUBLIC ACCOUNTS
Mr. William Estabrooks
A reminder that next week we'll be meeting over in the committee rooms, it's an in camera session. That is next week at 8:00 a.m. over in the committee rooms. On another order of business, and I would like to remind Dr. Ward about this, I have been asked to bring to your attention that at an earlier session Ms. Joanne Bree gave a commitment to - and we can check Hansard for the details - bring a report back to this committee. As of now we haven't received that, and we would request that you follow up with staff on that matter. I thank Mr. MacKinnon for jogging my memory. Mr. MacKinnon, do you have anything else to add on that topic?
MR. RUSSELL MACKINNON: Just briefly, Mr. Chairman . . .
MR. CHAIRMAN: Please.
MR. MACKINNON: It's quite straightforward, I believe. It's a copy of the policy for entrance into nursing homes.
MR. CHAIRMAN: The date was the key thing, is that not true?
MR. MACKINNON: Well, the date, the document that was provided was, I believe, March or April 2001, and she indicated that it had been brought in in 1998, and the only changes were the appeal process. That didn't seem to be consistent with what the 2001 document suggested. What I was looking for was the 1998 document, and she indicated she would provide it. We understood we would be getting it that same day and we haven't received it yet. It's going on three weeks now.
MR. CHAIRMAN: That's fine. Thank you for that. On that particular note, since that is the business portion of the meeting that I decided to get out of the way at the first, does anyone have any other item of consequence that we should deal with? Good.
I would ask my colleague from the NDP to begin the introductions this morning.
[The committee members introduced themselves.]
MR. CHAIRMAN: Welcome again to Dr. Ward. Although I know your colleague could introduce herself, go ahead please.
DR. THOMAS WARD: Good morning. I am Dr. Tom Ward, Deputy Minister of the Department of Health. I have with me Barb Oke, who is the Nursing Policy Advisor to the Deputy Minister's Office.
MR. CHAIRMAN: As you are aware, Dr. Ward, we usually like to have the first 15 minutes or so for our witnesses, and the important part of coming to the Public Accounts Committee, in our opinion or, perhaps if I may editorialize, in the opinion of the chairman is the exchange between the elected officials and the witnesses, so I would ask you to have your comments restricted to the time frame of approximately 15 minutes.
DR. WARD: In anticipation of discussion about health human resources, particularly in the areas of recruitment and retention, I have provided you with a series of handouts, which I will walk you through relatively quickly to give you a bit of a higher-level overview of the issue of health human resources, particularly from the planning aspect not only in Nova Scotia, Atlantic Canada but I guess more importantly with respect to the Canadian and international context.
I think most of us are aware that the primary issues that we hear about with respect to health human resources are that of an aging workforce. We hear much about the issues of retention, recruitment and what I have described as renewal, which is really the issue of continuing education or upgrading of health care professionals and significant issues in terms of the distribution of the workforce. It remains a challenge in terms of supplying health care professionals to smaller or underpopulated areas throughout Canada.
In terms of the challenges, as one begins to look and plan with respect to this, the majority of experience in health human resource planning in virtually every jurisdiction has been the use of a thing called the labour market approach, which is significantly different than an approach that I think we need to be taking on the health human resource side. We also need to recognize, as we begin to talk about health care, to try to sort out, when we are really talking about what I would describe as a sector or a component of that system versus the entire system at large. Then the last thing I would say is to think about some of the options available at the current time.
The approach that we're taking and we're trying to take on a national basis is one that is not a traditional labour market approach. In a traditional labour market approach there is some finite understanding of the potential demand. In health care we are unclear as to what that demand will be five, 10 and 15 years out from now. In a traditional labour market approach we see that the skill set tends to be fairly finite, it does not change significantly over a time period, if it does it can be upgraded somewhat. In health care, given the burgeoning, sort of the explosion, of technology, medication and other events, the skill set is changing almost daily, and to this point in time I don't think anybody is really clear as to what the solution is.
As I have pointed out, in a traditional labour market approach the market can be quantified, the skills can be quantified, a model can be developed and training programs can be established. With respect to the health care sector the bulk of current approaches have been significantly fragmented over the years, although we do have studies underway nationally that are described as sectoral studies, in fact they define only components within the system, components of the workforce.
When it comes to health human resources, I believe there are three major issues with respect to health human resources which I describe as the health human resource planning dilemma. The first issue that needs to be resolved is the question of needs versus demands. At the current time we do not have a good understanding or quantification of the needs within the system, and more importantly we don't have a model that can sort of extrapolate out towards the future.
The second piece is that we have not had a model that can really look at the impact of technology and knowledge. As an example, we do know that in this province, through the ICONS study, which is the application of appropriate care for patients, post-myocardial infarctions, that program raised the rate of what would be acceptable therapy from about, varying, 30 per cent, 40 per cent, 50 per cent up to about three-quarters across the province. We do know that with the appropriate application of post MI care the results are much better. Patients who are not well cared for tend to go on and have fairly, for lack of a better term, large floppy hearts, repetitive episodes of congestive heart failure, repeated cardiac admissions.
The challenge is, if we had a system that saw 100 per cent appropriate application of the therapy, what would the impact be on the system? Would we need more doctors? Would we need more ambulatory care? We don't have a model that can deal with that well. The other piece that very clearly goes along with that is the dissemination of knowledge.
The third component is we have not really talked about models of care. The majority of people are still focused on what I would describe as a hospital-based medical model. What we hear mostly about is doctors, hospitals and pressures on the hospitals. We don't hear about significant pressure for more ambulatory care clinics, for off-hour services, for integrated family care teams, other things that other health care professionals could be doing. How do we deal with scope-of-practice issues?
That becomes a significant issue for under-serviced populations. For under-serviced populations, whether that's an inner-city population or a community in a rural area, the models of care or how services are going to be provided somehow or other has to be factored into the debate and the discussion. In this province we have seen a significant example of a potential model of care with the issues on Long and Brier Islands, with a population of about 700 or 800 people who are relatively isolated. There are no physicians or nurses, and at the current time their front-line emergency care is provided by EMTs through EHS. The challenge is, if we have professionals who have some training there already, are there other things that that particular group of individuals could be doing? Could they be doing routine screening of blood pressures? Could they be doing flu vaccinations? It's the debate or the discussion about how you use your workforce and how you use the skill set that really needs to also be integrated into any planning model.
By the way, I think that any discussions around health human resources really has to be taken into an Atlantic Canada context and I say that for a couple of reasons. First and foremost, in any health care region, it's really characterized by a couple of things. One of them is it tends to have high-end tertiary quaternary care services, transplantation programs, big burns unit, advanced cardiac surgery programs. In order to sustain that type of a program, it really needs to be servicing a population of about 2 million-plus people. If you're not serving that population, you are not in a position to do the volume of work that will keep the skill sets up and, more importantly, probably will not keep the individuals involved in that process comfortable. They won't be happy because they're not doing what they were trained to do and they're not getting enough work. We certainly saw that this year with the departure of David Ross from the Children's Hospital, a paediatric cardiac surgeon who was not getting the volume of work he thought he should be getting. He was basically entering into the peak years in his career and he was doing less than 100 cases a year when, in fact, a good paediatric cardiac surgeon should probably be doing somewhere between 150 and 200 cases a year. In the mix of how do you balance these pieces out, we need to understand that
particularly for the higher end services, we really need to be thinking of an Atlantic Canada approach.
The second important piece when you begin to understand that is that high-end tertiary care entity also usually has a medical school and other health care professional schools attached. If we don't have the high-end volume of work to keep all the high-end specialists and others, we certainly are not going to be in a position to attract people to the faculty of medicine who we will need to teach our students.
Across Canada, of the current 16 medical schools in operation, at least four of them are in significant difficulties simply because they are unable to retain their academic staff. Saskatchewan, Manitoba, Sherbrooke and Memorial are having significant difficulties in maintaining their academic staff at the current time. With my fellow deputies and the Deputy Ministers of Education, we are growing increasingly concerned about this and are working to try to come up with a regional approach to resolve some of these issues.
When you get to the issue of clinical services planning and that's really how you get some sense of putting the models of care or the needs together, we've chosen, at the current time, within Nova Scotia to approach it in three phases. I would say that our approach on the clinical services planning side is pretty much lockstep with what is being done in Prince Edward Island, New Brunswick and Newfoundland at the current time. We have chosen to look at the system in terms of the acute care sector, continuing care and then lastly, emergency and ambulatory care.
We have, as a primary step, begun to deal with the physician resource planning piece initially, but again in that process, the models of care, how do you put together the team and what are they going to be doing is part of the debate or the discussion.
In any approach to looking at the system and the needs, you really have to balance off four things. First is the issue of sustainability, which is sort of a very common discussion across this country and that's to define the long-term viability of services. It's really to put together a core team with the resources required and a sort of a guaranteed population base for flow of patients to make that service sustainable or viable.
The second piece is the quality issue and that relates to what I have described as critical mass and clinical coherence. The critical mass piece and I have talked a bit about the 2 million-plus population to maintain a health region medical school, as an example, more specifically, on the critical mass side, one would normally assume that you need a general surgeon for about 25,000 population. Given the work life and changes in work life for general surgeons, they're saying, I don't want to work more than one in four, I want to be in a group. You're basically saying you need to have four surgeons serving about 100,000 people as a minimum doing some place between 800 to 1,200 cases a year. With those four general surgeons you're going to have to have the required back up of anaesthetist, special care units,
nursing staff, pathologist who are available to do the frozen sections, follow up from family doctors, some sort of a relationship with cancer groups. If you can't do that, the physicians are going to be unhappy or you're not going to be doing enough cases.
The second important piece is the increasing recognition of medical error or process-related poor outcomes. A recent book by the Institute of Medicine which I brought last week called Crossing the Quality Chasm really focuses on the sense that to keep a skill set up for a care team, they need to be doing a large volume of work. If you're doing one heart transplant every year, you're not going to be as good as somebody who is doing 100 a year.
The access issue and the affordability pieces are certainly the other two pieces that we have to put into it. Very quickly, with respect to Nova Scotia on the acute care side, some of the things we've been doing is trying to focus a bit on process efficiency. There will be a couple of slides included in your handout which really look at the clinical benchmarkings of taking length of stay by certain patient categories, looking at the spread across the province and then adjusting it to the 25th percentile.
There's a second sheet in your handout and what this really has done is the solid vertical bars are the utilization of acute care days per 1,000 population for fiscal 1998-99 for the nine districts across the province. You can see that the use of hospital days by each of the nine districts vary significantly from the Annapolis Valley which has been the lowest to Cape Breton which is over twice in terms of utilization and length of stay. These top three horizontal lines are the averages in Atlantic Canada, but as you move down, the larger darker lines are Ontario and British Columbia which have put in fairly aggressive programs around managing length of stay, early discharge programs, trying to optimize the use of acute care resources. That is, as we're moving forward, beginning to get some sense of benchmarks or standards across the province.
It's incumbent to remember that when we look at that, part of the issue is that you're going to require some downstream beds, some resources, whether it's home care resources or home nursing or long-term care, the other parts of the system that we don't focus all that much on.
I have added into the mix for you a second slide and this is really a comparator of the number of acute care hospital beds in the province over the last decade along with the number of licensed long-term care beds and the increasing or the use of home care. As you can see from the graphic, our acute care beds have decreased by about 40 per cent over the last decade and that's in keeping with the national average, by the way. The number of long-term care beds or licensed nursing home beds have remained pretty fixed during that five year period. What we have seen is a steady increase in the accumulated home care caseload.
So, again, as we start to look at the issues around health human resources and planning piece, if we need more long-term care beds and more home care, our planning and educational programs really have to be directed to those areas as we begin to optimize the use of resources within the hospital sector.
A couple of other pieces we've put into it is that with respect to our planning activities in the province - and we have a Physicians' Resources Steering Committee which is made up of a number of physicians from across the province supported by the Department of Health - there are some recommendations in that. The first one is that for in-patient beds is a requirement for about four or five family physicians in some type of a group practice. Currently, the Canadian College of Family Practice is recommending as guidelines for its members on call of one in five as being the maximum. There may be some special circumstances, but very clearly, you cannot run acute in-patient beds with two or three physicians. It is a very difficult proposition that certainly diminishes lifestyle and the off hours work becomes unpleasant and physicians choose not to practice that way. With respect to elective programs, and by that we mean cardiac clinics, day surgery programs and stuff, we're saying two to three surgeons, or two to three physicians, and any 24 and 7 on-call program requires as an absolute minimum four or more physicians. That is absolutely the norm across the country at the current time.
The last two or three slides, let me talk very quickly about what I describe as the three Rs: recruitment, retention and renewal. On the recruitment side, two big issues, one of them certainly is a national concern about the continued hammering on health care and professional lifestyles. As long as everybody is standing up and saying that this is really a terrible job, it's increasingly difficult to attract individuals into careers in the health care professions. If it's on the news every day that people are overworked and they're unhappy, why would you as a graduate from high school want to choose that as a career.
Two other pieces, the repatriation piece will be an increased emphasis on trying to get Canadian-trained health care professionals back from other jurisdictions, particularly the United States. The last piece in that that's a challenge for Atlantic Canada is that the forum of labour market ministers have agreed to a national portability of skill sets, and that's whether or not you have an architect, lawyer, pipefitter, welder, physician, nurse, that there is a requirement nationally that your credentials or your skill set is portable. You cannot put provincial restrictions on that. That basically says that it's very easy for jurisdictions which have significantly more resources to come and offer financial packages, remuneration, or something, but it is very attractive particularly to our young graduates.
On the retention side, very clearly I think the major issues are around the job and lifestyle. If, when you talk, or for the programs that have looked at the dissatisfaction in the workplace at the current time, much of it relates to lifestyle issues, job satisfaction, family issues, the presence or absence of collegial support, the money they're making. The Royal College of Physicians and Surgeons surveyed last year their graduating specialists. The most
important things for the graduating specialists were, first, that they be in a group practice with at least four people; second, that there be a senior individual in it, somebody who could mentor them; and then they began to worry about location and money. Specialists aren't interested in going and being the solo general internist or the solo general surgeon any more. It is certainly not acceptable to the bulk of graduates.
The last piece is the renewal of the workforce, and that is in a situation in health care where the knowledge base and the skill base, the technology is basically doubling, it appears about every 10 months. How do you keep up? How do you find the time to keep up, and we really have to think about a program to support people.
In terms of other big issues, education, I had talked earlier about the pressures on the medical schools. Most universities froze their intake at the professorial level in the late 1970's or early 1980's and have not put new professorial staff in. The end result is that virtually every educational program in the country, whether it's in arts or science, or law, there is a significant graying of the workforce within the medical school. Dalhousie, of our current about 240 full-time faculty positions, 160 of those individuals face mandatory retirement in the next 10 years. So, basically, the medical school is losing two-thirds of its core faculty in 10 years and there has not been a planning program for succession. It takes 10 years to train a specialist. So I think when I talked about other medical schools being in difficulty, the issue about the workforce on the educational side is huge. It's absolutely true for nursing, for medical laboratory technicians and for others; we have not invested in training the educators for the future.
Two other important pieces on the educational side are very clearly, we've got to figure out how to disseminate the learning process or the educational experience to other areas. It can't always be in large urban settings, and the third piece will be what is the new workforce for the future to look like. There are very clearly up and coming accountability issues, issues around remuneration, particularly with physicians, and a move from fee for service to other forms of payment.
The last piece is the issue of relationships. The system is looking for an integrated well-functioning team, but the educational programs for the most part continue to train physicians, nurses, lab techs and pharmacists separately and if that's how you spent your training, it's difficult to turn you out in the field and say, well, now you're a team player. Certainly the individuals who you would normally have looked at, sort of coaching and mentoring those teams, significant management or administrative people, have long since been taken out of the system.
I would wrap it up with a couple of things very quickly and one of them is the potential approach to the planning issue and this is a model that's being developed by the nursing people, Linda O'Brien-Pallas and her group from Toronto, I think we will be - Nova Scotia - participating in a study to look at the application of this model for the nursing piece. Lastly, on the national scene, the Canadian Medical Forum will sit on a management committee for a Task Force 2 which is to deal with the number of physicians in the country. There has recently been announced a nursing sector study which is really to look at nursing in Canada and, again, I would come back to sort of the outstanding issues or the lack of an overarching strategy both within Atlantic Canada and nationally on how to manage health human resources, the need to have a national debate on alternate models of care, and a way to understand the impact of knowledge and technology in terms of planning for the workforce of the future.
MR. CHAIRMAN: Does your colleague have anything to add at this time? Okay, it's 8:32 a.m. The next 20 minutes belongs to you, Mr. Steele.
MR. GRAHAM STEELE: Mr. Chairman, I would like to start by talking about the tentative deal that has been reached with the Medical Society. In yesterday's Chronicle-Herald on the front page it says the deal was reached after more than eight months of negotiation. Both Dr. Wright and Mr. Muir said it would help keep doctors in Nova Scotia. "'What we're looking at is to provide for the doctors a package that will help them stay in the province', Dr. Wright said Monday."
So clearly in the minds of the Department of Health, or the Minister of Health and the Medical Society, an important component of this deal that has been reached with the doctors is retention. I wonder if you could explain, Dr. Ward, as briefly as you can, what exactly is it in the deal that is expected to improve the retention rate of doctors in Nova Scotia?
DR. WARD: I guess I would make two comments. First and foremost is that we don't have a deal. We will have a deal if and when the Medical Society approves it. We have a proposed settlement that is being taken out to the membership for a vote. The second issue in terms of how it's going to assist in the retention piece is that there were a number of outstanding issues that were of concern to the Medical Society, that they believed if we could resolve through the course of the contract, it would assist in keeping their membership comfortable and remaining in the province and we believe that the proposed agreement will do that.
MR. STEELE: Whether you call it a proposed agreement, a tentative agreement, whatever you want to call it, there's an agreement that's on the table, but I didn't hear you answer my question. What specifically in the deal is expected to improve the retention of doctors in Nova Scotia?
DR. WARD: Specifically it will be the opportunity for us to have some off-line discussions with the Medical Society around alternate funding programs, to deal with the issue of on call for specialists in the outlying areas.
MR. STEELE: What's the alternative funding program? Maybe you could elaborate on that.
DR. WARD: An alternative funding program is an agreement for a system of remuneration that is a non-fee-for-service based system for physicians.
MR. STEELE: Is there an alternative funding arrangement that's part of this proposed agreement?
DR. WARD: No, we have a number of alternative funding agreements in place in the province at the current time.
MR. STEELE: Okay, well then let me go back to my question then. You will excuse me, Dr. Ward, if I say you are being a little vague here. The Minister of Health and the head of the Medical Society are quoted in the paper as saying that's going to help us keep doctors in Nova Scotia. What is it about the deal that is going to do that? I have asked you about alternative funding and you say, well, we already have some in place. So is there something new in this deal and, if so, what is it?
DR. WARD: I wouldn't characterize the issues as being new. I would characterize the issues, particularly for on-call and alternate funding, as being opportunities for the Medical Society and the Department of Health to sit down and stabilize or deal with issues that are of concern to physicians. Very clearly, we recognize that there is and has been a challenge in retaining psychiatrists in the province. The Medical Society, with the section of psychiatry would like to sit down with the Department of Health and look at the opportunity for an alternate funding program for psychiatrists.
MR. STEELE: If this proposed agreement is accepted by the membership of the Medical Society, what will be the cost to the province over three years or annually, however you want to put it; what is the cost to the province of this deal?
DR. WARD: At the end of the three year contract, it will be approximately 12 per cent.
MR. STEELE: It's 12 per cent of what?
DR. WARD: Of the current base.
MR. STEELE: I'm sorry. You have to excuse me. You are talking in terms that I don't understand and 12 per cent of a base. What is the cost in dollars to the province of this deal?
DR. WARD: Our current contract annually with physicians is about $360 million.
MR. STEELE: Okay and what is the cost of this deal, if it's approved?
DR. WARD: At the end of the life of the contract, it will be approximately $400 million a year.
MR. STEELE: Is that a number that goes up each year? You say that at the end of the three years it's going to be $400 million. Is it going to step up during each of the three years of the contract?
DR. WARD: Yes.
MR. STEELE: By approximately how much?
DR. WARD: In general numbers, approximately, I think it's about 2.5 per cent in year one and then slightly over 4 per cent for the remaining two years.
MR. STEELE: It's 4 per cent for each of the remaining two years?
DR. WARD: Yes.
MR. STEELE: Okay, because my math is a little rusty, but over the course of the three years, it appears to be an increase of something in the neighbourhood of 11 per cent. So that would make sense, 2.5 per cent and then 4 per cent-plus and 4 per cent-plus. I think both of the Opposition Parties - certainly we have, and I think the Liberals too - have been asking to see the details of the contract and yet the minister has refused. Can you explain why you think it is that the members of the Legislature shouldn't be able to see this deal?
DR. WARD: I presume that is an issue you will have to take up with the minister. I can't speak for him on that issue.
MR. STEELE: Will you table the deal today?
DR. WARD: No.
MR. STEELE: Why not?
DR. WARD: When the Medical Society has approved the contract, we will be happy to table it.
MR. STEELE: But what I'm asking you is why is it that the Department of Health feels that it can't table the deal until it's already signed, completed and too late to do anything about. For example, if the members of the Legislature and the public feel that there are pieces of it that aren't entirely appropriate for the spending of public money, why do we have to wait? In your mind, what is the reason for that?
DR. WARD: At the current time, my understanding is that the direction from my minister is that when and if the deal is ratified by the Medical Society, we will table it.
MR. STEELE: Okay, so it's your understanding that that is the direction from your minister. Is that right?
MR. DAVID HENDSBEE: Mr. Chairman, on a point of order, could I just have clarification about the role and mandate of this committee. I thought it was past expenditures that we were supposed to review and not speculation of what current negotiations are.
MR. CHAIRMAN: You are asking me for a rule of order, I'm watching the time and you are cutting into the time of the member for Halifax Fairview. I will take it as a point of notice and consult with Ms. Stevens, if I may. Would you continue please, Mr. Steele.
MR. STEELE: Just in answer to that, of course, Mr. Chairman, this deal that's been reached is for a portion of the health care budget that's around - what is it, 30 per cent of the total health care budget? - anyway a very large percentage of between $360 million and $400 million a year. One would think that the Public Accounts Committee has the right and the opportunity to call to public account a deal that will cost the taxpayers of Nova Scotia $400 million a year. But at any rate . . .
MR. CHAIRMAN: Instead of debating with me before I consult with Ms. Stevens, you can get on with your questioning.
MR. STEELE: At any rate, let me move on from the doctors and talk about another component of the health human resource question that I think deserves a lot more attention than it's getting. There are actually two, and the first one is home support workers. Now it's my personal experience as an MLA that some of the most difficult personal issues that come to my office involve home care.
Most of the people who come to my office say more or less the same thing, they are having a great deal of trouble with home care because there is an extraordinarily high turnover of home care workers who just when they get comfortable, if they even get comfortable with somebody, they're gone the next week. So they're always getting somebody new. For the
family members, they're training them and showing them how to do things and losing their respite time to do that, and then the next time somebody comes up it's somebody new again.
There is a real problem in Nova Scotia with the wages and terms of employment of home care workers. I wonder, Dr. Ward, if you could tell this committee, what is the best and most recent information you have about recruitment and retention of home care workers, or as some people prefer to call them home support workers?
DR. WARD: HRDC has recently completed a sectoral study on home care and home support workers. Within the last year we've had a bit of a changeover in the department, and we have re-established what is called a Home Support Worker Program with the community colleges that we're in the process of trying to ramp up to increase the number of workers in the field at the current time. The entire issue of home support, particularly for the home support workers, has become a challenge, at least an issue that's been recognized by the department in the last little while.
The difficulty or the issue that remains most difficult in all of this is that the department itself does not have control of the educational programs. We do have some opportunities to try to influence that at the current time, but we do not directly fund training programs, we do not directly control or operate the programs in any way. Certainly part of the discussion that I and my Atlantic colleagues, along with the Deputy Ministers of Education, will be having is how does the system have an opportunity to influence the educational programs or at least the output of health care professionals, whether they're home support workers or otherwise.
In terms of the training or funding side of it again, very clearly, as we're moving forward and having discussions with the various representatives of those workers, that opportunities to review skill sets and qualifications and levels of payments are part of the negotiation process.
MR. STEELE: Those negotiations have been going on . . .
MR. CHAIRMAN: Excuse me. The member for Sackville-Beaver Bank.
MR. BARRY BARNET: Sorry to interrupt. I'm having a difficult time hearing Dr. Ward, and I wonder if we could have his microphone turned up. I had some kind of beeping in the back here - there it is again. It's hard for us to hear on this side.
MR. CHAIRMAN: Thank you for that. Could you continue, please, sir?
MR. STEELE: I agree, I'm having a little trouble hearing as well, Dr. Ward. I wonder if it might be possible for you to speak up just a little bit. I'm really straining to hear you as well.
Those negotiations that you talked about have been going on for over a year. Most of the collective agreements expired over a year ago. The province has refused to engage in any kind of central bargaining, they are doing it unit by unit. Let's make no mistake, these bargaining units represent pretty much the entire province, particularly in the rural areas but also in HRM as well. These are people who are earning $10 an hour, give or take $1.00 or $2.00 and what they are looking for is a provincial wage rate of something in the neighbourhood of $12, as well as improvements and more predictability in their terms of employment.
I don't know if most people understand the kind of conditions that home support workers are facing in terms of widely varying hours of work from day to day, never mind week to week; the requirement that they pay for their own cars, which for many is an insurmountable barrier to entry; the fact that wages in nursing homes are simply better, quite a bit better, than they can get in home support, so people do home support only for as long as it takes them to find better work. This home care sector, which is the graph you showed, is growing and becoming, especially with the aging population, a more and more important part of the health care sector that is being served by workers who are being underpaid and treated very badly.
You can excuse some of these home support workers for saying that the department is playing softball with the people who are earning six figures and hardball with the people who are earning $10 an hour. What is the province doing, concretely, to try to improve the wages and working conditions of home support workers?
DR. WARD: At the current time, as you pointed out, Mr. Steele, those negotiations are ongoing at the bargaining table.
MR. STEELE: What are the prospects of settling on decent wages and working conditions for those workers in the near term, do you think?
DR. WARD: I presume that's a decision that, at the end of the day, will be made by the negotiating team and by the workers when they vote on a proposed agreement.
MR. STEELE: You talked about training as well. Within the past year, the training program has changed for home support workers so that now there's a generic program for continuing care workers. But what happens is that the people graduate from that program and, as I said, only do home support for just long enough until they can find better-paying work, typically in long-term care facilities. Is there a problem with the current training program that's leading to that retention issue? Does the province have any plans to make any changes to the training program in order to deal with the retention issue?
DR. WARD: As I indicated earlier, one of the challenges for the Department of Health is that we don't control those training programs. The standards, the curriculum is set by the community college or the training agency. Certainly I don't disagree with your sense of the need to get a better understanding of that. We are in the process of doing that.
MR. STEELE: The other occupational group that I believe is not spoken of nearly enough is the many thousands of medical technologists and technicians. All of us here in the Legislature in June, in the course of the debate on Bill No. 68, got a quick education in how many dozens and dozens of different occupations there are. They are the people who keep the hospitals and health care system running. Most of the talk is about doctors and nurses, and they made it very clear to all of us here that they can't be ignored; they shouldn't be ignored. Of course, that occupational group is particularly unhappy these days because of the wage settlement that happened over the summer. The nurses got a substantial settlement, which they deserved, but it was the medical technologists and technicians who got the short end of the stick and got a much lower wage settlement than what they had hoped for and what the nurses got.
I am told by my constituents in those professions, of consternation in those lines of work. Morale is terrible. On top of that, we have this report - which I know you're aware of, Dr. Ward - that came out in April of this year from the Canadian Society for Medical Laboratory Science, saying that Nova Scotia is in absolutely the worst position in the country for the future recruitment and retention of these technologists and technicians. What is the department doing to deal with these issues with regard to medical technologists and technicians?
DR. WARD: With respect to the issues of remuneration, that was an agreement that was voted on by the membership.
MR. CHAIRMAN: Dr. Ward, just excuse me for a moment please. I have a note there for you, but more importantly, Mr. Steele, I am going to give you an extra minute. You're quickly running out of time, however.
MR. STEELE: I am sure Dr. Ward's answer will take up the time, but . . .
DR. WARD: On the training side of it, there are three things that have occurred recently. First is that the training program which was originally run in combination between the community college and the Queen Elizabeth II Health Sciences Centre has been discontinued as of two years ago. That program was turned over to Dalhousie and now has become a baccalaureate-level program. We continue to fund a number of seats in the community college program in New Brunswick to train medical laboratory technicians, and we're currently in discussions with the community college and with others as to an opportunity to increase the potential of training further medical laboratory technicians in Nova Scotia.
MR. CHAIRMAN: Thank you. I would like to, if I may - and I won't cut into your time, members of the Liberal caucus. Mr. Hendsbee's point earlier about the mandate of the committee - it would seem to me that in the concern of one of the MLAs having a certain direction in their questions, that if for some reason the witnesses refuse to answer or bring to the Chair's concern that this would be something that they would feel uncomfortable answering for various reasons - in this case, the point that you made, Mr. Hendsbee - Dr. Ward didn't bring up that exception and continued to answer the questions, so I find nothing wrong with Mr. Steele's line of questioning. There could be other examples in the future, but matters of public interest that are brought here, I will allow the questioning unless the witness, for some reason, brings that concern to my attention. But I see your point.
MR. RUSSELL MACKINNON: I don't want to enter too deep into this debate, but I think the mandate of the Public Accounts Committee is rather explicit. I do stand to be corrected, but I think the question was should we be dealing with current expenditures, matters that are before Cabinet and the government and negotiations, or should we be dealing specifically with past expenditures? I believe the mandate is quite explicit on that point.
MR. CHAIRMAN: I thank you for your point of clarification. I know you sat in this chair on a number of occasions. Perhaps we could discuss that at a further time and in camera, but I thank you for the points. It's coming up to 8:54 a.m. and I will turn the time over to the Liberal caucus.
MR. DONALD DOWNE: Deputy and guests, I appreciate your comments. I will say that probably the average person listening to your presentation wouldn't understand 90 per cent of it or most of it, but I think if we can boil this down to common language it would be much appreciated by all.
I want to carry on with my colleague's questioning with regard to the issue of teamwork. You mentioned specifically about the team in health care. You mentioned about health care that if we don't have the team, it doesn't work. It doesn't function. As a sports player myself, I agree with you, but it seems abundantly clear that you've got selected members of the team to whom you're giving preferential treatment and other people on the team you're prepared to put to the wall. I will give you an example: Bill No. 68. Literally, we had to have nurses give their resignations to leave the Province of Nova Scotia at a time when all of us can say that we would like to have more nurses and less stress on nurses than we currently have. We have health care workers who ended up with a contract of 7.5 per cent. We have inequities in the system where you now have doctors possibly getting as much - the range, the word on the street according to the report by Peter McLaughlin in The Daily News is that the details are hard to get, but some sense that the raise for doctors could be between 21 per cent and as high as, emergency room doctors could increase by 37 per cent. Now, whether those are accurate or not, it's generally somewhere in that ballpark, at least from what I can gather.
My question to you is, how do you keep this team together and keep people happy in the workforce under a system where you literally put the nurses to the wall and told them to take this offer we're giving you or leave? Eventually, it changed around that they realized you had to deal with them, and then the health care workers as well, treating them with very little respect and then with doctors it seems like, bang, we got a deal, everybody's happy and let's just keep on going. How do you justify that as a Deputy Minister of a Department of Health that is dealing with patients when you know that the workforce are very frustrated, very much anxiety in the workplace, which ultimately has to have an effect on the patient care?
DR. WARD: My comments with respect to that, I would say the following. First and foremost is that at the end of the day the team relationships are a challenge, very clearly. The discrepancy in terms of levels of remuneration of the various members of the health care team have been in place for a very long time. The challenge of dealing with the physicians, more particularly, is an historic one. The Canada Health Act requires that any contractual relationship with physicians must have in it the opportunity for some sort of arbitration process at the end of the day.
The contract that has been in place with the Medical Society of Nova Scotia has always had the right of the physicians to go to final offer selection, period. It's not an issue of whether or not they would like to, it's part of their contract. This, against that particular background, against the demand very clearly that you and I are both aware of, of the ability of physicians to move elsewhere to practice, and our attempt in terms of dealing with the physicians is to come up with a remuneration package that is at least competitive in Atlantic Canada to try to keep the physicians we currently have comfortable and have them stay here.
MR. DOWNE: So the reality to what you're saying is that you're prepared to do more for doctors to keep them here than the support workers, the health care workers, the nurses, who are the underpinnings, the foundation of the health care system. You're saying to heck with them, we're going to just look after the doctors. That's basically what I am hearing you say. We don't have central bargaining for nurses, maybe we have it with doctors, but clearly I would have thought you, as deputy of the largest department in government and providing the biggest issue in Nova Scotia - health delivery - would be sensitive to the fact that you need a holistic issue in health care. You need everybody to be happy. You need everybody to be reasonably content. I think you can have all the doctors and specialists in the world, but if you don't have a nurse or if you don't have other health care workers to aid those individuals, you don't have a health care system. They deserve the same level of respect, I would think, deputy.
DR. WARD: I would simply say that I think some of your comments are unwarranted, to suggest that as deputy I am not aware of the issues related to all the health care professionals in the system I think is wrong.
MR. DOWNE: Let's take a look at the issue of mandatory overtime. There's mandatory overtime now for nurses. You know it and I know it, and I have talked to nurses from all over the Province of Nova Scotia and they are stressed out. I have talked to nurses who have had, for over a year, every paycheque with overtime because they had to go to work. They didn't want to go to work, they have to go to work. They're on call all the time. So, how can you say that system - they're frustrated. What are you doing about that?
MS. OKE: We have a number of initiatives underway for nurses. Certainly, the gains that they made in their collective agreement will go toward making the work environment more favourable. In addition to that, we've put in place the nursing strategy, which was announced in April of this year. We were specifically targeting some of that strategy towards retention of our current workforce, and those are the areas that we put in place around continuing education and orientation so that those entering the workforce, or making a move within the workforce, would have access to appropriate training and development, specialty education for critical care areas, mental health, peri-operative nursing. We now have just put our peri-operative program on-line in a partnership with the Nova Scotia Community College so that that can be accessed throughout the province. What nurses told us was that it was inappropriate for them to have to come and take education only in the metro Halifax-Dartmouth area. So they can do the theory component on-line and they can do the practicums in their home hospital.
MR. DOWNE: Thank you, very much. You are really referring to somewhat of the HR work that was started back in 1998 when they were looking at the strategy and some of those strategies at that time, I think, were talked about. I hear what you are saying, but the problem is still real today and I think it bothers the nurses, from what I gather, the fact that we can walk through a doctor's negotiation with kid gloves and when it comes to nurses and health care workers, you are prepared as a department to take them to the wall. It seems to me that if you are talking about team play, then the coach of that team should treat their people fairly across the board, at least have some sort of a process there.
You know it is interesting, I want to make a comment in regard to a report that was done about the benefits of healthy workplaces for nurses, their patients and the system. It says that Canada's nursing shortage is at least in part due to a work environment that burns out the experienced and discourages new recruits, but the environment can change. It goes on, that keeping staff is easier in a less stressful, more supportive workplace. A good relationship on the care delivery team benefits patients and may even reduce the death rate. Nurses work best and have more loyalty to their employer when they are respected and they have some control over their lives, such as the ability to set their own hours. It gets back to the issue that I talked about - mandatory overtime and I think there is a lot of frustration out there.
I want to go on to another issue. You talked about the study that is going on with nursing models in Toronto. Maybe there is something we can learn there, but we have nursing models in Nova Scotia and I think the nurses here will just tell you what the reality of the problem is. Maybe you can elaborate on the Toronto model versus the Nova Scotia model. Deputy, I think you brought that issue up.
MS. OKE: What the Toronto model is, it deals with forecasting the number of nurses that you need based on how the health care system is going to change over time, how you educate nurses and what kinds of attrition rates you have in the system. That has always been a challenge. I have been a nurse for a long time and we are in a nursing shortage right now. This is not the first nursing shortage that we have had and the forecasting model is going to help us to level the predictability and hopefully we will not have to go through another time like this. So that is what the Ontario model is about.
MR. DOWNE: Well, did you learn from the Ontario model. Bill No. 68, is that the answer to the nursing model in Ontario? I don't think so. We have articles in the newspaper that are saying like salt in the wound to the nurses here, so I don't know. The model must be something about loyalty and trust and wanting to work in an environment where there is respect and appreciation, whether it is a nurse or a health care worker. In a sense what I read in the articles and what I hear at home is that there isn't that today. My concern is no matter how much you want to talk about programs that you are going to have, if you can't keep them in the hospital, you can't keep them in the workplace and they are not happy, people are going to suffer because of that, whether they are the patients or the health care system overall. That is, I guess, one of the basic questions I would ask. How do you plan to deal with that, other than the community college training programs and so on and so forth? They are all important, but how do you deal with the fundamental issue of the frustration, the anxiety, the fact that you are in a workplace that is not very positive? How do you deal with that as a health care worker in today's environment?
MS. OKE: I think, first of all, I will point out that we didn't get where we are overnight. So it is going to be challenging and difficult to turn it around. I think it also is having a number of people work together. I am fortunate that I am able to work with a group of nurses from across the province who represent the employers, the educators, the professional associations for both registered nurses and licensed practical nurses, the unions, NSNU and NSGEU, and practicing nurses who keep me in touch with the issues and concerns that they have in the workplace. I think that it is all of us working together. I mentioned the strategies that we have put in place, it is that type of thing that we will have to do over time.
MR. DOWNE: So, in the meantime, the current frustration and anxiety and now, obviously, feeling like second-class providers of health in the system and the team as it were - the second line or whatever you want to call it - that is just going to continue for awhile, that is just the way it is?
MS. OKE: There are examples of where things are getting better and I think that we have to focus on those examples as well, and share the successes with other work environments that are having more difficulty.
MR. DOWNE: Well, I am sure that issue will be brought up a little later on. Thank you very much, and I appreciate your comments.
I want to move on to another point, deputy. You indicated that for an adequate service we need 2 million people, for a critical mass, well, we don't have 2 million people in Nova Scotia. We have almost 1 million people in Nova Scotia, so herein lies some of the challenge, maybe some of the opportunity, with regard to Atlantic Canada.
Last week I pointed out to you, and you concurred, that we don't know the true cost of providing health care delivery for our friends in other Atlantic Provinces who are using our health care system; in fact we are not getting our full dollar back for what we are serving the patients for. So if you are working together and you are saying that to maintain a critical mass that we currently have, you need the co-operation of the Atlantic Provinces, are you suggesting then that the QE II will be expanding to meet more requirements from other Atlantic Province and, if so, how are you going to be able to make sure that we are getting paid properly for it and not subsidizing the other provinces for health delivery when we don't have it in rural Nova Scotia?
DR. WARD: The issue of the critical mass of 2 million people, you are absolutely right. Will the QE II be expanding programs? I don't see them significantly expanding programs in the near future. At the current time, we basically offer the full range of high-end tertiary and quaternary services to Atlantic Canada. The challenge will be to maintain those populations in terms of referral patterns. Very clearly, if we are unable to come to some type of satisfactory arrangement around the funding and the other jurisdictions would choose to send patients elsewhere for bone marrow transplants or cardiac transplants, that very clearly would have a significant impact on our ability to continue to operate a program. So any discussions we have are a bit delicate, to say the least. We are trying to get reasonable compensation, but at the same time recognizing that there are other jurisdictions providing those services and that, for lack of a better term, the customer could go elsewhere and it would have a significant impact on our opportunities.
MR. DOWNE: My concern, deputy, is that we are not going to be subsidizing other provinces and having our health care system depleted in rural Nova Scotia to be able to do that. It is a Catch 22, and you will have to deal with that. You are the quarterback, I guess, who has to deal with it. I would like to ask, how many nurse vacancies do we have in the province right now?
MS. OKE: There are approximately 160.
MR. DOWNE: And are they mostly rural or are they urban?
MS. OKE: The largest employer with vacancies is the Capital District Health Authority, particularly at the QE II hospital.
MR. DOWNE: In the acute care level?
MS. OKE: Yes.
MR. DOWNE: And the acute care level is the area where they have cardiovascular surgery and all the major issues that are going on. That is a very intense area of health delivery and so we have the largest shortage there. What are you doing to rectify that specific problem? Because without the nurses in the acute care system, you're going to have a lot of specialists who cannot perform the jobs that they need to do. So here we are; we have the doctors not being able to perform their function without the nurses. How are you going to deal with that problem now?
MS. OKE: We are doing a number of things. One is that we have a bursary program for fourth year university students with a return-in-service commitment of one year, and a significant number of those bursary students who graduated in May 2001 went to the Capital District Health Authority. We also offer a relocation allowance to people from out-of-province and out-of-country to relocate to Nova Scotia. On October 1st the Capital District Health Authority had been successful in recruiting 22 from out-of-province and out-of-country, and I know that they continue to do so.
We started a campaign in the U.S. to bring Canadian nurses, and particularly Nova Scotian nurses, back to Canada. That is both Web site and print, and it will last for 10 weeks. We also do recruitment fairs. So we will do, by the end of this fiscal year, four major job fairs outside of Nova Scotia, and that's to let people know that there are opportunities in our province.
MR. CHAIRMAN: Excuse me, Mr. Downe, you have just under two minutes.
MR. DOWNE: This particular article in the newspaper, in both papers, points out that the salt in the wounds to the nurses is what's happening right now. I am concerned about the issue of acute care delivery at the QE II, you know, and if we don't have that, with all the other hospitals that feed into that facility, we're going to have a backlog and it's going to get bigger and bigger and bigger and more people are going to be more critically ill because of the fact that you don't have the nurses to be able to work with the doctors to do the job. How many doctor shortages do we have? What is the shortage of doctors in Nova Scotia?
DR. WARD: The last number I saw, I think, was about 70. There are certainly some significant distribution issues.
MR. DOWNE: Distribution, do you have an oversupply in Halifax in relationship to rural Nova Scotia?
DR. WARD: At the current time there is a shortage of physicians in the area of psychiatry, to some extent in anaesthesia, particularly in the outlying areas, and there is a province-wide shortage of family physicians, not only in the rural areas but in the metropolitan area.
MR. DOWNE: In the southwest areas, the South Shore and Bridgewater areas, in the area of psychiatry I understand we have like 0.2 of one person for the whole South Shore. I understood they brought back a retired doctor - I don't know if she's still there; I tried to verify that on the weekend - and she brought it up to about 1.2 or 1.6 of one person for the whole area. I think the requirement is somewhere close to six or seven. How do you justify not having enough specialists in that area, which is a huge problem not only for young people but for all ages on the South Shore? That is, to me, putting people at risk. How do you not deal with that issue?
DR. WARD: The challenge is to deal with that issue, Mr. Downe. On one hand, the issue is physician remuneration. We have to pay them appropriately, and very clearly the move to try to deal with some of those issues under the new contract is part of our opportunity. It is a competitive marketplace.
MR. CHAIRMAN: Thank you, Dr. Ward, and I know you'll probably come back to that important issue, Mr. Downe, in the second round. It is 9:15 a.m. and the next 20 minutes belong to the government caucus and the member for Sackville-Beaver Bank.
MR. BARNET: Mr. Chairman, I found it somewhat intriguing to learn here today that the actual numbers in terms of shortages, particularly in the doctors and nurses are 160 nurses and 70 doctors. My first question is going to be, I guess, quick and succinct. If we had 160 nurses and 70 doctors, am I correct in assuming that if we were able to attract those numbers in those two professions, it would simply resolve the issue for one day and then eventually we'll start the depletion process again the next day. Is that a correct statement?
DR. WARD: I think that's a very reasonable statement.
MR. BARNET: Having said that, obviously this isn't an issue that appeared overnight. It is something that has developed over a long period of time. What has the department done in terms of due diligence to look to the future, at our human resources numbers, and see where we are going to lose people because of retirement and attrition and recruitment from other jurisdictions. If we were able to fix that in one day, in six months' time we're facing another problem. What have we done in the past to look to this problem?
MS. OKE: In addition to the initiatives that I mentioned to you earlier, we have also increased the number of seats at the university. In September 1999 we increased the total number of seats by 30 per cent, more so in the St. F. X. campus and put a satellite campus in partnership with UCCB. So, we now have third year nursing students, baccalaureate nursing students, at that campus.
MR. BARNET: There have been a number of people in the province who have been highly critical of decisions that were made a number of years ago with respect to early retirement of nurses and requiring nurses who took an early retirement package not to be able to come back into the system. The word I hear is that there were 400 to 500 nurses who in the early or mid-1990's accepted a retirement package that took them out of that system. In your opinion, could that have contributed to the shortage of the 160 nurses that we have today, and if that program wasn't offered in the 1990's, would we be seeing a situation where instead of having a deficit position of human resources we would have a surplus?
MS. OKE: I'm not really sure what impact that initiative has on today's numbers. The numbers change constantly. When I mentioned the 160 vacancies, in that number is also the number that are temporary vacancies and those would be things like maternity leave. Certainly the move to the longer length of time that nurses have for maternity leave has impacted in the overall numbers of vacancies that we have.
MR. BARNET: My question then is, do you believe it would be prudent of the government or the Department of Health to look to the future needs of the department before you would offer a program that would see health professionals leave that would ultimately be required at some point in time?
DR. WARD: Before I respond to that I would make a couple of other observations about the workforce. Two significant events occurred during the 1990's. One of them was the downsizing of enrolment at medical schools; a 10 per cent reduction in entrance into medical school occurred. It was a national program and we're certainly reaping the effects of that. The second major event that occurred was the closure of a number of the traditional diploma-based nursing programs usually associated with hospitals and the move to the baccalaureate program which saw a significant decrease in the training seats also.
Where we currently are today is that you are seeing most jurisdictions increasing the number of seats as we have in terms of nursing, and the challenge of whether or not one should increase the number of seats with respect to the medical school program at the same point in time.
I think the issue of mandatory retirement programs is certainly a major problem. I think, very clearly there are a number of skilled individuals who are approaching retirement who would be of great benefit to maintain in the workforce. I do believe that we will see, over the next few years, some opportunities to change issues around mandatory retirement to stop those programs. I think, very clearly, with respect to academic institutions in particular, a number of professorial staff who were being asked to step down at age 65, most universities have put into place programs to retain those individuals for anywhere from an additional three to five years in some sort of relationship in the workforce, simply because of their experience and the requirement to have them available to teach.
MR. BARNET: That brings me back to the point you raised earlier about the fact that in 10 years' time two-thirds of the training staff at Dalhousie Medical School will be in a position where they will be forced to retire. It seems to me - and maybe I'm looking at this from almost too simplistic an approach - that if we know how long it takes to train a doctor or a nurse and we know when the current doctors and nurses that we have will be retiring, or at least have a reasonably good idea of when that is, and we understand from past experiences the track record in terms of retention that it's a matter of simply applying the math, encouraging the young people to go into those professions at the appropriate times, and filling the needs of Nova Scotians.
I guess what I fail to understand is why in the past we haven't looked forward to the issue that we're facing now. One thing that constituents have said to me is that they seem to think that the large problem we have with our health care system is money, the fact that there's a shortage or reductions in money, and many of us know differently, that year after year we've increased budgets for health care in the different departments, and it actually comes down to, a lot of it, human resources. The fact that we're paying nurses overtime when we could be using a straight-time nurse increases the budget, it doesn't decrease the budget.
It would seem to me that it would be in the department's best interest and the Province of Nova Scotia's best interest to develop some long-range thinking to look at our needs for human resources beyond today and our ability to train people so that we can get the right fit. What has the department done in that regard or is doing in that regard, and what have we done in the past in that regard? I believe, as do a lot of other people believe, that in itself is where the biggest problem that we're facing today lies, the fact that there was no long-range thinking five, six, 10 and even 15 years ago. No one looked at the future human resources issue. Can you comment on that?
DR. WARD: I think that's not an unreasonable observation. As I pointed out earlier, the downsizing in the number of educational seats in the early 1990's as part of cost-saving measures did not look to the long term. It was really a short-term response to financial pressures at that point in time. We are reaping the results of those programs.
As I pointed out earlier when I began my presentation, the challenges with respect to planning for the future are probably threefold. Most importantly, I think, are the issues around the models of care. How do you optimize the skill set of physicians, nurses, LPNs, continuing care workers and home support workers within the system? We do understand that some organizations have made a decision to go all-RN staffing, which means the nurses will end up doing tasks or things that, in fact, LPNs might do. Those are organizational decisions. The department itself can point those things out and ask districts or hospitals or institutions to respond to those issues, but the front-line management really rests at the level of the districts at the current time.
The issues with respect to physicians and locations and, again, optimal utilization are the things that physicians or family practitioners are currently doing that might well be done by somebody else, whether it is a nurse practitioner or using a primary nurse on-call system, or some other type of health care worker. I think that when I talk about the models of care issue, it is really a very complex and difficult issue.
One of the things that we are beginning to understand is that there is no simple answer to this and that it is really trying to cast your sense out five, 10 and 15 years from now to think about what's happening in terms of an aging population, what might happen in terms of significant changes in terms of technology and therapeutics. If the realm of genomics comes true, when you have a cancer, you can go and have an infusion of some type of new cell DNA and the cancer goes away and you don't require radiation or other drugs. How do we plan for that and who is going to be doing that, by the way?
I think that when I show this planning model that the Toronto people are bringing forward, it's an attempt to try to point out all the variables in that. It's a very complex and difficult system and to try to fix one component of it, it doesn't work. It causes problems or it has ripples elsewhere or changes and it creates other issues for you. Our experience of the past has shown that the quick-fix issues of changing one thing, you need to try to plan and think 10 or 15 years out from where it's going to happen.
As I said earlier, we are beginning to engage in that process. We are at least trying to get some sense of how we would look at the system in building it for physicians in terms of keeping general surgery programs up and well.
How do we provide primary care across the province? We do have a primary care task force involving physicians and others looking at how the front-line service is going to be delivered in all communities across the province. All of this, somehow or other, has to be put
into a mix to plan for the future and as was pointed out by some of the other members, the challenge very clearly is that we need to be engaging our Atlantic colleagues in that process. Again, it is a very difficult piece. If we can't get them to buy into the process, then we have some difficulties.
MR. BARNET: What time does my time expire, Mr. Chairman?
MR. HENDSBEE: At 9:45 a.m.
MR. CHAIRMAN: I would like to correct the member for Preston, doing the math, I think it's 9:35 a.m.
MR. HENDSBEE: Is it 20 minutes or 30 minutes?
MR. CHAIRMAN: You are new here. It's 9:35 a.m.
MR. BARNET: I did think that was quite generous, but I was prepared to accept 9:45 a.m., however, considering it's 9:35 a.m., I do have two additional areas that I want to explore and I really am concerned that I might not get to the most important one to the constituents I represent, and that is surrounding the Cobequid Multi-Service Centre and the human resources there. I'm afraid that I might get one of those long answers from Dr. Ward, so I think I will go there first.
In the beginning of your presentation, you spoke about the need to have, I guess I would say, a sustainable health care system that meets the requirements of communities in Nova Scotia and you talked about the numbers that we need to warrant the type of services that we provide here in Nova Scotia, a population or catchment basis of 2 million. In the community that I represent, and the member for Sackville-Cobequid and a number of other members and the member for Timberlea-Prospect, we are served by the Cobequid Multi-Service Centre. The people in that community hold that facility as a model of good health care.
I guess, in terms of explanation, it's probably the only stand-alone emergency centre that I know of in the Province of Nova Scotia. It's a stand-alone emergency centre. It has no hospital beds. It does diagnostic servicing and testing and provides clinics. To me, it seems like the type of health care system, or a component of the health care system, that may be valuable and beneficial to Nova Scotians from one end to the other end. Does the department look at the Cobequid Multi-Service Centre as the type of facility or a model type of facility that they would see being beneficial to other communities and can we see this as the type of thing that looks to the future of health care in Nova Scotia?
DR. WARD: Yes.
MR. BARNET: That's a good answer. Having said that, there has been some speculation in the most recent weeks about the commitment of the Department of Health to the Cobequid Multi-Service Centre. It is my view, and I believe the view of the minister and the department, that there is a commitment to move forward to replace that facility with a modern facility that meets the needs of the community. I guess from your position as deputy minister, does that commitment to replace that facility in a reasonable time period still exist, and can the people who are served by that take comfort in the fact that this department is moving forward on that project?
DR. WARD: Yes.
MR. BARNET: Okay, that's great. Now let's go to the issue that obviously is important, but not as important to people I represent. I had the opportunity over the past couple of years to do a considerable amount of travelling. I have travelled from one end of this country to the other end and I have also travelled to the United States and, as well, to Australia and to New Zealand. During my travel, one of the things that I have done is I have taken the time to explore the issues that other governments are facing. I spoke particularly to a number of people in Australia, New Zealand, Los Angles and throughout the Eastern Seaboard of the United States who are involved in governments. I spoke to people who are involved in governments in Africa; I spoke to people who are involved in governments in Asia and various areas and, to me, the one thing that is common with all of those governments in terms of an issue that they face is health care. Every single one of them, without exception, all said the same thing. They are faced with a shortage of one profession or another or all professions in the health care system.
I guess my question to you is, considering that I think all would agree that this is not a Canadian issue, it is not a Nova Scotian issue, it is not even a North American issue, it seems to be a worldwide issue, how is Nova Scotia going to resolve the Nova Scotia issue, considering there is all that competing interest from all those different countries? We know that we have put in place certain programs, but how are those programs going to resolve the issues of the 70 doctors and the 160 nurses that we need when we have to compete with deep pockets south of our border and even deeper pockets in some of these other smaller countries that I spoke about?
DR. WARD: I think, very clearly, the strategies that we need to be moving forward with are, to a good sense of the number of professionals we need, five and 10 and 15 years out from now and begin to plan for the educational programs to produce them. The second thing, very clearly, is we do need to deal with issues that have been discussed earlier, and that is the work life, job satisfaction and comfort level of people. If we can structure a system in
which people believe they are contributing, they are happy in their jobs, then, in fact, I don't believe the recruitment mobility piece will be as much of a concern for us. So it is managing both the lifestyle pieces and, at the same point in time, talking about how do we continue to maintain an adequate supply of health care professionals for the future.
MR. BARNET: Do you believe we have started building the foundation for this system? Obviously, you are telling us what we have to do. Have we begun doing that?
DR. WARD: Yes.
MR. BARNET: Okay, how much time do I have left, 30 seconds?
MR. CHAIRMAN: If I did my math, there would be eight minutes left for each of us, so if you wish to give the floor up at this time, I would accept it.
MR. BARNET: I will give it up.
MR. CHAIRMAN: We are going to go to 10:00 a.m. today, so it would leave us eight minutes each, and I return to the member of the Official Opposition.
MR. STEELE: Mr. Chairman, I am just taking notice of my time here. Dr. Ward, let's suppose there is an election coming up and let's suppose that I was thinking about what platform I was going to run on. If I said to you that I was thinking of running on the platform of promising more doctors, more nurses and more hospital beds, what would be your reaction to that kind of a promise if I was thinking of making it?
DR. WARD: Are you talking as a potential voter or are you talking as the Deputy Minister of Health?
MR. STEELE: No, as the Deputy Minister of Health, of course.
DR. WARD: As the Deputy Minister of Health, I would caution you against.
MR. STEELE: Why?
DR. WARD: Let's take each of the three issues. It's very clearly more physicians. We've had the most successful physician recruitment campaign on a national basis and yet we still find ourselves struggling in terms of requiring physicians. We will find ourselves in a much more competitive marketplace over the next number of years.
With respect to nursing, yes, I would like the opportunity to increase the number of nurses and, hopefully, our programs in terms of both increasing seats, bursary programs and better marketing will, in fact, deal with that. The issue of more hospital beds, my question
would be what kind of beds? My sense is that at the current time we probably have a reasonable number of acute care beds, but very clearly, we do have some requirement for convalescent rehabilitation and certainly potentially for more residential or long-term care beds.
MR. STEELE: Do we, today, have more hospital beds than we had in 1999?
DR. WARD: No.
MR. STEELE: How many fewer would we have roughly? I mean I know we have that chart that you showed earlier, but just roughly speaking for the record, how many fewer beds would we have?
DR. WARD: There have been a few changes over the last year, I am not sure as to the exact number.
MR. STEELE: Ms. Oke, if I could address this question to you, do we have more nurses today than we had in 1999?
MS. OKE: I am doing the math in my head. I think just a few.
MR. STEELE: One of the things that has bothered me over the last little while is that whenever the question of nursing numbers comes up, the debate seems to descend into dispute over the numbers, not over policy about where we are and how to get to where we want to go, but over just what the numbers are. What's your understanding of the numbers and do you agree with the Registered Nurses Association of Nova Scotia?
MS. OKE: Trying to pin down numbers for nursing is extremely difficult. All registered nurses are required by the professional association, if they want to work in this province, to register by October 31st of each year. However, after that date nurses who have been on leaves for whatever reason, whether it's maternity leave, or sickness leave, or they are just choosing to come back into the workforce, can re-register. So it will continue to be flexible throughout the year. What the professional association does is report a period in time and it is accurate for the time that they report.
MR. STEELE: And, Dr. Ward, if I could go back to you, do we have more doctors in Nova Scotia today than we had in 1999?
DR. WARD: Yes.
MR. STEELE: By approximately how many?
DR. WARD: I think it's around 70.
MR. STEELE: We have 70 more than we used to have in 1999 and yet we have shortages. So is it fair to say that that's more of a distribution issue than a numbers issue, that the problem is not so much how many doctors we have as where they're located? Is that fair?
DR. WARD: I would characterize it by saying there are a number of factors in that. Very clearly, when we say physicians, we need to separate as a minimum specialists versus family practitioners. Although people are registered with the college, we do not have any sense of the amount of service or hours of work. We have no understanding of how many are part-time, how many are working two or three days a week versus full-time.
MR. STEELE: So if I am understanding you correctly, and I just want to make sure that I am understanding you correctly, although the raw numbers of registered doctors may be higher, it's really difficult or impossible to say whether that actually means more services to Nova Scotians. Is that fair?
DR. WARD: Yes.
MR. STEELE: Because, of course, when we talk about political promises, it wasn't me who promised more doctors, more nurses and more hospital beds you know. I am not going to promise that in the next election, but our current Premier did promise it in the last election, and he said it was only going to cost $46.5 million. I just want to read the text of a radio ad because it's worth reminding Nova Scotians what their current government promised them in the last election. It wasn't a tax cut; that was buried deep in the blue book - the tax cut and the balanced budget.
What all of their advertisements focused on was fixing health care - this is very brief, this is a 15-second radio spot, Mr. Chairman, so it won't take me very long to read - Dr. Hamm says there shouldn't be any doubts about the quality of health care Nova Scotians will get in the future. Then a voice-over: The John Hamm plan will make health care the first priority by providing more nurses, more doctors, and more hospital beds in the community. Dr. Hamm comes back on: And we'll do that with a budget Nova Scotia can afford. Then the voice-over says: Get your copy of John Hamm's plan for health care by calling this toll-free number.
So that's what the government promised in the last election, more nurses, and I am hearing that if we do have more, it's a few. We do have more doctors, but we have no idea whether they're providing better service and, in fact, the distribution problem is just a little better, if it is better than it ever was, and as far as more hospital beds, it is simply not true, there just aren't. So I just want to be clear, Mr. Chairman, about what it is that our government promised in the last election and what, in fact, they've delivered.
Mr. Chairman, I have a minute left, so I want to go back to the issue that got cut off in my last round of questioning on the technologists and technicians. I have a news item here from November 10th saying that a shortage of radiation technologists in one part of Nova Scotia is so bad that not one person has applied for two current job openings. What words of hope can you offer to the medical technologists and technicians of Nova Scotia?
DR. WARD: Are you speaking of radiation technicians or medical technologists?
MR. STEELE: The news item says "radiation technologists."
DR. WARD: Radiation technologists are the individuals associated with radiation therapy, a cancer group.
MR. STEELE: Yes, X-rays, CAT scans, ultrasounds.
DR. WARD: For the last year we have been in discussion in Atlantic Canada about the opportunity to put in place a program to train radiation therapists for Atlantic Canada. At the current time there is a single program nationally that is run at the Mitchner College in Toronto, and for a number of years we have been purchasing seats at the Mitchner College to send Nova Scotians to train.
MR. CHAIRMAN: Your time has elapsed, Mr. Steele. It's roundup, 9:44 a.m. Mr. MacKinnon.
MR. MACKINNON: Dr. Ward, your department has a number of user fees, am I correct, for different services?
DR. WARD: Yes.
MR. MACKINNON: Would you indicate to the members of the committee what your department's definition of a user fee is?
DR. WARD: Your sense of user fees I would define as co-pays. It is a co-payment by somebody who is using a service that includes, at the current time, pharmacy and some of the home-care support programs.
MR. MACKINNON: Would you give an undertaking to the committee to provide a list of all the user fees that you currently have with your department, in the region?
DR. WARD: Yes.
MR. MACKINNON: With regard to doctors, LTNs, nurses, technicians and so on, what's the burnout rate with the doctors in Nova Scotia?
DR. WARD: At the current time we're in the process of looking at the longevity of physicians in terms of their . . .
MR. MACKINNON: What is it now?
DR. WARD: I don't know.
MR. MACKINNON: What is the burnout rate for registered nurses?
MS. OKE: I don't know how you're defining burnout rates and we don't currently measure any burnout rates.
MR. MACKINNON: Do you measure burnout rates for LPNs?
MS. OKE: Again, I don't know what the definition that you would be using is.
MR. MACKINNON: Well, what's your definition of a burnout?
MS. OKE: We don't currently measure burnout.
MR. MACKINNON: You don't measure, I see. So you don't know what the definition of burnout is for your department then you don't measure it, is that what you're telling us?
MS. OKE: That's correct.
MR. MACKINNON: What's the average age of a doctor in Nova Scotia?
DR. WARD: It's 47.
MR. MACKINNON: How many doctors in Nova Scotia do you have over the age of 65?
DR. WARD: In practice?
MR. MACKINNON: Yes.
DR. WARD: Don't know.
MR. MACKINNON: How many over the age of 70?
DR. WARD: Don't know.
MR. CHAIRMAN: Excuse me. Dr. Ward, I would assume with time you could give that information, could you?
DR. WARD: Certainly, we could speak to the college about that. But as I am sure that Mr. MacKinnon is aware, the Department of Health does not license physicians to practise in this province. That is held independently by the College of Physicians and Surgeons.
MR. MACKINNON: Wasn't there a buyout program instituted by the province several years ago that would allow doctors who were looking at retiring or perhaps phasing them out of the profession into a retirement stage - wasn't that program put in place by the province, and acted upon?
DR. WARD: If there was such a program, it was certainly well before my time. I am unaware of it, but if you would like us to look back, we would be pleased to do so.
MR. MACKINNON: Okay. For the record, there was one and I am not sure if it's still in vogue or not. You seem to indicate you're not aware of it.
My colleague raised the question about shortage of doctors, urban versus rural. I listened to your answer, but you really didn't answer his question. Where is the greatest disparity? Is it in rural Nova Scotia or urban?
DR. WARD: At the current time, my sense is that it's probably equally distributed between what I would describe as rural, very small communities, and we certainly have a large population within the metropolitan area that is currently seeking family physicians also. We don't have a sense that there is a lot of pressure in what I would define as the mid-size communities in the province.
MR. MACKINNON: With regard to an individual trying to secure a family doctor, recently I have received a number of complaints from constituents and individuals from different communities in Nova Scotia that they are having problems securing a family doctor. Is there much of a waiting list for Nova Scotians to secure a family doctor?
DR. WARD: At the current time, particularly, in the province we have a number of physicians. We keep a fairly up-to-date list in the department of physicians who are accepting new patients.
MR. MACKINNON: What's the waiting list right now? How many Nova Scotians are waiting for a family doctor?
DR. WARD: There is no list kept in terms of that.
MR. MACKINNON: So we have no idea how many Nova Scotians are looking for a family doctor and can't receive one.
DR. WARD: No.
MR. MACKINNON: The issue of burnout. I want to go back to that because it seems to me that what was announced - and I don't want to get into current expenditures because obviously that's not really the mandate of this committee, but the perception is there that we have a double standard. We appear to be ghettoizing - like the LPNs, the nurses, the lab technicians and so on versus the doctors. Whose perception is reality? Unfortunately, in many cases in politics, as you know, Dr. Ward, how do you respond to that concern? It's a psychological factor that is contributing to - as my colleague has mentioned - eroding the underpinnings of a co-operative, safe health care system.
DR. WARD: The challenges of the job - stress or what have you - talking about the burnout phenomenon, simply individuals who believe they're uncomfortable doing what they do and choose to change their careers. I have certainly done that in terms of my own personal and professional career. I think one of the issues, particularly, that is a little bit different in terms of the relationship of physicians and the other members of the health care team is that at the current time, physicians fall into the category of independent contractor. They have the opportunity to define their own hours of work. They have the opportunity of defining the workload they choose to undertake. They define the opportunity of where they choose to practise. You can choose to be an emergency room doctor or you can choose to do something else. As a family physician, you could choose to work 9:00 a.m. to 5:00 p.m. If you wanted to work on the weekends, you have that choice. So there is a fairly significant degree of flexibility for that.
Within the hospital sector, it is a different issue. The bulk of the nursing workforce at the current time is within the hospital sector and certainly have defined hours of work or responsibilities. They do not have that flexibility that the physicians currently have. Is that an issue? Absolutely. But as I said earlier, one of the big challenges for the system - and it is not an issue solely for the department, but it is for hospitals, district health authorities and the professions - is to deal with the lifestyle job satisfaction piece and how can we make it better.
MR. MACKINNON: I will pass to my colleague.
MR. CHAIRMAN: You have 40 seconds left.
MR. DOWNE: The issue of the doctors, rural versus urban, my sense, from your answer, and I have listened both times the question was asked, are you saying it is harder to
get to a doctor or to see a doctor or to be able to access a doctor in rural Nova Scotia than it is in the city? Could you give me a yes or a no on that one.
DR. WARD: No.
MR. DOWNE: The last point is, what are we doing about recruitments for home care support workers in the Province of Nova Scotia?
DR. WARD: At the current time, as I indicated earlier, we are in discussion with the community colleges to increase educational opportunities for home care and home support workers and hopefully we will be able to increase that workforce over the next few years.
MR. DOWNE: I would like to bring you down to some of the areas, doctor, when you are free, to talk about some of the rural issues and I would appreciate it if you would be willing to commit to that in the South Shore area?
DR. WARD: Yes.
MR. CHAIRMAN: Downtown Wileville will be welcoming you, Dr. Ward. Could you take us to 10:00 a.m., the member for Kings West, please.
MR. JON CAREY: Mr. Chairman, I think, Dr. Ward, would it be fair to say that the general public out there gets a mixed message from the press and from, at times, I think it is fair to say, the Opposition - they feel they are doing their job, but it almost borderlines on fear-mongering. Would you think that that makes your job more difficult?
MR. CHAIRMAN: You go ahead and answer it. I would like to have a comment, but I will resist.
DR. WARD: At a recent OECD meeting, there was a special session on the media, relating to media in health care. The commentators were people like David Irving from the National Post, John Inglehart, who has been the Editor for the New England Journal for a number of years. Their comments were very clear. I think they said two things. The biggest issue they see in terms of health care and its perception is that for the media, they still believe that the health care system is focused only on doctors and hospitals and that is where the biggest discussions are. What they do not understand is that in fact it is a system and that we really need to be talking much more about ambulatory care, population-based health, dealing with the determinants of health and dealing with issues in terms of long-term residential care and home care programs.
MR. CAREY: I think it has been established that the health care system is in a state of flux worldwide. People are very capable of adapting, I believe, but most of us are slow to change. We don't want to make the change. As I understand the program you have been
discussing and working on since you've been here is that there is a change. There is education for the public out there to understand that things are going to have to change. We are not going to have the same system that we had before and that this doesn't necessarily make it any worse, that they are going to have care, but it is a different situation.
So could I get you to comment on such things as the number of doctors and nurses in Nova Scotia that you have discussed this morning; how does our situation as far as salaries and working conditions compare to other areas and the bed situation that was mentioned from Dr. Hamm's ad, what about long-term care beds and so on? These numbers are increasing, are they not? Could you just give us a general update on those issues of conditions and salary.
DR. WARD: In terms of sort of the all-in, I guess, package of remuneration and benefits for all our health care professionals, we basically remain in a leadership position in Atlantic Canada which we believe is sort of our major marketplace. With respect to some of our professions, certainly physicians, again as an all-in package, we historically had been probably about three, but I do believe the wage settlements in the last while, particularly in British Columbia and Alberta, will see us backslide a little bit.
With respect to absolute numbers, we have one of the highest physician-per-capita ratios in the country. Certainly on the nursing side of it, if you look at the number of nurses per capita, Atlantic Canada by far leads the rest of the country. We currently have a ratio that is about 50 per cent higher than the national average of nurses per 1,000 population and we certainly are much higher than any of the OACD countries in that area and, again, I think it comes back to the issue about expanding the health care team and trying to define roles for those individuals and it's really the discussions around the models of care issues that certainly are major issues for us to deal with.
The issue you had raised about the number of beds, our ratio of beds per 1,000 population on the acute care side remains at the high end compared to other places in Canada. Certainly our sense at the current time is that you should be looking at about 105 long-term care beds per 1,000 population. We are at about that level.
Home care, the home support piece, we do believe that there are opportunities for us to be increasing the level of service. One of the fundamental issues that I think has been brought to the forefront today is that last week we had a fairly long discussion around the role of information and management and the absolute paucity of information and information management systems in the province. The move forward with the single entry access program is really the beginnings of putting in place some standards as to why people should go into residential care or long-term care. To this point in time there are no standards for home care. The home care and home support services are being delivered across the province by at least 15 different agencies with at least 15 different sets of standards and intake criteria.
If we want to go to some sort of a level playing field for Nova Scotians, some investment in standards and evaluation is certainly going to be part of it and, again, these are pieces that have to be put into the long-term planning mix. As I have said earlier, it's a very difficult and complicated issue. If there had been a simple answer, we would have found it by now.
MR. CHAIRMAN: Mr. Carey, I'm a bit remiss here, I apologize if I'm cutting your time, I didn't allow for any wrap-up from Dr. Ward or Ms. Oke, but I will allow you another question and then I would like to ask them for that opportunity.
MR. CAREY: I just have a short one. The comment of salary and respect has been brought up on several occasions, but you as a professional person, as a doctor previously practising and now here, salary and respect through our whole system, really one doesn't equate to the other. You can certainly have a lot of respect for people and the job they do, but the ability to pay and the demands of training and so on all factor into that. So could you just maybe quickly comment on your thoughts as a professional in the medical system?
DR. WARD: I think, as I had said earlier, sort of the traditional way of remuneration for the various members of the health care team has been in place for some time. The issue about the job satisfaction and morale piece of it, very clearly the morale in the health care sector has been decreasing for some time. It seems to be much more related to the job satisfaction pieces.
The studies that have been done over the last little while, particularly around both physicians and nurses, would seem to indicate a fair amount of dissatisfaction in the sense that individuals don't believe they're being given the opportunity to do all the things that they should be doing, that somehow or other their ability to practise effectively is being restricted and that through that process, I think they themselves feel that there is not as much respect for what they do as there previously was.
MR. CHAIRMAN: Thank you for that comment. Do either of you have anything more you wish to add, Ms. Oke, Dr. Ward?
DR. WARD: The issue of health human resources, the recruitment and retention pieces, the planning parts of it, I think is the single most complex issue that I have run across at the current time. It has been a focus for many jurisdictions and as you look around the world, there is now the National Health Service in Great Britain, the Health Human Resources Observatory, which in fact is a huge research group looking at the single issues around this.
Similar initiatives need to take place in Canada. We're beginning to see the glimmers of that, but again, we're in the process of catching up. I think Barb in one of her earlier comments said, that it's taken us a fair bit of time to get into this mess, at least a decade, and it's going to take us at least five years to see some significant changes.
MR. CHAIRMAN: On behalf of the committee, I would like to thank you both for being here and, Dr. Ward, for the last couple of meetings for being here. I remind MLAs that we'll be meeting in camera next Wednesday morning in the Committee Room and I believe we stand adjourned. Thank you.
[The committee adjourned at 10:02 a.m.]