STANDING COMMITTEE ON PUBLIC ACCOUNTS
Mr. John Leefe
MR. CHAIRMAN: I apologize to our witnesses that we are starting a little bit late. I believe there have been some traffic problems this morning and those now have been resolved, at least with respect to the membership of the committee. We welcome all of you here.
We have with us this morning from the Department of Health, Mr. Robert Fowler. Bob is the one with the glasses right here at the committee's right. Bob St. Laurent, Senior Director, two down; Judith Wood-Bayne, the acting Provincial Director of Home Care Nova Scotia with the light blue suit; Joanne Martell with the navy blue suit; and next to her, Dr. Michael Murphy who has been before us before. Welcome to all of you.
Bob, who is the lead-off batter here?
MR. ROBERT FOWLER: Mr. Chairman, I was going to do what you have just done, introduce people, but what I would like to do is turn it over immediately to Judith who has a short presentation to give, just to bring members up to date on where home care is as we sit today.
MR. CHAIRMAN: The power of delegation is indeed a blessing, isn't it?
MS. JUDITH WOOD-BAYNE: Depending on what end you are on.
I wanted to just bring you up to date on the progress of home care in the last few months since we last came to talk with you in January of this year. At that time, Susan McDonald Wilson, the Director of Home Care, gave you an overview of the program and she talked to you about the background of home care's development and the need for it in this province. The planning and transition to home care from the old Coordinated Home Care Program, which was a narrow and much more limited program, she gave an overview of the ways that Home Care Nova Scotia had put a foundation in place to increase accessibility for Nova Scotians. That included a 1-800 number which made the program accessible to everyone in a much simplified way, care coordinators in communities and hospitals across the province, expansion of services across the 24 hour day and seven day week and a much broader accessibility to the program based on unmet need and not based on age or income.
She also talked about the mission and functions of the program and the role that it plays in the reform of the health care system, that it plays a preventive role, substitution role for services in other facilities and a maintenance role to help maintain people with quality of life in their homes.
She also gave you a comparison of home care's development with that in other provinces and highlighted the way Nova Scotia's progress had occurred over a very short time-span when you looked at other provinces, if you will remember, that had grown their programs over 20 years in the rest of Canada.
We also gave you a summary of the first two years of growth of the program when we were here last and, if you will recall, I believe we had a 120 per cent increase in the program in the first year, about a 67 per cent increase in the second year of the program in the number of people who received home care services. We also have had an increase in resources in the program. We have grown approximately by about $10 million per year for the last two years for this program. We talked a bit about the challenges of building a sustainable program at that time and, as you know, during the second year we took steps to examine the program to ensure that we were managing the growth of the program and to really ensure that we were focusing the program on people who required services in their homes in a focused way.
I would like now to give you a brief update of our progress and our activities since we last talked and we have also provided you with some material which you have requested from us and we will be available to answer any questions you might have on that. In looking at our progress since we last talked to you, the Minister of Health, at the time, held a consultation in February with 50 to 100 stakeholders to discuss the next steps in the Home Care Program and look at how we should be sort of concentrating our energy in the program and the message that we very clearly got in that consultation was to consolidate the existing program, specifically the chronic home care component and the acute home care component.
Now since we have last spoke to you, there has been confusion around the title of the Home Hospital Program as we originally spoke of the program so we have made a name change in that program to call it the Acute Program which simplifies people's understanding, especially in the hospital sector of that program. So I just wanted to bring you up to date on that because we will be speaking about the acute and the chronic components today.
We have had a lot of growth in the acute side of the program. We have had a successful partnering with the regional health boards and the hospitals out there and we have seen an increase in utilization and comfort with the notion of acute home care. We have actually seen the acute home care grow to about 15 per cent of our monthly admissions in the past six months or so and we have lots of very innovative partnerships with hospitals and regional health boards to look at, ways that home care and the acute care sector can together provide a strong acute home care component.
We have introduced the Home Oxygen Service in the Home Care Program; that began province-wide in April and we have been able to address the needs of many Nova Scotians who didn't have access to this service prior to that. We have continued to develop an excellent quality management component to our program. I was just at the meeting of the Canadian Home Care Association in Ottawa - I just got back last night - and it is very exciting to see that Nova Scotia, with a program that is only a couple of years old, is right in the front of the pack in terms of developing things like quality management and beginning to look at things like outcome measures and that sort of thing. Other programs are just starting to do that after 20 years of existence.
We are back on track with access to chronic home care. We have eliminated the wait list that was in place at the time that we spoke with you last and the low priority people who were wait listed were brought into the program if they were eligible after assessment. We are also looking at other ways to sort of mature our program in making sure that we have good case management in the program, scheduled reassessments to make sure that our services are appropriate to the needs of an individual at a given time.
As in the government's announcement on home care in April, we have development work underway in several new areas of home care. We are looking at palliative home care in the context of a provincial palliative care working group under the provincial leadership committee and home care is participating in that to help to develop a model of palliative care of which home care is one part. So that group is meeting at this point in time and we expect that we will continue to work in step with this group to develop palliative home care.
We have a home care and mental health working group that is in place right now looking at the provision of existing home care services of those with primary mental health needs. We are involved in a caregiver support pilot working group to look at ways that home care can help to support caregivers in the community. We are doing research and policy
developing in the area of occupational therapy and expect to be introducing targeted occupational therapy services in regions during this fiscal year.
We are involved with the IWK in a pilot of paediatric orthopaedic home care which is aiming to provide services to children with long-term traction needs. We are also looking at the addition of other services on a pilot basis in partnership with the Western Regional Health Board like the introduction of social work services on a limited basis.
The program is continuing to grow in a sustainable way. During the first six months of this fiscal year, over 13,000 Nova Scotians had used the Home Care Program and this was a 50 per cent increase in people using the program since April 1, 1997. I think our challenge is to continue consolidating the program to help to support Nova Scotians to remain in their own homes and support families and natural support structures in the community. We have built a program, I think, that is very relative to people across the province and it plays a very important role in maintaining and improving quality of life for people.
We have a group of very committed staff in the regions and in the provincial Department of Health, and we are seeking ways to constantly improve the program for Nova Scotians. I think this will continue in partnership with regional health boards and other parts of the health care system with volunteers, families and communities across the province. There are a lot of other things that are going on too, but those are kind of our key initiatives at this point in time.
MR. CHAIRMAN: Bob, anybody else to whom you would wish to delegate the responsibility of speaking?
MR. FOWLER: No, Mr. Chairman, but I was remiss in the beginning. Judith referred to Susan McDonald Wilson, the director of the program, in her opening remarks. Unfortunately, Susan has been off on some extended sick leave, but she is doing well and gives her regards and, hopefully, will return to us very shortly.
MR. CHAIRMAN: Bob, please, on behalf of the committee, wish her well from us. We will begin with Mr. Fage.
MR. ERNEST FAGE: Mr. Chairman, I guess the first question I would like to pose is, when I look at 67 per cent growth and then you try to look at some type of audit or tracking system that those hours plus the amount of money that is being put toward home care is being tracked and used to its efficiency and maximum utilization. Why kind of checks and balances are in the system there to ensure that that is occurring? You referred to audit systems that other provinces have not had for 20 years and are coming on stream and Nova Scotia is right there with them. What are those audit systems?
MS. WOOD-BAYNE: I was referring to outcome measurement and those sorts of things when I was talking about the other provinces. In terms of audit procedures and how we track the use of resources in the system, first of all, we have care coordinators in the system who are responsible for resource allocation and assessment of people in the system. They are also responsible for continuing to manage that on an ongoing basis. So, they are accountable for that with each individual client in the program. They have an ongoing process of ensuring that a certain amount of assessed services are going to individuals by our service delivery providers in the community.
We also have regional directors of home care who do, I believe, look at the billing information and all those sorts of things we have from our agencies to look at the amount of services delivered as opposed to the amount of services assessed in the program.
MR. FAGE: I was more referring to the actual dollar value rather than the outcome assessment. When I look at the figures in the net expenditures for Health, actual in 1995-96 was $48 million, estimated for this current year was $49 million, forecast is $58 million, and then in the next year is $69 million. When we refer back to last year, with a growth rate of 67 per cent in that particular program, it seems like an amazing efficiency of money that it has grown the program by 67 per cent. When I look at actual usage in 1995-96 at $48.6 million and estimated in 1996-97 of $49 million, the program grew by 67 per cent but the efficiency in money was identical, that you were able to achieve that on the same amount of money according to the estimates there.
Is that reasonable that the growth last year, when you take your actual cost for 1995-96 for the Home Care Program of $48.6 million, estimate for the current year is $49 million, and you said that growth in the program last year alone was 67 per cent, in your opening statement? I am wondering about that efficiency, how that is occurring?
MR. FOWLER: I am not sure I understand your use of the word, efficiency.
MR. FAGE: Well, efficiency of money.
MR. FOWLER: In terms of the estimates for home care, we introduced the Home Care Nova Scotia Program, taking over from the old Coordinated Home Care Program, in June 1995. So, basically, we went into a comprehensive broad-based policy-based program in June 1995. Certainly the take-up of the program, not in terms of where we are today in terms of how the numbers are growing, which we fully expected right through to the year 2000 probably before we may reach a plateau, the speed of uptake out-stripped any of our expectations in terms of the pent-up demand; in other words, how quickly we would get to that. The best information we had from some other jurisdictions was that it would take us three, five, seven years to get to that full demand. Well, we basically, in that first year, took a huge jump. Quite frankly, it caught a lot of us, both within home care but certainly at the
senior administration level, off guard. I think there was probably a bit of a tendency to say, well, we don't believe this, this just can't be happening, there must be some mistake.
So, it would be fair to say that as we went into the 1996-97 fiscal year, when the estimate of $49 million, which is the number you are talking about, our actual expenditures came out at something in the area of $58 million. You may recall government announced the infusion of up to $60 million. Because that growth continued in the first full fiscal year, which was 1996-97, we were challenged, without question, to meet that demand, and we did our darnedest to do that without creating a pent-up backlog of services to people; in other words, our inability to meet service demand. What we have done is try to plot that growth in a managed fashion.
So, when Judith spoke in her introductory remarks of that $8 million to $10 million growth on an annual basis, that is what the former minister announced that we needed to look at this in a planned growth manner. I think how we measure our efficiency is that, in terms of the home support agencies, they are budget agencies, where we budget the agency and assign cases to them. So, the home care directors in the field regularly monitor their budget relative to the number of assigned cases and the hour of care in each of the care coordinators assigned case plans. That is how we would monitor, whether we get value for money in terms of that. It is, like many other health services, demand-driven. As people come to the door, our goal is to assess their needs, get them in the program as quickly as we can, and meet those needs, ideally from a home care perspective, to sustain them in their home and avoid them going into other more expensive options.
MR. FAGE: I think that is the point of why I was asking the question. Is that realistic when we see budgeting like that because when you move on to one of the next totals there and it's the forecast, and it's indeed more reflective of the $58 million for this current year, will $58 million be enough money to provide those services to finish out this current fiscal year?
MR. FOWLER: I think we are one year out of step. The $58 million is what we actually spent for the fiscal year 1996-97.
MR. FAGE: Excuse me, it's $69 million.
MR. FOWLER: It's $69 million and at the current forecasting we are doing with the home care directors in the field under Bob's leadership as Senior Director of Regional Support Services, our information tells us we are right there. Our current forecast would say we will be right on that number. If you said to me, could we provide more service if we had more money? Yes, we could, but being responsible, now that we have had two years experience in the program trying to plan the growth, that is what we do. The unfortunate part would be if our demand at the front end, services people need, took a spike here that would challenge us, then that puts us into a situation which we talked extensively about last year,
where we did have to wait-list people based on priority. We hope to avoid that at all cost. Judith used the word, sustainability, so meeting people's needs in a sustainable manner has to be our credo, I guess, in the program.
MR. FAGE: So, that brings me to the next question, waiting lists. Is it extensive now, not all?
MR. FOWLER: Maybe I will pass that on to one of my colleagues.
MS. WOOD-BAYNE: We currently do not have any waiting lists for services. We are not in a position where the demand, at the door as Bob was talking about, is causing us to have to wait list services.
MR. FAGE: So, what would be a normal wait say for a patient coming out of the hospital to be assessed and assigned a course of caregiving?
MS. WOOD-BAYNE: People enter the program at different speeds depending upon their level of need and risk. So, if you are coming from a hospital and you need services immediately to be able to return to your home, then you are assessed immediately, usually in the hospital. As long as we receive that kind of referral, you are assessed in the hospital and services are ready for you when you are ready to go home. If your risk is not as great and your need is not as immediate, then you may wait for the assessor to come to your home with a scheduled appointment, like you would going to a physician's office or whatever, and there are all kinds of different amounts of time in between that depending on your level of need and risk.
MR. FAGE: I have a letter here from a constituent in Nova Scotia that they and their family claimed the understanding, when the client left the hospital, was that they would be eligible for home care and would have home care commence immediately once they were at their home. This client claims that they waited 13 days. They found that completely unacceptable that they would wait 13 days before a coordinator or an assessor showed up to assess this patient's needs. Is that normal in the system or is this a case - obviously I don't know the person personally and I am taking it for its validity of what has been sent to me, but that seems excessive to me and would warrant that maybe there are problems here and there.
MS. WOOD-BAYNE: There are a couple of areas where problems can occur. If a referral is not made to Home Care, we have care coordinators in the hospitals but a referral has to be made to the program in order to ensure that assessment is done and those services are put in place. Sometimes that referral does not get made so people may have been led to expect perhaps in the hospital that home care services would be made available but if we are not made aware of that person and no referral has been made, then that person could
conceivably fall through the cracks in that respect. Once again, if a referral is made and the need for services upon leaving the hospital is there, then Home Care makes that assessment usually in the hospital and gets the services arranged before the person goes home.
MR. FAGE: In this case the family and the client claimed that the reason given to them was that there was no home care worker available, so that was why the client had to wait 13 days. That is really what they are quite upset about, that it was 13 days because no one was available.
MS. WOOD-BAYNE: I can't speak on the particular case without specific information but . . .
MR. FAGE: That wouldn't be a norm?
MS. WOOD-BAYNE: No, that would not be a normal situation.
MR. FOWLER: We would certainly follow up on that individual case, Mr. Fage, if you would like.
MR. FAGE: I will give it to you later.
MR. CHAIRMAN: Just before you go on to Mr. Holm, you made reference, Judith, to the referral not having been made. Who would normally, if you are waiting for another party to refer to you, who is that party who is responsible for referral?
MS. WOOD-BAYNE: If someone is in a hospital and a staff person within that hospital decides that a particular patient can . . .
MR. CHAIRMAN: Is this the staff of a hospital or is this one of your staff?
MS. WOOD-BAYNE: In that case it would most likely be someone who worked within the hospital who should refer to our assessors in the hospital.
MR. CHAIRMAN: What do you do? Sit and wait for the phone to ring? Surely somebody has to be in charge and there must be a system in place, there must a process there, there must be a flow chart that says the person who fills this job description is responsible for the referral. Well, I will take a specific example, Queens General Hospital. What person has the responsibility for making referral to your agency?
MS. WOOD-BAYNE: There are different ways that happens in different hospitals and according to the condition of a patient so that if somebody is being referred to the Acute Home Care Program, the physician makes the referral to the program. Somebody might be identified by a discharge planner, for instance, who says this person could use home care and
they call our coordinator in the hospital and say there is someone on this particular floor of the hospital we think could use your services. Could you please come and do an assessment? So it depends upon the type of patient, the hospital, the discharge planning role and there is still a discharge planning role within hospitals.
Home Care doesn't deal with every person who leaves the hospital. Only certain people need home care services when they leave the hospital. So there is a referral process between the acute care sector and the home care sector which has to take place in order for that patient to be identified and assessed.
MR. CHAIRMAN: Now you say that with respect to acute care it is the physician who makes the referral and you are satisfied that you have been able to develop a culture within the medical community that that is done on a regular, routine, everyday basis?
MS. WOOD-BAYNE: The development of that relationship with physicians is one that takes time and has taken time in every province of Canada.
MR. CHAIRMAN: That is fine for the bureaucrats and the doctors. It is not so good for the person who needs the care. They can't afford time to be taken.
MS. WOOD-BAYNE: It is a process, we currently have a full-time provincial medical advisor, Dr. Murray Nixon, who is now working with us full-time for the province to help to raise awareness with physicians of the Home Care Program of acute home care. We also have three regional medical consultants who work in the regions of the province to sort of help raise awareness among physicians that this option is available for their patients as they leave hospital.
MR. CHAIRMAN: Well, I am concerned at the soft language, raise awareness. That sounds like an anti-smoking campaign, raise awareness that if you smoke it could be injurious to your health. Well, it strikes me that from what you have told us, an acute care patient already has something wrong with him that is injurious to their health and yet it seems to me that there is a soft pedal going on here with respect to the relationship with those physicians who may not have bought into the program or who may not include it in their daily decision making. Shouldn't you be more aggressive than that? This program is there for a reason. There is a need.
MR. FOWLER: If I might. If you look at the Acute Home Care Program, which, if you think of, that is where the physician referral is key, there is no question in the world. We need to work harder and longer and more aggressively all the time with that because that is a matter of, if I might, the acute care culture and the community culture coming together. Obviously, for a physician, it is critically important that he or she be very comfortable that if they are going to either have their patient not go into the hospital and/or leave the hospital ahead of time, in other words, days they would have had as hospital days can now be
adequately and safely looked after at home, it is critically important that they understand what home care can deliver, who the service providers are and that type of thing. That is why we are working very aggressively right now and we have a number of very successful partnerships integrating the service with hospital providers so that there is a comfort level not only from the physician but the specialists that may be looking after that person, the discharge planners, the nurses on the floors, so that there is a comfort level that the hand-off, in fact, is transparent to the client because after all, whether you are on the acute care side or on the home care side, what you are after is meeting the clients' needs.
That interface, in terms of changing the way people have historically done business or provided services takes time and needs to be nurtured. I guess, Mr. Chairman, I believe we are being very aggressive and we have challenged the field directors of home care to go out, meet with the regional health boards, with site managers, with physicians and hospitals on a regular basis to address that type of culture change so everybody has that comfort level because the physician does remain, particularly in the Acute Home Care Program, responsible for that care and there is a follow-up process.
MR. CHAIRMAN: We are running along here. Mr. Holm.
MR. JOHN HOLM: A few questions, if I might. First of all, we talked about the growth of home care going from 7,000 to 18,000 and projected to go up to about 30,000. Of that number, I am wondering first of all, I guess, going back a step, those who are leaving hospital, what percentage, have you figured out the percentage of those who leave a hospital who are going to need some kind of either home care, acute care? Do you have any information on that?
MS. WOOD-BAYNE: We expect that of our population within home care that about 15 per cent of home care users will be people requiring services in the acute home care component.
MR. HOLM: But what percentage of those are people who are being released from hospital? I am not talking about, and I know that there can be different reasons that you are in for a minor procedure and so on, but what percentage of those who enter hospital, when they are released, discharged, what percentage of them are going to need some kind of in-home support whether it is acute home care, what have you?
MS. WOOD-BAYNE: I don't have those figures. You are talking broader than the ones who would also come into the acute component of the program because there are lots of people who leave hospital who do not require acute home care but do require some services when they leave hospital. But I don't have the figures on what percentage of hospital patients need services when they leave.
MR. HOLM: In terms of those who are, when we are talking about the numbers, for example, 18,000, how many people would be receiving services on any given day? When we are talking about the 18,000, that sounds like a large number. How many on an average day and what length of service are they receiving?
MS. WOOD-BAYNE: I have statistics on how many would be receiving services on the last day of the month. That is the way we measure our services. Our caseload at the end of a month obviously grows over the period of the year. So we start with our existing caseload on April 1st and at the end of each month, look at how many active cases we have at the end of a particular month.
MR. HOLM: What I am trying to get at, I guess if you say the last day would be the average, if we wanted to use it that way, what kind of average caseload do you have at the end of each month?
MS. WOOD-BAYNE: I don't have an average because it grows every month.
MR. HOLM: So you don't work it back each month and find out how many are receiving care at the end of each month, on a monthly basis?
MS. WOOD-BAYNE: Yes, I have those statistics but as I said, there is sort of an accumulated amount that occurs every month. I can certainly make some statistics available to the committee if you would like to look at monthly caseload and accumulative caseload over the year.
MR. CHAIRMAN: So do you want those statistics?
MR. HOLM: Yes, I would appreciate it when that can be made available.
MS. WOOD-BAYNE: Okay, sure.
MR. HOLM: One of the things that we hear about is the early discharges from hospital and that that is obviously placing an increased strain on the services. I would be interested to find out, as well, if you have any information on those who have been discharged, received some level of service and then ended up going back into hospital. When we are talking about 18,000 a lot of those people, every time that they have to receive a new service in and out of the system, a lot of those services once would have been provided for in a hospital by maybe a longer stay. Do you have any of that kind of information? Can you provide that?
MS. WOOD-BAYNE: I am not sure that we have that kind of information at this particular time. Those are some of the things we are starting to look at in terms of outcome measurement for the program. So those are some of the measures that you could look at to
say, what are the outcomes that people are having as they go through from hospital into the Home Care Program. Those are some of the things we are looking at in terms of outcome measurement as we are developing that.
MR. HOLM: When we are looking at this and where I am coming from, I guess, is on long-term planning and when you are taking a look at the efficiencies of the operation and efficiencies isn't only dollars and cents, efficiencies are the levels and manners in which you are meeting the needs of the clients. If I could go back again just briefly to the matter that was being discussed earlier about discharges and so on. It was my understanding that before a person is discharged from the hospital they are to be assessed and if they are going to be in need of one or the other levels of in-home support, that those are to be set up prior to that person being discharged. I know that there is certainly an awful lot more pressure now placed on families, where the families are being expected to provide a lot of the services. Some of those families, of course, feel very uncomfortable doing certain kinds of procedures and also there often aren't the family people available or willing to provide those services.
Can you assure us that no people in this province are being discharged from hospitals without there first being assurances that whatever kind of in-home support, whether it be acute or whatever care, is provided before they are discharged from hospital? Can you give that assurance that that is not happening today.
MS. WOOD-BAYNE: As I said before, we have care coordinators in each of our hospitals and we have immediate response times when there is someone who requires assessment before they leave the hospital and service to be set up before they leave the hospital. That is the number one group in terms of response times for the program. Once again, if a referral is not made to Home Care, we can't necessarily say that those services will be in place but we are working very hard to raise awareness in the hospitals that referrals need to be made before a person is discharged from hospital. Home Care needs to have lead time in order to set up services, obviously, it doesn't happen in a five minute time-span, there has to be lead time for the assessment and the services to be set up. That is part of the kind of relationship that has developed in the hospitals to make sure that always occurs and that people who require services when they leave the hospital don't end up leaving hospital before those services are put in place.
MR. HOLM: That almost, in a sense, leaves the potential for a conflict and I don't say this as any kind of criticism for the case coordinators and, if I am not wrong, there are only a handful of those who are really trying across the province, who have the responsibility to be doing all of that work and are under a very heavy workload and I am not trying to be critical of them at all. The need to have all of the assessments done and then as you correctly pointed out the need to have lead time so that you can put the appropriate services in place and that is balanced with the pressures to put people out of hospitals a.s.a.p. to save money and it strikes me, maybe I am wrong, that there is a tremendous potential, at least that the needs, because of time elements, the inability to have enough people doing that, if you don't
have sufficient staffing available out in the communities to provide the level of services, that many people can fall through the cracks. That is certainly the kind of thing that we have heard and I am wondering, am I totally off base in that concern and if not, what kind of planning, what kind of resources are being committed to ensure that those real needs are being met prior to the discharges to ensure that the service is there?
MS. WOOD-BAYNE: Once again, we are working very hard in this program to continually improve the service that we provide to Nova Scotians to clarify processes within hospitals, between hospital and home care, to make sure that there is a smooth transition between hospital and the home and to make sure that we can access those services in a timely way to have them available for people who are leaving their homes.
It is obviously a challenge as you get into more rural parts of the province and as you are discharging people, for instance, from the Queen Elizabeth II out into rural parts of Nova Scotia. But I think we have in place a province-wide system that makes some of that easier than it would be if we didn't have a province-wide system in the sense that we can much more easily have someone discharged from the QE II, for instance, out into another region and another province with flow of information and information right to an assessor in that other part of the province to set up services. We have worked on quite a few processes to make that as seamless as possible for the patient.
Obviously, it remains a challenge quite often when it is a later in the day kind of service and the care coordinator has to scramble to get that service in place and those sorts of things. Especially in the acute component of the program, we would not accept someone into the program if those services are not available to be available when that person gets home. The safety of the service to the patient is key for us and there are a few things that have to be in place. One is that the service has to be in place in the home, there has to be a physician who has agreed to manage the care, to direct the care of that patient in the home and those sorts of things have to be in place before we would accept someone into the program.
MR. HOLM: I don't challenge that people work very hard. I wonder if I could ask a couple of specific questions. When will home care be devolved off to the regional health boards? Secondly, really tying in with that last part, when we talk about being able to meet the needs and the challenges, it strikes me that there has to be a long-term human resources plan in place. Has a long-term human resources plan been developed or is that going to be left up to the regional health boards? A lot of this kind of information that we have been talking about is going to be necessary in order to have done that, such as to determine the number of members, the mix of the home care staff, the number of coordinators, care providers, RNs, LPNs, is the other term, and so on. Has there been or is there or when will there be a human resources plan developed to address those longer planning issues?
MR. FOWLER: Maybe I will start with what I understood your first question to be, about the devolution of home care. The key word for the department . . .
MR. CHAIRMAN: You have about three more minutes to talk with Mr. Holm, so if everybody would kind of keep their eye on the clock.
MR. FOWLER: All right. The key word within the Department of Health, in partnership with both the regional health boards and the non-designated organizations is what we are concentrating on as integration. At this point in time there is no decision taken as to the date of devolution of home care to the regional health boards.
We continue, as we work with our own, within the Department of Health, the long-term care sector, nursing homes, homes for the aged, and also our colleagues at the Department of Community Services who have, as you would be aware, a number of the other services, small options, other community-based options, residential care facilities and so on.
One of the key things that I think is unanimous throughout the human service field is that we need to look at how we have integrated service delivery and integrated access to those services that makes it simpler. So at this point in time there is no decision taken in regard to the time for devolution.
MR. HOLM: Just tied in with that one, if I could just interrupt, has there been any consideration of bringing all these various service providers in under Home Care Nova Scotia, rather that devolving things off?
MR. FOWLER: The second part of this; there is Home Care Nova Scotia, in terms of the care coordinators, their field directors who do the care coordination. They are civil servants, they work for the Province of Nova Scotia, as we sit today.
The service providers to Home Care Nova Scotia are a various cadre of not-for-profit agencies, homemaker agencies, the VON. In some cases, where we have not been able or we inherited, and it is a combination of both, to provide services where we have, in fact, particularly on the nursing side, in fact only on the nursing side, we have community health nurses in some areas of rural Cape Breton and other areas where we, in fact, provide the service directly.
MR. CHAIRMAN: I think we will have to move on now to Mrs. O'Connor.
MRS. LILA O'CONNOR: I would like to start off by asking about the Home Oxygen Program. It was a program that was very close to my heart. I had a constituent who, unfortunately is now deceased, but campaigned very hard for that program to become province-wide. I would like to know how many people are on that program now, across the province.
MS. WOOD-BAYNE: As of the end of September, there were over 200 people in the program. That does not include the transitioning of the people who were on the QE II's specific Home Oxygen Program, who are being moved into the Home Care Program now, as well, and people under other government programs that sort of had home oxygen in different ways. There are 200-plus, yes.
MRS. O'CONNOR: Thank you. I would also like to ask about the palliative care. You have talked about trying to bring that under the Home Care Program. A number of hospitals have palliative care volunteers, caregivers in their hospitals. Are you going to include them in the home care or how do you plan to do that?
MS. WOOD-BAYNE: The palliative care working group, under the Provincial Leadership Council, is looking at a broader regional provincial model of palliative care which would have home care as one piece of that but which is an integrated delivery model that would look at the palliative types of services you would need in acute care, in long-term care, in home care, the volunteer pieces, the sort of need for specific clinical consultation that would go across these sectors, how you tie in the volunteers, all those sorts of things, looking at it in an integrated fashion. So it doesn't mean that home care is going to develop a palliative Home Care Program necessarily that includes everything but how does home care, how do services in the home link in with an integrated system of palliative care in a region. That is what that working group is looking at at this point in time. So home care will be one piece of that. We know there are lots of people within the Home Care Program who would be considered to be in a palliative state but we would be part of that system and not necessarily bring new services under home care.
MRS. O'CONNOR: So volunteers will still play a very important role?
MS. WOOD-BAYNE: Oh sure, yes. The volunteers would always play a very important role. There are standards, for instance, that have just come out from the Canadian Palliative Care Association that look at things like standards for volunteers, standards for all the different components of a palliative care program.
MRS. O'CONNOR: Last year we spent a lot of time talking about the wait listing. We are still four months into this year's budget and, knowing that winter is coming, it is always a bad time of the year. You say now that you are right on target. How close is the target? For instance, are you over the target a little or under the target or right on? I am really concerned about wait listing, I think it is a terrible word, I hate it with a passion. I know how the VONs hate it and the nurses hate it so I am really concerned. Do you think you are going to get through the year without wait listing? I know that is putting you on the spot but that is what you are here for.
MS. WOOD-BAYNE: I am not anticipating at this point in time that we are going to have any problems. We are doing okay with our budget this year, we are maintaining it in a sustainable way. I can't say what is going to happen next month or the month after, in terms of you don't know when increased demand is going to hit the program.
MRS. O'CONNOR: But knowing what you know from past years, you feel secure this year that you will get through until March 31st without having to wait list, hopefully?
MS. WOOD-BAYNE: I am optimistic, yes.
MRS. O'CONNOR: You are optimistic, okay. Well, I am concerned - I take it that this is your document - with cases per care coordinator for the western district, 197, which seems to be the highest caseload for many of the districts. I guess my first question is, why are we so high? Is it because we have more sick people in our area? Are we short caregivers or just what is the reason?
MR. ROBERT ST. LAURENT: Perhaps I could answer that, Mr. Chairman. The number of clients per caseworker, per care coordinator, are based on the budgeted FTEs, as is indicated in the paragraph following that little chart. At any one time, depending on the workload and the number of cases being managed, that number is probably much lower than that and this does not include the care coordinators who are located in the hospitals.
MRS. O'CONNOR: Care coordinators located in the hospitals, do you mean the ones who make the decisions on what type of care you have when you go home?
MR. ST. LAURENT: These are the care coordinators who would be working with doing the assessments for other than the acute patients.
MRS. O'CONNOR: Okay, this is chronic care. Is this per month or is this - I mean is this the average out for the year, that we have done 197? What is the normal caseload for a coordinator per month? You don't have that?
MS. WOOD-BAYNE: This is the average caseload per care coordinator and what it has tried to do is separate out those care coordinators who solely do the hospital-based intake process. So in some regions they are shared and in some regions the care coordinators do both. They do the hospital work and the community work. If they are a shared position, they are included here so that could explain some of the difference. In metro, for instance, we have lots of care coordinators who do only hospital and they are an intake point through the hospital. They transfer that case to a community-based care coordinator, either in Halifax or metro or somewhere else in the province. We have tried to exclude that because it is not exactly carrying a caseload in the same way that those other care coordinators do.
MRS. O'CONNOR: Okay, but the provincial average is 164 and the western area is 197, so we are way above the provincial average. Because the western district seems to be the highest, is there anything happening to help lower that? The other three areas do not even reach the provincial average. I know you have taken it all and you have divided it up and that is how you have gotten it. Still, I have a concern with the western district. It is well above average and it is well above what the other three areas are. I guess my concern is, are there more people in that area? Well, there have to be more people in that area using the program, but why? I guess I have a concern that the number is extremely high, and how is it going to be helped to lower the caseload? Even though you have explained it, I still have a concern that it does seem to be high.
MS. WOOD-BAYNE: Well, it is certainly something we need to look at as a program to make sure that we have consistency. There are other factors that could be at play there in terms of the complexity of the caseload. In more rural areas where there is not the same range of other options for people, you may end up carrying a caseload with a lot less complex needs on it, whereas, for instance, in the metro area those needs are more easily referred to other resources that are available in the community, so there may be some difference in complexity of caseload. It is something we need to look at.
MRS. O'CONNOR: On the acute care, you say you are on target with that, with the 15 per cent. You find the hospitals now are starting to be more receptive to the fact that you can do the hospital and the home, or whatever you want to call it now, and all that. You are happy with the way that is progressing and there is still more to do on it?
MR. FOWLER: Happier.
MS. WOOD-BAYNE: Yes, I think it has so much to do with the sort of partnership and collaboration that is happening between regional health boards and hospitals and Home Care. That sort of took a while to get that handshake developed, but it is really starting to happen in the regions now and we are looking at a slightly different model in terms of having more joint hospital and home care type initiatives. I think that is really helping to raise the comfort level of the acute care sector which is not as used to the care in the community. The shared model is helping to raise that comfort level and so on. I think we are moving in the right direction on that.
MRS. O'CONNOR: Even though I find that the caseload is high in the western district, I will tell you that I hear good things about it. Thank you.
MR. CHAIRMAN: Mrs. Norrie.
MRS. ELEANOR NORRIE: I want to talk a little bit more on the home care issue raised by the previous questioners. First of all, the first questioner talked about the quantity and the number of patients - clients - that are being served by the Home Care Program. I think
those numbers reflect success in the program. The number of people using it, the growing numbers that are evident by your presentation, show the people are learning about it and that the communications are well coordinated. Also, there was a question about budget. I feel that the department has done a very good job in making sure that the budget meets the need rather than the need meets the budget, because with the infusion of money last year, make sure that the dollars are there to provide the service. I guess the other issue that has been brought up here is the process involved.
I would like to move further along and talk not about quantity and budgets, but talk about quality because I think that's the first concern we should all have, is the quality of services that the clients are receiving. I am from the northern region; I think the Home Care Program there can be held up as one of the greatest successes in the province. I've had a good relationship with the service providers as well as the coordinators and I think of Mrs. O'Connor's question about caseload. It should be pointed out that caseload per care coordinator is completely different than caseload per caregiver. I think it's the caregiver and the quality of services that should be considered.
I know that I don't have a letter that Mr. Fage has, but I have had a number of one on one conversations with people, mostly seniors in my area, who have described their illness, first of all, the care they've received and they've come to me and sought me out to tell me that it's working, how pleased they are, how much easier their recovery has been and the success of the program in the area and the quality of services they are receiving. I guess with the comments that have been made prior to my question, I would like to ask, what have you done to ensure that people are getting that quality of service right across the province? I have nothing but good words to say about it from my area. If it's not happening across the province, how are you ensuring that it will or is happening?
MS. WOOD-BAYNE: When did you come on staff, JoAnn?
MS. JOANN MARTELL: January 1996.
MS. WOOD-BAYNE: We wanted to hire someone in this program who would help to ensure that we had quality service in this province. Our director was very far-sighted in saying we need a coordinator of quality management in this province who will take the home care sector and help to bring it along in terms of the quality and the standards and all those kinds of things. I'm going to turn the question over to JoAnn Martell who is our Coordinator of Quality Management for the program and I think she can probably give you a little bit of information on the initiatives that are happening from the provincial, the regional and the agency level in terms of quality.
MS. MARTELL: As Judith said, I've been with the department, well, it will be two years in January. My role is Coordinator of Quality Management for the provincial program. Much of the focus of my job in the past two years has been, as much as it's possible to ensure
the quality of a service, to do that. I have worked with the regions and with the provincial program to set up an initiative that will drive the quality initiatives of the program and take into account the initiatives that have already begun or have already been established in the regions.
Part of that, and much of the focus to this point, has been on the setting of standards for service delivery because, as you probably know, most of the services provided within the Home Care Program is by home support workers, which is a non-regulated profession at this point. The program established standards and a system for monitoring adherence to those standards. That has been much of the focus.
Where we are now is in the consolidation of the provincial initiatives, in that we are focusing on regional quality management plans and programs using initiatives that they already have begun and kind of consolidating them with a client focus. Since I started my job a year ago in January, the CCHSA, the Canadian Council on Health Services Accreditations, has put out standards on home care and our efforts this year, and probably for the better part of the last year, have been along the same lines. We have changed our standards documents in the whole process to more closely follow their model. We hope, in fact, to have our program accredited by that body within the next three or four years.
There is also a risk management component to the quality management initiative. So that is just a general overview of where we have been and where we are going.
MRS. NORRIE: I think that is important. I think it is one of the areas that regardless of dollars, regardless of the quantity, the numbers of clients and whatever at the end of the month or whatever, I think that we have to make sure that the clients, that the people of Nova Scotia are receiving good, quality health care. That has to be the bottom line as far as I am concerned.
Part of that, I think, could be assisted. There was some question about discharging from hospitals and referrals. Patients come to the hospital, they have to be admitted by the doctor. You are not discharged from the hospital without a doctor signing off on the discharge. I think that is one area, be the gatekeeper, if you call it, and then you go to your care coordinator. The words that you were using were referred to as soft words but it seems to me that the doctor is the front-line person here. That is the person who should be making sure that those people who are leaving the hospital should not be discharged unless they are in a state of recovery or state of wellness, that they should go home regardless. Is there something happening there with the doctors, themselves, and with the Medical Society to make sure that they are aware that the Home Care Program is there and the levels of services that would be required by their patients are in place?
MS. MARTELL: Yes, as Bob and Judith both said, that is an extremely important component and Dr. Nixon has been quite aggressive in ensuring that the home care resource for acute care is not only used but is used appropriately. Of course, it will be one of the roles of the quality management teams on a local basis, to ensure as much as possible not only that home care is used but, for example, when I say used appropriately, there would be no advantage to discharging a patient to home care only to have them readmitted and start looking for a bed and going through that whole process again two or three days later. So it is not only the use of the acute home care service that we are focusing on and that he is focusing on, it is the appropriate use. That is exactly the kind of concerns of the quality management program.
MRS. NORRIE: I would like to move on, just to ask the question, there was also going to be some discussion regarding Emergency Health Services; is there a presentation on that or are we moving right into that without a presentation, Mr. Chairman?
MR. CHAIRMAN: I didn't think we were going to have a presentation on that, Mrs. Norrie. That would take another 15 minutes, I would think, and we could move directly into questioning but if you want to put a question to Dr. Murphy or any of the others, feel free to do so.
MRS. NORRIE: I think it is also one of the most important things here in the province, given recently some of the concerns that have been stated by the public. I would like to move into the Emergency Health Services, if I might, to talk about the ambulance fleet that we have there now. Can you give us a bit of an overview, perhaps, if there is no presentation, on what we have now compared to what we had say four or five years ago?
MR. CHAIRMAN: Well, I am watching the clock and I have allowed roughly 15 minutes per questioner, excepting for Mr. Fage and myself early on in which we both stayed pretty well within 15 minutes. I don't want to get into a 15 minute presentation so, Dr. Murphy, if you can be succinct because Mrs. Norrie's time would be up about 9:19 a.m. and then Mr. Hubbard wants to get on.
MRS. NORRIE: A five minute overview.
DR. MICHAEL MURPHY: Mr. Chairman, I would like to, at this time, update what has happened from the time we met two years ago to today and lay some of the groundwork of understanding what EMS systems are all about because there are new members of this committee. But without doing that, let me specifically address the question that Mrs. Norrie raises and that has to do with fleet and fleet implementation. The implementation of the fleet program began about two and one-half years ago to replace the fleet of ambulances that were owned by the private operators, the Ambulance Operators Association of Nova Scotia and that was speculated to involve about 150 vehicles. That 150 vehicle roll-out will be completed, I think, by January. Some of the 150 vehicles actually will not be the type 2
general utility kinds of vehicles that most of you see on the streets today but will be customized to provide a variety of other functions including critical care transport, which are the box type vans that you see, and multi-patient interfacility transport. Because those vehicles are more expensive than the type 2, there will be actually fewer number of vehicles in total. Our fleet numbers that we speculate are required to deliver the quality of care are somewhat less than 150, so this number marries very nicely to that. I don't know if that answers your question but that is succinct.
MRS. NORRIE: Thank you very much. I think there may be other questions.
MR. CHAIRMAN: Eleanor, you have a couple of minutes left if you would like to continue, if not we can go to Mr. Hubbard.
MR. RICHARD HUBBARD: Staying with the ambulances, Dr. Murphy, there were some grumblings a couple of years ago in this House about the structure of those ambulances. I guess, first of all, were they valid; and secondly, have those grumblings been rectified, that they weren't wide enough and that they weren't this and they weren't that?
DR. MURPHY: I think every complaint has validity. I think the point of where those complaints came from emphasized the validity because they were from people who used them day to day, they were the workers in the field. So through the vehicle modification committee that we have through EHS, the suggestions in terms of vehicle design were listened to and the structure has been modified to accommodate the issues raised by people in the field.
In addition to that, as we have brought new vehicles into the fleet, because different hospitals, different regions and different providers have different needs, depending upon the types of equipment they have and the types of patients they transport, and the critical care fleet is a good example, each of those has been customized to meet the needs of the stakeholders in the various hospitals, regions and sophistication of clinical care they provide. So that the modifications in the fleet have occurred according to the desire of the stakeholders, meeting, at the same time the North American Triple K standard, which is the North American-wide standard.
The same thing is true of the multi-patient transport fleet. I don't mean to chew up too much time, Mr. Chairman, but the most efficient way to transport patients of low acuity that are non-time sensitive is by using a single vehicle to transport multiple patients at one time. That program was piloted by the QE II hospital, the old VG Hospital in a multi-patient transport van. What we have been able to do is to identify the general characteristics of how that can be done safely and now we are working towards dealing with non-designated facilities and regional health boards to identify their needs in terms of multi-patient movement to accommodate the most efficient means of transport possible. That's what is going on now with the next phase of fleet roll-out is to look at multi-patient transport vehicles.
MR. HUBBARD: I guess the reason for my question, it hits kind of close to home because, as you know, those vehicles are made in my home town, so I have perhaps a bias towards them.
Another question, Dr. Murphy, with regard to the air medical transport program, how has that been working, how often does it fly and those kinds of things?
DR. MURPHY: The statistics on the AMT program are quite remarkable. We have done about 350 missions in the last year and we continue to do something in the vicinity of 20 to 30 missions per month. As you will recall, the initial structure of the AMT program was to contract with a management organization that was best in class in air medical transport and our management contractor for that is STARS, the Shock Trauma Air Rescue Society of Nova Scotia, a not-for-profit organization. They have two aviation contractors that they deal with in a three way relationship with the province. One of them is Canadian Helicopters providing the aviation component for the helicopter, which is a Sikorsky 76 or S76, which very nicely meets the needs of Nova Scotia because of our geography and where our airports are located. We recently have awarded a standing offer fixed-wing contract to Provincial Airlines, also managed under the STARS contract to provide the fixed-wing component.
As the program has rolled out, initially we viewed it to be targeted as a site-to-site transport, meaning usually hospital to other hospital and almost always from peripheral hospitals to central hospitals, for instance from Inverness to Sydney or from Yarmouth to Halifax. That program has worked very well around four specialty transport teams including neonatal intensive care, paediatric intensive care, obstetrical care and adult critical care.
The next evolution of that is to move to something called scene response, which we are investigating this year, which was in the strategic plan roll-out to be in year three, which is where we are right now. Scene response is a very complex issue and requires a high degree of sophistication at the ground transport level, public safety agency cooperation and coordination through central dispatch. As we timed out the strategic roll-out, you needed those things in place first before you could bring on scene response. Scene response is important because it delivers usually to trauma victims the most important elements of care in reducing death and disability from trauma. That is in the plans for this year.
MR. HUBBARD: That leads me to another question. If you could give me an update on the first response in the province.
DR. MURPHY: The first response initiative as outlined in my report was to occur this year and it is at the point of being rolled out in January of this year. The First Responder Program has several fundamental components. One of them is the ability to coordinate first response according to pre-determined dispatch criteria, ordinarily coordinated through a single dispatch centre and dictated by the individual first response agencies. The second part of that is the ability to provide some funding in terms of training and equipment. The third
part of that is to address the issue of liability. All of those things are being wrapped up as of this month so that we will be able to roll that out through our first response advisory group in January of this year.
We have had some pilots of first responder relationships and programs. The one on the Eastern Shore is the one that I think we discussed the last time we had this meeting.
MR. HUBBARD: I do have a couple more questions. We hear a lot, too, about the medical dispatch centre. Are you confident that the emergency medical dispatch centre will be able to successfully handle all emergency medical dispatching for the entire province?
DR. MURPHY: Our experience to date has been very positive. The initial concerns surrounded volume of calls coming into the centre. We dispatch somewhere between 80,000 and 100,000 ambulance calls a year. Over and above that, the first response volume which would be anticipated to be in about the 40 per cent to 50 per cent range because 44 per cent of our calls are emergency calls would also be required to be handled, placing the number somewhere between 115,000 and 120,000 calls a year. That was brought to bear in the design of the centre initially and in the staffing of the centre. The intense work that has been done in terms of communications and dispatch is around the infrastructure that supports it, the ability to communicate over the airwaves or wireless transmission, the ability to use cellular transmission and the ability to use land lines. The infrastructure to do that certainly exists. The ability of the centre to match the need with the resource seems to have been successful as we rolled this thing out piecemeal and that is why we attempted not to bite off more than we could chew and do it in a staged process.
MR. HUBBARD: I spoke with the people in Yarmouth when they opened their centre a couple of weeks ago. They were talking to me about the number of jobs that had been created. Do you have any idea of the employment figures that created around the province?
DR. MURPHY: I cannot give you exact figures, but I can tell you that in terms of dispatch, as of the end of September there were 37, I think, positions that were created in dispatch and - I may be off by two or four, one way or the other - recently the addition of 5.2 FTEs to handle first response dispatch. Those are new jobs. Those are new high-tech professional jobs. In addition to that the hours of work in the old system were long and therefore it was necessary for the ambulance contractor to hire large numbers of new people into the system. I cannot tell you exactly how much those numbers are. I can get them, though, through our registry of people that are eligible to work. Again, those are jobs in the regions and the areas and local jobs. They are health professional jobs that people have either been upgraded into or hired into.
MR. HUBBARD: I was surprised because I think in Yarmouth, if I recall, the chap there told me that 10 jobs had been created just in the Yarmouth area alone so I sort of multiplied that by how many times.
DR. MURPHY: It is a large number. It is in the hundreds.
MR. HUBBARD: A couple of hundred people, I suspected.
I guess maybe my last question, I would ask you, how are these newly designed Emergency Health Services saving money for the province?
DR. MURPHY: I don't know that the services themselves save money. I think what the services themselves do is save lives, which I think is why we implemented the program. If you look at lives saved as being costs averted or reduction in disability and morbidity or the degree of illness in a community, then those are dollars saved. I think the investment in EHS, which is a small investment on a global scale of how much money we spend in government and how much money we spend in health, is money well invested in reducing death and disability.
The number one cause of out of hospital preventable death from trauma is airway management or failure to manage the airway. Therefore the emphasis in the program is upgrading to advanced life support capability, so we do prevent those deaths. I am sure you have read in the paper some of the responses that have occurred, the Plymouth incident is a good instance where there are at least a couple of individuals in that accident who are alive today who wouldn't be alive.
You may say, well, how does that save money? Aren't they cheaper dead than alive? Probably, as an economist, if I was sitting at the New England Journal of Medicine, I might take that view. I take a different view sitting where I sit in Emergency Health Services.
MR. HUBBARD: Just to finish off, you touched on the Plymouth incident. That was an accident, folks, that happened in Yarmouth County in September, a terrible tragedy and I want to just say that the comments that I had back from the people involved were how well the system worked for those people. Thank you, Dr. Murphy.
MR. CHAIRMAN: Thank you, Mr. Hubbard. Dr. Kinley.
DR. EDWIN KINLEY: Mr. Chairman, I would like to start, if I could by just making a few comments and I have some questions. First off, I would like to congratulate the people administering this program and bringing it in. It is breaking new ground and it is a learning experience for everybody. It is a cultural change for the health care system and it is being well done and it is certainly well needed. I think there are a lot of reasons to congratulate you on this.
In terms of the wait list, I just have a few other comments. I think the fact that your wait list is down indicates that you are meeting the need and I just wonder if you could comment, one of the questions I would ask is about the anticipated growth in the plan. You
have some figures here from the other provinces and you say, I think, 2.5 per 1,000 and so on. That may give you the target that you have to plan to reach, I would assume, as to what the need will be. So you have a way to go but you have some idea of what the growth is going to be and what the final cost will be if those figures are applicable to us and presumably they are.
In terms of referrals from hospital, there have been some comments on that and the referrals from the hospital are well done. The medical and nursing staff and so on are becoming well acquainted with this. It was a new thing and, as I say, people had to get confidence with it. It isn't easy to just decide you are going to send somebody home from hospital in a condition that you are not used to. You are not sure about it, you have to get confidence in the services and so on and those things are developing. The care coordinators are working very hard and they are working very closely with the staff and they have had educational programs for the staff at all levels. There isn't a need and an urgency in it because of the fact that beds are closed so that the home care system is a part of that that has to be in place, as everybody has said. I think that the confidence is being gained in the home care system.
In terms of the percent of population needed in each hospital, in each region, is somewhat different. Obviously the central region has a higher percentage of people with critical illnesses and major problems that are looked after so that they do need more expensive home care when they go home, people being discharged from those areas. The cost in terms of each region is going to depend on where their patients come from.
I am just telling you this because I have this information and I have been working with it for a long time.
MR. CHAIRMAN: You will have to move to the other side of the House.
DR. KINLEY: No, I just think that I am answering questions. I could ask all these questions. The process of referral starts on admission. This is the goal in the hospitals; the patients come into hospitals and the referral starts on admission. An estimate is made on how long the patient is going to be there and what the needs would be on discharge. An assessment is made of what the assets and resources are for the patient at home and the planning on these things starts on admission, to make sure that things are in place when they go home.
MR. CHAIRMAN: Do you have any questions?
DR. KINLEY: Yes, I do. I was going to ask you about the PIT, the assessment instrument that you have for the care coordinator. In patients being discharged from hospital, it is perhaps easier to fill that out but people outside, is that instrument the same instrument as you do by telephone? Is that assessment still made by telephone?
MR. CHAIRMAN: Please don't use acronyms, it confuses those of us who don't work with this on a day-to-day basis.
MS. WOOD-BAYNE: I believe Dr. Kinley is referring to the priority intake tool, which is a tool that we use to assess the potential client at intake, to look at the level of need and the level of support and so on that they have, to see the priority at which we should bring that person into the assessment stream.
When someone is leaving hospital, needing services, going into acute home care, when it is a referral from Adult Protection, when it is very clear that support systems are breaking down and this person is at risk, that priority tool helps us to assess that and to show us that we need to very quickly assess that person into the program. So it is used almost as a screening to determine how quickly we assess a person. If someone has lots of natural support systems and their risk is not particularly high for not having the service and so on, then their appointment for assessment will be set at a later date.
When someone comes out of hospital and needs acute home care or different kinds of conditions like that, we don't even use that tool. It is more from the community to sort of stream our assessments.
Can I also refer to a couple of other points you made on the number of people who would use home care in any particular province? We have used information from other provinces in estimating how many people in Nova Scotia would use home care over time. But, of course, issues like the age of your population, income levels, morbidity levels, mortality levels, all those things will make one province a little bit different than another province. So we have tried to look at provinces that are quite similar to ours in age structure, urban-rural structure, all those kinds of things, to look at what we think the future use of the Home Care Program would be.
DR. KINLEY: I just wanted to ask you, though, is the telephone still the way that you do a lot of the home assessments?
MS. WOOD-BAYNE: No, that telephone screening is just for intake. We then have an assessment by the care coordinator, usually in the person's home. It is a lengthy assessment that looks at all of their unmet needs, the resources available and all kinds of different factors in determining what services need to be provided by the Home Care Program. So that is just a short screening that we use the telephone for.
DR. KINLEY: Also, if I can get to the quality control which I think is obviously essential to this to know the outcomes, to know whether this is the way we will tell whether or not you are really accomplishing anything and what the quality of it is. Are there information handling techniques available to do that?
MS. MARTELL: It depends on the specific kind of information you are talking about. We are in the process of implementing a computerized system that will give us some information. So the amount of statistical data that we have at this point is limited. What we will do until we have more sophisticated methods is collect information manually.
DR. KINLEY: The palliative care program that you mentioned, I take it that the home care will just be part of that and it is an initiative done by another group, being carried out by another group?
MS. WOOD-BAYNE: Yes, it is actually. The Provincial Leadership Committee, which is made up of the regional health boards and the non-designated health organizations in this province, meets with the Department of Health and the deputy minister. That committee has asked, as one of its initiatives, that palliative care will be looked at in a much broader picture than just the home care services that need to be provided. So it is looking at the way services are integrated and what home care needs to have in place to be part of that integrated system.
DR. KINLEY: Just one final question, Mr. Chairman. Dr. Murphy mentioned liability in regard to first responders, I think. Is that an issue with any of the home care support services?
MS. MARTELL: Absolutely. It is one of the components with the quality management plan for the program and because we are not dealing within a four-walled institution, the workplace is many different places and many different venues, there are huge liability issues that we have to be proactive in addressing and are doing that. So yes, it is a big question for us.
DR. KINLEY: That is all, Mr. Chairman, thanks.
MR. CHAIRMAN: Mr. Keith Colwell.
MR. KEITH COLWELL: I would like to ask some questions about the First Responder Program because my area was the initiator, I guess, or the pilot project for that. I would just like to know how it has progressed since we originally had the first meetings and the fire departments had different views on it. In my area I know they dramatically changed those views and are probably one of the biggest supporters of first responders in the whole province now. How has it rolled out in the rest of the province?
DR. MURPHY: That's the characteristic of the First Responder Program because the real impact of first responders is in non-populated areas. It is in non-urban areas where the volunteerism and the spirit of volunteerism and the ability to volunteer and provide the service is so important. All first response agencies will commit differently to the program so the design of the program has to allow for that flexibility, to say that those people who are unable, for whatever reason, to participate should not be discriminated against because they cannot, they just simply don't have the ability.
Other areas are willing to donate a certain amount of expertise and time so the program has to be willing to accommodate that. Other areas wish to respond to virtually everything that occurs in the community, in terms of medical first response or medical emergencies. Of course then the issue becomes not one of the commitment but becomes one of public safety. The reason I say that is that the movement of emergency equipment around communities, often at high speeds and high intensity and high adrenalin, is an issue that we have to wrestle with internally among the first response agencies and emergency health services.
Almost all of the injury and death-producing accidents that occur with emergency response vehicles occur in emergency mode, certainly ambulances and fire trucks. Those of us who live in Halifax don't have to think far back to New Year's Eve a few years ago at the corner of Bell Road and Sackville Street, when there was an accident involving a fire truck.
So the balance of moving heavy equipment in emergency response mode is balanced against the public safety medical first response needs. So you move through those various needs and those various degrees of commitment.
The way the program is structured is to be a voluntary program, that it is offered as a voluntary commitment of first response agencies to access the funding available for training, for equipment and to address the liability issue.
The flexibility within the communication centre to identify the first response agencies that wish to participate in a level of participation is important because not all of them wish to participate to the same degree and that is reasonable. So the role of the program is structured to accommodate that need.
As you say, the Eastern Shore is very different than some other areas of the province, where you just don't have that kind of capability, so we are sensitive to that.
The second thing about the First Responder Program was that people had access to training in a variety of places, wherever they seemed to be able to get it and get it most cheaply. It seemed important to us that there be a standard of training offered, that some independent third party evaluate the quality of training materials being offered by these various training agencies and that that be accredited or licensed or stamped with approval,
on behalf of Emergency Health Services. That program begins in this month so that training agencies can submit their credentials to an independent third party evaluator, who according to criteria set up by Emergency Health Services for training and the education objectives and outcomes we expect, will then be able to have their training programs approved or recognized to go out and offer to the first responder community. This brings up another series of issues related to reciprocity, retroactivity and priorization of particular groups and those who we hope we will be able to priorize such as rural groups for training initially.
I think the First Responder Program has come a long way in terms of the organization, the policy and the process, since we talked about it two years ago. I think what it will do is provide a standard level of training, it will provide reciprocity and recognition across the province, it will provide for a varying level of commitment, depending upon the ability of your individual department or agency to participate and it will provide a level of funding support so that your agency is able to access that to provide first response.
The other thing that it will do is through the dispatch process, give us an idea how we will retrospectively review the program in terms of the quality provided for the dollars being spent, which I think is the mandate of the organization that I represent within health, to say, what are we getting for the dollars we spend.
MR. COLWELL: One thing I have seen in the First Responder Program which I think is excellent and anyone that is not participating is losing a golden opportunity, especially in a rural community, is that the Department of Health really cooperated with our fire departments. Our fire departments couldn't believe the cooperation they were getting and I think that says a lot for the efforts being put forward to make that happen. I have sat in on meetings and they said, are you really going to do this? And they really did. It was nice to see and was help that they needed.
The other thing that I saw with the First Responder Program was that the firemen realized all of a sudden not only did they have the capability to go to an emergency situation but they also had the capability, in the case of a fire when their normal work was going on, that they had trained people on-site all of the time, that if there was an injury with a fireman they could respond to it immediately, or a resident in a property that might have been hurt. That really added to the program very successfully, at least in my area.
One of the big questions that came up at the time and I know my area was reasonably well addressed, initially and I really haven't been keeping track of it the last few months, was communications. That came out as the biggest, single problem we had. The police couldn't talk to the fire department, they couldn't talk to the ambulance and nobody could talk to anybody. In an emergency situation, that is a very serious problem. How is that being addressed now?
DR. MURPHY: The initial plan for inter-agency communication was through the integrated wide-area network. In the meantime what we have been able to do is to address the issue through the Nova Scotia Integrated Mobile Radio Service or SYSTAM, through the communication centre, to access any level of provider whether it is on VHF or 800 megahertz wavelengths to communicate back and forth among agencies. It allows actually the final response vehicle to talk to the ambulance directly through the VHF network. It also allows a fire vehicle, if they require the ability to speak to a physician or the Com Centre to patch an ambulance through to a physician so that we can allow that kind of communication as well.
In fact, if a fire or ambulance vehicle, and we are focused mostly on ambulances in our Com Centre, is responding to a scene, we can actually patch the caller directly through the Com Centre to the ambulance en route. We have that kind of flexibility now that we didn't have a few years ago. I know that was an issue, for example, in Annapolis County, where there was a disaster and there were police, fire and ambulance responding but we did not have the ability, at that time, for ambulances to talk to fire trucks, to talk to anybody else. So we appear to have gotten around that technologically now to push it to the point where the caller who has got the emergency can actually talk directly to the ambulance en route to the scene.
MR. COLWELL: I've seen in my own area, we have had some weird circumstances where an ambulance from outside the area was called in and couldn't find the place and by being able to talk to each other, it made it very easy, they give them detailed directions. Plus, being able to talk to the ambulance operators or the emergency room doctor when the first responder is there is very important. It gives them a level of comfort and also the people they are seeing. I think that's important.
I personally think the first responder has been terrific in my area. I mean, it's given us response times down in the low minutes, one to three minutes if you're fortunate enough to have a volunteer fireman that's trained, that lives next to your place, which is otherwise in rural areas totally impossible. Has there been a large percentage of fire departments, I realize it doesn't have to be just fire departments but other individuals in the communities, taken up in other rural areas or is it pretty well stagnant?
DR. MURPHY: It's hard to know because I think we're just beginning to roll out the initiative and it's difficult to know the level of commitment and interest of the various services that wish to provide first response. There's been a lot of interest across the province and I'm sure if you talk to any of the local elected officials they'll tell you there's been a lot of interest in first response. The history has been strong especially in places like North Queens, Eastern Shore or places where there has been tremendous commitment on behalf of first response.
I think there's a lot of interest out there. I do believe though it's very important that was as emergency health services and that other individuals in positions of influence recognize that volunteerism is valuable and it's inappropriate for us to put pressure on groups that just simply don't have the ability to provide it. To get into this business to the detriment of their
own employment or their own ability to actually provide the service, that's been a substantial issue for us. We recognize it. That's why we work so closely with the Fire Officers' Association which really is the voice for most of the volunteer side of the fire operation in the province. In fact, their representative at fire advisory is the voice of fire; at fire advisory the representative of first response advisory is the voice of fire.
That's a very important issue for us. I think it's an important issue for everybody to understand that.
MR. COLWELL: Yes, and on the ambulance service now, they're being taken over by Maritime Medical, is that correct?
DR. MURPHY: We're in the final stages of working through that relationship with Emergency Medical Care, a subsidiary of Maritime Medical Care. Yes.
MR. COLWELL: Another thing, I think I've had every problem there was in my area at one time or another with ambulance responses. It hasn't all been negative by any stretch of the imagination. Initially when we set up an area, my riding actually was the first gray area in the province where the closest ambulance would respond. In the past where one operator had a location, as protected territory would be a better description of it, and if there was an ambulance literally 100 feet away, it necessarily wouldn't be able to respond. Now with this integration of the whole system, that should eliminate that whole problem, shouldn't it?
DR. MURPHY: Not only should but has if I could use the Plymouth example as an example of how it has. That two vehicle crash had seven identified individuals injured at first call into the Com Centre. The first vehicle on the scene identified the seven and we were able to move seven vehicles to the site to accommodate the number of people injured. In doing that what happened was the Com Centre then shifted resources from the entire rest of the province to back-cover the population so that they did not go without emergency ambulance service.
At the same time, the medics at the scene were able to identify people who were so severely injured that they would likely require transport. In the process of removing people from the scene to Yarmouth Regional Hospital, who was pre-notified as to what was coming and how injured these people were, we were actually able to launch the air ambulance prior to these people arriving at the hospital so that the amount of time spent in the institution in Yarmouth was minimized in order that they receive definitive care and move down the road.
So that kind of coordination is absolutely essential and that was one of the driving forces behind the amalgamation of 54 separate islands of operation into a single moveable force around the province so you can backfill.
MR. COLWELL: That probably has improved the overall average response time, I should think.
DR. MURPHY: We do not work in averages, as you know, we work in fractals so that our standards would require that you have a 90 per cent response time reliability for whatever kind of call it is. We subcategorize them into 10 types. Our goal is to have a 90 per cent response time reliability for presumptively defined calls, emergency and non-emergency, within those 10 categories.
The difficulty we have is that we do not know what it was before. We have no information in terms of what response time reliability we had prior to the implementation of a centralized dispatch. I can now tell you by geographic region, by complaint, by type of call, the time it took to process the call, roll the ambulance, arrive at the call, get to the hospital. I can give you that kind of information. Now at least we know what we are paying for.
MR. CHAIRMAN: You have about a minute, Mr. Colwell. One more quick question.
MR. COLWELL: Knowing that information must be tremendously valuable because it allows you now to streamline it and ensure that you are getting the best possible response time and allow you to move resources around to correct that, would that be true?
DR. MURPHY: I think that is correct in general terms, yes.
MR. CHAIRMAN: Two quick questions and I hope the answers will be quick. First of all, with respect to home care. I would be interested in knowing how many hours are delivered in the home for this year and for each of the full years preceding this year that you have been in operation. I don't want to know about caseloads, I want to know how many hours are actually delivered in the home? You may have to bring that to the committee.
MS. WOOD-BAYNE: Yes, we would have to bring that to the committee. We have hours of home support that are delivered and we have visits for nursing. That is the way it is contracted and provided.
MR. CHAIRMAN: Dr. Murphy, I am just a simple guy from the country. Would you explain to me who owns EHS? We have ambulances; we have equipment; we have buildings; we have radio networks; we have salaries that have to be paid. Who owns all that?
DR. MURPHY: We contract with an individual who provides service so that the contract with the provider is a management contract. The ownership of the assets in that relationship, depending on how vital they are to the provision of service, may be owned by the contractor or they may be owned by the Province of Nova Scotia.
MR. CHAIRMAN: So how many contracts do you have now?
DR. MURPHY: Right now, we have a contract for the medical transport operation, a contract for the dispatch operation. We will be moving towards a contract for the ground operation. We have a contract for training. How many is that?
MR. CHAIRMAN: How many companies are involved today in Nova Scotia in providing that service?
DR. MURPHY: In ground ambulances? As of today there are probably about five or six.
MR. CHAIRMAN: That would be compared to how many when you started?
DR. MURPHY: Fifty-odd, and we are transitioning to one.
MR. CHAIRMAN: You are transitioning to one, and that one is?
DR. MURPHY: I cannot tell you for certain who it is until we end up with an operating plan that we approve and a budget that we approve. The speculation is that it will be Emergency Medical Care.
MR. CHAIRMAN: I do not recall seeing any tenders called in the paper for this. What happened? For example, there used to be an ambulance service that was owned locally in Queens County - Chandler's. An excellent service that would stand the test anywhere in the province. People were very comfortable with it. It is gone. It has disappeared. Poof!
DR. MURPHY: What has gone?
MR. CHAIRMAN: That company has disappeared with respect to the delivery of services.
DR. MURPHY: I believe they sold that company to a Mr. MacDiarmid and then Mr. MacDiarmid in turn sold that company to EMC, I believe.
MR. CHAIRMAN: I see, and how much did EMC pay for all of these companies? Can you provide us with that information?
DR. MURPHY: Not right now, I cannot. I do not know what they paid.
MR. CHAIRMAN: Would you please?
DR. MURPHY: At the time that the consolidation is complete that will be public knowledge.
MR. CHAIRMAN: But that sale has already taken place. Why do we have to wait until the consolidation occurs? That's a done deal.
DR. MURPHY: Let me back you up. Individual companies have sold their operations to another company. As we move through this process, as you recall, we had a three-step requirement. Step number one is that because the public has a vested interest in the quality of care delivered, we want to make sure that the company that is involved in purchasing has the ability to deliver for the citizens of Nova Scotia. The first step of that process is they have to have the management and financial wherewithal and depth to at least survive the transition and move onto step two of that process. Many companies step forward and wish to be involved in purchasing other companies. It has happened in Nova Scotia over the years where an individual might wish to buy an ambulance company and since EHS began a couple of years ago we said, we don't think you not having a job, not being employed, not having a financial package together, ought to be buying a business to provide a public safety operation. We have denied that for individuals and companies.
MR. CHAIRMAN: I am watching the clock, Dr. Murphy and I appreciate your effort to provide detailed information but I really feel that I have to move on. Just let me ask this one last question. I gather from what you have said this morning that Maritime Medical is in the process of becoming the manager?
DR. MURPHY: They are attempting to become that company, yes.
MR. CHAIRMAN: Is that a not-for-profit company? Is it a company that would work for a profit? Is it a gesture of public goodwill on behalf of MMC?
DR. MURPHY: Let me talk to you first of all about the company that we are doing business with, it is called Emergency Medical Care, a subsidiary of MMC. We have been unsuccessful in finding private sector partners that would do this for nothing. I wish that we were able to find people who were willing to do that but we have been unsuccessful.
MR. CHAIRMAN: But there were a lot of private sector partners out there when you started who were prepared to do it, who aren't in business anymore. Aren't we going in a circle?
DR. MURPHY: I don't believe so, absolutely not. Those companies that were doing this business were doing it because there was an added advantage to an accompanied business such as funeral homes or they were in the business because it generated a profit. We recognized that the people that we want to do business with are people who wish to excel and those private sector companies that wish to do the operation wish to make a profit. Therefore, in order for them to generate a profit they will work hard to justify the level of profit that we will allow them to take. That is the form of the relationship that we will develop with them.
MR. CHAIRMAN: So Maritime Medical has been sole-sourced then, to use an expression that is current?
DR. MURPHY: No, an inappropriate choice of words. Anybody can come in and buy an ambulance company provided they had the approval of the government that they were able to provide that service. What has happened is that Emergency Medical Care, the subsidiary, has gone around and purchased service from individual operators around the province. We have allowed that consolidation to occur.
If I back you up - because I was on this track to begin with - in order for the province to go to bid for a good or service they have to have an in-depth understanding of what good or service they wish to produce if they want to get a reliable bid. In the ambulance business, that means that you have to have a very clear idea of what kind of response time reliability you wish to have and globally around the province, what kinds of workers you wish to put into the mix and more than that, what kind of ancillary drivers you wish to have in that bid. If you don't have that information it is not much use to go to bid because you won't get a bid that means anything. You have to understand that in going forth to bid you have to have the appropriate information. So we didn't go forth to bid because it was not that kind of procurement.
MR. CHAIRMAN: Thank you, Dr. Murphy. Now we have come along to 10:00 a.m. and we have an item that we are going to have to spend some time on. We would normally go back to the beginning, so I am going to give Mr. Fage the opportunity to ask one question, Mr. Holm to ask one question and one of the members of the government to ask one question. We will look for snappy questions, snappy answers and then we will deal with the other business.
MR. FAGE: Mr. Chairman, just back to EMC and the purchase of private operators. There are still several left and these private operators have been dealing with a lawyer who is under contract to both your department and EMC or in an association. Using words such as, you will have nothing unless you sell or, you are gone if you don't sell, is that the normal negotiating practice that EMC or the department is in favour of when they are negotiating with a private operator who wishes to maybe remain in the system or wishes to buy out other operations but is having trouble finding the funding? The question is what is that operator to do when he is under, apparently, that type of distress in the obligation to sell?
DR. MURPHY: The question you raised is one of tactics and whether or not what tactics are acceptable. I am not aware of the kind of issues that you have brought forward. If you have specific information related to that in terms of specific individuals I would be happy to address it.
MR. HOLM: To summarize in one question. I guess I put it as a given that EMC is in fact going to be the sole provider, it is just a matter of time before that is finally inked and so on, but that is going to end up being the case. I just want to tie that in as well with the ambulances, and so on. It certainly does appear that the number of ambulances is going to be dramatically reduced from what it had been and there have been concerns raised about the positioning and the equality of the service across the province.
One question, I will put it this way. First of all I will ask this question, the new high-tech ambulances and so on that are being purchased, are they going to be the property of the province, are we going to own those or are they going to be transferred to the private-for-profit partner, EMC? Secondly, how is it going to be monitored in terms of ensuring that in fact there is equality of ground service across the province? It is a major concern particularly in the rural parts of the province.
DR. MURPHY: You positioned some statements that are probably incorrect, I won't address those in terms of number of vehicles. The ambulances are acquired under a capital lease and are the property, through that capital lease, of the lessor. As the lessee, the province has control, instantaneous unimpeded access to those vehicles at any time.
MR. CHAIRMAN: Were there other questions that you wanted to respond to that Mr. Holm raised? He asked about the number of ambulances.
DR. MURPHY: He asked only one question, so am I allowed to respond to the preamble?
MR. CHAIRMAN: He asked who is going to own those ambulances or who owns those ambulances at the end of the day, I think?
DR. MURPHY: At the end of the day, the lessor, the person who leases the vehicles on the capital lease, the province owns the vehicles. So it is responsible for the distribution of those vehicles when they are done. You may or may not know that used ambulances cannot be sold in North America. So we have to have a vehicle to distribute those ambulances outside the country. That is why the relationship with Tri-Star is so important. They understand the markets for used ambulances outside, we have a revenue stream for used vehicles, by turning them into camper vans.
MR. CHAIRMAN: The third part to Mr. Holm's question was, are there fewer ambulances on the road today than there were when this process began?
DR. MURPHY: No.
MR. CHAIRMAN: There are more?
DR. MURPHY: There are more ambulances than were in the subsidy arrangement penned in 1992.
MR. CHAIRMAN: Okay, the lucky winner from the government caucus is Mrs. O'Connor.
MRS. O'CONNOR: And he asked one question that had a, b and c in it. That's my trick. I would like to ask about the VON, if you could explain how you fund the VON. The VON does fund-raising and people don't understand why they have to do fund-raising when they are paid by the government because they feel that you pay for all the services. So if you could explain. I know why they do fund-raising but I want you to explain why they do. Would you explain how they are paid, please, are they paid by the number of nurses, number of cases or the number of hours?
MS. WOOD-BAYNE: Our arrangement with the VON is that we pay them for the number of visits that they provide to Home Care Nova Scotia clients.
MRS. O'CONNOR: You pay them by the number of visits but there is a fee for a visit?
MS. WOOD-BAYNE: Right.
MRS. O'CONNOR: There are two fees, in other words?
MS. WOOD-BAYNE: There is a provincial average fee for that visit. The provincial VON distributes that funding through its branches. Those branches all have different rates that a nursing visit costs them as well, so it is done on an average visit provincially and then distributed to the agencies across the province.
MRS. O'CONNOR: So if a visit costs more in the branch than what it has paid for, that is why it has to do the fund-raising.
MR. FOWLER: Yes, I think the important part is that we have a contract with VON Nova Scotia and they have branches that provide the service, so we deal with VON Nova Scotia on a province-wide basis for all the services they provide.
MRS. O'CONNOR: And not per branch. Well, I am going to ask the third part of my question. Is the contract signed and for how long is the contract?
MR. FOWLER: The current contract with VON Nova Scotia is month to month. We basically meet with the provincial director of VON Nova Scotia on an ongoing basis, to look at the ongoing contract duration and we are actually discussing them now, as we enter the next fiscal period.
MRS. O'CONNOR: Okay, thank you very much.
MR. CHAIRMAN: Well, I want to thank the witnesses for being with us this morning. Dr. Murphy has very kindly offered to have the committee come out and have a look at the air service. We are looking forward to arranging a date. Dr. Murphy, thank you. I know that many of us have had the opportunity to speak with the crew of the helicopter and it is certainly providing first-rate service to Nova Scotians. I am looking forward to having a formal visit with them.
I want to thank the witnesses and remind all of you that you have been asked for specific information and we will look forward to having that provided on a timely basis. So we will make sure that you get minutes of today's committee hearings so you can review them for your own purposes and ensure that you are complying with the requests that have been made of you.
We have a matter that I would ask the committee to stay for. The witnesses may leave and I thank them on behalf of the committee for appearing with us this morning.
A few weeks ago we had the Gaming Commission here as witnesses and Dara Gordon, the acting Chairman of the commission, headed that delegation. We have been provided some information by Ms. Gordon, as a consequence of that meeting. There was a question raised whether, in fact, Ms. Gordon had provided all of the information requested of her and, more specifically, the belief, the contention at that time that among the body of information that she had been requested to bring to the committee was what is commonly called the McGhie Report. I have had the opportunity to thoroughly review the Hansard of that day. Also as a consequence of reviewing that Hansard and taking instruction from the Public Accounts Committee, I have met with the Clerks at the Table to seek their advice, which was rendered consequent to their review of the minutes of the day.
Having received my direction from the committee and having discussed this matter at length with the Clerks at the Table, I am of the view that Ms. Gordon is not, with respect to the letter of the request, in breach of anything that this committee requested of her. She was not specifically asked for the McGhie Report. The request was rather more vague than I believe many of us had initially thought, so it is the view of the Chair that she has not
breached any protocol, has not refused to provide information which specifically was asked for.
We have a number of choices which flow from that. We can recognize the fact that each new experience provides us a new lesson to learn and that from this point forward, when we want specific information, we must ask specifically for that information.
If it is still the wish of any member of the committee to have that information provided, the Chair would be more than pleased to entertain a motion that Ms. Gordon be requested to provide that information or, indeed, it may well be that the committee may wish to reschedule the Gaming Commission and Ms. Gordon in order that that matter be discussed in the formal structure available to the committee. That is my response to the direction given to me by the committee and I will be pleased to hear any views that members of the committee may wish to express.
MR. HOLM: I am not going to challenge your ruling in terms of whether or not there was a breach. I would put a motion on the floor, however. I would request that this committee do in fact contact Ms. Gordon and that we ask for, specifically, clearly, that report.
MR. CHAIRMAN: That report being?
MR. HOLM: The whatever it is report.
MR. CHAIRMAN: The McGhie Report.
MR. HOLM: Yes, and that we ask that it be delivered forthwith. Certainly there were comments made in her response when she indicated she would not and that it would compromise their competitive position. I was always under the impression, unless I am missing a few of them around the province, which is possible, but I always thought that the Sheraton was the only operation in town and that they had a monopoly. I fail to see how it could be interfering with their competitive edge. I would like to move that we request that report and, failing that, if the response is negative, I would indicate that I would be, at a subsequent meeting, requesting that Ms. Gordon be invited back to this committee. That would, of course, be one of the primary reasons, to get access to that report.
MR. CHAIRMAN: The motion specifically is that she be contacted by the Chair and requested to provide the McGhie Report to the committee as soon as possible.
MRS. NORRIE: I do agree with your ruling. I want to state that first. Also, I know that we all agree with the policy of accountability and disclosure. That falls under the Freedom of Information and Protection of Privacy Act. It not only provides for accountability and disclosure, but also for protection of privacy and a process of independent review. There are principles of due process which would be applied here. I am aware that the caucus offices
have all applied to the Freedom of Information and Protection of Privacy Act and I think that everybody here on the committee would agree that to be referred to the Freedom of Information and Protection of Privacy Act would be the most appropriate way to go. She has gone that route. It is the correct approach and I think it is important that all parties here should be treated fairly and also be afforded the benefit of due process. I would like to state that I think that is the proper approach that we should be following.
MR. FAGE: I have no problem with the ruling but I think we have to come back to the spirit in which the request was made. The committee as a group, Public Accounts, decided that was the document and the information they would like to have presented. Even though the request was maybe somewhat vague and the reply came back in the form it did, I think the spirit of what was agreed to is paramount here and that is that the report should be coming forthwith. In that regard, I certainly have no problem with what Mrs. Norrie is saying about due process. I think this is also due process, too. If it was already agreed that the document should be provided to the committee, then it should be provided in haste, not in another due process, both of them being valid. I would second the motion.
MR. CHAIRMAN: We do not need a seconder, but I am sure Mr. Holm finds comfort in that. I, as the Chairman, also have a view. I concur that the spirit of what was asked in the committee did in fact catch up the McGhie Report; however, we are restricted in what we do request and the fact is that the McGhie Report was not specifically named and so we are stuck with that fact. I am also aware as I'm sure are all members that the Minister of Finance has expressed a view that this information should be public. I think the committee would have strong ally in that respect. I would ask members to give consideration to that. I think the Minister of Finance, in fact, wrote a letter to the chair of the commission in that regard. Mr.Holm?
MR. HOLM: One other added point, and that is, and although I don't have the minutes here with me, I seem to recollect that Ms. Gordon had indicated that there is certainly no difficulty in providing that when negotiations with the Sheraton have been completed. Unless there are yet more revisions to be made that haven't been made public, those negotiations have been complete and we did have provided to us the outcome of the amendments that they're looking for. They have also been provided to Cabinet. Even the rationale that is being provided as not providing the information of the report to the committee, does not appear valid.
I think in the spirit, as the member from Cumberland North points out, the indication of the intent was quite clear. It may not have been specific enough in a technical-legal sense, but I think that the indication was very clear. There can be no question as to the spirit of what had been intended. I think that the spirit of the response was, yes, it would be provided.
MR. CHAIRMAN: There is a motion on the floor. Is the committee ready for the question?
Would all those in favour of the motion please say Aye. Contrary minded, Nay.
The motion is carried in the negative.
I also have the duty to advise the committee that Mr. Ralph Fiske, the former chairman of the Gaming Corporation and I have been in contact with each other. Mr. Fiske has advised me that should he be invited by the committee to appear he would certainly be pleased to do so. I provide that simply by way of information to the committee. Any decision with respect to extending an invitation resides with the committee.
MR. HOLM: If I might, we had some discussion, I think it was last week about setting the agenda and I'm trying to determine those whom we would be inviting to future meetings. I certainly think that inviting Mr. Fiske to attend would be very important for our ability to get to the bottom of a lot of matters that are going on. I don't know, given the decision that we had made at our previous meeting, that today is the appropriate time to be moving that he be invited. Suffice it to say that I think he should be invited and certainly will be supporting that request at the next meeting when we are setting our future agenda.
MR. CHAIRMAN: Yes, and we will in fact be meeting next Wednesday at 9:00 a.m. in the Committees Room to hammer out a post-Christmas agenda. We are going to have something of a challenge because a number of people who sit on our committee are also involved with the Unity Committee. The chairman of the Unity Committee is the vice-chairman of this committee. Mr. Holm, you are on that committee I believe. Mr. Fage is on the committee, Mrs. O'Connor and Mr. Carruthers. Obviously we've been an excellent training ground for committees of importance. The fact that I'm not on it, I suppose, says something about that too. Our secretary, of course, is part of that committee. So, I would ask the chairman of the Unity Committee if she would bring her schedule to next Wednesday's meeting so that we have that to review in conjunction with the schedule we will set up with respect to the Public Accounts Committee in the post-Christmas period.
MRS. NORRIE: I would suggest that is the proper place for all of the requests to go to next week's meeting, when we do set our agenda. I too had a concern with the membership of both committees. Hopefully, by the end of this week we will have our agenda set and I will have that available for Wednesday morning.
MR. CHAIRMAN: Thank you. If there is no other business to be brought forward to the committee, we stand adjourned.
[The committee adjourned at 10:20 a.m.]