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27 mars 1996
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Sujet(s) à aborder: 
Public Accounts -- Wednesday, March 27, 1996

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9:00 A.M.


Mr. John Leefe


Mrs. Francene Cosman

MR. CHAIRMAN: I will call the meeting to order. This morning we have witnesses before us from the Emergency Health Services, Department of Health, Dr. Michael Murphy. Dr. Murphy is accompanied by Karen Ursel, Director of Ground Transport; Tony Eden, Fleet Manager; Marilyn Pike, Co-ordinator Air Medical Transport; and Mr. Grant Lingley, Project Co-ordinator, Dispatch/Communications. We also have with us this morning, the President of the Ambulance Operators Association of Nova Scotia, Robert Schaffner; and from Metro & District Ambulance Service, we have Bernie White and Gerry Green. They are seated in the second row. From the Halifax Regional Fire Service, Roy Young, Manager of Safety Training and Development. Mr. Young is also sitting in the second row at the back and we have our staff from the Auditor General's Office with us this morning as well.

We will begin by giving our witnesses an opportunity to provide us with a brief statement with respect to what they are all about and then we will proceed to questioning. Dr. Murphy, if you would like to begin.

DR. MICHAEL MURPHY: What I would like to do, first of all, is to take a few minutes and outline what has gone on with Emergency Health Services since I joined Emergency Health Services as Commissioner actually in July of last year. Many of you are aware that in 1993-94, I was asked by the minister to assemble, as Commissioner of a study, information regarding Emergency Health Services and provide a report. In doing that, we worked with many parties involved in Emergency Health Services around the province in identifying where we were and where we might go and that report, which is called the Murphy Report, was tabled in this House, I think, in April or May 1994.

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After that report was tabled, Emergency Health Services, from the government's perspective, went on to bring on a Director of EHS, Diane Golden, in an interim fashion to get several programs off the ground, including the purchase of ambulances and identifying some priorities as far as air ambulance or air medical transport was concerned. In July 1996, I was hired as Commissioner of Emergency Health Services and although I took up the post in July, I really did not get under way until the end of September as I divorced myself from other activities. I had previously been Director of Emergency Medicine at the children's hospital in Halifax.

Beginning in September and October, I sat down with the Emergency Health Services team, looked at the report that I had prepared in 1994 and attempted to put together a strategic plan on the programs that needed to be developed to roll out a comprehensive safety net for Nova Scotians. One of the issues related to health renewal and reform was the safety net issue. If you are going to attempt to restructure or reconfigure the health care system, the people require confidence in its emergency health care safety net. So the programs that we put together and proposed provided a very tight sieve size in that safety net. I think it is safe to say that the emphasis of the strategic plan is really on the rural side of the province as opposed to some of the more urban side of the province but as we discuss EHS, perhaps we can highlight how some of those initiatives are perhaps more rurally based than urban based.

In your resource package, if you would like to turn to the tab called Submissions, you will find on the first part of that section, an Organizational Chart of Emergency Health Services. It is kind of a unique sort of diagram as to how we fit in the global system and you will see that there are several circles on that page and one of them is the EHS system. You will see that the EHS system has multiple players, including the Department of Health, the providers of care, the professional associations, manufacturers and suppliers and the various programs that we use to put the rubber on the road, so to speak.

In the middle of that, you see what the Emergency Health Services agency looks like and the people who were introduced to you this morning on this side of the House who helped me bring this to fruition. You see that there is a Commissioner of Emergency Health Services, and that is me, that we have a PreHospital Ground Ambulance Co-ordinator and that is Karen Ursel, the person who is responsible for understanding how ground ambulance services are delivered, what standards we ought to have and monitoring what performance we are getting. Fleet Procurement and Disaster, in the person of Tony Eden, in implementing 150 ambulance fleet over two to three years requires some degree of coordination, obviously in surveillance of the quality of the fleet and how it is being maintained.

One of the crucial and fundamental aspects of Emergency Health Services that is, I think, quite different now than it was in the past, is the understanding that it is fundamentally a medical enterprise so that the Medical Director of the program, in an acting position, is Dr. Ed Cain. When you are looking at developing an Emergency Health Services agency, you have to understand that, especially in rural areas, we need to implement advanced levels of medical care that are not always undertaken by physicians. They are undertaken by physician surrogates known as emergency medical technicians or paramedics in some jargon. Therefore, the ability to extend those advanced acts and surveil what goes on rests with the medical direction arm of the agency and that is why we have a very powerful, I think, infrastructure related to the delegation of medical acts and the extension of advanced procedures in the rural area where we think they are most effective in saving lives.

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We have several provincial programs that we will roll out, hopefully, over the next two years including such things as telephone advice and medical transport trauma program. You will see those detailed in the strategic plan. Marilyn Pike is an expert in program development and she has worked with us, at Emergency Health Services, as Director of Provincial Programs, in helping roll those things out and putting together the process under which they will be developed.

Communications and dispatch is one of the fundamental aspects of ground ambulance transport and the integration of ground transport with air so that you allocate the appropriate resources to the appropriate need. One of things that we are doing, along with the players in the field, is to try to put together a rational system of effectively delivering an advanced life-support-capable ambulance to the scene where it is required as quickly as possible and that very much rests with central coordination and dispatch. So that is a key function and Grant Lingley is the gentleman who is working with us to help that happen.

I don't want to take too much time away, Mr. Chairman, but I think that if that sort of lays the groundwork, perhaps we could go from there.

MR. CHAIRMAN: Thank you, Dr. Murphy.

Mr. Schaffner, would you like to tell us a little bit about your association and where your association stands with respect to this initiative?

MR. ROBERT SCHAFFNER: Well, our association is made up of all the subsidized ambulance services in Nova Scotia. There are 59 operators throughout the province. We had recognized early on that the system that was in effect for the past 25 years did have to have some alterations in many aspects from the funding formula through to, as I would agree with Dr. Murphy, on dispatch and items such as that.

We had been, for years, on a system that paid on a per call basis in the smaller communities in particular but not just limited to smaller communities. Because of quite a major decrease in the number of calls, that type of a formula became a problem as we tried to increase medical standards. So there are several aspects of what Dr. Murphy has referred to, that we recognized there had to be some changes. That is not to say that we understand, at this point, all the suggestions but a lot of them are just, at this stage, in discussion stages. So, I cannot comment specifically on those issues yet.

MR. CHAIRMAN: Thank you, Mr. Schaffner.

I wonder, Mr. White, would you care to make a statement for us with respect to your organization? (Interruption) Yes, quite often in here we have to wait for our lights to come on. Just hold your hand up and they will see you on TV.

MR. BERNIE WHITE: There we go.

MR. CHAIRMAN: Amazing, isn't it?

MR. BERNIE WHITE: It is, technology.

MR. CHAIRMAN: Technology is a wonderful thing. That is our central dispatch up there.

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MR. BERNIE WHITE: Myself and Mr. Green, next to me, are representing the Canadian Union of Public Employees, Local 3264. We are employees at Dartmouth Ambulance Ltd. which is now known mostly as Metro & District Ambulance. We service from Musquodoboit out to close to the Black Rock area, encompassing all of Halifax-Dartmouth but not Bedford and Sackville - yet, anyway.

We are pleased to be here, of course, and we have been pushing for the last seven or eight years to have the very changes to come into place. The system over the last 25 years, like Mr. Schaffner said, has not kept up with the changes in technology and education that are out there. We are looking forward to seeing more changes happening. We have some new ambulances on the road; these are very good ambulances and it is nice to have a nice tool to work with out there.

We are looking forward to the changes, but we only wished they had come a little quicker, especially here in the urban areas. I know they are trying to get the rural areas up to ALS rather quickly. The biggest bang for the dollar would actually be if we got the urban area ALS as quickly as possible. We service something like 30 per cent of the population of the province, so we see a lot of sick people.

We have a new communications centre in place over at the VG Hospital which has been working out very well over the last month or so. From the street level it is very nice to see professional dispatching. Aside from that, I guess we are just looking forward to being partners in change in reform of the ambulance industry in Nova Scotia and are pleased to see that it is happening.

MR. CHAIRMAN: Thank you very much. We will now turn to the members of the committee for questions. Mr. Taylor.

MR. BROOKE TAYLOR: Dr. Murphy, can you describe the difference between basic life support system and the advanced life support system?

DR. MURPHY: That is a really good question. The fundamental difference between the two is that an advanced life support provider undertakes sophisticated interventions that are generally performed by physicians. Those are called delegated medical acts. As an example, advanced life support providers divide their advanced procedures into three broad categories. The first one is the management of electrical difficulties with the heart so that you use machines called defibrillators that jump-start the heart or to change the rhythm of the heart in life-threatening rhythm disturbances.

The second one is intravenous therapy and intravenous therapy is divided into two sections, one of which is starting the IV and administering fluids into someone who might be bleeding, for instance, or might be in shock for some other reason then you administer volumes of fluid intravenously to bring the blood pressure up to enhance their survival. The second part of that is the administration of medications intravenously. A good example would be administering glucose to a diabetic whose blood sugar is low, or administering life-saving medications to someone who is having a life-threatening allergic reaction.

The final category is the management of airway difficulties. That would include the insertion of a device into someone's mouth, into their windpipe to allow them to breathe. That is only one of the advanced airway kinds of procedures, but it is a good example. So advanced life support workers have an array of advanced procedures that they undertake and they have

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the background knowledge to understand when to use them and when not to, so there is a very substantial knowledge base and judgment component that goes into this.

When we introduce advanced levels to pre-hospital care workers - for the sake of argument I think we will call them paramedics for the time being, because I think people are familiar with that term - it is important that we have good training programs in place, that we understand that the capability of the people coming into those programs is really quite sophisticated so they can understand the judgment component, and that we have very good quality control mechanisms. The quality control mechanisms include what we call off-line control, which are algorithms or protocols that will be followed and specific ways in which these procedures will be done. As part of that off-line control is a continuing review of how they are done and whether they are done in appropriate situations and technically correctly.

Finally, to look at the outcome of whether or not they were, in fact, required to be done and produced a positive outcome or a negative outcome so that as we look at honing the system further, we understand what the relative risks and benefits were.

The on-line control is the availability, all of the time, of a physician over the telephone or the radio when you run out of protocol. As an example, if you are running a cardiac arrest, where someone's heart has stopped, and you have put the tube in the airway; you have started the IV; you have given some of the drugs; and you have delivered some of the shocks, but now you find that you are permitted to go just so far before you have to contact the physician. Then you would contact the physician and the physician would say, I think this is the best course of action based on what you have told me. So, that it is medically controlled or medically directed is the term we use.

Now, the basic life support providers are also sophisticated health care providers and it should not detract from them, because they are the majority of people who provide care in the province, who have completed first aid courses, CPR courses, and have then gone on to do more medical training to become what we call an emergency medical attendant or an emergency medical technician. Fundamentally, what they are responsible for doing is understanding mechanisms of disease and injury that they commonly see, especially life threatening ones, understanding what they need to do to prevent further illness or injury from occurring and doing that and transporting rapidly, usually, to another echelon of care, ordinarily an emergency department. Although that might not be the case; it might be to an air ambulance; it might be to an advanced life support ambulance but, traditionally, it is to an emergency department.

Does that describe the differences? It is kind of long-winded.

MR. TAYLOR: No, I thank you and it seems very clear that the ALS system is much more superior to the BLS system.

Metro & District Ambulance was given a district in the Musquodoboit area and it is my understanding that the Emergency Health Services is terminating that contract come the end of this month and may be going back to the future, so to speak, in awarding the contract to Crowell's Ambulance Service out of Sheet Harbour, which provides the basic life support system. I just wondered if you could confirm or, perhaps, deny that comment?

DR. MURPHY: Let me comment on it. Some time ago, an ambulance service in Chezzetcook had been providing service on the Eastern Shore and because of the difficulties that they experienced in finding volunteers who were willing to do that around the clock

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asked if they could get out of the ambulance business, and approached Emergency Health Services and proposed that that occur.

What we then did was look at providing a service in an interim fashion until we were able to find the exact needs of the area. We went to Metro & District and said to them, would you be willing to provide the service on an interim basis in this area, at whatever level you currently provide in metro which, as Mr. Green has alluded to previously, is sometimes advanced life support, sometimes basic life support and they said yes to that. In the meantime, we looked at the needs and the cost benefit equation of who would cost what and came to the judgment that what Crowell's was offering to provide, as far as level of care was concerned, was precisely the same level of care that Metro & District had provided in terms of emergency medical, ambulance defibrillation capability, providing the equipment to provide that care and, occasionally, providing a paramedic who would be available in that area as well.

So, from our perspective, when we looked at the two proposals, we identified that the quality issue between the two was the same. Some people would disagree with that but that was our judgment.

MR. TAYLOR: A number of people do disagree with that and, in fact, comments have been made that you gave us the BMW and now are giving us back the VW, so to speak. I am wondering . . .

DR. MURPHY: I do not personally agree with that. I think that the comment is a good one though.

MR. TAYLOR: Well, Crowell's provides the BLS system and the one we have been receiving is the ALS and you have made the distinction and it is very clear. If Crowell's is given the contract come April 1st then, obviously, we will be going back to the basic life support system.

DR. MURPHY: Let me come back to my previous statement. In analyzing the quality and consistency of care delivered on the providers that are providing the care, we did not believe that that was the case.

MR. TAYLOR: Just one further question, Mr. Chairman.

MR. CHAIRMAN: Certainly.

MR. TAYLOR: Dr. Murphy, can you tell me, you talked earlier about divorcing yourself from other activities, I wonder if you can tell me if you also work in Ontario, perhaps in Hamilton?

DR. MURPHY: Yes, I do. I am the Director of Emergency Medicine at McMaster University Medical Centre.

MR. TAYLOR: How time consuming is that occupation?

DR. MURPHY: The split that I have is I do roughly two-thirds of my time in Nova Scotia and roughly one-third of my business time in Ontario. My family resides in Nova Scotia. So that my base is here and most of the work that I do is here. How time consuming is it? The second part of your question. It is the third emergency department that I have had the privilege to be specifically involved in. The amount of time and energy that it takes

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fluctuates up and down. I am happy to say that things are on a pretty smooth keel in Ontario right now, as far as that emergency department is concerned, as opposed to the government, but things seem to be going very smoothly at that emergency department.

MR. ROBERT CHISHOLM: My understanding, Dr. Murphy, when some of the hospitals were being closed around the province, particularly I am thinking of the Valley, there was going to be some effort put into pre-hospital care medicine and advancing that or upgrading it to the advanced life support service level. That hasn't been done in the Valley area where the two hospitals, the Eastern and Western Memorial Hospitals, have been shut down. Can you bring me up-to-date on what is happening there with respect to that service?

DR. MURPHY: Did you say has or has not been done?

MR. CHISHOLM: Has not been done.

DR. MURPHY: It is in process. The manpower and training initiative is huge. Let me just start provincially and then we will get down to specifics. One of the things that we need to understand provincially is, who currently is out there providing care and what level of sophistication of care do they provide and what sort of training have they got. When we know that, and we are in the process of getting the information now in assembling our data base, then we can have a very surgically, precise strategy as far as training is concerned province-wide. Because we couldn't really wait until we had the data base before we embarked on training, we had to really carry both of those initiatives forward concurrently. So we are getting the data base together for the province as far as understanding who currently is providing ambulance-kind of care, but at the same time, I have approached the School of Allied Health at the QE II Hospital in what they call the Emergency Medical Technicians School to put together a training strategy at the basic level, both distance and on-site, as well as at the advanced level.

Let me talk specifically about the advanced level of training. There are, because of health reform, requirements, I think, to institute advanced life support training in a fairly aggressive fashion around the province. So that what we have asked the school to do is to put together some kind of a system to be able to identify how they are actually going to roll that out. They have come up with a three point plan. One of them is to go to communities and evaluate the people that are already providing care as far as aptitude and ability is concerned. The second part of that is to work with the health care institutions and providers of care to understand what the resources for training are and need to be. The third part of that is to embark on a modular implementation. I talked about earlier the three types of advanced life support procedures, and then to select one of those and to begin the modular development of the programs. They are rolling that program out in all four health regions of the province, beginning in the east and moving to the north, the west and the central region this year. In fact, central region, just to answer a question Mr. Green alluded to earlier, training rolls out, I believe it is in August. I don't have the precise schedule in front of me and I can provide it for committee members, but my recollection is that the central region, which is the final piece, comes on-line in August.

[9:30 a.m.]

Let me go back to specific hot spot issues. This is historical for me because I was not involved in this decision but my understanding is that industrial Cape Breton, Annapolis and the Valley were identified as specific target areas to pilot and roll out the advanced life support programs. I may be wrong there, but I think it is virtually completed in Annapolis.

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The next area was Berwick, Kentville (Interruption) Thanks. Bob has given me the crib notes here that most attendants in Kings County, through the School of Allied Health, have been trained now. Now I don't think all of the modules have been completed there, to my recollection, but again I could find that out for you later, Mr. Chisholm, and Michael O'Reilly is one of the cardiologists at the Valley Regional Hospital and he is the medical director of that program.

So, the next part of that, where it is already going on is in the industrial Cape Breton area where the evaluation has been completed, the letters of agreement with all health care institutions has been done and we are now, I think, at the airway stage in industrial Cape Breton. The letters, as of this month, have gone out to the people in the northern region to begin that process in northern region which, for us, is important because of the tie-in to 911, attempting to coordinate the roll-out with other activities that impact on us.

MR. CHISHOLM: Okay, thank you.

DR. MURPHY: It was wordy, I am sorry, but that is how . . .

MR. CHISHOLM: No, no. That is good. Mr. White, in his presentation, representing the workers of Metro & District, mentioned he and his colleagues have been vocal supporters of the new emergency health system. I assume because he is still indicating their support that in fact his group has been involved in the plans as they have been developing.

I wanted to ask you, though, specifically with respect to emergency medical dispatch and people who are in the system, who have been in the system, who are in the system now, that when there is a change, when the employers there change, what will happen with those employees? Are they being rolled over, are they being upgraded?

DR. MURPHY: Let me take it piece by piece. First of all, that is if there is a change. One of the principles, if you go back to the original document, was that we had lots of resources in the province, including not just the owner-operators but the providers of care and that we regard that resource as one that we want to maintain in the system so that in developing future contracts, it is important for us, when we develop contracts for providers, that Nova Scotians are protected in their ability to gain access to those positions, provided that they have the appropriate training expertise. That is why it is so important for us right now to address the value of the provider by advanced training modules so that, in fact, at the time we begin to move into new contractual arrangements, if they come down the pike, that we are on solid ground and saying, hey, wait a minute, guys, the Nova Scotians are the people who ought to be doing this work.

I think that, without sort of getting too far sidetracked from the issue, one of the fundamental issues, I think in EHS, has to do with wages and benefits and the regard that we have for the providers in the field. I think that the providers have been substantially undervalued and because of that I think that the attitude that many of the health care professionals have towards ambulance workers has not been what it ought to be. I think that the wages and benefits that they have demanded have not been what they ought to be. I think that if we look at the system funding as a whole, it is likely that there are sufficient numbers of dollars in the system to make sure that we have reasonable levels of wages and benefits for the people who are actually providing the care.

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The challenge is to establish and develop a system that eliminates inefficiencies and redundancies so that money that we spend that way now can be funnelled to the people who are providing the care. So the challenge, the gauntlet, that lies before us, from the worker perspective, is to do precisely that. Step one is identify who they are. Step two is to ensure that we deliver to them the training that makes them valuable and more valuable members of the team and finally identify inefficiencies in the system now where we spend money that ought to be diverted to those people who are providing the care. Now there are numerous incentives that we are considering, as far as contractual arrangements are concerned, that will do that but I think that that is a fundamental process that is going on at EHS right now, is to understand that dynamic.

Now we don't have all the information at our disposal and that has been one of the problems in the EHS system development here, is that we do not have a lot of information, but we are trying.

MR. CHISHOLM: But in terms of the emergency medical dispatchers, if there is a change of employer, they will be rolled over into that new employment situation?

DR. MURPHY: I would hope so. That really is the role of the employer to do that but from the EHS point of view, our desire is to see that occur.

MR. CHISHOLM: We tried to get some of those protections in the legislation.

DR. MURPHY: Yes, I understand that. I remember that we talked about that.

MR. CHISHOLM: Yes. Could you tell me, briefly, what is going on at the VG Hospital? I know that they have been cut back, I think, to one ambulance now. My understanding was that they were going to be incorporated into the regular system. Before they were sort of separate, weren't they? The emergency unit there was under the VG Hospital and it was separate. It was a different employer. They were under the Province of Nova Scotia whereas the other ambulance operators and attendants, technicians, were under the other system. What is happening there? I understood that they were going to be incorporated into the province-wide system but yet I see that they have been cut back by one ambulance and I am wondering what is going on there.

DR. MURPHY: Let's talk about that for second. As you know, I was Director of Emergency Medicine at that hospital. We brought para-medicine on line in 1987. Tony Eden, sitting off to my left, is still the ambulance manager at that hospital, although he has been on loan to us at EHS.

The system in Nova Scotia, funded by government, is divided into two parts, as you say. One of them is through a hospital-based service at the VG Hospital. All of the other services in the province that are subsidized by government are through the Ambulance Operators Association. Our hope is to see that in the future there is a high degree of cooperation at the level and many of the arrangements that we make in the future will drive that, I think.

For the time being, though, to specifically address the issue that you have raised, historically, if you went back several decades, I believe that there were, in fact, two staffed ambulances at the VG Hospital and perhaps going back into the 1970's. Tony, is that correct?

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MR. TONY EDEN: There was one vehicle on 24 hours a day and a second vehicle during peak times.

DR. MURPHY: Okay, and that was an emergency ambulance.

MR. EDEN: That is correct.

DR. MURPHY: That was back in the 1970's. Well, since the 1970's, that has not existed. In fact, there has been one emergency ambulance available around the clock there and that has been what has been staffed, that has been what is available. The second vehicle was provided as a backup in case something happened to the primary vehicle so that if there was breakdown or scheduled maintenance, then they had a reserve vehicle to rely upon. So there has been no change in the reliance of the system on a single staffed ambulance 24 hours a day, seven days a week. What we have done at EHS is to say to the VG Hospital - I think they damaged or destroyed one of their vehicles in an accident recently - we have said to them, if you require an ambulance, please let us know. We will get you another ambulance ASAP because we have a variety of vehicles in the province.

The difficulty is that it is very hard for EHS, looking at the entire system, to say if you require, because of the state of the ambulance in your non-VG Hospital system, you require a new ambulance, it is hard for me to park one in a garage somewhere in case something happens to the primary vehicle. So I think that we have made what we think is a reasonable decision on that, to say that it is more important for us to ensure that there are good vehicles everywhere.

Now, in addition . . .

MR. CHAIRMAN: I wonder, Dr. Murphy, if we could be a little more succinct. Our time is short and I think Mr. Chisholm has another question that he wants to put.

DR. MURPHY: The VG Hospital staffs a patient transport unit eight hours a day that shuttles patients among the various hospitals in metro in addition to the emergency ambulance.

MR. CHISHOLM: Okay, I guess my last question, at this point - I might come back to the VG Hospital situation again - there was some considerable concern raised last week with the length of time it took to deliver a patient to the hospital or to deal with an emergency situation. Metro & District were involved. There were some concerns raised about that kind of delivery time. I wondered if you would respond, on behalf of EHS, as to what is happening in metro with respect to that kind of delivery time?

DR. MURPHY: That is a substantial concern of ours as well. I can tell you that is under investigation right now so that we can understand what the components are and make reasonable recommendations. I cannot carry that further because of the investigation status of it right now. I do not mean to be cagey, but it is a sensitive issue that requires in-depth evaluation. Karen Ursel is investigating that on behalf of EHS. We will have a report that will be public.

MR. CHAIRMAN: For the record, could we be specific with respect to which case, because there has been more than one reported in the media.

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DR. MURPHY: Well, we have many investigations undergoing. The one that you are specifically talking about was a gentleman in North End Halifax.


DR. MURPHY: You said the name, I did not.

MR. CHISHOLM: The report will be made public?


MR. CHISHOLM: We expect to have that report by . . .

DR. MURPHY: Month end, four days.

MR. CHISHOLM: Thank you.

MR. CHAIRMAN: Mrs. O'Connor.

MRS. LILA O'CONNOR: I have a question for Mr. Schaffner. You say there are 59 operators across the province. Are there any ambulance operators that are not part of your organization?

MR. SCHAFFNER: Well, the Victoria General Hospital, at the present time, is referred to as separate.

MRS. O'CONNOR: Besides the Victoria General then.

MR. SCHAFFNER: There is a service in the Halifax/Dartmouth area that is somewhat similar to ambulance services and it is a transport service, that is not a member. All of our members are required to provide 24 hour service. This other service provides transportation from nursing homes to hospitals. I believe the rest, other than industrial ambulances set at sites like Michelin and that type of thing where they are restricted to those plants.

MRS. O'CONNOR: No, I meant there are no other ambulance operators across the province then that are not a member of the Ambulance Operators Association of Nova Scotia. They are not acting independently?

MR. SCHAFFNER: Not in an emergency type service.

MRS. O'CONNOR: With 59 operators, it sort of looks like most operators will have two new ambulances by a timeframe. I do not know if you can answer this question or Dr. Murphy. Will any operators have more new ambulances than any of the others, or are you going to even it out across the province?

MR. SCHAFFNER: We have already addressed if for several years. We have a contract with the province that existed for many years. In that contract, we stipulate the minimum ambulances for each area and that is assessed by geographic area, by population and by call volume. By using that formula, yes, some will have more than others. Definitely the larger centres would have more vehicles, but what has been attempted to be done so far is to distribute at least one vehicle, two vehicles, to those areas. We began in some areas where the need was most obvious.

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MRS. O'CONNOR: I have been hearing through the grapevine that there have been some problems inside the ambulances; with the stretchers, they are not long enough or the stretchers are too long, there is not enough room to sit on the side to do what you are supposed to be doing. Can you answer that?

MR. SCHAFFNER: First of all, I want to say that Mr. Tony Eden, who is here with us today, is the fleet manager and between him and the company that manufactures them, Tri-Star, there is a committee formed that has ambulance personnel and ambulance owners on it. Mr. Eden is chairman of that. It is specifically to address those types of concerns that you have mentioned. These vehicles, like the first ones that came out, it was told to us that that does not mean those changes could not be made once they were identified. So, rather than having 60 operators, we filter through to this committee who deal precisely with concerns expressed mainly by ambulance attendants who are in them every day.

MRS. O'CONNOR: My last question is on the first response. The first response, at these times is usually the fire departments. What training and who is going to be offered to the fire departments, and I am not talking so much about the paid fire department, I am talking about the volunteer fire departments.

MR. SCHAFFNER: I may defer that to Dr. Murphy for a medical point of view, but there is a response course being developed by the School of Allied Health to respond directly to the needs that you refer to for first responders. But maybe Dr. Murphy could elaborate on that a bit more than I could.

MRS. O'CONNOR: Sure, I appreciate that.

DR. MURPHY: I should actually pick up on that because it is one of the primary initiatives they are undertaking at EHS. The first responder programs are a very important part of the safety net in communities, especially at the volunteer level because there are small communities where professional ambulance response times may be long, because most communities have voiced a desire to have medical training in many of their volunteer firefighters. When we looked at this issue about one year ago, and again I wasn't there but when Diane Golden identified the issue, it was apparent that there was some confusion as to exactly what that course ought to entail - how much we ought to talk about trauma, how much about cardiac, how much about this and that - because there were multiple commercial products on the market and it was unclear as to what the product that met the needs of the providers was.

What EHS has done is to contract with the School of Allied Health, because they are the experts in education, to bring someone on board to go around and identify with the volunteer fire services and the paid services what the details of that curriculum ought to look like. We expect to see that report which will not only include details of what the curriculum ought to look like, but what the details of the training agencies ought to look like, what sorts of funding arrangements ought to be in place to support training and equipment, what kind of equipment ought to be available in the first responder programs, so that we can then embark on the implementation of the first responder program. Does that answer your question?

MRS. O'CONNOR: Well, it does but there is also another concern on the cost. Most volunteer fire departments are that, volunteer, and any fund raising they do is for their training but also for other things that they need within their department. What is this going to cost a volunteer fire department, how many volunteers from each department are you going

[Page 13]

to ask to be trained, how are you starting that off? That is real concern, especially in the smaller volunteer fire departments.

DR. MURPHY: It is an enormous concern of the volunteer fire departments. When I did my report, that was very clear, people were very concerned about being forced into first response and forced into costs. So to go back to the report and it is reiterated still by Emergency Health Services and by myself that we are not forcing anybody into anything, but if you wish to become involved we want to identify for you what the best curriculum is; where you might access that, because we will know who the appropriate training agencies ought to be; and then we will be able to identify what costs ought to be incurred and how much of that cost we ought to, as EHS, incur. That involves multiple costs, not just for training but also for equipment.

I don't want to digress too far because Mr. Leefe will give me heck, but if you go back to 1987, 1988, 1989 in Halifax County when the Cole Harbour Fire Department wanted to become involved in first response, we put together a working group in Halifax County when I was department head at the VG Hospital and we identified precisely the same issues, that it was reasonable for volunteer fire services to be involved in medical first response. They wanted to be and their communities wanted them to be, but clearly it was a fundamental responsibility of Health to be involved in some of that funding because municipal rates, we didn't feel at that time in making our recommendation, ought to be responsible for something that is a health or provincial responsibility. I still understand that and that is part of the recommendation that I made. We simply have to know what kinds of dollars are required and how much of that we can afford to undertake.

MRS. O'CONNOR: Okay, thank you very much.

MR. CHAIRMAN: Mr. Colwell.

MR. KEITH COLWELL: I would like to pick up on the first responders further. Thanks to the Department of Health, we have a pilot project going in my area in first responders which has been excellent from the fire department standpoint and from the community standpoint. Could you elaborate more on the advantages of the first responders in response times, cost effectiveness and potential outcome for someone in an emergency situation?

DR. MURPHY: I don't think there is a lot of science about the benefits of first responders, but that is part of the reason we are building the system the way we are building it, so that we can develop that science; in other words, identify from doing reasonable studies what the reasonable outcomes are. But I don't think you need to be a rocket scientist to sit back and identify the fact that if you have people in communities that are volunteers that are trained, the effect is improving the quality of care delivered at the community level. It isn't just at the basic level; we talked about basic and advanced levels.

There is no reason in the world, with the technology we have today, why some of those advanced life support kinds of procedures can't be done at the level of first responders so that you are looking at substantially decreased response times for someone trained in health response. We believe substantial improvements, not just in injuries prevented because they have been cared for appropriately, but in providing care that will lead to a better outcome; I think defibrillation is a pretty good example of that. So we think it is a fundamental piece of the safety net.

[Page 14]

MR. COLWELL: When you say reduced response time, basically you can have a trained first responder as a next door neighbour and they would be followed in by the fire department or whoever is providing the first responder with their equipment and then with an ambulance. Is that the correct order it would possibly work in?

DR. MURPHY: I think that is exactly the way you want to see it work and that is why dispatch is such an important component of EHS: identifying what your resources are, identifying the thresholds in which you deploy those resources. Because first responders don't want to be going to in-grown toenails and twisted ankles, first responders want to go where they are required to provide life-saving care. So what we need to be able to do is to use our emergency medical dispatch and deployment net to understand when you require a first responder, when those first responders in that particular volunteer area - there are 318 fire departments in the province, they will all have different desires at what threshold they want to become involved - and then coordinating that with the ground and air support that we need to provide the best care. That is what we are trying to do down the road.

MR. COLWELL: The thing that has amazed me going through this process, if you tied that into response times, what is your definition of response time? Because I understand that first off there was a problem with response time, how it was measured. What is the definition now?

DR. MURPHY: Generally speaking, from the time your call is received at the 911 dispatch centre to the time the ambulance crew arrives at the scene as the elapsed time for notification to arrival.

If I could digress just for two seconds, I just want to talk about the difference between a performance based contract and a level of effort contract. In a performance based contract, people you are paying to provide a service, we expect as a province and as the people funding this, that we have certain expectations that if you call an ambulance, it will arrive within a certain amount of time and the people who arrive will have a certain type of training and they will be in a vehicle that is of a certain standard, I think we expect that. You can hold your contractor, because you are actually in a financial arrangement, to that performance based contract. There are negative and positive financial incentives that go with that.

It is very difficult when you are dealing with a volunteer organization. With volunteer organizations, you deal with what we call level of effort contract. But one of the beauties of volunteer organizations is the level of effort that they exhibit is superlative. They want very much to make sure that they provide a positive impact in the communities. So the issue becomes different, but we want to make sure that we have established a contract with these volunteer agencies because they expect us to provide for them certain things and we want to be able to provide that for them in order for them to effectively deliver care.

Now when you come back to standard response times and what is the expectation, it is different in every community because of the kind of availability of the volunteer fire department has for members. However, on the ambulance side, we expect to be able to say that we expect an ambulance to be on scene within x number of minutes 90 per cent of the time, so that we have some measure against which we can judge the performance.

MR. COLWELL: The other thing with the first responders that strikes me as very important is that you no longer have to necessarily be a firefighter based on the wishes of the individual fire department and that would give you, in the event of a fire even, someone who has medical expertise not being taken away from a fire scene who can provide assistance to

[Page 15]

an injured fireman or an injured occupant of a home. Could you just maybe tell us what advantages that would entail?

DR. MURPHY: There are a whole host of health-related professionals out there, especially nurses, CNAs, respiratory therapists, x-ray technologists, who live in communities and who are willing, able and anxious to become part of the first response net. We have seen that in several parts of the province actually. We are looking at doing a kind of pilot project in Port Hawkesbury now because we have that kind of support. So I think there are a lot of resources that communities have at their disposal that we as EHS need to help identify and apply to the problem, because I think it will lead to better outcomes.

MR. COLWELL: One last point. Also, with the Department of Health assisting in whatever manner they are going to assist with with first responders training and supportive equipment, materials or whatever, typically that money would come from fund raising or the municipal tax base, which would still be solidly in place. So basically, the volunteer organizations through the Department of Health and the province will have more financial resources provided, again dependent on what level they are interested in, ultimately helping ensure that the tax rate and area rates don't go on for this sort of thing.

DR. MURPHY: Exactly. That is exactly the way we feel about it.

MR. COLWELL: It provides them with a lot better equipment and training that maybe they just couldn't afford otherwise.

DR. MURPHY: Yes, I think that is true. I think that is true across the province; as we looked, we found that was a very basic need of the services. If you think about it, I think it makes sense. We are in the health business, this is a health business, it is not a municipal responsibility it is a provincial responsibility, I think. We have taken that position and one of the programs that we want to roll out with EHS is first responder.

MR. ALAN MITCHELL: Maybe I will ask a few questions on some of the more mundane parts. I am interested in the relationship between the system and the ambulance operators. Perhaps if you could first deal with the ambulance themselves. Could you step through it for us quickly, who purchases the ambulance, the sort of contract you have with the operator, what happens at the end of the period when the ambulance loses its use, I think in two years or whatever, how it is returned, how it is disposed of and those sort of questions.

DR. MURPHY: The details of the contract are, in fact, the ambulances are leased by the province, so the province is the primary lessor. They are leased and provided to the operator to provide service. The maintenance schedule surrounding the ambulances and the requirement to adhere to that maintenance schedule by contract with the operators is very stringent. What we want to get back out of this at the end these leases are vehicles that we are able to sell and sell profitably, because if we get them back in off the road before 200,000 miles, then one-half of the sale price, after a refurbishing cost, reverts to the province. So we have a vested interest in ensuring that a substantial portion of our investment recurs to us, which means you don't drive them into the ground for two reasons. You don't want them to be unreliable because they are life saving pieces of equipment but you want to maximize the resale value. The second part of that is, we are attempting to establish a relationship with the operators now in our contract that will also financially advantage them for taking good care of the vehicles, so that we align the interests.

[Page 16]

MR. MITCHELL: The lease payment that the operators pay, does that fully cover the cost of the ambulances so that they are supplied to the operators at a full cost recovery or is there some subsidy in that area?

DR. MURPHY: Since the program has been rolled out, the arrangement with the Ambulance Operators Association, because of the degree of financial instability in the system and our wish to make it more stable is that none of the cost, until we have a new contract, has actually been passed on to the operators; it has been absorbed by the province as a cost to the province providing the vehicles without charge to the operators. What we are in the process of doing now is negotiating a contract to integrate some of that cost into the contract. Do you understand what I mean?

MR. MITCHELL: Yes, I think I follow that. I was also interested in training. You have dealt with a good part of that but the cost of training, the cost that the province will pick up and the cost that the operator will pick up. I assume that is a shared responsibility. I take it from what you have said earlier that that is still under development?

DR. MURPHY: That's right. I can't give you all of the details because they are not all clear at this point in time, but I think that from the point of view of the human resource, which is a vital piece of getting an advanced life support system on the road and maintaining quality of care, training is a very important piece of that. Because so many of the workers that are now in the field are pre-existing workers, I think that the responsibility we have for those people is to work with them as much as we can, minimize or eliminate the cost to the individual. That doesn't mean that there is no cost to the ambulance operator, per se, because the ambulance operator in many instances has time to consider or back-fill time. I can't speak for the operators because I don't run their business but I think that there is a cost to both of us, there is a cost to the operator as well as a direct cost to the province for providing some of the training.

MRS. FRANCENE COSMAN: I just wanted to pick up on the training aspects as well. This summer in the United States was probably one of the worst examples I have ever seen in terms of an ambulance delivery in a crowded parking lot, it took 17 minutes to get through it, to tread through it, and when the operators got on-site with the victim, they had no oxygen in their tanks and it went from bad to worse. The person died on the dockside. It brought home to me, as a former nurse, the importance of what we are trying to do in this overhaul of our ambulance system in Nova Scotia.

[10:00 a.m.]

So, I guess from the perspective of training, and Alan did touch on a couple of questions there, are we moving to a common standard of training, and what is the basic minimum of training that it would take to put someone into the role that they play? Is there a difference in urban and rural settings, between the kind of training the person would get? Some of those issues around the training question I am interested in. I do not know who wants to have a stab at that one.

As well, the communication set-up that we are using between individual ambulances. What happens in a case where you have a standby ambulance waiting out in the wings? What happens if there is a delay in getting a patient lifted back to another hospital? Do ambulances talk to one another or is it only the dispatch that talks to the ambulance? I am interested in some of the communication issues. I do not mind you taking your time to answer the question,

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I do not know about the Chairman, but I would like to hear some commentary on those two areas.

DR. MURPHY: Why don't I start with the training piece first, and we then go into communications and dispatch after that.

The levels that we expect to see recognized for the province are probably at a minimum three. One of them is emergency medical dispatch, which is a specific training program for dispatchers to allow them to understand what the caller is requesting; the urgency of the call; how to juggle the resources that are available; and dispatch the appropriate resource to where it is required.

The second part of that is the emergency medical technician, or emergency medical attendant at the basic life support level. The training program and level of accreditation we expect to see at a minimum is that level, and that is a Canadian Medical Association accredited program to provide trainees at that level.

The final level is the EMT advanced or EMT paramedic kind of level. What we want to see developed is a consistent level of advanced life support provision at the advanced life support level. So, as we establish our database, we have looked really at those three kinds of levels of training to provide consistency across the system.

As far as staffing is concerned, we expect to see by April 1998, if we are successful in our training program, at least one advanced life support worker on every vehicle, with the potential to have a basic life support worker on every vehicle as well, so that we can deliver advanced life support, if we need it, with all dispatch in the province being done by EMD trained people, emergency medical dispatch trained people.

So, yes, there are standards. Yes, we have goals and, yes, that is what our manpower and our training strategy is all about.

MRS. COSMAN: So that is the optimum that we are aiming for and what do we currently have?

DR. MURPHY: Well, we do not know. We are in the process of assembling the data. We have about 500 returns from 800 people and we are in the process of entering that into our database to understand how many of those people have achieved EMA or EMT, which is the basic life support level; how many of them have attained intermediate levels between basic and advanced; and how many are advanced.

So, I do not know. We know there are probably 800 to 900 employees in the system full and part time right now. What we do not know is the details of what their certification and training is.

Now, let us go and talk about the communications piece. In an ideal world, the communications would be at all levels, back and forth between ambulances; back and forth between an ambulance and an aircraft; between police and fire and ambulance; and back and forth between dispatch. The hub for us is dispatch. Dispatch has to understand what is going on with its resources at all times in order to know when to up-scale and when to down-scale a response. I think it is important for EHS, I know it is important for EHS to be intimately involved in two initiatives that government is undertaking. One of them is 911 and the other one is the provincial I WAN, because the I WAN provides for us, in Emergency Health

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Services, for a basic need as we move down the road. We see, within two to four years, the ability to transmit sophisticated information from ambulances to receiving institutions, such as electrocardiograms, for instance. That is just an easy example that everybody can understand.

Right now some elements of care that you receive only in a hospital, we should be delivering in the field. Many of them are very kind of ordinary, such as advanced life support procedures like intubation and IV therapy. But some of them are quite sophisticated, such as the administration of drugs to break down blood clots in coronary arteries, which we call thrombolytic therapy. One thing that is interesting is that no one in the world is really doing the kind of research that needs to be done to demonstrate whether or not that is useful and the infrastructure we are developing here will allow us to do that.

MRS. COSMAN: Is that it?

DR. MURPHY: For now. (Laughter) It is very exciting. It is a very exciting piece for me.

MRS. COSMAN: Just picking up on the 911 system that is going province-wide and the kind of regional dispatch you would have in your network, do you have it on paper now and in practice? For example, if you have a major accident on one of our 100-Series Highways that calls out several ambulances, how do you grid in the remaining structure around that hot point? Do you have a system in place now that can do that, or does the system sort of suddenly get all of its resources focused in one major emergency? I am curious about this; I don't know if you have an answer for it.

DR. MURPHY: It is called a maximum response dilemma, that is what you are describing. It is a well-recognized thing in emergency response. I can tell you that it exists to varying degrees in varying parts of the province. In some places it doesn't exist at all, in some places it exists in a highly developed fashion.

I don't know if you have heard what is going on with EHS as far as amalgamating dispatch in various regions. We recently did in central region, we are doing it now in northern region, we will be moving that way in western region and eastern region as 911 rolls out for precisely that reason, to identify the resources required and apply the most effective resources that we need without sending people who don't need to be there or draining an area. That is a persistent problem for the ambulance operators; we are actually working with them to make that come together because that is their problem as well as ours.

MRS. COSMAN: So in a sense this is also in the future in terms of having all of those problems ironed out and a standard, applicable response situation that would be on paper, this is the drill and once a year we are going to practise it. Essentially you are saying that is in the future?

DR. MURPHY: Yes, but we have a time line on it. Our goal is to see that by the end of December 1996.

MRS. COSMAN: Okay, thank you.

MR. CHAIRMAN: Mr. Fogarty.

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MR. GERALD FOGARTY: Dr. Murphy, I would like to ask you a few more questions about the lifespan of the ambulances; you alluded to that a few minutes ago. Did you say 200,000 miles or kilometres?

DR. MURPHY: Kilometres.

MR. FOGARTY: That would be, what, approximately 2 years?

DR. MURPHY: Two to three years. It would vary, Mr. Fogarty. There are some areas of the province that might not put 200,000 kilometres on a vehicle for a long time but there are some areas that might do it very quickly.

MR. FOGARTY: You talked about the resale value of these vehicles. What would be the intention and where would they be sold?

DR. MURPHY: I think most of the market for resale is offshore. We work pretty closely with Tri-Star, obviously, in our dealing with Fleet and it is in our best interests as a province, as well as Tri-Star's, to get the best price we can for these vehicles. I know Tri-Star, for instance, has been looking at places like Cuba, like Vietnam, that are offshore that are very interested in purchasing state-of-the-art vehicles but can't afford to buy them off-the-shelf, so to speak, because they are too expensive. So I think we need to develop those markets together.

MR. FOGARTY: So it wouldn't be financially viable or wise to spend too much money on them at 200,000 kilometres to extend their life, to keep them in repair, to maintain them, is that what you are saying?

DR. MURPHY: No, the balance is the important part of that. You have to make sure, we have to make sure, these guys have to make sure that this lifesaving piece of equipment can respond 100 per cent of the time. We are looking for a zero breakdown rate for these machines and what we need to do is ensure that we - that is what Tony Eden is fundamentally involved with - understand how to maintain a fleet so that it is always able to respond, but minimize the cost of maintenance, because ultimately what you are going to do is maximize your return when you turn the vehicle over. So fleet management is a real science.

MR. FOGARTY: We hear about a certain percentage of emergency calls for an ambulance, and I think it applies in Nova Scotia and other parts of Canada and probably other countries, where a certain percentage of these calls are not really emergencies, that the victim, if you like, or the individual who needs medical attention could probably be placed in a car and driven to a hospital. Are we better able now, since the implementation of the new EHS program, to identify and perhaps differentiate between what is a genuine emergency call and what perhaps may not be?

DR. MURPHY: I think it would be inappropriate to say that now we are. Now we have sufficient power in our technology to enter the data into a data base and understand what it might be and we are doing that as we speak. But I couldn't give you an answer in a prospective fashion about that, which is what we really need to be able to do, because I don't have the information.

MR. FOGARTY: So there aren't certain questions that are now put by the responder on the telephone, which would help to identify whether this is, indeed, a genuine emergency?

[Page 20]

DR. MURPHY: There are, only in that it allows you to gauge the urgency of your response and how many responding units you might require, just like I was asked by Mrs. Cosman earlier. Our goal is to understand, do you need a first responder and a lights and sirens ambulance and an air ambulance right away, or do we downgrade that response to say, well, we don't really need the first responder now but we do need to send an ambulance and fairly quickly, or we can send an ambulance less quickly. I don't think it is, to my knowledge, in any jurisdiction in the country refined to the point where we are able to say, well, you don't need an ambulance.

MR. FOGARTY: That is pretty risky, isn't it?

DR. MURPHY: You are not kidding. There is a rule that says, when in doubt send 'em out. We are in the business of public safety, so that would be pretty risky, especially for the people.

MR. FOGARTY: So it is difficult, then, as you say, if you get a call for an ambulance, then you have to assume that the individual, the victim needs an ambulance and you go ahead with it?


MR. FOGARTY: Thank you.

MR. CHAIRMAN: Mr. Carruthers, and then we will go to the Opposition members.

MR. ROBERT CARRUTHERS: Dr. Murphy, this may be a touch off your expertise, but in the communities I am questioned on a regular basis, especially from the volunteer fire departments, who are entertaining the possibility of becoming deeply involved in the response system, or on the other hand perhaps not being quite as involved. One of the big questions I get is, what is the exposure of the volunteer, what is the exposure of the fire department? Perhaps they get involved with the early response, maybe even get into the ambulance field at some point. I know we have legislation with regard to volunteers, liability and some regulations in that regard, but it is a pretty vague field, in my view, and when questions are put to government members and lawyers in the field, it is a tough question; there is no clear-cut answer.

I wonder if you have been involved in that, if you have been able to make any recommendations in that regard, whether you see a possibility of assistance by way of legislation or regulation that might make this field a bit clearer and give some solace? I am thinking mainly of the rural volunteer fire departments that my friend Mrs. Cosman and others have referred to.

DR. MURPHY: It is a really good question, it is a complex question, it is one that we have been addressing for some time and it is one of the commitments that I made in my report, to address the issue and understand what the medical-legal liability is for these particular providers, especially on the volunteer side. I think it is broader than that. In fact, we aren't just talking about volunteers, we are talking about paid, and we are not just talking about first response, we are talking about basic life support and advanced life support so it becomes stratified. The answer to the question, in the medicine field, if you ask five doctors what you do for this, you get five different answers. Not that I don't love lawyers to death, but my sense is that we have been getting several different answers, as many of your people have.

[Page 21]

However, consistently at the basic life support level for volunteers - and let's be very specific - the answer I have received consistently from lawyers across the public and private sector when I asked that question from EHS's perspective, is that the liability risk is exceedingly low because the type of intervention that they are doing isn't really an intervention of preventing further injury, so the risk is exceedingly low. There has never been a successful case in this country at that level. They feel that the volunteer services, or Good Samaritan provisions in that Act, provide coverage at that level. It becomes less clear as you move to paid services and quite unclear when you move to advanced life support. So we are carrying that question forward to our legal counsel and I don't discount the requirement to look at legislative solutions to make sure that we are able to protect the people delivering the care.

MR. CARRUTHERS: That is of great help because I think it has to be looked at. As you say, that is always a question that comes up, the strictly volunteer person and at what level is a person paid? The fire departments get their uniforms paid for, certain expenses, are we now dealing perhaps with a paid individual or are they not? These are all the questions that keep coming up. Of course, I love lawyers to death just the same as yourself, but yet we do get a number of different answers depending on, well, what chair you are sitting in. Are you looking at the fire department, from that aspect? Is the government from the health services? So, I would be happy if this study were to proceed to the extent that there might be some recommendations, especially with pay and who is paid and who isn't. It is a tricky situation. I believe the risk is low also. It is like the fellow who is unemployed, if there is only 2 per cent unemployment in the world but he doesn't have a job, it is 100 per cent unemployed to him. So the comparison can be made.

I want to get a little bit parochial here if I could. I represent a district in Hants County, Hants East, and it has come to my attention, through the 911 system, that there are some border communities that have traditionally used fire service and, perhaps, ambulance service from another community, a community that might be outside, for instance, regional board boundaries or what the 911 system considers a boundary. To be a little clearer, for instance, Bartlett's Ambulance Service covers most of Hants East. Arsenault's Ambulance Service covers some of it and it has come to my attention recently that there are communities in the Rawdon area, the border, that have used fire department services from over in Hants West and use ambulance services from Arsenault's that is really across this imaginary line.

I get concerned that because of some imaginary line such as a regional board line, a county line, a line that is drawn by the 911 people, that there may actually be people closer to services that they are not set up through the 911 system or the ambulance service to get, some who are closer to Arsenault's Ambulance Service, Bartlett's have to deliver because of some imaginary line. It is a new system, I realize there are some bugs in it but I wonder if you have had any dealings with it, if you had any problems with it?

DR. MURPHY: I don't know if I have had specific problems with it. We had specific dealings for years because of the lines and Mr. Schaffner probably has less hair today because of some of those issues.

MR. CARRUTHERS: I know the problem, yes.

DR. MURPHY: Certainly it is a different colour than it was 10 years ago. Those are the issues that he deals with on a day to day basis. But I think that our goal is to say our responsibility is to the people who live in every nook and cranny of the province no matter where they are, and we expect them to get the service they need when they need it despite

[Page 22]

imaginary lines. So the direction that we are taking is to move in that way, which, incidentally, is the direction that he is moving in as well. So we are both on the same line on that one.

I think it is a big issue. As long as it is tied to the funding and the driver in the system, the fee for service issue, I think it will continue. So our goal is to see a responsibility that is geographic in nature as opposed to a fee for service driven system, because that is what you expect. You expect that you live in a piece of geography and that the response time criterion or performance that we require applies to you as much as it applies to anybody else no matter where imaginary lines may fall. So that our responsibility is to ensure that you get that service and the service that you require within the performance standards.

MR. CARRUTHERS: So then it would be your view that the people in rural areas could take some comfort in that these lines won't be hard and fast and there certainly will be steps taken from your angle, also from the operator's angle, that it will be the closest and quickest service that will be delivered to them ultimately as opposed to some region, and I don't necessarily mean the health regions, but counties, coverage by fire departments, any of that nature?


MR. CARRUTHERS: That's the type of answer that a fellow really likes. One other, just a broad sort of question. We talk about the necessity of moving quickly in the rural areas because that is where we found that the most danger exists in people suffering from non-early response. Where do you see us now - take a picture at this point in time - in terms of comfort that rural people can take? In my district there are people who live a great distance from ambulance or any hospitals, no hospitals in my area. It is a long way to Walton at midnight when a person has a heart attack.

MR. CHAIRMAN: It's a long way to Tipperary.

MR. CARRUTHERS: That's right. If you take a picture in time right now, and you compare it, let's say, to 5 or 10 years ago, what kind of comfort can people take in improvement in our emergency care system? I mean right now, not speculative in the future but right now, today, what kind of comfort can people take?

DR. MURPHY: I think it is a mosaic. I think if I lived in North Queens or if I lived in certain parts of Cape Breton I would be very comfortable. I think a lot of work has been done by volunteer first response agencies and a lot of work has been done in coordinating the response with the ambulance service and local physicians and nurses to provide an excellent level of care. I think if I looked at the Eastern Shore, where a lot of work has been done by local communities to make things happen, I would be feeling more and more comfortable as time goes on. I think that our goal is to see communities identify what their requirements are, what their needs are, as we work with them to bring them to that same comfort level.

I think it is difficult for me to give a more specific answer than that because it is such a mosaic across the province and because I don't have specific knowledge of every nook and cranny the way many people who represent those areas do. I have a great deal of difficulty understanding where we are now compared to 10 years ago because that really wasn't part of what I did 10 years ago. My speculation is that in two years we would see a very much fortified system in those areas.

[Page 23]

MR. CARRUTHERS: Just a short thing. If there is any written information in that regard, if we have any statistics in that regard, could you provide it to the Chairman? I am not suggesting that you do, and I am not sure you can tell for sure if you do, but if your people could just have a look to see if there are any statistics in that regard or some numbers and provide it to the Chairman, if possible?

DR. MURPHY: If we have them, sure.

MR. CHAIRMAN: Dr. Murphy, I have a series of questions, most of which I think can be answered quite quickly, a couple of them are a little sharp and I hope you will understand that that is the nature of the committee and there is nothing personal intended with respect to the way in which the questions are phrased. It may be that some of these questions can be better answered by some of your staff and if you wish to defer the questions to them, that's fine.

How many ambulances have been purchased to date?

DR. MURPHY: As of the end of March, we have delivered, I believe, 69 vehicles.

MR. CHAIRMAN: What is the cost of each vehicle?

DR. MURPHY: The gross cost is $63,000. The net cost with rebate at turning in is $53,500, I believe.

MR. CHAIRMAN: How many will be purchased at the end of acquisition?

DR. MURPHY: The number in the contract is 150.

MR. CHAIRMAN: Where does the ownership for each of these vehicles reside?

DR. MURPHY: The ownership resides with the lessor and the province is the primary lessee. Now, you are asking me who the lessor is, and I am not certain who that is, I can find out for you but I am not certain.

MR. CHAIRMAN: So we have 150 ambulances, the Department of Health has leased them but we don't know from whom they have been leased? (Interruptions) Perhaps Mr. Eden then can answer the question. The ambulances are leased and they are leased from?

MR. EDEN: They were initially leased from Tri-Star Industries, and a company owned by Tri-Star called EHS Efficient Health Services is who that was transferred to.

MR. CHAIRMAN: All right, so they own the ambulances?

MR. EDEN: Yes, they own the vehicles and the only thing that is in the name of the Department of Health is the lease and the license plate.

MR. CHAIRMAN: So none of the operators then will be leasing the ambulances?

MR. EDEN: Not as part of the agreement between Tri-Star and the Department of Health at this time.

[Page 24]

MR. CHAIRMAN: So the capital costs then of the ambulances is being met by the lessor?

MR. EDEN: Right, the Department of Health is who is currently paying for the vehicles.

MR. CHAIRMAN: Yes, but that would not be a capital, you would only have a capital cost if you were buying the vehicles. You are not buying the vehicles.

MR. EDEN: No, it is the capital lease program.

MR. CHAIRMAN: All right. I am just a slow fellow from the country you see. There are four regions, Dr. Murphy?

DR. MURPHY: There are four health care regions, yes.

MR. CHAIRMAN: How many operators do you anticipate there will be in each region, or does it vary?

DR. MURPHY: I do not know that. My sense is that the province is, from a business perspective, a single market place. The goal that I would have is no matter how many independent operators there are in each region that they actually operate, at least in coordinating regionally if not provincially, in providing many of the services to get the best efficiencies and economies of scale.

MR. CHAIRMAN: So, the new system is up and running?

DR. MURPHY: Which new system?

MR. CHAIRMAN: Your new system. We are divided into regions. A number of the new ambulances have been delivered and are in operation.

DR. MURPHY: Let me talk just to take you back just a step. Emergency Health Services is a provincial program or central program, as opposed to a regional program falling under regional health boards. So, we address the issue of standards as far as equipment, training and performance on a province-wide basis as opposed to by region. So, the relationship among the owner/operator providers of care, meaning this gentleman's people and the provincial government through EHS, is a central arrangement. We now are providing funding in the same way that we have for years.

In fact, the fee for service contract goes back, the subsidy arrangement goes back many years. We are continuing to provide funding according to that subsidy arrangement right now. We are in the process of changing, we hope, from a fee-for-service funding arrangement to a geographic fixed-funding arrangement to allow appropriate service.

MR. CHAIRMAN: You referenced the regional health boards. Was that an incidental reference or in fact are they a player with respect to determining operation within their region?

DR. MURPHY: Very much so, but at the operational level. So, the integration, and it is as yet unclear as to how it will happen with each individual regional health board, but my meetings with the regional health board executive directors would indicate that we need

[Page 25]

to be involved at the operational level of understanding what the regions will be responsible for; what EHS will be responsible for; where we are accountable; where they are accountable; and how the accountability back and forth will work; and it fundamentally works at the level of provision of care.

MR. CHAIRMAN: So, we all know where we have been. We understand where the government intends us to be at the end of the process. But, we are still pretty fuzzy with respect to precisely how we are going to get there.

DR. MURPHY: I think it would be imprecise to say pretty fuzzy. We have a lot of clarity as far as to the relationship of EHS with government is concerned and the relation of EHS with regional health boards. I think where the imprecision comes in is the yet to be defined community health boards and what the level of integration will be at community health boards.

MR. CHAIRMAN: It strikes me as a very spastic way to approach massive change, but that is my opinion and I am sure it is one that you do not share. At any rate, let us go on to a few other questions. I do not want to impose too much on the committee's time.

Under Section 13, the agency is empowered to build, acquire, maintain garages and depots. How many are scheduled to be built or acquired? Do we know that? Or is that still a decision to be taken?

DR. MURPHY: It very much depends on the structure of the contract that we strike with the providers of care, whether or not we will own any of those or not. So, I think that until such time as we see clarity in the contractual arrangements with the providers of care, it is impossible to be specific as far as that is concerned.

[10:30 a.m.]

MR. CHAIRMAN: Section 17 of the Act, since we are with it, states that the Agency is not a servant of the Crown. Government By Design, however, states, ". . . the entire emergency response system will be renewed under the jurisdiction of a Crown corporation, . . . Emergency Health Services will be an integral part of the reformed system.".

Now, is it a Crown Corporation or is it not a Crown Corporation? If it is a Crown Corporation, how can it be that none of its employees are, therefore, servants of the Crown or employees of the Crown?

MRS. COSMAN: Mr. Chairman, would you just run over that, the last part of your statement in which you compare Section 17 of the Act to Government By Design?

MR. CHAIRMAN: Yes, it is in our work-up book here.

MRS. COSMAN: What section were you referring to in Government By Design?

MR. CHAIRMAN: It is Page 42. I am just trying to understand whether we are one or the other because it appears to me we cannot be both. We cannot be hermaphroditic, either we are a Crown agency with employees who are employees of the Crown, or we are not a Crown agency, who are not employees of the Crown. I do not care which way it is. I just want to know which way it is.

[Page 26]

DR. MURPHY: I believe there is consistency within the Act in that it states, under Section 6(1), "There is hereby established a body corporate to be known as the Emergency Health Services . . . Nova Scotia.". A body corporate is not defined as a Crown Corporation, it is defined as a body corporate, which is a legal definition as I understand it.

MR. CHAIRMAN: You made reference on a number of occasions to the needs of rural communities and you have a number of your officials here. I wonder if any of you have worked or practised in rural communities?

DR. MURPHY: I cannot speak for everybody here, but I do not believe that anybody has actually been employed in a rural system.

MR. CHAIRMAN: I thought probably that was the case. Now, you mentioned in response, I think, to a question from Mr. Taylor that you spent two-thirds of your time working in the employ of the province and one-third of your time elsewhere. I wonder if you could tell us the recompense you receive from the province for your two-thirds of the time here?

DR. MURPHY: I am paid an hourly rate by contract with the province to a ceiling of, I believe, 1,400 some-odd hours a year is the personal service contract that I have with the province.

MR. CHAIRMAN: Okay, if you worked those full 1,400 hours, how many dollars would that be?

DR. MURPHY: It would be about $140,000.

MR. CHAIRMAN: For two-thirds; well, that is not bad. I should have been in Emergency Health Services, not an MLA, I guess.

Now, the minister said in a statement, and unfortunately I cannot put my hands on it but I copied it out of the statement last night. There are only five or six emergency medical experts in Nova Scotia and then here I quote him, I am one and I have hired the other six. Who might the other six be, any idea? I assume you are one of them, so that will leave you five to figure out.

DR. MURPHY: I think it depends on how you define expert. If you define expert as those holding certification by the Royal College of Physicians and Surgeons of Canada in Emergency Medicine - now I may not know them all but I can tell you some of them - Doug Sinclair who is VP Medical Service at the QE II; Ed Cain who is the Acting Medical Director of EHS; Graham Bullock works at the Victoria General; I may slight someone by not thinking of them; John Ross works at the Victoria General.

MR. CHAIRMAN: In 1991, there was an institute created, you were one of the directors, the Institute for Emergency Medicine, Dr. Stewart was one of the directors, he is now Minister of Health, Mr. Eden was one of the directors, Mr. Eden is now seconded to the Department of Health?

DR. MURPHY: On loan.

MR. CHAIRMAN: You are now seconded from . . .

[Page 27]

MR. EDEN: I am not seconded, Mr. Chairman, I am on loan from the Victoria General.

MR. CHAIRMAN: You are on loan from the Victoria General. So the Victoria General is paying your salary while you are here?

MR. EDEN: That's correct.

MR. CHAIRMAN: Have you been replaced at the Victoria General?

MR. EDEN: In an acting position.

MR. CHAIRMAN: What is your salary, Mr. Eden?

MR. EDEN: Approximately $35,000.

MR. CHAIRMAN: Oh, you're underpaid, you ought to go on strike. There was also a Diane Golden who is the director of the association, does she have a position with respect to any of this?

DR. MURPHY: Diane was initially seconded, I believe, I don't know the details but I believe she had a seconded agreement from the Victoria General Hospital and Department of Health as Director of EHS and when I came on board as Commissioner in the transition, she then moved to looking at something else within the Department of Health.

MR. CHAIRMAN: So she is in the Department of Health.

DR. MURPHY: I have not followed her, I don't know what her current status is, but she . . .

MR. CHAIRMAN: But she is in the Department of Health now anyway. Dr. Murphy, you were a director, Dr. Sinclair who is now a VP at QE II is a director, it appeared to me from what I knew that Dr. Cain was the only one that had been left out and I wondered what terrible sin he had committed but now I understand from your statement a few moments ago, that he is also a director at the Victoria General, did you tell me?

DR. MURPHY: Do you want to know what he does now?


DR. MURPHY: Now, he is an emergency physician at the Victoria General and works with Emergency Health Services as the Acting Medical Director for EHS.

MR. CHAIRMAN: So he would work very closely with you then?

DR. MURPHY: Oh, very much so, yes.

MR. CHAIRMAN: Wherever friends meet I guess, eh? Now, for my last question, has there been an offer made to the current operators to give them an opportunity to acquire shares or some form of equity in the event that the province moves towards one company for delivery of services?

[Page 28]

DR. MURPHY: I don't know what kind of internal arrangement the current ambulance owner/operators might make. That is really up to them as long as, from my perspective, it is fair to those people who are involved in the arrangement.

MR. CHAIRMAN: The department has made no offer to the operators in that respect?

DR. MURPHY: Ask me that question again?

MR. CHAIRMAN: I will ask Mr. Schaffner, he can answer the question, he is an operator. Mr. Schaffner has there been any offer made or any discussion surrounding an offer by the province to the operators respecting giving current operators an opportunity to acquire any form of equity in a super agency?

MR. ROBERT SCHAFFNER: There are two levels of change, perhaps, that we have been talking to the department about. First is an interim type of arrangement that may be from 12 to 18 months and it is more the taking away from the, what I call, the per call system on to a more basic funded system. Following that, there have been some discussions of the second phase of which you refer to where there may be one operator in terms that one company, all operators would be within one company. That is still very much at the discussion stage and there have been consultants come in from outside Nova Scotia that have met with us in seminar form and explained how it worked elsewhere. There is nothing concrete at that level other than discussions.

MR. CHAIRMAN: Can you give us an example of one or two of the elsewheres?

MR. SCHAFFNER: Throughout the United States, in Florida and those areas where some of these folks here have visited and reviewed those systems. How appropriate all aspects of that would be to rural Nova Scotia is something that we have to review under, as Dr. Murphy says, performance contracts. We have no problem with performance contracts where you have to be specifically at a certain location within a certain time, as long as they are reasonable within Nova Scotia versus warmer climate weather and that type of thing. Even the one contract for the whole province, we have had one contract but dealt with each individually, but now it is a little different philosophy and at this stage it is simply, as far as we are concerned, under study.

MR. CHAIRMAN: Thank you, Mr. Schaffner. We have 20 minutes left, actually a little less than 20. I won't have any more questions and if we could make another round and limit it to one question each then that will pretty well give everybody an opportunity to get in before we close off. Mr. Taylor.

MR. TAYLOR: Dr. Murphy, I am sure the task of putting together the Emergency Health System must be very time-consuming and quite arduous and tedious, however, I am a bit perplexed that you can find at least three months of your time to spend at another career in Hamilton and, of course, that perhaps is represented in the contract you have with the province and it may be drawn up in such a fashion that it enables you to do that. That is just a comment.

My question would be, in the Musquodoboit area and the Eastern Shore, we have received the advanced life support system and that system has been provided by Metro & District Ambulance Service, it is going to be terminated come the end of March. I think I was able to determine that from our previous exchange.

[Page 29]

DR. MURPHY: Maybe I could just clarify that. You are making the statement that you have had advanced life support services in place now with Metro & District consistently at all levels. I don't believe that is true.

MR. TAYLOR: I didn't say consistently at all levels. If I could just finish and put the question, Dr. Murphy. We received from Metro & District Ambulance Service and perhaps have been led or misled to believe that it was ALS, the ALS system. Can you tell me whether or not Crowell's Ambulance Service, who I have been told will be receiving the contract and whether or not it went to tender or not I don't know, but can you tell me whether or not Metro's contract in the Musquodoboit area and the Eastern Shore will be terminated come the end of March and we will be receiving ambulance service by Crowell's out of Sheet Harbour, who provide the basic life support system and service that we had in the past or at least those citizens in that area received in the past?

DR. MURPHY: What I would say to you is that the service provided in that area will be provided by a service located in the area and it will be at the consistent level that it is being performed now. The issue of boundary is one that we haven't determined precisely yet because I believe, as one of the previous members have stated, that lines etched in concrete don't best serve the needs of the people but there needs to be an area of service that best meets the needs of the people and boundary areas. But I can say to you that the quality of the service to be delivered by a service based in that area will be delivered by Crowell's Ambulance substantially as of the end of the month.

MR. CHAIRMAN: Mr. Chisholm.

MR. CHISHOLM: I wanted to see if I could work in three questions like Brooke did on his but it is not like me to do that. I want to ask Mr. White and Mr. Green, who are not only representatives of the attendants and technicians at Metro but also involved in the provincial association, I believe; I assume you have had experience dealing with the new ambulances and you would have heard from your colleagues across the province, what is your spin on these new units?

MR. BERNIE WHITE: The new ambulances are very comfortable to work in. I know somebody here earlier today had said there were some complaints about it being tight in the back, or something like that. I have worked in one of the new EHS ambulances since they first came on the street - I was given one of the first ones - and I found very few problems in the back of an ambulance. The biggest problem would be the weight of the new stretchers, but that is dealt with by using different pieces of equipment to take people to the stretcher, instead of taking a stretcher up a couple of floors and things like that. The new ambulances are a lot better than what we have been working in, very much better than what we have been working in, and I don't know why people would complain that there is something wrong in the back of them. There is plenty of room to work in, a very comfortable, stable ambulance that appears to have set up so that the patient is safer in case of an accident, I can sit better in case of an accident, and I just don't understand where people are saying they are a bad ambulance. They are a very good ambulance; they are a nice tool.

MR. CHISHOLM: What about the idea that they don't handle the rural roads as well as the old ones did, or something like that?

MR. BERNIE WHITE: Our area of coverage, like I said, used to go from Musquodoboit to down around Black Rock area. That encompasses what I would think would be the rural, as well as the urban. We do a lot of calls out Timberlea way and a lot of calls

[Page 30]

down in the Goodwood area and they seem to handle just fine. They seem to hug the road, they have good suspension on them, they have excellent brakes and they are a fine vehicle to work with. It is nice to have a good tool.


MR. CHAIRMAN: Mrs. Cosman.

MRS. COSMAN: I was somewhat concerned about the sort of tone we set this morning which was new for us as a committee in our line of questioning; comments about who is being paid too much or who is being paid too little or someone should go on strike. Personally I don't find those appropriate comments in this setting. We have tried for the last couple of years to keep the questions at a certain level of professionalism and I do have a bit of a problem with that.

As a member of this committee, I think I am more interested in the accountability issue of whether the person is doing what they contracted to do. You can't compare apples and oranges, you can't compare a doctor's salary with a non-medical person's salary and come up with a judgment on, you are paid too much or paid too little. So, I have a problem this morning with the conduct that we are exhibiting here. I don't think it is appropriate and I just want to be on record for that.

I was interested in pursuing a question around equipment checking, what kind of a drill we would require through EHS. Is there a standard drill right across the province that is utilized for each shift, for example? I keep thinking of this incident last summer in the United States where they didn't have any oxygen in the tank. I don't know who wants to answer that, but I am curious about the standard drill that is utilized in our fleets on every shift to check equipment.

DR. MURPHY: I can't speak for the individual operators about every shift. My understanding is that individual ambulance operators have different standards as far as checking and restocking are concerned. We have a specific standard as far as equipment and supplies are concerned and we monitor that with regular checks, as well as spot checks. Rather than monitoring every ambulance, every day, every shift, we leave that to the contractor providing service and they have a certain standard there to live up to. We monitor that standard with scheduled and non-scheduled inspections.

MRS. COSMAN: So would that be something Mr. Schaffner might want to comment on as well?

MR. SCHAFFNER: I would agree with Dr. Murphy. One thing I should point out is that items such as oxygen are obtained from the hospital, so there would be absolutely no reason why that wouldn't be in the vehicle at all times. In our contract, which we have had since 1969-70 with the province, it very specifically states all the minimum equipment that has to be in each and every vehicle and that is checked, as Dr. Murphy said, both on a regular and non-scheduled basis.

In my 25 years of representing the people in the ambulance service, that has not become an issue with the inspectors that they weren't adequately - like if there was some item, maybe some small items, they were replaced immediately after the inspector's request. But as far as lifesaving devices, that type of thing, that has not been brought to my attention by those people as being inadequate. He has a complete inspection sheet as he goes through

[Page 31]

the vehicle. He says, open the door, fellow, I am here, and down the list he goes. That has not been an issue that has been brought to our attention provincially.

MRS. COSMAN: That is a comforting answer, thank you.

MR. CHAIRMAN: Mr. Carruthers.

MR. CARRUTHERS: Just one question. I may be misinterpreting some of the questions and answers, so I am really looking for a touch of clarification. It is my understanding that the new ambulance, both the vehicles and equipment contained therein and the general service they provide, that we are looking for an equality across this province. For instance, if you were in Inverness County or Queens County or Yarmouth County or Hants County or in the Musquodoboit Valley, we would be seeking to have an equality in terms of the equipment located in those vehicles and the level of training that the drivers would have. I realize there are two sets of services, the doctor type service, but these emergency services, when the ambulance gets to the door, we look to expect an equality, generally speaking, of the service from one end of this province to the other. Would that be a fair comment?

DR. MURPHY: It is a fair comment. The term equality perhaps doesn't allow one to excel, might be a way to put it. If what we expected was equality, then we would rule out areas of excellence. So what EHS wants is standards, so there is consistency at a standard and if you wish to exceed that standard and excel, we expect that to occur, that is human nature.

MR. CARRUTHERS: Perhaps I worded that wrong. There would be a certain minimum standard and then if one particular service just happened to have a couple of really good people working, of course they would excel. Well, we would find that anywhere. But what I am looking at is that there is not some different level of standard between one level and another. If I were to look at Arsenault's or Crowell's or any other, I don't expect one to be at a certain level and another one to be much more qualified with different equipment, better machines, better ambulances, I wouldn't look to that second scenario to happen in this province, would I?


MR. CHAIRMAN: Mr. Colwell.

MR. COLWELL: There have been insinuations made here by the honourable member for Colchester-Musquodoboit Valley that Crowell's Ambulance is going to provide an inferior service to the area of Musquodoboit Harbour and surrounding areas. I understand that Crowell's Ambulance has been in existence between 20 and 30 years. Maybe you could tell me how many complaints you have had against that particular company in that time?

DR. MURPHY: I have only been in place for a short period of time, but being in Halifax County I have had a long history with Crowell's and a long history with Metro & District. I go back a long way; in fact, I can remember as medical director at the VG Hospital being involved with probably the first pre-hospital defibrillation project in the province, which was in Sheet Harbour and Crowell's Ambulance. So I have history on both sides of the coin. I can't tell you the numbers of complaints we have had from one and the other - I probably wouldn't tell you anyway - but I don't know the numbers of complaints on either side of the coin. I am certainly unaware of any complaints regarding response times or quality of care or due diligence with Crowell's, because that would have entered into our consideration I think.

[Page 32]

MR. COLWELL: It is my understanding that Crowell's in recent history, in the last four or five years, hasn't had a single complaint.


MR. CHAIRMAN: I want to thank all of you for being with us today. While there may be some of us who are concerned with respect to the level of achievement we will experience respecting this change, all of us must, nonetheless, hope that you are successful because that is in the public interest. We look forward to watching this evolve not only with respect to Emergency Health Services itself but, also, with respect to the new relationship between Emergency Health Services, the operators, the attendants, as it changes, as we moves towards the final goal, which has been laid out by the minister and by the government.

I do want to thank all of you for being with us today and for providing us with forthright answers to some pretty forthright questions. We very much appreciate it and we look forward to hearing from you again at some future date, when we have had a further opportunity to assess the degree of success with respect to the implementation of the new Emergency Health Services here in Nova Scotia.

So, thank you to all of you and we bid you adieu. I would ask the committee to wait for a moment because we have a little business to carry out ourselves. Thank you very much.

Two things, first, we have one witness left to call before the committee, the Nova Scotia Restaurant Association and TIANS. There are a number of dates open. I would suggest that we look at Wednesday, April 17th which takes us away from the two short weeks but, also, leaves us in a timeframe where we are not into extended hours.

MRS. O'CONNOR: Do you mean the next meeting being April 17th?


MRS. O'CONNOR: What do you mean we are into extended hours by then?

MR. CHAIRMAN: Well, with the House proroguing tomorrow, we go back to the normal hours.

MRS. O'CONNOR: It takes two weeks, all right.

MRS. COSMAN: Mr. Chairman, I just want to get back to the full committee on the subcommittee's work and scheduling a date for that, because I do not want it to get too far away from us. Would you look at a schedule for that, please, because it is going to get off the track again? I do not want that to happen.

MR. CHAIRMAN: All right, could we aim for April 17th for TIANS and the restaurant association, and for April 24th to deal with the committee? What we will then do is circulate the draft for each of our sessions and move towards completing our report and, hopefully, have it ready to table not too long after the new Auditor General's Report comes in. Of course, once the Auditor General's Report for the immediate past fiscal year is available, then we will draw up our new schedule. Robert.

[Page 33]

MR. CHISHOLM: I just want to comment on what Francene had to say. I really thought that was just unbelievable that you would dress down another member in front of the people that we had asked here. I have sat through meetings where Keith Colwell has gone after somebody who has been here from the Farm Loan Board and from other things. It may not be important to you, but there is no reason to suggest that it is not important to John or anybody else to find out what kind of remuneration, what kind of contract that somebody has. If you do not think it is appropriate, then let us bring it back to the committee.

What we do here is a hell of a lot different than what used to happen under the former administration when Bernie was the chairman of this committee. It was much more of a political adversarial thing and things have toned down considerably. I was not going after the kinds of things that John did, but I was pleased with some of the information that came out. You may not like it, but you are one member of this committee. I just thought it was rude that you would take the opportunity, or that one member would take the opportunity to dress another member down in front of the very people that we have invited here to ask.

Whether that makes any difference or not, that made me very uncomfortable. We can get into those kind of squabbles on a regular basis, if we want but I do not think it does us any good to do that in public.

[11:00 a.m.]

MRS. COSMAN: It is laudable that you are coming to the defence of the Chairman and . . .

MR. CHISHOLM: I am not coming to the defence of the Chairman, I am coming to the defence of the committee.

MRS. COSMAN: Well, you are because he is quite able to dress me down if he so chooses. I think that the seeking of the information that is sought, I have no problem with that, but we are saying comments that I think will show on the record that I had a problem with and I don't think they were appropriate and I still would hold that viewpoint. I have no problem with asking someone what their contract is, what they are earning out of that contract. The line of what we were trying to do today was to embarrass one of the witnesses. I have a problem with embarrassing one of our witnesses. I don't have a problem with asking him about his salary but when we start to say, well, you know, you live a third of the time in Ontario and you are two-thirds of the time here, and you are being paid a lot of money, well, the guy is a doctor, he is being paid $100 an hour . . .

MR. CHAIRMAN: But he is also a doctor, Francene, who doesn't have any overheads.

MRS. COSMAN: Well, at any rate, John, if I embarrassed you, it wasn't my intention to make your life miserable.

MR. CHISHOLM: My point is not in John's defence, my point is in how this reflects as a committee to the public. That's all I am saying. John is a big boy, he can handle himself and you can handle yourself and Mike Murphy can handle himself, I just thought that kind of petulant squabbling over who intended to say what reflected on me as a member of this committee and I didn't like it.

[Page 34]

MR. CHAIRMAN: The Chair appreciates both interventions and I think this is part of our continuing evolution as a committee. I think it is good that we can discuss these things among each other as colleagues. We won't always agree.

MR. CARRUTHERS: I just wanted to say one little quick thing before the member left. I agree generally speaking, there seems to be a bit of a change in the tone in the last couple of meetings or three meetings and I must say that I really enjoyed the tone we had before and I hope that we don't change the tone. I didn't mean that to the Chair and I don't mean that to Mrs. Cosman or to the member or any other member here. I just get this little feeling that we are starting to change. I hope it isn't, gee, we are getting close to election, now we are going to throw out all the good things we did for two years. That is not aimed at any Party or any person but that we all take that into consideration because we were doing real good.

MR. CHAIRMAN: I think that that is a helpful intervention. One last thing, I would seek the approval of the committee to allow our committee minutes, the public minutes that is, of our public sessions to be put on the Internet with the legislative material. Hansard is going on the Internet and it would seem to me to be appropriate that we put on our committee's deliberations.

MR. CARRUTHERS: I will agree with the public committees, it is the same as Hansard. (Interruptions)

MR. CHAIRMAN: Exactly.

All right, we will meet tentatively on April 17th for the restaurant association and TIANS and on April 24th to deal with Francene's committee report. Thank you all.

[The committee adjourned at 11:03 a.m.]