The Nova Scotia Legislature

The House adjourned:
October 26, 2017.

Public Accounts Meeting - Legislative Chamber (2107)
















Wednesday, April 12, 2017


Legislative Chamber






Departments of Health and Wellness and Finance and Treasury Board

Health Care Funding and

February 2017 Report of the Auditor General 

Follow-up of 2013 and 2014 Recommendations






Printed and Published by Nova Scotia Hansard Reporting Services





Public Accounts Committee


Mr. Allan MacMaster, Chairman

Mr. Iain Rankin, Vice-Chairman

Mr. Chuck Porter

Ms. Suzanne Lohnes-Croft

Mr. Brendan Maguire

Mr. Joachim Stroink

Mr. Tim Houston

Hon. David Wilson

Ms. Lenore Zann


[Mr. Ben Jessome replaced Mr. Brendan Maguire for a portion of the meeting]


In Attendance:


Ms. Kim Langille

Legislative Committee Clerk


Mr. Gordon Hebb

Chief Legislative Counsel


Ms. Nicole Arsenault

Assistant Clerk, Office of the Speaker


Mr. Terry Spicer

Deputy Auditor General


Ms. Tammy Squires

Assistant Auditor General









Department of Health and Wellness


Ms. Denise Perret, Deputy Minister

Dr. Robert Strang, Chief Public Health Officer

Mr. David Bartol, Senior Executive Director, Corporate Services & Asset Management

Ms. Christine Gibbons, Director, Corporate Process and Quality

Mr. Tim Guest, VP, Integrated Health Services Program Care &

Chief Nursing Officer, NSHA


Department of Finance and Treasury Board


Mr. Byron Rafuse, Deputy Minister

Ms. Lilani Kumaranayake, Executive Director,

Fiscal Policy, Economics & Budgetary Planning

Mr. Rob Bourgeois, Director, Government Accounting

















9:00 A.M.



Mr. Allan MacMaster



Mr. Iain Rankin


            MR. CHAIRMAN: Good morning everyone. I would like to welcome you to this Public Accounts Committee meeting. I call this meeting to order. Today we have with us the Department of Finance and Treasury Board, and the Department of Health and Wellness. We will start with introductions.


            [The committee members and witnesses introduced themselves.]


            MR. CHAIRMAN: Thank you - a reminder to make sure your phones are on silent.


            Today’s topic is health care funding and the Auditor General’s follow-up on Auditor General recommendations from the 2013-14 Auditor General’s Reports. We will allow some time for opening comments from both Finance and Treasury Board and Health and Wellness. Perhaps we’ll begin with Health and Wellness. Ms. Perret.


            MS. DENISE PERRET: As noted, the subject is health care funding with a focus on federal transfers and the Auditor General’s Reports from 2013-14, those recommendations.


            There are two parts to federal funding. There’s the Canada Health Transfer, which is focused on having provinces and territories adhere to the principles of the Canada Health Act. It tends to be per capita funding that doesn’t have strings tied to it except for those principles under the Act.


            New funding that has been announced by the federal government is accord funding, which is focused on what the feds would say is health system transformation. They’ve put in additional money specifically, as they state, to improve health outcomes for Canadians as one of their goals and to address gaps in the health care system. Their focus, in the discussions that we’ve had and in their discussions in the media, has been on home care - so they are reinforcing that shift we see across the country from acute to community - and on mental health funding with a special emphasis on filling gaps in services for those under 25 years of age. Just as provinces and territories have recognized the need for a shift in the way health care systems are structured and how we provide services, the federal government has also expressed its commitment to effect change.


            There’s a research binder that’s put together for members of this committee. It was particularly well done, I thought, for this session. One of the items in it is David Naylor’s report on innovation in health care. It’s an important report. It shouldn’t be on a shelf. It should be in front of everyone. Dr. Naylor, in a very straightforward manner, sets out what some of the issues are in our health care system and the opportunities and challenges before us. It’s a very instructional document and a good background for the discussion that I’m anticipating here this morning.


            He notes, and we’ve discussed this before, that access to primary care in this country has been an ongoing concern for over two decades. He observes - his words - that Medicare in Canada is badly aging.


            We’ve had this discussion and I have to say that in the Nova Scotia context, because all provinces and territories are faced with these challenges and opportunities - the one thing that stands out for me is that we’re seeing a tremendous response from outside government circles, from front-care health workers. Doctors Nova Scotia issued a report that went public today. I’ve met with pharmacists, paramedics, we’ve discussed in this Chamber, there are a number of people who step up to the challenge.


            As I learn more about the story in this province, it’s very much like the 1990s. In the 1990s we had significant fiscal challenges in health and we saw dramatic responses - the closure of hospital beds. We saw many of the same issues that we’re dealing with today with the ED departments that were closing. What came out of that is a tremendous innovation particularly in community paramedicine, which as we discussed, it leads the world in many respects.


            We had the pleasure of hosting the federal Health Minister in late January. She toured the EHS communications centre and was very interested to hear about the response of the paramedic community to providing services to seniors in the community, and how that could be scaled and spread in Nova Scotia and across the country. She received a presentation from pharmacists on the Bloom Program, which is a program that provides in-depth medication management to those suffering from mental illness. Also importantly, the pharmacists provide important navigational services for patients and link with other health care providers in a collaborative fashion. There are about 221 patients enrolled in that program.


            She learned a bit about our Strongest Families Institute and how we have online services through phone and Internet, providing mental health services to children, youth and families. Her response to that was that she was impressed and that was in line with what the federal government is thinking it wants to support as we move forward.


            In regard to the recommendations from the Office of the Auditor General, I think we can report that good progress is being made by the Department of Health and Wellness and by the Nova Scotia Health Authority. In particular we’re pleased with the progress in public health.


Recently there has been an announcement that we’ve adopted the Panorama IT solution. That is going to provide us with an immunization and vaccine inventory, we predict by the Fall of 2017. It increases our ability to track and report notifiable diseases and increase our surveillance capacity. This is really important because the more we know about population health needs, the more we can respond on a community level and organize collaborative care, primary care to meet the needs of specific communities.


            We know there has also been a lot of work done in meeting the recommendations on alternative funding payments to physicians. Where there is still work to be done is on wait times. I know there has been a significant investment on this front. We had an additional $4.2 million in 2014-15, another $2 million in 2015-16 and $8.1 million in 2016-17. What we’ve seen in the most recent report is that Nova Scotia - and I think it was the only province - showed significant improvement on all fronts. That doesn’t mean that it has reached the levels it needs to reach, but the investments seem to be moving us in the right direction.


            There’s always more work to do and I’m very appreciative that Tim Guest from the Health Authority is here to address questions you may have on that front. I’ll close there and look forward to your questions. Thank you.


            MR. CHAIRMAN: Thank you, Ms. Perret. Mr. Rafuse, would you like to offer some comments?


            MR. BYRON RAFUSE: Good morning to the committee. I’d like to make some brief opening remarks on health care funding and I’ll follow up to the Auditor General’s 2013-14 recommendations.


            Nova Scotia is one of nine provinces and three territories that have agreed in principle to new health care funding. As with other federal funding, formalization of this will be done through federal legislation. Originally we called this an agreement but now that it is being implemented it will now be implemented through legislation because more provinces are onboard.


            The Canada Health Transfer is an unconditional transfer designed to assist provinces and territories with health care funding, as the Deputy Minister of Health and Wellness has indicated. To receive the transfer a province must agree to the five principles of the Canada Health Act: universality, accessibility, portability, comprehensiveness, and public administration. Starting in 2014-15, the Canada Health Transfer was modified to distribute a national pool of cash on an equal per capita basis based on a jurisdiction’s share of the national population. At that time, the CHT was extended in federal legislation for 10 years, the end year being 2023-24.


            In 2017-18, the escalator in the CHT became the three-year average growth of the national nominal GDP with a floor of 3 per cent. The floor will be in effect for the 2017-18 fiscal year.


            For 2017-18, the national pool of cash is $37.1 billion. Nova Scotia is estimated to receive $967.2 million, based on having 2.6 per cent of the national population. In addition to the Canada Health Transfer, the federal government has offered the provinces and territories $11 billion of targeted funding for home care and it’s $5 billion across the next 10 years. For mental health, it’s $5 billion across the next 10 years; for home and community health care infrastructure, an additional $1 billion over the next four years.


            The province is currently in the process of finalizing the details regarding the reporting under the targeted funding. Revenue for the targeted funding initiatives will commence in 2017-18. Further details of this will be provided in the province’s budget of 2018, which will be tabled on April 27th.


            Nova Scotia receives about one-third of its overall revenue in transfers from the federal government. The Canada Health Transfer is the second largest of these transfers. In 2016-17, that amounted to $944 million. I should note that health care spending is government’s biggest expense and is currently at $4.3 billion.


            The rising cost of health care is a challenge for every jurisdiction in Canada at the present time. We have made strong efforts in Nova Scotia to slow the budgetary growth in the sector using innovation and technology to deliver health care, joint purchasing, shared services, and reducing administration costs within the province.


            I believe my colleague at the Department of Health and Wellness would agree that the partnership we have with the federal government is very important for the health and wellness and services we provide to the citizens of Nova Scotia.


            In relation to the Auditor General’s Reports of 2013-14, I’m pleased to report that the Department of Finance and Treasury Board has completed 18 of the 25 recommendations. Furthermore, we have plans to complete five more of the remaining seven this year. Of the remaining two, we have partially completed those requirements and continue to work on full implementation.


            To highlight the work the Department of Finance and Treasury Board has completed, we have updated procedures and processes to support the government’s financial statements and communications with stakeholders. These processes include updating processes and procedures, supporting major line items in our consolidated financial statements and within our revenue estimates process, and the thresholds related to tax changes.


            We also ensure amounts in the general revenue fund and the consolidated financial statements are supported and are reported in accordance with the Public Sector Accounting Standards. We’ve improved communications between ourselves and government agencies to ensure more timely completion responses with issues and deficiencies that are identified in their statements by their auditors are dealt with in a timely manner.


            I thank you for the opportunity of opening remarks and I look forward to the committee’s questions.


            MR. CHAIRMAN: Thank you, Mr. Rafuse. We’ll begin with Mr. Houston of the PC caucus for 20 minutes.


            MR. TIM HOUSTON: Thank you for your opening comments. Deputy Rafuse, could we get a copy of your opening comments? There are a lot of numbers in there, which I appreciate, so if we could get a copy of that it would be great.


            MR. RAFUSE: Could I wait until I get you a clean copy? I have a lot of notes on it, but no problem.


            MR. HOUSTON: I wouldn’t mind your notes. (Laughter) I was just trying to capture - so the Premier announced a deal with the federal government two days before Christmas. It was a deal, an agreement, I think you referred to it - we’re not calling it an agreement anymore because it’s going to end up in legislation. They agreed to something and there are a lot of moving parts probably, I assume, to what was agreed. Most of those moving parts are unclear to me. I’ve watched some of the minister’s press clippings, and it seems like maybe they might be unclear to him as well. But I’m wondering how unclear they actually are.


Do you have anything you can provide to this committee that says, this is what we agreed to two days before Christmas in terms of the funding that will come each year and what the stipulations might be around that? Could you table something for this committee that would show what the agreement was?

            MR. RAFUSE: When I give you copies of my opening remarks, that actually does outline it. We originally called this an agreement because at the time, as you realize, there were bilateral conversations going on because the discussions at the national table were not successful at that time.


In December, there were actually three provinces that had agreed to additional funding for health care. At that time, since there were only three provinces, our discussions with the federal government were, well, we need to have this wrapped up in some type of an agreement. As we worked through that, it was quite clear to us that the federal government was actually having conversations with other jurisdictions because that conversation kind of slowed down for them, so we stopped talking about an agreement.


            It wasn’t until we actually got confirmation when the federal government tabled its budget, that it did enable the transfers of this additional money which is outside of the CHST, to enable the federal government - which is in fact, the more typical way in which federal transfers do occur to provinces. There usually isn’t an agreement, per se, but there’s an understanding, and then it’s embedded in legislation. Those things that I did talk about earlier - the principles of the CHST remain, but there is targeted funding for home care, mental health, and infrastructure in those areas.


            MR. HOUSTON: I want to talk about that. First off, just so I understand, who negotiates the agreements? Is it the Department of Finance and Treasury Board or Department of Health and Wellness? Who actually represents Nova Scotia in those negotiations?


            MR. RAFUSE: At the federal-provincial-territorial Finance meetings in December, the Ministers of Health were asked to join that meeting. Likewise at the Ministers of Health FPT meeting, I believe in October, the Ministers of Finance joined that meeting. It has been a joint effort of both departments along with the offices of the Premiers in all jurisdictions, and the federal government were involved in this.


            MR. HOUSTON: Thank you. In terms of what the deal is - the deal was signed very quickly. Who knows - maybe we can find out why we jumped. I do have some questions about how that deal improves health care in Nova Scotia because that’s not clear to me at all.


Going into those discussions, a lot of media reports have suggested that the transfer rate that was agreed to is not what’s needed to maintain the level of services in this province. In other words, there was a lot of discussion - I’ve seen the number 5.2 per cent, which is a very precise number - that we would have needed federal transfers to have escalated at 5.2 per cent a year to maintain the level of services that we have. That’s not the deal that was reached.


I’m wondering, are you familiar with that 5.2 per cent number?


            MR. RAFUSE: Yes.


            MR. HOUSTON: Is there any validity to that number, that that’s the number that would have made the finances of this province around health care work more efficiently and effectively? Is there any validity to that number? Is it a number that came from your department?


            MR. RAFUSE: Leading up to this conversation, there was a lot of work done at the official level to talk about what the health care spending growth has been across the country. Work was done by all provinces and territories. It looked at the historical trend pattern of health care spending and also the federal government’s participation rate in provincial health care spending.


At one time, that rate was at approximately the 50 per cent level with the federal government. That has dropped down to levels - depending on what province you are, you’re in the low-20 per cent rate. The thinking out of those groups was where if you look at perhaps historical spending patterns, a rate of around 6 per cent was developed. The 5.2 per cent rate, I believe, was a rate which would bring the federal government’s participation up to the 25 per cent level, that being the appropriate target for federal participation and provincial health care expenditures. The difficulty - not the difficulty . . .


            MR. HOUSTON: Is that relevant to Nova Scotia - 5.2 per cent would have brought us up to 25 per cent.


            MR. RAFUSE: I’m not sure - that was the national average. I’d have to get the precise amount for Nova Scotia.


            MR. HOUSTON: It would be interesting to have the precise number. If 25 per cent is kind of what people accept as what the feds should be paying, are we at 25 per cent?


            MR. RAFUSE: No, we’re not. That is a guide but there’s no requirement for the federal government to be at 25 per cent. In fact there was no requirement for the federal government to change anything. They had an agreement on health care funding that reaches out and legislation in place that goes to 24 per cent, 25 per cent. So there was no obligation to the federal government to do anything. This was an ask from the provinces. They were looking for amounts because the Canada Health Act previously had escalator clauses around 6 per cent. That was changed back, as I indicated . . .


            MR. HOUSTON: It was a huge issue in an entire federal election. I don’t want to debate what the federal government is obligated to do, or should or shouldn’t do, but they certainly made some promises to get themselves elected and now it changed. I’m more interested in the impact of that change on Nova Scotians.


            I guess what I’m hearing is that 5.2 per cent is kind of a number that’s relevant nationally and the relevance of the number is that it would bring the federal contribution to the cost of health care in provinces up to 25 per cent. We’re going to get the number for Nova Scotia but it sounds like the provinces universally accepted that 25 per cent is what we should strive for as the federal contribution?


Would that be fair to say, that that was the provinces’ position - including Nova Scotia - that the feds should be paying about 25 per cent? Would it be fair to say that that should be the Nova Scotia position, you should be paying 25 per cent?


            MR. RAFUSE: That was the position that was presented at the table as a negotiating . . .


            MR. HOUSTON: Okay, so that was our starting point and our ending point was quite a bit lower, even though we were amongst the first people to stand up on the chair and say isn’t this wonderful, we’ve got a deal. But we didn’t get a deal that’s helpful to the province - that’s what I’m wondering. 


            This year the federal transfers under the Canada Health Transfer - I think you said $967 million and then an additional amount under the targeted funding. What’s the additional amount for this year under the targeted funding?


            MR. RAFUSE: The additional amounts of the targeted funding will be included in our budgets that will be tabled on April 27th.


            MR. HOUSTON: Okay, so you’re not able to say what that amount is.


            MR. RAFUSE: No, really the convention would be that I would not release an amount that . . .


            MR. HOUSTON: Okay, but you can say the $967 million because that’s some old formula, is it?


            MR. RAFUSE: Not only is that actually on the federal government’s website that they give us that information on CHT funding in December where they actually project what it is, based on the formula for the upcoming year and revise the amount for the current year we are in, based on an updated figure of our population.


            MR. HOUSTON: And presumably they’ll put the targeted funded number online, too, when they are ready, I guess?


            MR. RAFUSE: I think they would be, but that would be up to the federal government.


            MR. HOUSTON: The timing - is there anything you can point your finger to that says, that was so compelling what they offered two days before Christmas that we just had to sign it right at that moment? Is there anything you can kind of succinctly say, this is the reason we jumped at this so quick?


A lot of people would say that the fact that the Maritime Provinces, the Atlantic Provinces jumped pretty quick obviously gave some momentum to the federal government, that I personally would say hurt all Canadians in their negotiations with this. That’s my personal opinion.


            What can you point to that says we had to sign this right then and there?


            MR. RAFUSE: I think that would be a question best asked to the ministers and the Premiers who made the decision on whether or not to accept that deal. I can tell you that at the federal-provincial meetings in December when there was an agreement on the funding, the federal government actually pulled all the funding off the table and there was nothing on the table at that point for targeted funding.


            The reason to accept that deal is one which you should really speak to those individuals. I would just advise them about what the implications would be on a fiscal perspective.


            MR. HOUSTON: Were you surprised when you - did you hear it in the news at the same time I did, that a deal had been reached?


            MR. RAFUSE: I was part of the conversation.


            MR. HOUSTON: How would you characterize your feeling when you heard that the minister said, I signed it?


            MR. RAFUSE: I advised him of the financial implications of what the deal was and what the dollars would mean, based on our understanding of the agreement.


            MR. HOUSTON: The province signed the deal - odd timing, just before Christmas - obviously. It’s also odd timing because we signed it when we were probably recruiting a new Deputy Minister of Health and Wellness. I’d like to ask the deputy minister, were you aware of these - you started the job on a certain day. You were probably offered the job some time before that. Was this deal signed after you were offered the job - if you can remember the timeline?


            MS. PERRET: I was officially offered the job at the very end of November, so it was signed after I was offered the job. But I had not started - I didn’t commence until January 16th.


            MR. HOUSTON: Do you recall if you were consulted or kept informed during the month of December that this was happening and they were probably going to sign a new deal? Because I know when you get offered a job, you’re not really on the payroll, but you kind of start assimilating yourself into the culture and getting up to speed. Were you consulted at all on what might be signed?


            MS. PERRET: No, I was working in my former job until the end of the first week in January, so my loyalties were there, and I removed myself from all federal-provincial matters.


            MR. HOUSTON: Deputy Rafuse, in your opening remarks you referred to the funding as unconditional at one point, but you also referred to the five principles that must be respected. It’s my understanding that if one of those principles is not respected in some way, it can jeopardize all the funding. There is some risk around the funding. You have to respect the principles, otherwise the funding is at risk. Is that fair?


            MR. RAFUSE: That would be my understanding, but those principles were pretty broad, yes.


            MR. HOUSTON: I’m just wondering about the types of things that could put the funding at risk. The Nova Scotia Health Authority is going through an accreditation process right now. Maybe the Deputy Minister of Health and Wellness can tell us the accreditation for the Health Authoriy. I read that it was the Spring of 2017. Has the accreditation process started?


            MS. PERRET: I’d like to check with Mr. Guest on the specifics.


            MR. TIM GUEST: We have started our preparation for the accreditation process and our visit is in October 2017.


            MR. HOUSTON: There are reports in the media every day now, and even the deputy minister referred to some of the reports that have come out from doctors, from the NSGEU. I’m thinking of issues like the code census and issues around the delivery of health care that people are rightly so concerned about right now. Is that the type of thing that can impact the accreditation process?


            MR. GUEST: Not directly. How we plan for and respond to those issues would be more relevant in that process.


            MR. HOUSTON: I do want to talk about the delivery of certain services in certain areas of the province and not in others. I’m thinking about that in the context of the universality of the delivery of health care.


            We are supposed to have universal access to health care services to every citizen in every province in this country. That’s one of the principles. When I look at some of the services that are delivered, particularly in rural areas - I’m going to talk about palliative care. Richmond was an example. Somebody said to me this week that in Richmond County you can’t get access to palliative care services after 4:00 p.m. each day. Then when I dug in, somebody said, well actually, the Health Department’s palliative care framework explicitly states that the people cannot be expected to provide this type of care everywhere in the province. I don’t know how familiar you are with the palliative care framework, deputy, but I’m wondering, are these the types of things we should be concerned about in terms of the transfer money?


            MS. PERRET: I wouldn’t link it directly to the transfer money. I wouldn’t make it a direct link. I can comment that one of the things that the federal government has promoted very strongly is that it wants the accord funding - it sees it as an incentive to improve the provision of palliative care in the province. I think it feels quite strongly about that in the context of medical assistance in dying as well, that it sees a need to have a provision of full services there, and it is seeing that as a gap across the country so it is trying to provide incentives and direction on addressing those gaps.


            MR. HOUSTON: So you don’t have any concerns about the universality of health care delivery in this province. Are there any areas where you are concerned that maybe we’re not meeting that criteria?


            MS. PERRET: I didn’t say I didn’t have concerns. When we talk about universality, certainly if we talk about it in terms of transfers, that only applies to funding for hospital and physician care. So the terms of the Canada Health Act on universality is just that Canadians get hospital care and physician care in the insured services context paid for by public funds. That’s what universality means, so I was answering in that context. I believe we do that in Nova Scotia - the federal government has no concerns with our payment for those services here.


            MR. HOUSTON: Okay. So we have a number of areas in this province right now where people don’t have a doctor. We have a number of areas in this province where people might call around to a physician’s office in a neighbouring community and they are asked, where do you live? They are often told that you don’t live in our geographic area, we can’t take you on as a patient.


            That’s an issue for me. That’s an issue around access to primary health care. I’m hearing about patients being dismissed - we have that in our community, being dismissed from a collaborative care clinic.


            Where are we at in health care in this province when you call up and try and get a doctor’s appointment and they ask you where you live and then say no, I can’t help you because you live in that area and not this area? Where are we in health care in this province when you call a doctor’s office and the first person who answers the phone asks you, well why is it that you want to see the doctor because well no, you can’t see the doctor for that. That’s what’s happening, because it takes so long to patients that they need gatekeepers to figure out. That doesn’t seem like universal access to health care. Does it seem like it to you?


            MS. PERRET: I agree that that’s where Nova Scotia and other provinces are focused on how to improve that access. As we’ve discussed, part of the improvement to access is to increase the number of providers who are able to support each other and to back each other up. If we’re just going to focus on access through a physician, we have quite a narrow gate there. If we look at all our 40,000 health care providers and use them to their full scopes, in collaborative teams, we increase the access point. So as we’ve discussed, that’s the focus of part of the shift, part of the change we’re trying to effect in this province.


            Your question has a number of angles on it. I would agree with you, some of the responses that you just indicated that people receive would concern me. As we are restructuring the system, and I was very pleased to see Doctors Nova Scotia with its report because I think that opens up an important discussion, but partly we’re talking about to what degree do physicians have autonomy as to where they locate, who they see, when they work and to what extent, and we feel increasing public pressure, does the province come in and try to manage that and plan for that? So there’s a shift there.


            MR. HOUSTON: Yes, and the shift is fine and the vision is fine and all those things and a doctor for every Nova Scotian - well maybe not this year, maybe in three years and stuff. I guess that’s all fine - I don’t have a lot of faith in the execution on that.


            I just asked a simple question, where we’re at now in the last two years and three years and four years - there hasn’t been universal access to health care in this province, has there?


            MS. PERRET: In terms of what the federal government considers universal access, there is.


            MR. CHAIRMAN: Order, time has expired. We’ll move to the NDP. Mr. Wilson for 20 minutes.


            HON. DAVID WILSON: Thank you for being here. Actually I’ll keep on with the theme that my colleague has just brought up, that’s around physicians and their ability to provide care to Nova Scotians.


Are you aware of the Supreme Court ruling in B.C. when the British Columbia Government tried to, I would say, dictate to physicians in that province where they could practise, and the Supreme Court ruling had indicated that the province is limited on doing that and they couldn’t do that? Are you familiar with that ruling? Are you concerned that the approach that the current government and the Health Authority has taken could potentially put us at risk of physicians in this province taking the same path that physicians in British Columbia took, to try to tell the government of the day that you can’t restrict access to primary care, access to family doctors because of where you live in the province.


            MS. PERRET: I’m not intimately familiar with the B.C. case. I think that there have been a number of initiatives by different provinces looking at how to plan for services to improve access for services and as I said, because traditionally we have private providers in primary care on the physician community who have a great deal of autonomy in where they locate and how they go. So it needs to be a collaborative effort to have that planning process.


            I think that some of the restrictions - I mean, the other province that actually does it more proactively, and within the bounds of the constitution, is Quebec. So there are ways of planning the system to focus on patients, to focus on communities and what they need because that’s at the heart of everything. I think we have general agreement with the professions, the Health Authority and the department that that’s where we start, and then we’ll have those discussions and sort things out.


            MR. DAVID WILSON: You mentioned that there are restrictions. Would you agree that the current government, the system itself - the Health Authority - are placing restrictions on physicians on where they can practise and who they can see in the province?


            MS. PERRET: There are no restrictions on a physician being licensed in the province.


            MR. DAVID WILSON: That’s the interesting part of it because I understand that Dr. Harrigan indicated to physicians that you are able to practise anywhere in the province. But the kicker to it is that the privilege and approval to order tests will be - that’s what’s restricted. So it’s great that you can have a licence to practice anywhere in the province - just hope that your patients that you’re seeing don’t need tests to be ordered.


Is that correct that yes, they can practise anywhere, but they won’t be given access to order tests at the local hospital or clinic in the area that would do the testing needed to try to determine what is actually wrong with a patient if they’re seen at a physician’s office?


            MS. PERRET: My understanding is that - and as a relatively new initiative - the Health Authority is looking at credentialing as one tool in negotiations with physicians as to how we service individuals in communities. So the starting point is - what are the needs of communities, where are our primary care assets and how do we plan to serve those communities and individuals better? That sometimes is a negotiation and possibly a bit of a tension between autonomy and the service to the community.


            Where I think we come together - where you can bring the discussion around to agreement - is that increasingly we know we need to focus on health needs of communities, and we need to talk about these issues with the patient at the centre. Then we’ll talk about how we serve the patient and accommodate provider interests.


            So one of the things we’re doing in response to balancing physician autonomy and gaps in primary care service is building these teams so we’re putting in linkages. By saying linkages I don’t want to underestimate the value of these services. We have nurse practitioners and we’ve talked about it in this forum and the Naylor report on Page 7, I believe in your package, says since the 1970s we know that nurse practitioners can do 70 per cent of what a general practitioner can do, effectively without affecting negatively health outcomes or expectations.


            To fill the gaps in the first order of business isn’t to restrict where physicians are going - it’s to put in new resources such as nurse practitioners, family practice nurses and then we’ll start to connect things.


            MR. DAVID WILSON: Why would we jump ahead of having that in place by restricting ability for physicians to open up a practice? I know it has been very frustrating, and it is kind of counter to what the Premier’s commitment to Nova Scotians has been since he tried to seek office four years ago - a doctor for every Nova Scotian.


            So we talk about a collaborative approach, which I agree with. We understand, but ultimately Nova Scotians need access to family doctors. Is this an exercise to get around the legal requirement of a province to make sure that they don’t infringe on the charter rights of physicians? To me, that’s what it sounds like.


            I was very frustrated when Dr. Harrigan was here when I said that there are restrictions in place and she was indicating there wasn’t - and we know of the community of Weymouth, for example. So is this just an exercise to make sure that the government won’t find itself in court in a few years or in a few months or whenever that happens? I know it’s a long process, so most likely a few years. Is that what’s behind some of the changes and the language of not saying you’re not giving a licence to a physician to practise in the province, but not offering privileges really handcuffs their ability to provide primary care? I see it as an exercise in trying to circumvent ending up in court. Would you agree or not with that?


            MS. PERRET: I would not agree.


            MR. DAVID WILSON: Okay. We’ll have to disagree on that. We’ll have to see where this all goes into the future.


            When it comes to the budget - and I should remember this, but it has been a few years - how do we allocate the funding for physicians? A physician is licensed, they have a practice, and they bill the province. Is it done quarterly? I know when the budget is presented there’s an overall estimate of what physician services will cost, and we try to figure out what the upcoming year will be. How is the money allocated? Is it allocated quarterly, or is the full sum put aside and ready to be used?


            MS. PERRET: My understanding - and if I’m incorrect, I will correct it later - is there is a budget approved for physician services, and physicians provide those services and bill us through our medical service programs. Those billings are paid in the normal course.


            MR. DAVID WILSON: So money is not allocated from Finance and Treasury Board on a quarterly basis? Maybe the Deputy Minister of Finance and Treasury Board can answer.


            MR. RAFUSE: As with all departments, there’s an annual appropriation, which goes through this legislative process. Within the Department of Health and Wellness would be an amount allocated to physicians, and it is an annual amount. I would think that they would allocate it out monthly for internal reporting purposes, but the actual budget is provided on an annual basis.


            MR. DAVID WILSON: It’s interesting - we talk about a physician for every Nova Scotian. The people who don’t have physicians, we hear the ratio of per capita, which you can interpret in many different ways. I believe we’re the second-lowest in the country when it comes to funding to physician services.


            Currently, we have in Central Zone I believe 30 vacancies. There’s 58 across the province from the most recent information I have, as of January. I believe there’s 30 in Central, seven in Eastern, seven in Northern, and 14 in Western.


            Is there a savings to the province if those positions stay vacant? I know, because I was there, that when a vacant position is in the department, that’s a bonus at the end of the year. It gives you wiggle room to spend that money. In the last month, we’ve seen - my lord - $70 million or $80 million of spending from the Premier. Is there a savings from those 58 positions? That’s just primary care. That’s just family doctors. I’m not talking about specialists. Is there a savings to the province for those 58 positions the longer they go vacant?


            MS. PERRET: I really appreciate you asking that question because if there is a perception of that out there I would like to set the record straight that there is absolutely no focus on saving money by not advancing it. In fact, I think what we would find out - and if Mr. Guest has some more information, he can add to it - is that there’s actually an investment going into the effort to recruit physicians. If anything, we are organizing our resources and putting more effort in. I think that the Health Authority put in place recruitment officers in each zone, for example. Those would be new people.


            MR. DAVID WILSON: Over the last year, are you able to provide the committee with the dollar figure around the vacancies that have been there over the last year, or will I have to wait for the Budget Estimates to get that number? Can you provide us a figure of what the province has saved in vacancies in the last fiscal year when it comes to family doctor openings here in the province?


            MS. PERRET: I’ll ask people to correct me here if I’m wrong, but the physician budget is a volume-driven budget. There is an estimate of what the costs of physician services are in the province. That is part of the requirements of the Canada Health Act - that people access physician services, and those are publicly paid-for dollars. So it’s a bit of an anomaly compared to some other aspects of the budget where some other budgets have hard caps on them. Generally speaking, physician services is a soft cap because it’s driven by a need in the province and those payments are made because we’re committed to public funding for insured physician services.


            If there is a discrepancy, if there’s a delta in a budget between a forecast and an actual, that’s just a reflection of the forecast and the prediction of what the volume will be. There is no effort to restrict the hiring of physicians in order to save money on that line.


            MR. DAVID WILSON: I know the government is moving in the direction that here are these vacancies, physicians need to sign on to those positions. In the Central Zone, for example, there’s 30 since January. How many people applied for those jobs? There’s 58 in the province, can you give us a figure of how many physicians have applied over the last six months to the vacancy positions? Do you have those figures? If not six months, actually in the last year would be very helpful.


            MS. PERRET: The recruitment is managed by the Health Authority so I’m just looking at Mr. Guest if he has those figures. If not, I’ll make that inquiry.


            MR. DAVID WILSON: I know he was flipping the page so maybe he found it there.


            MR. GUEST: I can’t give you specific numbers as to physicians who have expressed interest in coming to work here in Nova Scotia. I can tell you that since April 2015 we have hired 71 family physicians and 106 specialists.


            MR. DAVID WILSON: The question is - and I think I’ve asked this before - how many retired and how many left? Do you have that? Why wouldn’t you have that right next to how many you hired? To me, that makes sense - we need this, we hired this many. I mean from my understanding there are another 20-some, almost 30 ready to retire just in the Central Zone, from the information I have. You don’t keep that side by side? I’m a bit confused on why you wouldn’t do that.


            MR. GUEST: The numbers of physicians that we’re actively recruiting would include those, as well as vacancies - positions that are open. It would consider both.


            MR. DAVID WILSON: A position in these collaborative clinics and the path forward if a physician is being asked to provide care in a certain region, it goes along with kind of the geography of the area that you live in. Will that doctor be able to bring the patients that they currently have with them, if they agree and sign on to one of these vacant positions? Or will that patient wait-list stay wherever that physician was practising at the time? Or will they be able to bring their current patients with them, to a new position, if they sign on to one of the vacant ones that are identified?


            MS. PERRET: My understanding is that they could bring patients with them. We’re not at a point in the system, though I read with interest this point in Doctors Nova Scotia’s discussion paper, we’re not at a point where we’re rostering patients, that we’re assigning patients to physicians. Patients have mobility of seeking physician care across the province.


            MR. DAVID WILSON: But the vacant positions are in areas that the residents don’t have a doctor so potentially then - so you’re saying that there are no restrictions on doctors being able to bring their current patient roster with them, is that what I’m hearing?


            MS. PERRET: Unless someone corrects me, that is my understanding. I’m not aware of any restrictions in that regard.


            MR. DAVID WILSON: With the recent paper - I don’t know if it was yesterday or today - I got it yesterday, but I don’t know if that meant it was released yesterday. Is the department going to respond to this? If so, what’s the timeline on the response?


            MS. PERRET: The department was very happy to receive the paper. We’ve had discussions with Doctors Nova Scotia - certainly I have - saying we need to engage on policy discussions. I think this is a very positive initiative and we’ll absolutely engage and have these discussions and we appreciate this, just as we do from other professions and front-line workers who have provided input into the system.


            MR. DAVID WILSON: It’s quite timely, the paper, I think and I believe if I’m not mistaken, I just kind of went through it, there’s about 10 recommendations. I think many of them can assist the department and the government in their attempt to ensure that Nova Scotians have access to a family doctor and primary care clinicians. So there is a bit of an urgency, I think - especially when you look at some of the recommendations. Like recommending that walk-in clinics be maintained during the transition to a better primary health care system, and there are many more around funding and, as you mentioned, making sure that current residents who have doctors continue that if the doctor chooses to move.


            You can’t give a timeline on a response? I would assume the minister will get this today. Will you ask the minister, how long will we take to respond to the paper that Doctors Nova Scotia released?


            MS. PERRET: You make an interesting point. I don’t see it as a paper that gets an absolute response. I see it as a paper that starts a discussion and hopefully a collaborative discussion as we go forward.


            I want to say that I think from the department’s perspective we agree with those points made in the document. I recall the CEO of the Health Authority also indicating that we’re not looking at sharp edges as we shift the system into collaborative care. We want the existing system to be stable. Ms. Knox acknowledged that physicians in solo practices - there will still be new physicians coming in that replace those physicians when they retire in solo practices. Walk-in clinics do serve a purpose, absolutely. We’re going to encourage linkages to the public and shift the system in a considered, careful way over time.


            MR. DAVID WILSON: I would hope that what you said isn’t completely accurate - that it starts the discussion. I would hope now that - and I know you’re new to the position - but I would hope that the current government has been engaging with primary care physicians and family physicians over the last three and a half years. Part of the paper is the frustration some of the family physicians have with the amalgamation of the district health authorities and they’re feeling not part of the decision-making.


            The new system and the road forward and the change in model of care will not be successful if it doesn’t include the front-line health care workers – front-line health care physicians. The model is there. We’ve implemented it with the Collaborative Emergency Centre model and unfortunately I don’t see the same thing happening here. When it comes to decision-making, it seems like physicians are required to act after decisions are being made.


            Just quickly I want to go to the mention of the agreement with the federal government or whatever it’s going to be called once the legislation comes in. Will the terms of that agreement or that legislation be released to the public - the terms that are involved in that - or will we see it in legislation or is it going to be very vague? Is legislation going to be vague or will the public get to see what was in the agreement that was signed in December 2016?


            MR. RAFUSE: Yes, you will. Actually in the budget that was tabled by the federal government there is a provision in there to enable the flow of money. There will be further regulations, I would suspect, that have to be developed at the federal level. All federal regulations in these matters are open to the public. So they will be available when they complete those.


            MR. CHAIRMAN: We will move to the Liberal caucus, and Mr. Rankin, for 20 minutes.


            MR. IAIN RANKIN: This is a good report. In my three and a half years on the committee, I’ve never seen the completion rate so high, so I think the department should be commended. I want to ask my first question to the Deputy Auditor General because we had the in camera session so I don’t want to quote anything he had said in that. To what would you attribute the vast improvement in the follow-up recommendations from 2013 and 2014? Is this a good news story?


            MR. TERRY SPICER: Yes, overall, it is a good news story. I think the recommendations - we’ve plotted them in the report and they are moving in the right direction. To your other point, I think there are a number of reasons you can point to as to why that might be. I think management of the various departments that have done well need to be congratulated for that. Obviously they’ve put a lot of effort and focus on making those recommendations work.


            Also, as I mentioned, the Public Accounts Committee and other oversight bodies, oversight and accountability is an important control and tool to help move these things along. I think recognition of that effort has to be done as well.


            MR. RANKIN: I do think it’s important to recognize the management team, a lot of them are here today - the highest completion rate in 10 years. That’s something to be proud of from the department.


            Now questioning the department, I’d like to start with a similar type of question. What is attributing to the success of improving the processes and procedures and implementing these recommendations, improvement of outcomes? On a broad level, can we attribute some of that to the amalgamation of the district health authorities? Maybe I’ll ask the Deputy Minister of Health and Wellness.


            MS. PERRET: Thank you for the question. I would say there are two sides to that coin initially. I think the process of audits is an important process always and having the recommendations come forward. The process of going through the audit is enlightening and I think everyone learns from it. I think those are processes you want to embrace and take seriously. Clearly the department did that.


            I think that then going through the amalgamation you’ll see a number of areas in the recommendations that do benefit from having a consolidation of the Health Authority so that it operates with a provincial focus, it has that platform, and also a clarity of role between the department and what it’s doing and the Health Authority. The short answer would be yes, I think that has been part of that.


            MR. RANKIN: Can you point to any tangible improvements when you look at the amalgamation of district health authorities, did the different district health authorities have different policies and procedures? Was there any internal competition, when we’re talking about whether it’s physician recruitment or anything? Does it help improve - can you point to any of the outcomes that we’re seeing now? I’ll dive deeper into the specifics of outcomes but maybe we’ll start with that.


Did we learn from other jurisdictions in terms of best practices? I know you came from another province and I won’t ask about that province. Do you sense that Nova Scotia has learned some things? How do you feel about the implementation of this transformation thus far?


            MS. PERRET: I’ll give a general answer and then I’ll ask Dr. Strang or Mr. Guest to fill it in. Clearly, especially when you’re looking at wait times and the organization and developing efficiencies in surgical suites, having a province-wide perspective and being able to coordinate the response to that on a provincial basis is clearly an advantage.


            I think the same would be true with respect to population health, population health surveillance and the organization of that initiative. I can ask them to be more specific, if you’d like.


            MR. RANKIN: Maybe we can just talk about wait times, since you mentioned that. In the last three years, are you able to point to any improvement? The one that I think MLAs hear most about - I certainly do - is knees and hips, how is Nova Scotia doing? Have the wait-lists improved or not? What are the outcomes?


            MS. PERRET: In all five priority areas that we focus on when we’re talking about wait times, Nova Scotia showed improvement on all of them. I think it was the only province that improved on all because there were some backsliders in the group. To improve you have to have a significant process.


            In areas such as radiation therapy, cataract surgery, and hip fracture repair, the province is really showing good traction there in moving ahead. There is a way to go on hip and knee surgeries but again, I think the platform and the planning that’s going on with the new Health Authority is setting the stage for that progress to continue.


            MR. RANKIN: You said, to put it in context, that other provinces have not seen improvement in their wait times? I know I saw a report last year where in Canada in general, wait times were growing across the board. So we’re in the Atlantic Region where we face more challenges with the aging population, I think it’s 1,000 people a month now reaching the age of 65. I just want to make sure I’m hearing that correctly and I don’t know if there’s anything you can table that actually shows that notwithstanding our demographic challenges and other jurisdictions around us going up in wait times, that we’re actually moving down, and that’s the trend, and trends are important. I just want to make sure that I’m under the understanding that in Nova Scotia wait-lists are going down; in other jurisdictions wait-lists are longer.


            MS. PERRET: Not exactly. In Nova Scotia, on all five of the areas where we measure wait times, our wait-lists are going down. We were the only province that showed progress on all five. There are other provinces that made progress on some. There are many that are ahead of us still, but all other provinces had a decline in some of their wait-lists is all I was pointing out.


            The investment that we’ve made over the last number of years, the amalgamation of the health authorities, and a greater platform for efficiency planning - it looks like that is paying off and that we are clearly moving in the right direction. There’s more to do and we need to keep at it.


            MR. RANKIN: Obviously, there’s always more to do. With the recommendations from the Auditor General, you look at Chapter 6 and there’s progress here: “The Department of Health and Wellness should obtain a signed letter from all physicians added to academic funding plans . . .” - that’s done. “The Department of Health and Wellness should develop targets for all academic funding plan deliverables.” - that’s done. I can go on and on - there are 12 or 13 that are all complete.


There’s one that’s not. I think it’s part of this committee’s job to help normalize when something is not complete. The one that’s not complete in Chapter 6 is, “The Department of Health and Wellness should have current, signed contracts for all alternative payment plans and academic funding plans.” - that’s stated as not complete. So again, to help normalize that response, I think there should be an opportunity to say where you are with that, so a status update. Where are we at for those signed contracts? Maybe you can give some kind of data there or if there’s a percentage of how many contracts are actually complete.


MS. PERRET: In regard to what you are referring to - the signed contracts - I believe 593 have signed, seven have not, so it’s largely completed. I think to reasonably expect that those that have issues with it, we need to understand and address those issues, so there’s a bit of a process involved.


MR. RANKIN: Basically, over 90 per cent of the contracts are done, so that recommendation is over 90 per cent complete even though in the report it counts as a non-complete.


MS. PERRET: Correct.


MR. RANKIN: Let’s look at some of the other recommendations. Chapter 4 - looking at ones that aren’t complete - “The Department of Health and Wellness should implement recommendation 4.5 from our February 2008 Report to develop an electronic immunization registry.” I think you referred to some progress in your opening remarks. I could be wrong, but the Panorama, does that relate to that recommendation? Is there any status update for that recommendation?


MS. PERRET: The province is proceeding to implement Panorama, which will give us an immunization and vaccine inventory by this Fall. I’ll ask Dr. Strang to comment.


DR. ROBERT STRANG: We are in the process now of a two-year project implementing Panorama. One of the components will be managing our inventory of vaccines as well as developing capacity for Public Health-delivered vaccines to be entered electronically.


Moving forward from Panorama, we need to then do the work as we develop the one-patient/one-record linking vaccine records from primary care providers, including doctors and pharmacists. So ultimately we will have a complete immunization registry. We are already linking in the primary care providers who are on the EMR. We are accessing their data around immunization.


I just want to make sure people understand that Panorama itself doesn’t produce a complete immunization registry. It’s the first step, and then we link in other sources of immunization data as we move forward on the one-patient, one-record.


MR. RANKIN: Where are we with the one-patient/one-record? I think that’s a huge benefit to the system for more coordination. I think it relates to there being one Health Authority and sending electronic messages from family physicians to whatever surgeon or operating room that a patient arrives at. Do we have any sense of timeline when we’re going to be able to see that come to fruition?


            MS. PERRET: That is moving ahead. People are quite excited about it. The request for supplier qualifications was issued in January 2017 and attracted a good response. Those responses are being evaluated, so this project is moving ahead. It’s hard to comment on it when it’s in a controlled supplier environment right now.


            MR. RANKIN: On the other recommendations, I guess I’ll just ask for a status update. “The Department of Health and Wellness should develop a plan to implement public health protocols following approval. The plan should include detailed timelines and involve input from stakeholders impacted by the new protocols.” Is there any kind of a status update on that?


            DR. STRANG: The Public Health protocols are part of our ongoing work between the department and the Nova Scotia Health Authority. They’re not a time-limited project, and that’s why it’s listed as ongoing. There will always be work ensuring that the work of Public Health is guided by what’s in the protocols and periodically revisiting those protocols to make sure they’re up to date.


One of the things we have done during the transition from nine health authorities to one is a significant amount of work that has been done internally within the Nova Scotia Health Authority Public Health Services, in creating greater consistency across the province with public health. One of the key pieces that is driving that consistency is the protocols, so moving towards public health practices more consistent and more in line with the Public Health protocols.


            MR. RANKIN: Maybe you can tell us more about the upcoming clinical services planning framework for surgery, which determines the services that will be offered in each location.


            MR. GUEST: We’re actively working on developing a service plan that meets the needs of the population and looking to make sure that the service offerings that we have in each of our facilities enable that to happen now and into the future.


            MR. RANKIN: In terms of surgery scheduling with the district health authorities amalgamating into one, is that facilitating a broad strategy in terms of a provincial lens, or is that being improved through amalgamation as well?


            MR. GUEST: Yes, we have recently been able to operationalize an organization-wide program for surgery. We now have the medical leadership largely in place as well as the operational leadership in place to have a structure to revise, create, and review our policy, our protocols, and our program, looking at it from a system perspective and not the nine entities that we came from. That will be a real enabler to help us do that work.


            MR. RANKIN: I know that there were challenges moving people from district health authorities to another one. Does this amalgamation facilitate an easier move if someone had to go to a surgery in a different zone? Is that more streamlined now?


            MR. GUEST: Yes, our credentialing process within the organization has certainly made that easier - I can give you an example. Last year at the Colchester site in Truro, we had a number of surgeons - our capacity was low there. We weren’t maximizing the OR time we had, so we had 20 days when surgeons from Halifax went to Truro. They did 104 surgeries and over 400 endoscopy procedures during those 20 days.


            MR. RANKIN: Is there any other progress at the hospital level in terms of - I know at one time, a doctor had to sign the release to allow a patient to leave. Are we able to say that we’re freeing up space for doctors to be somewhere else and have a nurse practitioner, for example? I know that that was something that was worked on. I brought it to the department’s attention before. Is that now under implementation?


            MR. GUEST: I would say that is ongoing work. We certainly do that in a programmatic way that’s very intentional. I wouldn’t say that it’s complete. We would be doing that work really on a priority basis as the need for it determines.


            MR. RANKIN: Okay, and is there anything else you can point to, whether it’s alternate system delivery or coordinated care that’s improving outcomes but at the same time being responsible with the financial envelope that we have?


            MR. GUEST: I can certainly speak from a surgery perspective. Looking at the service fully as a system certainly has enabled us to maximize the resources that we have more. I can give you a couple of examples. The Colchester example is one. Another example is maximizing how we use the Hants Community Hospital so we can do more surgeries in that location to allow the prime operating room capacity in Halifax to be used for higher, more complicated surgeries. We’re looking at doing that as much as we can.


            Another example is in the Western Zone, where we provide a zone-based service for orthopaedics where orthopaedic surgeons from Kentville do procedures in both Bridgewater and Yarmouth to maximize the available resources we have, minimizing travel whenever possible, and also enabling them to use the Kentville OR time for the types of procedures that only that facility is able to do.


            MR. RANKIN: As that relates to the QEII VG redevelopment and building infrastructure outside the peninsula, is there still an appetite to look at facilities outside of the core of the city? I’ve brought this up before but the Halifax west zone is where the growth is in HRM, so ultimately something in the same form of Cobequid Centre, like an outpatient-type centre which I see as more efficient and better utilization of FTEs within the system. Is there still an appetite to move in that direction?


            MR. GUEST: Certainly that planning is ongoing. What we are looking philosophically at is doing the work that needs to be in the hospital setting and, where possible, moving care that can be done safely and with high quality in the community setting, into the community.


            The Cobequid example you speak of is a really good example of how that can successfully be done and that is one of the planning parameters in the QEII redevelopment project.


            I would also add that one other philosophical approach that we are taking is by maximizing the capacity in some of our regional hospitals in the province. It will allow us to slow the transfer of care to Halifax when it can appropriately be done out in those regional centres, to allow Halifax to focus on quaternary tertiary care that only they are capable of doing.


            MR. RANKIN: And that, in your view, will improve the quality of care?


            MR. GUEST: I think it will improve the quality of care. It will improve access and I think it will help us to have a more stable peri-operative program across the province.


            MR. RANKIN: Okay, thank you.


            MR. CHAIRMAN: We’ll move back to the PC caucus, Mr. Houston for 13 minutes.


            MR. HOUSTON: We’ve seen the Premier making a lot of announcements over the last five or six weeks - even the last couple of days - a lot around health care. I just wonder, when the Premier makes announcements like he did yesterday, around bricks and mortars, he is kind of picking off a list that you’ve put forward?


Have you put forward a list of capital priorities and are the announcements we’ve seen in the last two or three days, let’s say - are they just following your capital priority lists? That’s for the deputy.


            MS. PERRET: The capital planning process is an inclusive process that involves the Health Authority, the department and communities and community health advisory boards. The lists that go together - some of them are longstanding lists that projects have been on for a number of years. I think all of the projects we’re seeing going ahead have been identified before.


            MR. HOUSTON: Can you table a list of maybe the top 15 capital projects, according to that process? Would you have that list?


            MS. PERRET: I’m just conferring with my colleague. I think that would be part of the information that comes forward when the budget is tabled.


            MR. HOUSTON: Well, if it’s a longstanding process and some of them have been on there for a while - presumably there is a list and has been a list - can you give me the list from six months ago or something?


            MR. RAFUSE: Just to give clarity, the process the deputy spoke about does feed into what we refer to as the TCA committee, which makes a recommendation to Treasury Board. The information that goes in there is subject to Cabinet confidentiality, as we’ve discussed before and we have discussed with the Auditor General. So we do have limitations on what can be provided.


            MR. HOUSTON: If I think about schools, there is a known process for schools. We know that this government jumped that process and put schools where they wanted to for political purposes. Is there anything you can tell me that would dispel my concerns that that’s what’s happening? Even if you think about the couple of announcements yesterday - were yesterday’s announcements the top two on the list?


            MR. RAFUSE: As the deputy indicated, those items were on the prioritized list coming up from the department. Some of them are longstanding. Those are the ones that have been chosen to be advanced.


            MR. HOUSTON: Okay, so we can’t see the list, and we take at face value that they’re on a list somewhere. Where they’re on that list who knows - it’s at the Cabinet’s discretion as to where they do the projects. Is that a fair summary?


            MR. RAFUSE: In the democratic process we have, Cabinet and Treasury Board have the obligation or the right to make those decisions, to make recommendations.


            MR. HOUSTON: There is nothing you can share with this committee, which discusses the finances of the province, that would alleviate my concern that we’re just seeing purely political decisions made on the eve of an election. Is there nothing you can share with us that would say, no, this is the process? Can’t do it, right?


            MR. RAFUSE: I can tell you that those announcements are accommodated in our fiscal plan and in the capital plan of the province.


            MR. HOUSTON: Let’s think about one of the announcements yesterday. A fiscal plan implies that there is some costing around it. The Premier made an announcement yesterday. He said, I don’t know how much it’s going to cost or when it’s going to get done, but I’m here to announce today - he’s breezing in on the eve of an election to tell people that he’s got some goodies for them. Certainly your fiscal plan probably has things costed, no?


            MR. RAFUSE: The announcement yesterday you are referring to being Pugwash?


            MR. HOUSTON: Pugwash or down in Bridgewater.


            MR. RAFUSE: As with all major capital projects, there are various stages and various levels of certainty about the costing. The certainty of these projects will not be known until the complete planning is finalized. We do make provisions on the capital plan and the out years knowing that commitment has been made, but it’s based on the information we have. We tend not to want to release those numbers because they are subject to finalization, community involvement, physician involvement and the final design of those facilities.


            MR. HOUSTON: With the serious issues we have with health care in this province, it strikes me as odd that the Premier would be running around announcing things that he doesn’t know how much will cost or when they’re going to happen and not actually focusing on - hey, how about we get some doctors so people can see an actual primary care physician. Does that strike you as odd?


            MR. RAFUSE: No, actually it sounds to me to be prudent - to not be throwing out numbers which can’t be validated.


            MR. HOUSTON: I don’t see the prudence in announcing things that you can’t cost, but whatever. I’d call it political, I wouldn’t call it prudent, so we’ll move on from that. We know political announcements are being made. We know they’re not costed. We know they may or may not happen. Maybe someday every Nova Scotian will have a doctor. That was going to happen in 2014. It’s now going to happen in maybe 2019, but prudent is not a word I would use for what’s happening.


            We know the federal government is going to take some action around the legalization of marijuana. I would just like to ask the Deputy Minister of Health and Wellness a quick question. Have you done any analysis of what the possible cost to the health care system might be coming out of the legalization of marijuana over the next five or 10-year period? Have you done any kind of costing? Would there be a cost? Common knowledge suggests that there will be some cost to the health care system of legalizing marijuana. Do you agree with that or not?


            MS. PERRET: I am going to refer the question to Dr. Strang who has been leading this.


            DR. STRANG: No, there hasn’t been any costing done because we don’t know the regulatory framework under which cannabis will be legalized. There is a lot of detail which needs to come from the federal government. There are significant decisions which have to be made here provincially, but I think we need to understand that there is no lack of access and therefore, use of cannabis today.


            Our objectives that have been approved by Cabinet under legalizing cannabis will be, first and foremost, to protect the health and the safety of the Nova Scotia public, as well as to decrease the footprint of organized crime. So depending if we adhere to those objectives, we will actually get decreased use and overuse of cannabis and therefore presumably decreased health and criminal justice and other costs. It all depends on what decisions are made around how we regulate this.


            MR. HOUSTON: Is that your succinct - if I tried, in the interests of time, to boil it down, you would say that legalization of marijuana will result in less use and less overuse of marijuana.


            DR. STRANG: It depends on how it’s legalized. It depends on what framework and how it’s sold and . . .


            MR. HOUSTON: Where it’s sold and age - would they be the two influences of your kind of guess on what happens?


            DR. STRANG: Where it’s sold, what age, do we allow marketing? There are a whole range of decisions to be made both federally and provincially. We look at other substances like tobacco and alcohol and other things.


            MR. HOUSTON: Do you have any thoughts on the age? I heard that 18 is what the feds are going to go with. Do you have any opinion if that’s too high, too low?


            DR. STRANG: The discussion we’ve had and then the direction from Cabinet has been that Nova Scotia should stick with a minimum age of 19 and if there are opportunities to move higher than that, in collaboration with other provinces, to do so.


            MR. HOUSTON: Okay. Thank you for that. What’s the average length of time that a physician vacancy remains vacant in Nova Scotia? Do we have an average length of time? Does it take a year to fill them? Six months to fill them? Do we have an average length of time?


            MS. PERRET: I’m going to look to Mr. Guest if he can fill this in. The point I want to make at the outset is that the process of enrolling, having a list of patients looking for a doctor - remember, we’ve been . . .


            MR. HOUSTON: In the interest of time, the question is, how long does a position stay vacant?


            MS. PERRET: Well part of the answer is that is not a new issue, it’s a longstanding issue across the country . . .


            MR. HOUSTON: So there should be more evidence as to how long.


            MS. PERRET: Starting in this province last year is the first time we’ve put together a list and the first time that it has been tracked, so it’s still relatively early days of starting a process that’s very intentional about tracking the need and starting to link need to community demand.


            I’m not aware that there is, in this short period of time, an average period that has been tracked but I’ll let Mr. Guest correct me if I’m wrong.


            MR. GUEST: That would be correct. At this point, I’m not able to respond to that.


            MR. HOUSTON: Too early to say, okay, fair enough.


            I do want to ask a question about payments to specialists in this province. Is there something happening where the Health Authority or the department is withholding back a certain amount of money due to specialists, 10 per cent? Are you aware of that happening, that specialist remuneration is being held back by 10 per cent?


            MS. PERRET: I am going to refer it to David.


            MR. CHAIRMAN: Mr. Bartol.


            MR. DAVID BARTOL: The AFP contract provides for a holdback of 10 per cent. That’s managed within the departments.


            MR. HOUSTON: Is that new or old?


            MR. BARTOL: That’s new in this current agreement.


            MR. HOUSTON: So in this new agreement there is a holdback of 10 per cent on monies that are due for services that were rendered, right? The services would have been rendered but they’re holding back 10 per cent.


            MR. BARTOL: It’s a holdback within the AFP departments, pending confirmation of fulfilment of deliverables, yes, and it is managed within the departments.


            MR. HOUSTON: Do you have a sense of whether specialists are happy with that or not happy with that?


            MR. BARTOL: All I can say is that the AFP contract was ratified to 87 per cent of favourability by the AFP physicians. We haven’t heard any statements of unhappiness around those practices.


            MR. HOUSTON: Okay, fair enough. I just want to try and understand the targeted funding from the federal government. It was kind of advertised over the Christmas holidays as I think, $287 million, which was $150 million for home care and $130-plus million for mental health.


Are you familiar with the number, Deputy Rafuse - $287 million? Is that over 10 years? I know you don’t want to get into the specific annual amounts, but that’s the number that was published.


            MR. RAFUSE: Those would have been 10-year amounts.


            MR. HOUSTON: I know you can’t say how much of that is going to happen this year and next year and stuff until the budget comes, but is there any science behind that? Is there a plan for - if we had $150 million for home care, we could do this or we could do that, or was it just a number went down on a piece of paper and the minister said sure? Is there a plan for that?


            MR. RAFUSE: The plan to use that money would be within the Department of Health and Wellness. This is an allocation based on a federal transfer and the dollars attached to it. How that money is used and the reporting back to that is a separate initiative.


            MR. HOUSTON: I only have a minute. Does the Department of Health and Wellness have a plan for how those monies will be used and can they share that plan with us?


            MS. PERRET: Our understanding from the federal government is that they want to put in place an accountability framework that will have specific - I’ll use the word “eligible” although I don’t know if that’s entirely the correct word - types of activities that will be eligible for the funding.


            MR. HOUSTON: So we don’t even know. They want to know how you spent it, I’m wondering how you’re planning to spend it - you’re saying, we don’t know how we’re going to spend it until they say how we can spend it.


            MS. PERRET: They need to give us the parameters of what projects or types of projects that they consider eligible for that type of funding.


            MR. HOUSTON: They haven’t done that?


            MS. PERRET: They haven’t done it yet, no.


            MR. HOUSTON: It has been five months. Is that not uncommon?


            MR. CHAIRMAN: Order, the time has expired. We’ll move to the NDP caucus. Mr. Wilson, you have 13 minutes.


            MR. DAVID WILSON: In the Auditor General’s Report for the Chapter 1 of the follow-up for recommendations from 2013-14, it indicated concerns remained with some organizations. One was with the Nova Scotia Health Authority, saying that it “Has not established targets, leaving Nova Scotians unsure when surgery wait times will improve.”


            I know in 2013, Stephen McNeil, our current Premier, promised to reduce wait times and that he would put in $8.1 million to operating rooms to ensure that the province meets the six-month standard for hip and knee replacement. We know now hip is around 17 months and knees are around 20 months. I’m just wondering if that $8.1 million was invested in the operating rooms over the mandate of the current government?


            MS. PERRET: Again, I’ll ask Mr. Guest to go into more specifics, but yes I believe that the investment that has been made to reduce wait times - the value of that investment is being seen in the reduction of wait times and progress is being made, but Mr. Guest might elaborate.


            MR. GUEST: The access to the additional money did have an impact in our volumes. In 2015-16, we were able to do 614 procedures for individuals who were waiting longer than a year. In this current fiscal year ending in March, we increased that to 855. This would be the first year we’ve been able to spend the full allotment that we were given out of the $8.1 million. We did request additional money from the department and were given access to do that, which did enable us to get to that 855.


            MR. DAVID WILSON: So there has been a reduction, but part of the commitment from the Premier was to meet the six-month wait time targets. The Auditor General is saying that the Health Authority won’t even establish if they agree or don’t agree with making those targets.


            Is it that the Health Authority is pushing back on the commitment from the Premier or is it that the Premier really probably should never have made that commitment to Nova Scotians? It’s not realistic with the funding formula that the Treasury Board and the current government is giving towards trying to meet that six-month target that provinces are trying to reach. Are you concerned that you haven’t fulfilled the Premier’s promise or is that something that the Premier probably should not have made that promise to Nova Scotians?


            MR. GUEST: I can’t comment on the Premier’s comments, I have not heard them. What I can say is that we are in the process of putting in place targets. We intend to be fully compliant with the Auditor General’s recommendations by the Fall of this year. We have said all along that this is going to be a lengthy process to meet the national benchmark. We have a way to go. We are headed in the right direction, which is a big change from two years ago when we continued to get worse year over year.


            I think it’s going to take a change in how we do business in order to meet the target but it is our goal to get there. We believe it is the right thing for Nova Scotians to do, but it’s not going to be an easy road.


            MR. DAVID WILSON: I appreciate that, and I think that’s definitely misguided on the Premier’s side to try to state that. Of course the other area is the commitment of a doctor for every Nova Scotian that he indicated prior to becoming Premier of this province. I know that his commitment was to open up medical spots - I believe it was 25 a year - so in year four there would be 100, potentially, as we move forward. Of course they don’t start practising right away; they’ve got to finish their schooling.


            Has that commitment been kept and are we going to see a benefit from an additional 100 spots? Is the Premier at a position that he can check off that box as he goes and asks for another mandate from Nova Scotians?


            MS. PERRET: The answer to that question is something I have to follow up on.


            MR. DAVID WILSON: So you’re not sure if the 25 spots per year were added to Dalhousie. I’ll take you on that and hopefully we’ll find out sooner than later.


            In August 2015 the Premier said he was opposed to the federal government providing health funding to the provinces based on population, without taking the aging demographics into account. We know that we have one of the oldest populations. Did the government ask the federal government to change the funding formula to take into account Nova Scotia’s aging population?


            MS. PERRET: I think my colleague will take that.  


            MR. CHAIRMAN: Mr. Rafuse.


            MR. RAFUSE: Certainly it’s quite well known that a strict per capita funding formula does come to the detriment of provinces like ourselves that have an aging demographic. Unfortunately you can’t get agreement across the country where other provinces are quite adamant that a strict per capita is the way to go. Therefore, it would be to our benefit because it does reflect our reality, but you could not get agreement, there are some provinces that are adamant not to shift off this.


            MR. DAVID WILSON: I understand that but we didn’t negotiate a health agreement with the other provinces, we did it on our own. Did the province ask the federal government to take into account the aging population of our province? Getting agreement from across the province doesn’t matter because we didn’t work with them to get our agreement in the first place.


            Was the request from the team of negotiators that Nova Scotia would like to see our aging population factored into the formula for health transfers?


            MR. RAFUSE: That was a request for the change, but that is a national agreement. The CHT is a national agreement.


            MR. DAVID WILSON: I know the federal minister was very vocal, publicly indicated that when she goes to the Finance Minister to ask for more money she needs to be able to tell her minister that the money will be used for health care.


            Over the last two and a half years I know under the current government there has been an underspending of health budgets. I believe $22 million last year or two years ago and then $23 million, so about $45 million underspent in two years. Then of course we know also around the health infrastructure budget that was severely underspent, I believe through the mandate of the government there was about $140 million - $150 million in the budget for that and I think $70 million or $75 million was spent.


Does that weaken our position when we’re negotiating with the federal government to say we need more money in Nova Scotia, not only to meet our aging population, but the government - I mean the federal minister is saying that we need to show that money is going to health care, yet here in Nova Scotia we’ve underspent significantly, I would say, in a number of areas of the budget.


Would that weaken our position in trying to ask for more funding for Nova Scotians when we’re negotiating with the federal government?


            MR. RAFUSE: That never entered into the conversation with the federal government. They’re well aware that we based our projections on actual spending, not for actuals versus budget. The trends that were developed in response - or to develop a position between all provinces looked at national trends as well as provincial trends. So no, it did not factor into the conversation.


            MR. DAVID WILSON: Hence why maybe we may have jumped the gun on negotiating - I would agree with my colleague when he said I think we put the rest of the provinces at a disadvantage jumping quickly a couple of days before Christmas.


            I talked about the infrastructure budget, for example. Hospital infrastructure budgets were significantly underspent. Across three years of budgets, there was $146 million, but only $72 million was spent. We just heard yesterday from the Premier that a replacement for the Pugwash hospital is a commitment from the government. I think I heard construction in 2018.


            Why would we underspend the budget for three years and then, on the eve of an election, commit to people in Pugwash that we’re going to replace their hospital? Are Nova Scotians supposed to just take the Premier at his word? Most likely there’s an election between now and construction of the Pugwash hospital. Are Nova Scotians supposed to just take the Premier at his word and roll the dice and hope that they commit to this?


            I have to say there’s a number of examples where the Premier has said many things before getting elected - a doctor for every Nova Scotian, the Film Tax Credit would be supported and maintained, continue to make sure there was a reduction in ER closures, and I think I could go on and on.


Why would we underspend the infrastructure budget for three years, yet yesterday, the Premier is announcing the replacement of a hospital and actually saying the construction time? Do you see concerns there? Maybe it is just about a pending election and not really about the needs of communities in the province. I don’t know if the Deputy Minister of Health and Wellness would like to answer that.


            MS. PERRET: I think my colleague would like to answer the question. I haven’t been part of the capital planning process for a number of years, so he can probably provide a better perspective.


            MR. RAFUSE: That is true - an underspend in health capital has happened over the last couple of years. The understanding we have and what the department reports in to us is that, as the system is going through a major administrative reorganization and as they go forward on their health services planning, you do need to pause on things to make sure that you’re doing the right thing. That was the reason why the underspends occurred.


            MR. DAVID WILSON: I know in the announcement, the Premier indicated construction in 2018. We know that the Centennial Building has been at the forefront for a number of years now in need of replacement, yet there’s no timeline on when we will see construction happening with the transition of services out of the Centennial building. Can you give us an update on when we will see bricks and mortar for the replacement of the Centennial Building at the VG site?


            MS. PERRET: I don’t have a timeline for you, but I can tell you that the planning for the QEII project is very intense and is going ahead at speed.


            MR. CHAIRMAN: Mr. Wilson, you have about 30 seconds.


            MR. DAVID WILSON: It’s interesting that the Premier can tell us the construction timeline on one project yet not give us the budget for it. And yet for a project that has been in the works for years now, we still don’t know where those services are going to go or where we may see a new facility being opened up.


Obviously, it’s evident. The evidence has shown that the Premier and the current government have not put in place priority on health care here in Nova Scotia . . .


            MR. CHAIRMAN: Order. Time has expired. We’ll move to the Liberal caucus and Mr. Stroink.


            MR. JOACHIM STROINK: Thank you very much for coming again today. I guess I kind of want to have a discussion on the transfers that come from Ottawa and how we derive those numbers, and also a little bit of an historic piece to this too because under the federal Conservative Government there was a significant unilateral decision on health transfer costs.


So that Nova Scotians can understand where we are today, can you explain what happened and how we got to the number that we’re at now? That would be a great segue into the questions that I kind of have for you today.


            MR. RAFUSE: I’m going to start and then maybe I’ll ask Lilani to fill in. Certainly under the previous government there was a change in the way in which the formula - there was a built-in escalator of 6 per cent, the government chose to unilaterally change away from that and into a strict per capita spending. Those agreements were enshrined in legislation until 2024.


            I can give you some historical pattern, but I’m going to ask Lilani to fill in what I’ve missed or maybe fill that in a bit better than that for you.


            MR. CHAIRMAN: Ms. Kumaranayake.


            MS. LILANI KUMARANAYAKE: As we discussed, the current agreement is a 10-year agreement that lasts until 2023-24, so there was no impetus for the federal government to negotiate the current time, apart from looking at the priorities and the needs.


            One thing that was really significant is in 2017-18, the 6 per cent escalator - the way the CHT transfer works is there is a pool of money and it is allocated across the provinces purely on a per capita formula. That was brought in by the Harper Government.


            The second change, which is going to commence this year, 2017-18, is that that escalator will be reduced to a three-year moving average with a minimum of 3 per cent. This year it will kick in at 3 per cent. So were there no changes, all the provinces would be - the growth in our transfers would reduce, and we estimated that would be over $20 million for Nova Scotia.


            With the new Liberal Government in Ottawa, there was an ability to be able to discuss and look at some of the priorities and say - our current growth in health care transfers is going down because of the previous government’s changes in the escalator, however, we do have needs, and this is how the discussions around more targeted funding have arisen. It’s anticipated that the federal government will be spending about $11 billion in addition to the CHT transfer.


            MR. STROINK: So it was more with the Liberal Government - the feds - it was more of a bit of a negotiation on how the provinces can utilize those monies. In those two aspects, what did Nova Scotia get in those negotiations with the Liberal feds?


            MS. KUMARANAYAKE: We will still continue to have our base transfer - the CHT transfer. The benefit for provinces of that base transfer - that’s $967 million for next year - is that it’s an unconditional transfer. That’s used as part of our $4.3 billion budget, but it’s used according to the priorities that we have.


            In addition, there is this targeted funding, particularly for mental health, et cetera. Those envelopes are currently being negotiated. Deputy Perret said the discussions are ongoing as to what those eligible programs are. We anticipate there will be federal legislation for this targeted funding coming through this budget implementation process.


            MR. STROINK: That’s all I have now for the transfers. I might come back to you on another question. My question now is for the Deputy Minister of Health and Wellness. The question that people need to understand - I hear it a lot - is the wait times for hips and knees are an issue in Nova Scotia, but there is a historical factor that people aren’t understanding. How did we get to where we are today? How did we get this massive backlog with hips and knees?


            MS. PERRET: I think there is a combination of factors that you would see across the country. The reason you have this focus on five wait-list factors is - it wasn’t an issue just for Nova Scotia. It was an issue across the country. Part of that is the complexity of running the hospital systems, the increased demand over - and I’m not sure what the timeline is - the increased demand for hip and knee surgeries across the country, it was quite a dramatic incline. So the system has been responding to increased demand and the need to become more efficient.


            You see initiatives like Nova Scotia has undergone with a consolidated Health Authority to create that platform for more efficiency in different provinces as well, but a number of factors are in play.


            MR. STROINK: On the list right now, we had such a massive backlog of patients to have the surgeries. Where are we now, compared to where we were four years ago?


            MS. PERRET: I’m going to refer it to Mr. Guest because I know there was an emphasis on what they call the long-waiters, to deal with that first.


            MR. GUEST: Thank you for the question. Since 2012 our volumes of procedures that we’ve done for hips have increased by 7 per cent. Our volumes of knees have increased by 10 per cent. Those are the numbers that we are performing.


            There has been a subsequent increase in demand on the hips side. On the knee side in that time frame, it has gone down by 1 per cent, so it has enabled us to start to catch up there. We have had a higher focus on knees during this time frame because our wait-list for individuals waiting for knees is considerably longer than hips and they are waiting a considerably longer period of time.


            I would say that we are starting to be able to see a dent in the wait-list but it’s going to take a considered effort for us to be able to tackle that backlog. This year and the previous year was the first year we’ve actually not seen the list grow, which has been a considerable change in what was happening before.


            I can add a comment to your previous comment about how we got here. Prior to the establishment of the Nova Scotia Health Authority, the previous nine districts all had different sets of priorities of which they prioritized their resources, they weren’t all aligned. We also had challenges with health human resources. We’ve had issues with anaesthesia coverage over the last five, 10 years that ebbs and flows. We’ve had nursing shortages in some areas of the province, in the ORs particularly. A couple of the previous district health authorities prior to the establishment of the long-waiter strategy had caps on their surgeries because of funding, so there’s a multitude of reasons why the backlog has grown.


            Moving to one Health Authority with one set of priorities, one set of processes, and dealing the same with all those issues certainly is an enabler for us to be able to do a better job of dealing with that issue.


            MR. STROINK: What I just heard is, what this government has done by changing to one Health Authority is it has significantly helped the processes within the Health Authority in hips and knee surgeries, as an example. Is that a fair statement to say?


            MR. GUEST: I would say that it has given us the opportunity to have a consistent approach with how we allot resources so we are all steering the boat in the same direction with the same goal. I think that’s the biggest contribution to what it has enabled us to do.


            MR. STROINK: Also I guess on the long-waiters list, are there people on that list who have been there for a very long time but are on that list for health reasons and until their significant health issues change, then they’ll be able to have their surgery. Is some of that happening on that list?


            MR. GUEST: According to policy, in order to be on the list you have to be eligible and ready to have your surgery at any given time. There are periods when an individual goes on the list that their health status changes. According to the government policy related to being on the wait-list, the timeline should cease and it starts to count again when they are considered medically eligible to have their surgery.


            We’re doing a significant amount of work making sure that the list is accurate and we’ve done a lot of cleanup. I can say that since 2012 we have decreased the longest-waiting individual on the wait-list by 29 per cent.


            MR. STROINK: Thank you very much. Back to Mr. Rafuse. In the upcoming budget there’s an initiative on the small business tax that’s occurring. Can you just explain what that initiative is?


            MR. RAFUSE: Yes, the Minister of Finance and Treasury Board announced that in the upcoming budget, the threshold for businesses eligible for the small business tax rate will be raised from the current level of $350,000 to $500,000. For those businesses that meet certain criteria, that income level now will reduce from the general rate to the small business rate.


            MR. STROINK: Then also the small business tax would be decreased?


            MR. RAFUSE: No, the small business rate will stay the same.


            MR. STROINK: What I’m trying to get at here is, are most doctors self-employed?


            MR. RAFUSE: I think all doctors are self-employed. A lot of them are incorporated professionals, if that’s what you’re asking.


            MR. STROINK: Yes. So what I’m trying to get at is, is this a great new tool to recruit doctors into Nova Scotia? Does this help with that process?


            MR. RAFUSE: Yes, it is a tool. If the doctor chooses to incorporate themselves, this would be valuable to them as well.


            MR. STROINK: Excellent, thank you. Now, going back to something that was said earlier about doctors in Nova Scotia and the shortage - I know we had this conversation last week, but I need to say it again, because there has been some misinformation again. Where are we in Canada with all our other jurisdictions in the recruitment process of a plan? You came here specifically to Nova Scotia for a reason, Deputy Minister of Health and Wellness. Can you share that again so that people who might have missed it last week can hear it again this week?


            MS. PERRET: You’re correct. Nova Scotia is a very attractive place to come if you’re interested in health care reform, partly because there’s an innovative collaborative spirit here. There are good discussions, and we’re seeing that. We have health care workers, front-line workers, and professional groups contributing to that discussion. The platform, the size, and the progress made in this province really position it well to move ahead. I think it is among the leaders in Canada for the type of shifts that need to be made in the system.


An example is the proactive nature of physician recruitment. I think it is highly organized here. I can’t say for sure that no one else is at the same point, but I know that we are among the leaders.


            MR. STROINK: Can you also just give us a quick timeline for the QEII, for the infrastructure projects that are occurring there?


            MS. PERRET: Thank you for the question because I wasn’t able to answer Mr. Wilson when he asked. There is a timeline for the QEII on our website. So I’m happy to say that if you go to, you can watch the planning process from that perspective.


            MR. CHAIRMAN: Order. Thank you very much, everyone, for your questions and of course our witnesses for all the answers. Mr. Rafuse.


            MR. RAFUSE: Earlier, somebody asked for a copy of my opening remarks. I would like to table a copy, and I have a copy for all the committee members as well.


            MR. CHAIRMAN: Thank you very much, Mr. Rafuse. We have some time left, and I will allow both departments to provide some brief closing comments. Perhaps you can keep it to about two minutes, if you can. Ms. Perret.


            MS. PERRET: I’ll just respond to a question that I didn’t answer earlier with respect to the capital plan. I’m advised that we provided the committee with a list of projects that are on the capital plan last November or December. South Shore and Pugwash are both on that list. There would be some information provided to the committee.


            Then I thank the committee for this opportunity to have this discussion. I actually learn something from these discussions, and I’ve now come to describe it as an unusual onboarding process, but one that I actually do appreciate. Thank you for the discussion.


            MR. CHAIRMAN: Mr. Rafuse.


            MR. RAFUSE: Thank you very much for having me here. If you want to invite me back sometime to talk about internal controls or financial reporting - a topic which we never got to - you’re certainly welcome to do that.


            MR. CHAIRMAN: Thank you very much.


            Our next meeting is on April 19th, and that is to discuss regulatory review. We will have the Office of Regulatory Affairs and Service Effectiveness with us. Prior to that meeting, we have a subcommittee meeting to select topics for future meetings. That begins at 8:30 a.m. on April 19th.


            On April 26th, we do not have a meeting, but on May 3rd, we have a meeting on school capital planning. That’s on Chapter 2 of the November 2016 Report of the Auditor General. The Auditor General has offered a briefing prior to that meeting.


We have a couple of options. As I mentioned, our next meeting begins at 8:30 a.m. and would conclude at 11:00 a.m. Usually we do our briefings before the meetings, but that’s not to say we couldn’t add a briefing in on the 19th for the May 3rd meeting. The other option is to have the briefing on May 3rd, perhaps at 8:30 a.m. - a half hour before the meeting starts. Do members have a preference?


            I did see a couple of heads nod in favour of 8:30 a.m. on May 3rd. All those in agreement? I see agreement. Our clerk will make note of that.


Is there any further business to come before the committee? Hearing none, this meeting is adjourned.


            [The committee adjourned at 10:56 a.m.]