HANSARD

NOVA SCOTIA HOUSE OF ASSEMBLY

COMMITTEE

ON

PUBLIC ACCOUNTS

Wednesday, February 23, 2005

LEGISLATIVE CHAMBER

Department of Health/Doctors Nova Scotia

Printed and Published by Nova Scotia Hansard Reporting Services

PUBLIC ACCOUNTS COMMITTEE

Mr. Graham Steele (Chairman)

Mr. James DeWolfe (Vice-Chairman)

Mr. Mark Parent

Mr. Gary Hines

Ms. Maureen MacDonald

Mr. David Wilson (Sackville-Cobequid)

Mr. Daniel Graham

Mr. David Wilson (Glace Bay)

Ms. Diana Whalen

In Attendance:

Ms. Mora Stevens

Legislative Committee Coordinator

Mr. Roy Salmon

Auditor General

Ms. Samantha Holmes

Communications - Doctors Nova Scotia

WITNESSES

Department of Health

Ms. Cheryl Doiron

Deputy Minister

Ms. Jane Breckenridge

Director, Physician Services

Ms. Linda Penny

Acting Manager, Accounting Services

Doctors Nova Scotia

Mr. Doug Clarke

Chief Executive Officer

Ms. Carol Walker

Policy Analyst

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HALIFAX, WEDNESDAY, FEBRUARY 23, 2005

STANDING COMMITTEE ON PUBLIC ACCOUNTS

9:00 A.M.

CHAIRMAN

Mr. Graham Steele

VICE-CHAIRMAN

Mr. James DeWolfe

MR. CHAIRMAN: Ladies and gentlemen, I would like to call to order this meeting of the Public Accounts Committee. We are pleased to have with us today representatives of the Department of Health and Doctors Nova Scotia on the subject of doctors' billing. I would like to first recognize the Deputy Minister of Health, who is well known to this committee, Cheryl Doiron, and ask her to introduce the colleagues she has with her today.

MS. CHERYL DOIRON: Mr. Chairman, I would introduce, to my right, Jane Breckenridge who is the Director of Physician Services in the department, and to my left, Linda Penny who is now working in our finance department but was very recently the Manager of the AFP.

MR. CHAIRMAN: Thank you very much. I would also like to recognize and welcome Mr. Doug Clarke, Chief Executive Officer of Doctors Nova Scotia, who is appearing before this committee for the very first time. Mr. Clarke, I wonder if you could introduce your colleague.

MR. DOUG CLARKE: I have with me Carol Walker who is a Policy Analyst with Doctors Nova Scotia, and directly behind me I have Samantha Holmes who is with the Public Relations of Doctors Nova Scotia.

MR. CHAIRMAN: Thank you very much. I would now like to ask the members of the committee to introduce themselves, starting with the member for Halifax Needham.

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[The committee members introduced themselves.]

MR. CHAIRMAN: I would now like to call on Ms. Doiron and Mr. Clarke to deliver an opening statement. I have asked them, and they have agreed, to limit their combined opening statement to 15 minutes. Ms. Doiron, you have the floor.

MS. DOIRON: Mr. Chairman, family physicians are the foundation for publicly funded and accessible health care. They are often, as you know, a person's first entry point into the health system. According to Statistics Canada, more Nova Scotians have access to a regular family doctor than any other Canadians. About 95 per cent of our citizens have a

regular family doctor, well above the national average of 85.8 per cent. The system is enhanced by the support of other providers as well and we continue to look at expanding community-based health care teams working together to support primary health care.

Critical to the acute care sector are specialists. We offer highly specialized services across this province and that is only possible with the services of highly trained and experienced doctors. Our commitment to ensuring Nova Scotians have these services translate into just over $500 million each year, and that is a current year figure. We are accountable for these dollars, how they are spent and what we get from them.

The department's recruitment coordination efforts support the nine district health authorities, the IWK Health Centre, communities and the groups of doctors throughout the province. This partnership is critical for the successful recruitment of new doctors and keeping the ones we have.

Since April 1, 2004, more than 50 new doctors have been recruited to Nova Scotia. We also know that during this time, some doctors have chosen to leave. However, there has been a modest net gain in the number of doctors we have. Nova Scotians need to understand that recruitment is a never-ending story. Because of the nature of doctors' work as private contractors, they have the ability to relocate when a new opportunity comes their way or when they are looking to make a change and there are a variety of reasons why they would want to make a change: family reasons, educational opportunities, professional reasons, community fit or they simply may need a change. We hear about doctor shortages, however, it is important for people to know that Nova Scotia has a stable base of doctors. We know there are some key areas of pressure including anaesthetists, psychiatrists and family doctors in some rural areas. So the question is, how does Nova Scotia respond? I will outline four key areas.

First, how we plan for physician resources in the future will require better planning tools than we have used traditionally. We have started that process. The department is engaged in province-wide physician resource planning. We have conducted broad consultations with doctors currently practising in the province and we plan to match up

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recruitment strategies with identified gaps and problem areas in the province. This is a long-term process but one that we are very excited about.

Second, we also know that doctors, new graduates in particular, are looking to work in a technology-friendly environment. Technology not only supports quality patient care, it becomes a recruitment tool. We are working on many fronts to meet this expectation. Some examples include our Telehealth system, the first province-wide Telehealth system in the country, and still a lead in terms of looking at expanding the use of Telehealth for not just teaching but also clinical reasons. We are currently in negotiations with InfoWay to bring money to the province to allow us to move that forward.

We also have been working on the provincial implementation of a PAC system which is the picture archiving computerized system for x-rays and diagnostic imaging images. That means that we will be able to send diagnostic imaging film - not film, I guess, but image - anywhere in the province. So as long as we have a technologist who can operate the equipment, the pictures can be read anywhere. So somebody in Advocate Harbour can be diagnosed in Halifax, determinations can be made whether they need to be moved or not and we know that there are many values to this kind of system in a province such as Nova Scotia.

We are getting along very well with the implementation of a hospital information system. I know you are familiar with MediTech. There are now components of MediTech in every hospital in this province but the complete roll-out won't be finished for about another year, year and one-half. This, again, is going to bring in the opportunity for records and clinical information to be sent anywhere in this province when patients have to move from place to place, or when they're travelling and need access to services.

We are also now working on the electronic health record that will be supporting primary health care, so that primary health care physicians and other practitioners such as nurse practitioners will have that opportunity to have a computerized system in all of these things and any other system we put out there being inter-operable, so that the information can be sent from one part of the system to the other or to any place in the province.

The third key area involves training more doctors. We know it's the doctors who train here who are most likely to remain here. That's why in 2003-04 we increased the number of seats at the Dalhousie Medical School by eight. That brings the total yearly undergraduate enrolment from 82 to 90 students.

The fourth and final area I would like to talk about is compensation. Last year, the Department of Health and Doctors Nova Scotia reached a four-year funding agreement for fee-for-service physicians. This contract helps us maintain our competitive edge in attracting and keeping doctors while living within our means. The majority of our doctors are still paid on fee-for-service. That being said, we know that new graduates are looking for alternatives

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to fee-for-service compensation and Nova Scotia is responding. In fact, we are among the country's leaders in the development of alternative funding plans.

We know we need to do this in the context of affordability, accountability, while meeting the health needs of Nova Scotians. We have found that alternative funding plans enhance our recruitment and retention efforts and also allow us to provide stable services to some of our rural communities. AFP has also allowed us to find ways to enhance quality patient care, strengthen academic programs and provide integrated and community-based health care delivery. These are the outcomes Nova Scotia wants to see in the health care system.

To give you an idea of the importance of this, over the past seven years we have seen significant shift toward alternative funding. In 1997-98, about 9 per cent of doctors were paid solely through alternative funding. Today, it's approximately 30 per cent. These are primarily rural physicians and a variety of specialists in both urban and rural centres.

In conclusion, we know that Nova Scotia is competitive in the Canadian market. While we are not number one, financially, we know that doctors choose a home to practice for more than just money. The other attributes Nova Scotia offers in terms of lifestyle and community are among the many reasons why doctors come here. Our recruitment efforts explore all of these aspects and this requires us to work in partnership with all stakeholders.

I would like to recognize the work of Doctors Nova Scotia in this partnership. We continue to work collaboratively to achieve our shared goals. That is, to provide high quality health care for Nova Scotians. Thank you, Mr. Chairman.

[9:15 a.m.]

MR. CHAIRMAN: Thank you very much. I will turn the floor over to Mr. Clarke for his opening statement.

MR. DOUG CLARKE: Thank you, Mr. Steele. I would like to thank you for the opportunity to come and present here. In the nine years that I have been with Doctors Nova Scotia, I believe this is the first opportunity we have had to come and present to you. I think the only way we are going to be able to keep up with the increased expectations on the health care system and on its providers, such as the doctors, is by carefully examining how we do things now, having these discussions and exploring new options as we figure out ways to improve. I look forward to that discussion today.

This is also a welcomed opportunity for me to explain more about our association, how we support physicians providing care in Nova Scotia, and also, how we do work with the province and the Department of Health to make sure these things happen. As Cheryl pointed out, one of the things is, we do have a lot of doctors in the province in the specialist area. That is because of the joint work together.

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I would first like to talk about the association, Doctors Nova Scotia. Doctors Nova Scotia was formerly known as the Medical Society of Nova Scotia. We changed the name last year. We saw this as an opportunity to move to what Doctors Nova Scotia really is, which is helping the physicians and the people of this province.

The association represents the physicians, the medical students and the residents. We have about 3,000 members, of which 2,000 are practising physicians. I will just take a second to present you with our mission statement because that's what we go by. Our mission is to maintain the integrity and honour of the medical profession; second, to represent all members equitably; and the third one - and these are in no particular order - to promote high quality health care and disease prevention in Nova Scotia.

I want to talk about the third one first. We are the first association in Nova Scotia to put more than 15 per cent of member dues back into health promotion. We are a leader in this area in the country. It is actually 17 per cent of our fees that go back into communities for health promotion. We are the presenting sponsor for Sport Nova Scotia. We are involved in tobacco cessation efforts. We are a sponsor to the Bluenose Marathon Youth Run. We were the main sponsor for the Gold Medal Plates Olympic Dinner. Our most recent initiative this year is: we have hired a staff member to launch a school-based, youth running program in which we expect to have 2,500 kids participate in year number one. Behind every single one of these events are dozens of physicians volunteering their time to help work at these events, speak to kids in the schools and be active on non-smoking committees.

Physicians want to help provide Nova Scotians with the information they need to be healthy. They know that one of the key ways we can reduce waiting lists is to prevent the patients from walking through the door in the first place. Unlike most other services, physicians are trying to reduce the demand. We have spent a substantial amount of money on health promotion but also in creating a Web site for the people of this province so that they can move towards a more healthy lifestyle. Unfortunately, as we are all aware, despite these efforts, there is - and we can expect that there will continue to be - a high demand on services, especially as our population ages.

We talk about new delivery of funding models. In order to meet these ever-increasing demands for physicians' time and services, physicians are continuously looking at ways in which they can improve on how they deliver health care, while also exploring new models that will help them obtain a better work-life balance. Recognizing this is what our members are looking for, our association strives to offer the membership options in their remuneration to support various practice and delivery models.

We have learned that there is no one ideal funding model for all physicians and by creating options, we will have better success in matching the physician job to the area that they would like to live. We also recognize that a physician's job is comprehensive and depending on the group or the location, the physician needs to be involved in teaching,

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research for new treatments and cures, counselling patients and their families - not just patients anymore - and, of course, most importantly, providing clinical care to their patients.

New delivery and payment models better recognize these roles and responsibilities. The Department of Health also recognizes this and we have been working closely with the department to develop new funding and care models. I am just going to briefly talk about the two main models. There are a number of different ones but the two main ones I will just touch on briefly because I am assuming that a lot of questions will be about this area.

Fee for service. It's a model that's volume-based. I would like to point out that from my point of view, fee for service is a bit of a misdemeanour. It's actually fee for encounter, the system that was designed. A lot of services that can now be done with technology are not funded through the system so, it's a fee-for-encounter system, not a fee for service system.

There are many advantages to it, a number of patients have seen the doctors seeing the patients, putting them through the system more quickly, because it is volume based - that is some of the advantages. There are disadvantages, too, in that the time you get to spend with the patient sometimes is lacking.

Alternative funding plans. Just to touch briefly on those, my definition of an alternative funding plan is anything that isn't a fee for service, so that keeps it pretty wide open. The main ones that we have are academic funding plans which are at the IWK and QE II in the Capital District, and at the present time the vast majority of specialists in those two facilities are now on alternative funding plans. It allows them to do more than just see patients, which is what the system on fee for service funds, it allows them to teach, it allows them to spend time on tough situations. As these come in, though, there needs to be changes to how we measure things. We have to make sure that the deliverables in these contracts are there and that the physicians know what they are.

I see that the Auditor General is here today. I think it's important to note that in the past he has indicated that these contracts must have deliverables and we are a big supporter of this. We believe that in order for the system to work into the future, there must be accountability on both sides and that the physicians need to provide the deliverables to the patients of this province. We can talk more about that in your questions.

Recruitment and retention. Again, the Department of Health has touched on that. We've done well in areas of this province, but we still have a couple of specialty areas - and I'll repeat them - anaesthesia, psychiatry, and we do have areas like general practitioners in the community. One of the things that we do have to be careful about as we move to new models is how we change the system that the general practitioners live under - they are the heart and soul of the primary care system and we need to change that. Governments openness to new delivery models and payment methods will be key to the success and recruitment in these areas.

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New physicians entering the health care system have indicated they're not willing, again, not willing to follow the pattern of a traditional physician role. They want to work in team settings, they want to work with other health care providers, they want to take advantage of available technologies that will help them care for their patients and, very important, they want a balanced work and personal life.

Doctors have one of the highest rates of suicide in this country. The new physicians coming out don't want to live the way physicians in the past have lived, where they're working 80 hours a week and on call the rest of the time. We are pleased to see government move forward on the Physician Human Resource Plan and look forward to working with them to put this in place. This is important as our population ages because not only is the population of the province aging, so is the population of physicians.

In conclusion, there's a lot of work to be done to improve the system. Our association, along with its members, is open to any discussion that will help make positive change for the profession. We are not wedded to any one particular method, we are open to any.

I'll use this opportunity, while I have the floor to talk to this group of decision makers, to remind you that success in improving our health care system and its associated spending, will only be possible if the politicians, the bureaucrats and other key decision makers in the system, take the time to listen and partner with the health care providers who are on the floor facing the challenges of the system every day and those are nurses, physios, pharmacists and doctors.

Hopefully, over the next couple of hours, I will be able to provide you with some insight on some of the challenges facing physicians, facing you, as decision makers and we'll be able to apply what you learn to benefit Nova Scotians and the health care system. Thank you.

MR. CHAIRMAN: Thank you very much. The first round of questions will be 20 minutes.

The honourable member for Halifax Needham.

MS. MAUREEN MACDONALD: I want to start maybe just by saying as you were both speaking I was thinking about Dr. Margaret Casey, who was recognized, I think, last week with the Order of Canada and shortly before that, I think, in the Spring with an honorary doctorate from Dalhousie. I'd like to say she was my family physician for many years and it was such an honour, I felt so heartened when I saw the recognition of her work. I think that for many of us, when we think about our family doctors, whoever they are, it

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engenders that kind of - often, I think - goodwill, because they are the people who have been there for us when we've really needed them.

I think without any question the points you've made about physicians as the foundation and the backbone, in many respects, to our health care system is so true. Having said that, this topic today is an area sometimes that I feel, as my Party's Health Critic, is not sort of discussed enough. The future of our health care system is very much relying on how we develop and use our human resources, and the physicians are an extremely important part of this. So, how we use our health care dollars - I guess I would say - to create an environment that will result in good quality health care is very important. I think that some of the changes you're speaking to here today, around alternative funding plans and what have you, are not well understood, even by members of this Legislature.

When I look at the estimates that are tabled here in the Legislature at the time of the budget, the biggest expenditure in our health care area, in fact, is for medical payment, but the only detail we ever have is this one line in the budget which tells us that in 2002-03 the actual expenditures were approximately $400 million and the estimates for the year that we're currently in, the forecast or the estimate is approximately $511 million. So it's a big chunk of change for which we don't have a lot of detailed information.

I want to start by saying I did introduce a Private Member's Bill back in the Fall that would have as part of the Public Accounts, a detailed breakdown of the distribution of billing throughout the province. There was an absence of rousing applause when I introduced that legislation, I will readily admit, but this is, I think, such an important issue to help us really understand more detail than what we get in our Public Accounts. So, I want to start by asking the deputy minister, if you can tell me who has access to the billing information and the detailed information that we don't actually get?

MS. DOIRON: We definitely understand that the billings that occur in the province are open through FOIPOP, that process has been going on more recently and I know it's not completed yet, but as far as we're concerned, the dollars that are spent for physicians and certainly breaking them down by districts or anything of that nature, to me, should be information we can readily provide to anybody who would like to have it. We can certainly speak to that and give you more detail on that this morning if you would like to ask any more specific questions on it. We have no hesitancy in sharing that.

MS. MAUREEN MACDONALD: So the minister has access to this information?

MS. DOIRON: The minister would have access to that information. We may not bring it to his attention on a regular basis unless we have issues and we are into particular discussions. What we tend to be discussing more is the issue of the numbers of physicians that we have in particular areas and whether, in fact, there are vacancies and what we are

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doing in regard to recruitment and those more challenging areas, but if he wished to look at that kind of information in regard to billings, it could certainly be provided.

[9:30 a.m.]

MS. MAUREEN MACDONALD: Does anyone outside the department, outside of the FOIPOP process, have access to that information?

MR. CHAIRMAN: Mr. Clarke.

MR. DOUG CLARKE: Doctors Nova Scotia has access to it and if I could pick up on that, Maureen, one of the issues that we, at Doctors Nova Scotia, firmly believe is that the information on doctors' billings, on the alternative funding plans, should be transparent. It should be available to members of the Legislature. They should know what it costs for physicians in the province and not just the $500 million. They should know what it costs for ophthalmology services. They should know what it costs for general practitioners in any community. What we don't see any benefit in, though, is having the names attached to each one of those. If you are setting health policy, we believe it is absolutely important that you have all that information. However, tying it to a particular physician does, in our view, nothing to help the system develop a better look at it but as far as having a breakdown of that, we would have absolutely no problem and if we could help in making sure that people understand what that $500 million is made up of, we would be pleased, if you need more information in the budget packages, to work with the Department of Health. Again, it's their package but we could work with them to provide areas where it is, disciplines where it is, specialities where it is, so you have a handle on it, but as far as the individual, we have a concern about that.

MR. CHAIRMAN: I know Ms. Doiron wanted to add something briefly to that.

MS. DOIRON: Mr. Chairman, all I wanted to add was that, of course, the billings are managed for us through ABCC, the Atlantic Blue Cross Care. Certainly we own the data and will continue to do so but we can have access to that data at any time and in any way that we would want to break it out. Through the negotiations we are currently carrying out with them, they will be actually implementing more up-to-date electronic systems that should allow us even better opportunity to do that kind of analysis and breakdown. So if it would be helpful for the Legislature or the people of Nova Scotia in whatever fashion would be suitable in terms of sharing that information, we have no hesitancy in doing that.

MS. MAUREEN MACDONALD: I really appreciate the points you both have made. I think we have hit a point in health care reform in planning where there is an appetite for primary health care reform and let's get on with it and, maybe, on some level a bit of frustration. You hear physicians speaking about their wish to have nurses in their practice but their inability to get nurses under the current regime or their wish to see a medical patient

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record province wide but with the extreme cost, the burden of the cost of the technology and the training that that will require, I think that there is some frustration.

I want to go back and I think it would be, yesterday I was at the Mental Health Conference all day and it was interesting at the end of the day I met with some folks who were concerned about access to psychiatric services and were telling me about a psychiatrist who is unable to get a billing number. That triggered for me the whole issue of how do you get billing numbers in this province? How do physicians get a billing number? I don't think this is well understood. So this is maybe an opportunity to explain to the members of the House and the public exactly how this system works.

MS. DOIRON: I'm going to ask Jane Breckenridge to address that.

MR. CHAIRMAN: Ms. Breckenridge.

MS. JANE BRECKENRIDGE: At the present time there are no restrictions on billing numbers. If a physician moves to the province and wants to practise in this province, they are able to access a billing number.

MS. MAUREEN MACDONALD: So this person with psychiatric specialization could, in fact, just open an office and locate, and that would be the end of the story, whether there is an over-supply, let's say, in an area, or there is an under-supply to other areas, like Yarmouth, for example.

MS. BRECKENRIDGE: If you'd like, I can address that. There are also areas in which there are alternative funding plans that are in place and if an alternative funding plan is in place and people are working full-time within that plan, then in those situations, they would not be billing outside of that plan. If they wanted to move to an area where an alternative funding plan was the mode of remuneration, then they would belong to that alternative funding plan.

MS. MAUREEN MACDONALD: So would it be fair to say that the alternative funding plans then are a mechanism that have some incentives built in to try to encourage physicians to locate in areas where they are most needed? Is that how it works?

MS. BRECKENRIDGE: Actually, I would like to refer that back to the deputy minister, thank you.

MR. CHAIRMAN: Ms. Doiron.

MS. DOIRON: I think that we have seen that alternative funding plans actually have had a positive effect on recruitment. Part of what that does is allow some of the different forms of practice that Doctors Nova Scotia referred to. Basically, what we have been

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attempting to do is to support more collaborative practice opportunities and groupings, regardless of what they may be and where they are located. We would certainly like to move forward more actively on that. So where it is appropriate for people to work in teams and where, in fact, we are able to attract doctors because of a different way of funding them, we really have seen, I think, that that has allowed us to really bring and retain physicians to the province.

So, yes, one of the factors, though, is that, of course, if somebody chooses to enter into that, we certainly don't force them or push them that way. Then they can't bill under the fee-for-service plan. So if, in fact, a doctor, psychiatrist, or otherwise, comes into that kind of situation, then they would not be permitted to bill otherwise. So whether the instance that you spoke about has any relationship to that, I'm not sure.

Certainly, I think that there are a lot of attractions to go toward a more salaried approach. I think it was about two years ago when the Canadian Medical Association did a review, a survey of their members across the country and there was a very high rate of response. I'm thinking somewhere in the territory of about 70 per cent of doctors who were actually interested in going to some kind of alternative payment approach.

MS. MAUREEN MACDONALD: Thank you.

MR. CHAIRMAN: Mr. Clarke.

MR. DOUG CLARKE: Just with the specifics of that, it's the position of Doctors Nova Scotia that any physician who moves into the province can get a billing number, as Ms. Breckenridge said. We have negotiated away the right, in some of the alternative funding, for them to use that billing number, so what we do is, we call it put in abeyance while they are a member. But there is no reason that anyone can't get it if they're not in the alternative funding plan. That's held while they're in there. It's separate.

Just a second thing to touch on, the alternative funding plans have been very successful in allowing us to recruit. We've made some in-roads in some areas. In areas where we have them, we don't have vacancies. We have very little turnover and we have very few vacancies.

We have been able to compete with other provinces that have significantly better funding mechanisms with regard to the amount that they get for fee for service. So these things, for the specialist portion of our group, especially in the Halifax-Dartmouth area, the IWK and the Capital District, have been exceptionally good in helping us recruit and retain the physicians that we have.

MS. MAUREEN MACDONALD: Thank you. So it would be fair to say then that the alternative funding plans are successful in terms of delivering recruitment and, maybe,

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retention as well for people, certainly, in the specialty fields. But what about in the rural areas? How successful have they been there?

The other question I would have would be in relation to what the Auditor General has

flagged in the past, other measures for success. I guess that would be the volume of work that gets done, that people still have access to physician services and that the need is met in the communities where people live.

MR. CHAIRMAN: Mr. Clarke, why don't you start and then we will move it on to Ms. Doiron.

MR. DOUG CLARKE: Okay. First on the rural areas - let me identify - there is really, in the rural areas, two types. We have a specialist alternative funding plan which are really provincial plans, where we negotiate a rate, for example, for an anaesthetist, for all the anaesthetists in the province, outside of the Capital District, and then they can determine whether they want to sign on to these, or not.

They have not been as successful as the ones in the Capital District. We have some people on them. They are getting better. It's a learning experience, as you can imagine. We had 30 years of fee for service. We are moving to an alternative funding. It takes a while to get there. I like to tell people that we're absolutely the best at it in the country and we're absolutely the worst at it because we have had a lot of experience in doing it and we are getting better. So I think it's going to improve.

There are also general practitioner contracts outside of Halifax. They have been a Godsend. They have worked extremely well. We do not have the problems in rural areas that a lot of other provinces have. Now, having said that, if you have two doctors in an area and one leaves, you have lost 50 per cent of them, so you have a problem in that particular area. But, in general, we do not have large turnovers.

There are a number of rural areas that need physicians. Hopefully, we are currently working with the Department of Health and the College of Physicians and Surgeons of Nova Scotia to work for international medical graduates, to bring them on and to bring them into areas where we need them in the province. I think, from those, they are working but they are not great. We need to get back.

With regard to the Auditor General's comments on measures, when alternative funding plans started, the measuring tool that we used was the same tool that we used on the fee for service. It's not the right measuring tool. The reason we are changing the system is because we are not just providing that clinical care. We are providing more than that. We need to improve that but having said that, we are currently working on the biggest one right at the moment with the Department of Health, which is the Department of Medicine at the QE II, which is 150 specialists, approximately.

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I will say that having gone through the experience, and we are getting close to a contract, that the measurable deliverables that we have are as good as any business in this province would have at the end of this. So we are getting there but I think what's important for the members to realize is that we are not measuring the same thing we were measuring under the fee-for-service system. That is one of the components but we are also teaching, we are also doing research and as we said before, very importantly, we are seeing patients in this province, and making sure that they are seen clinically.

MR. CHAIRMAN: Ms. Doiron.

MS. DOIRON: Thank you. I want to support what Mr. Clarke has been saying because, certainly, we see it the very same way, no difference in interpretation, whether it's the Department of Health or Doctors Nova Scotia, because we are both seeing the same results.

We have, I think, that shared commitment to try to define and improve the actual deliverables and we are probably, again, breaking ground in this province because I don't think it's been as effectively developed in other areas. We were early in on AFP and I think we are now heading out to some other levels of accountability around that. I think that it makes it a lot easier to kind of get to the other side of that when both the department and Doctors Nova Scotia share that commitment. We are not losing energy in terms of trying to get to that shared point.

So now it becomes a matter of working with both of our groups, with a particular specialist group or whatever group we are trying to define the deliverables around. While we have been working on principles around deliverables, these specific deliverables will be specific to each contract and particular specialty or GP group.

I would like to make you aware, as well, that Dalhousie University had informed us that prior to AFP being introduced into the setting at Capital Health and at the IWK, they were rated as 11 out of 16 medical schools in the country - they are now rated at five out of 16. So, they believe that that has actually brought their rating substantially higher and certainly interests a lot of people going into medical school, so I think that's another positive effect that we've seen from them.

[9:45 a.m.]

Finally, I think that with the Auditor General's comments mainly around deliverables, I think we will be in a position to more greatly satisfy that and probably it's incumbent on us from the Department of Health to get together with the Auditor General and to give a fuller explanation of where we are with that kind of process. We will be intending to do that in the near future.

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MR. CHAIRMAN: That brings us to the Liberal caucus for the next 20 minutes.

The honourable member for Glace Bay.

MR. DAVID WILSON (Glace Bay): Good morning, everyone, it's great to see everybody here. I guess we've reached a new era in co-operation or something, everybody is smiling and happy to be here this morning, and co-operating to a great extent. So, I guess I'm left wondering if that's the case and information is flowing freely then why do some people have to file freedom of information requests to get information that they're requesting and what's that based on? I guess I could ask that question and I will, eventually, but I'm just speaking out loud at this point in time.

I agree with my colleague from the NDP that it's not an area that is discussed enough but I would also suggest that it's an area that a lot of people really don't spend a lot a time worrying about, whether a doctor is funded by fee for service or an alternative funding plan, because if you're in this province and you've spent eight or nine hours in an emergency room waiting to see a doctor and there's none available, and you don't have a family physician, and you don't have a clinic to go to, you really wouldn't care how much you paid that doctor as long as he or she walked in the bloody room and started waiting on you at that particular point in time. In general, most Nova Scotians would say, I think, what's an alternative funding plan and how much are doctors paid?

Now, I would suppose there are some people who would say that doctors are the problem in the health care system. Do they get paid too much money? Are they not working hard enough? We had the opportunity last year of travelling this province and speaking with health care providers across the province in our round table for wait times. We talked to doctors and physicians in rural parts of this province who have caseloads of 3,000 to 4,000 people, who are tired beyond even explanation. I was amazed they were at the meetings that we went to, they were that tired. They told us, as a person, that the most important thing for them is not how much they're getting paid, the most important thing for them right now is a quality of life, that's what they're worried about.

New doctors coming into this system aren't looking to make hundreds of thousands of the dollars. They're going to other parts of this country and other countries, as a matter of fact, so that they can get a 9 to 5 schedule and have time with their families, that's what we've heard so far.

So, I would be interested in knowing first of all from the deputy minister, you made the point there has been a significant shift to alternative funding plans right now. The majority of physicians in this province are on a fee for service but I'm interested in knowing exactly how much of a significant shift towards AFP and if in the future, as you see it, is that going to be the way, the AFP, instead of fee for service? Are we at the cusp of replacing the fee for service with alternative funding plans?

[Page 15]

MS. DOIRON: Thank you for that question. At this point in time I think we do see that there will probably be more interest and uptake for AFP and probably there will be more of that interest in some of the more rural areas. As well, most of the doctors in Capital Health who are specialists are on that so there may be more family physicians in this area who would prefer to choose that. We have heard interest expressed by some other groups of GPs who are outside the Capital Health area, so I think it's a matter of simply allowing that to come forward and to allow them to make those choices and, I think, we will see more of that happening.

The other area that we certainly see growth in and much more interest in and we get quite a few, either suggestions, proposals, or questions, is around collaborative practice. We have moved forward on some of that and I know in some of the smaller rural areas where people were concerned about whether they would have access to a doctor on a regular basis, when some of the districts first introduced collaborative practice with a nurse practitioner and maybe other professionals into a practice area, initially there was a fair level of feedback from the community saying, what is wrong with us, aren't we good enough to get a doctor, that we're going to get a nurse practitioner?

Now that we have about 13 of them out there in various areas and communities, now we're getting feedback from many communities saying, what's wrong with us that we can't have a nurse practitioner? So I think that through a variety of mechanisms we are going to see growth, in terms of physicians who will choose to enter into these alternative payment schedules on their own, or in groups of physicians. I think we're also going to see a substantial growth in other ways of coming together as teams in terms of particularly things that could be very valuable to some of the rural communities, and take a lot of pressure off the doctors who have been constantly the front end of a system. In some of these other collaborative approaches, there can be some limiting of that with other practitioners, carrying out the roles that they can provide, that doctors will not have to do what they are currently practising. I think we will see a lot of progress in that area over the next decade.

MR. DAVID WILSON (Glace Bay): Mr. Clarke, I would like to ask you a couple of questions, if I may. We're talking about doctors who are on the front lines, and you mentioned general practitioners. You would consider them, I guess, to be the heart of the system. You mentioned that we need to change the system for GPs. How so?

MR. DOUG CLARKE: Well, I think what we have to do is provide options. It's been said two or three times here today, with regard to new students coming out, they don't want a lifestyle like what has existed for GPs in the past. They want to work in teams.

Our school system now in this province, all the way up, you work in teams, the whole school system. You get to Med school, you work in teams. Then you graduate and you go work by yourself in communities and it's very hard. Over a long period of time it's draining. The whole system is built on their backs. So we need to work, as Ms. Doiron was saying, in

[Page 16]

these teams and that has to be done. But in order to do that, the fee for service system doesn't work. It has to change. The funding model, whatever it is, has to change to accommodate that.

I don't think we'll ever get away entirely from the fee for service system, nor do I think we should. There are a lot of people that would like that, they are independent contractors who want to put a lot of hours in and see a lot of patients. That's good for the system. There's a balance, no question about it, but have a lifestyle for the physician. At the same time, we want to make sure that the physicians that are graduating keep up their skills, are seeing patients and the patients in this province are getting access. That's our main goal, so the system needs to change.

MR. DAVID WILSON (Glace Bay): Are you telling us then that in terms of recruitment, in terms of retention, that going to an alternative funding plan would actually solve those problems? There are chronic problems in this province.

MR. DOUG CLARKE: I don't think anything in and of itself will solve those problems entirely. An alternative funding plan is one mechanism involved in the team work approach. For example, if you have a nurse practitioner in your office, you have three docs, two nurse practitioners, and let's toss in a social worker and a couple of others to make a good system there, that system is only going to work if the model for funding that group changes because, right now, the physicians get paid for only seeing the patient. If the nurse practitioner sees them the physician doesn't get paid.

So what you want to do in a system like that is have the individual that's best, most appropriate to see the patient, see them, and if it isn't the doctor, that's fine, but there has got to be some funding mechanism that allows that group to get paid, not necessarily just the physician, the group. That's what I'm talking about, alternative funding. When I mention alternative funding, I'm talking a broad spectrum which, in my definition, is anything but fee for encounter.

MR. DAVID WILSON (Glace Bay): Deputy Minister, you stated that we have a stable base, I think, were the words that you used, in terms of supply of doctors, let's say, for lack of another phrase, in Nova Scotia, but what about the rural area in this province? You wouldn't describe that as stable in terms of doctor availability?

MS. DOIRON: If you look at all of the rural areas over a period of time, we probably can say that there is a reasonably stable supply of physicians in the rural areas. But, as has been pointed out already, if you go into a small community that has, maybe, one, two or three physicians practising and one of them leaves, then you certainly can get a problem for the period of time it takes to replace the physician. So I think that what you see is more of the highlighted concerns that come from those smaller communities which may make it appear that there are real problems out there in the rural community, but taken together and over a

[Page 17]

period of time, we don't see that level of turn-over that will kind of suggest a level of crisis. That's not to suggest that there can't be real problems at times, stabilizing a particular community again. But we do try to also provide some incentives for physicians to go to those areas that are outside of more urban-type settings.

MR. DAVID WILSON (Glace Bay): Excuse me for interrupting but, right now, the most stable area would be the metropolitan area of Halifax-Dartmouth and so on. That is where most of the AFPs are, are they not? That's what I heard here today.

MS. DOIRON: There are many AFPs in the Capital District area but we are also getting an increasing number of AFPs out in other areas of the province. Certainly, if you look at the Cape Breton area, I think they would suggest that they have a reasonably stable supply of physicians as well, but they may find particular communities at a time are so challenging.

MR. DAVID WILSON (Glace Bay): I'm glad you brought it up because on any particular day in Cape Breton, there can be an emergency room in Glace Bay, New Waterford or in North Sydney that's closed because of a physician shortage.

MS. DOIRON: That's correct.

MR. DAVID WILSON (Glace Bay): So I would consider that to be somewhat of an urban area. I know people in Halifax like to think of Cape Breton as rural but we tend to think we are somewhat urban anyway. We're close to it. We're getting there eventually. But, I mean, that seriously is a problem that has been, as I said, a chronic one and through physician recruitment, AFP and whatever else has been tried in this province, it has not worked. The problem is still there, wouldn't you agree?

MS. DOIRON: I think there are some problems that we still have which is, I think, one of the reasons why we are looking at other approaches for ensuring that we can provide more stability through alternative means. We are now working, of course, as other provinces are, with Health Canada, looking at various models of alternative payments. I mean, there are various approaches that can be taken with that so it's not AFP or fee for service, it's a variety of models that are being explored to see where they will work best. Some models will work fine in Capital Health and the university setting, but there may be a slightly different model that might be more effective for some of those smaller areas.

MR. CHAIRMAN: Mr. Clarke, I don't know if you have something you want to add.

MR. DAVE WILSON (Glace Bay): But before that, Mr. Chairman, could I ask how much time I have left?

MR. CHAIRMAN: Certainly. You have seven minutes left.

[Page 18]

MR. DAVE WILSON(Glace Bay): Okay, I'll be sharing some of my time with my colleague for Halifax Citadel.

MR. CHAIRMAN: Thank you. Mr. Clarke.

MR. DOUG CLARKE : Just very quickly. Mr. Wilson, you are absolutely right, the system that we have now - and I would agree with the Deputy Minister - there are areas of stability and I think, overall, we are doing okay but there are chronic areas where we have problems. That is no question. Strait-Richmond is in the paper every second week, all right? That's a problem area where we have to look at another method of resolving that problem. We have problems in Yarmouth. We have problems recruiting general practitioners to the Yarmouth area. So there are problems that the system hasn't resolved that need to be resolved. If you are taking the words that we are saying, that the system works perfect in this province, it doesn't. There are problem areas and they need to be fixed.

Having said that, we do have, I believe - using the Deputy Minister's words - a solid base to build from but we need to fix some areas of this province. I believe the system that the College of Physicians and Surgeons is working with us on, which is to look at international medical graduates, train them here in this province and have them go into areas with time frames to stay there, will help, but again, it probably won't solve all of them.

MR. DAVID WILSON (Glace Bay): Well, before I turn over the remainder of the time to my colleague, let me ask you, Mr. Clarke, then if you are going to have problems recruiting physicians when organizations and political Parties in this province are going around filing freedom of information requests to get the salaries of every physician. Is that going to create a problem for new doctors coming in? Are doctors not in an uproar right now over that happening?

[10:00 a.m.]

MR. DOUG CLARKE: What I can tell you is in the nine years that I have been at Doctors Nova Scotia, I have never seen such an uproar from the physicians in this province. They have no problem with transparency of incomes or transparencies of monies earned by physician groups in communities and that but they are absolutely clearly upset with the approach that was taken to have what they believe is private information made public for, in their view, no good reason.

MR. DAVID WILSON (Glace Bay): Let me turn the floor over to my colleague, Mr. Chairman.

MR. CHAIRMAN: With a little over five minutes remaining, the honourable member for Halifax Citadel.

[Page 19]

MR. DANIEL GRAHAM: Thank you, Mr. Chairman. I'm not sure whether I am going to get through all of this. We may be able to pick it up in the second round of questioning with the time that we have left. I want to, because I think it is important to commend Doctors Nova Scotia for their incredible work around the question of health promotion and committing 17 per cent of those fees toward the health promotion, disease prevention areas including the foresight that is recognized by you in putting it toward Sport Nova Scotia, the Bluenose Run, anti-tobacco movements, all absolutely solid stuff and I would encourage you to continue to do that. I would also invite you to explore other areas that are health concerns with respect to other types of addictions like, for example, VLTs in this province and the desperate health concerns that are created by the addictions by Nova Scotians to VLTs, approximately 15,000 people in this province are problem gamblers and it has wide implications.

Let me go to the broader issues. Fiscal challenges. Three years ago, when I first got involved in politics, one of the first things, the big wall that faces somebody who gets involved in public service and the way that you have described them, I think you described the dynamic around your role and our role rather accurately. We are faced with fiscal challenges in this small Province of Nova Scotia and it's the first thing that one encounters when you start to make choices and you look at the growing problem with health costs. It's not just about physicians, it's about increased technology and aging population, cost of pharmaceuticals, but it also relates to the cost of the physicians who provide the service because that's an enormous part of the overall budget.

I noticed last year that while there was talk that health and education were going to be protected in last year's budget, the commitment in increased revenue to health was in the range of $240 million whereas in education, it was about $22 million. The people in education have a belief, rightly or wrongly held, that when health wins, education loses in this province because there is a finite pool of money to go around. So when you create efficiencies, the students who are in our classrooms are the ones who potentially win at the end of the day.

So I want to walk down the path with respect to alternative funding and ask you some questions about that. I see the two greatest issues that face health care, the two most popular subjects are controlling costs while maintaining service and primary health care, providing good health care. Those are the two big issues out there. I see them as win/wins when we approach the question of how physicians are ultimately remunerated.

Ms. Doiron, you spoke about I think at least five advantages that are created through alternative funding: enhanced recruitment, stabilized rural environments, more time with patients, integrated programs, and I would just take some additional advantages, less administrative costs, increased efficiencies with patients. Consider those patients who come to an office and are being serviced by a doctor instead of a social worker, are being serviced by a doctor instead of a nutritionist or a health educator or a nurse practitioner. Those are all

[Page 20]

efficiencies, particularly in areas where they have the population to support that, that I think ultimately can be created. It is interesting to note that while we have 30 per cent of our physicians on AFP, it would appear that 70 per cent of them find this to be a favourable alternative.

So my question ultimately relates to how radically are we prepared to move in these directions? How many sacred cows are out there? Recognizing that one of Mr. Clarke's biggest issues with respect to family physicians, which I think it is absolutely valid, is that the encounter fee program needs to change, because family physicians are being asked to follow their patients when they're carbon copied on everything that happens with specialists, but they don't get paid a nickel or dime for that. At the same time, they will be sued if they don't properly follow the patient's progress through the system. Something needs to change, I would suggest, in that respect. So that is something they need.

On the other side of it, I'm not sure, Mr. Clarke, that it is the doctors who should just have the choice all the time and that will drive the move toward alternative funding. If, as a matter of public policy, it is decided by the Government of Nova Scotia that we need to move in that direction more radically than we have, then let's make it happen and let's ensure that it is sufficiently attractive for everyone out there to make it happen. Who is in charge here? It seems to me that the government is, it represents the people of Nova Scotia and if a more radical move to alternative funding is the way we need to go, let's make it happen.

MR. CHAIRMAN: That concludes the time for the Liberals.

MR. GRAHAM: I will get to my question after we finish because there is a specific question that follows directly from that.

MR. CHAIRMAN: I would like to turn the floor over to the PC Caucus.

The honourable member for Pictou East.

MR. JAMES DEWOLFE: Mr. Chairman, I hate to interrupt my colleague there. He was on quite a roll, but we will get back to that and we are looking forward to hearing more from you.

Good morning, ladies and gentlemen. Thank you for being here and good morning, deputy. Ms. Doiron, in looking through the legislative binders that we are provided, I see that the statistics on doctors' billing indicated that doctors have increased throughout the whole of the province since this government took office in 1999. I think that is significant considering the fact that we hear of certain challenges in finding specialists and particularly in some communities in the province, as was previously indicated. I am just wondering, what do you contribute to this increase in numbers?

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MS. DOIRON: I think there are a number of things that contribute to that increase. Certainly, I think we have remained reasonably competitive in terms of the remuneration that we have been paying. I believe that also, through the negotiations that take place with the various groups, we have been increasing some of the numbers that they can recruit to their various groups and because of the options that have been there in a number of areas for going to AFP, I think that has attracted some doctors to come and fill the additional positions that we have identified in many areas. In addition to that, we have added resources to the system on several occasions to try to bring together groupings of health professionals to form teams out in the practice areas and this seems to be becoming a much more preferred way of practising, as Mr. Clarke has referred to.

So probably with other factors involved, we have brought that together and the increases that you will see basically combine some of those factors so that while you might see, for example, in 2003-04, that the actual physician dollars went up by 9.3 per cent, some of that would have been in terms of the additional salaries or dollars that were given to physicians and some of those dollars would have been in some of those areas I'm referring to, particularly in permitting them to fill more vacancies.

For example, this past year we recently concluded the first AFP with the psychiatrists in the Capital area and within that, I think we brought them to a level that was sadly lacking for a period of time. We brought them to a more competitive salary level and we added a substantial number of positions to allow more attractive practice in the field of psychiatry and more opportunity for patients to have access.

MR. DEWOLFE: During this same time period that I indicated, since the government took office, the province has experienced a decline in population in some parts of the province. Does the growth in the number of doctors and the decline in population mean that the doctor-to-patient ratio has grown in Nova Scotia? Also, what does it mean for improved patient care?

MS. DOIRON: We probably would see some pockets where that is the case and I guess you have to look at it community by community in the sense of knowing whether, in fact, it is one of those problem areas that have been referred to or whether it's a reasonably stable area. In areas where it has been stable relative to the supply of physicians then, obviously, that's going to change the ratio in a way that's positive for access.

We've also been attempting to up the numbers that are available for practice in areas that are having difficulty in getting physicians. So, again, through a variety of factors, there has been some positive change but there also remains some challenges.

MR. DEWOLFE: Ms. Doiron, how important is doctor billing and financial remuneration to physician recruitment and physician retention?

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MS. DOIRON: I think that it's certainly a significant contributing factor as to whether a physician is going to choose to practice or to move to Nova Scotia from another area. We know that there are some parts of the country that are likely to provide higher remuneration on a continuing basis, such as Alberta. We don't necessarily try to stay ahead of provinces on that level of funding, but we have been actually quite close to that.

In a number of areas our doctors are paid at the highest or the second-highest level in the country and certainly in all areas we would be above the middle range. There are other factors that I think influence doctors to come here. I would suggest that probably it would be the same way with a lot of businesses today, that people are looking at their lifestyle, they're looking at the opportunity to raise their families and to participate in communities that they feel comfortable working and living in. I think Nova Scotia offers many of those kind of options. We hear from many people coming into the province that that is part of the reason for choosing to come here.

MR. DEWOLFE: There are other factors to keep doctors here, too. My own personal doctor said it was challenging getting offers from the U.S., to go across the border and he chose to stay. He said it's a beautiful part of Nova Scotia and indeed, there are lots of beautiful parts of Nova Scotia. In the last number of years we have state-of-the-art schools now in most areas and more coming, and improvements in health care - MRIs. That keeps other professionals here, too, when you have things like that happening across the province. So, I guess there is a lot of factors involved in retention of physicians, I would expect.

We hear a lot about shortages of doctors, particularly from areas where there is a definite shortage but I'm wondering about other provinces and other jurisdictions. I'm sure you look at those areas, too. Are they experiencing any similar shortage of physicians?

MS. DOIRON: Absolutely, there is probably similar situations across the country, particularly in specific areas. The areas that we mentioned, for example, with anaesthetists and psychiatrists, I would suggest it's even greater than a national issue, so it's probably an issue in countries beyond Canada but it's certainly is an issue across the country. We meet pockets of that, certainly, that's why we took measures in the past year or so to create circumstances that would be attractive to physicians to come to practice in those areas.

We are still having, as I think you know, quite a challenge in the Capital area for anaesthetists, so that's work that is being carried on between the district and the department

currently and hopefully we'll have as much success there as we've had with building up the psychiatrists, but it has not yet been achieved.

[10:15 a.m.]

Yes, we have put in other areas high-level diagnostic equipment that doctors are basically trained on today as they expect to have the resource available to them. We've now

[Page 23]

become, I think, the lead province in the country in terms of access to MRI and we'll be building on that further, so we do still have many challenges. We have attempted, particularly in the rural areas, to provide incentives and to get new graduates to go to specific communities we identify as areas that need physicians. We basically have a plan that allows them payment of their fees that they come out of school with so their expenses are covered off for a period of three years for up to $15,000, and a variety of other mechanisms. So, put all together we are looking, at this point in time, at being on the higher end of the supply across the country, as opposed to the middle or the bottom end.

MR. DEWOLFE: In broader strokes, you hear a lot of statistics about health care workers and at the end of the day it's rather confusing. I was wondering, in terms of actual numbers of doctors and nurses, how does Nova Scotia stack up with other provinces based on population? Any statistics on that whatsoever? Ms. Penny, maybe you have something.

MS. DOIRON: I'll start that answer and then maybe I'll hand it over to Ms. Penny. Again, we are doing reasonably well in that supply area but, as we know, the entire country went through a very difficult time during the 1990s with the federal deficit reduction program. What the results of that were was to lay off and to reduce the supply in schools of many of the professions. Certainly among the top areas of concern would be physicians and nurses, but we're also into areas of concern around pharmacists, around other professions like lab technicians and so on. We have been rebuilding in those areas but it's going to take time to get that supply. I'm going to ask Linda to give more specifics here.

MR. DEWOLFE: Just the ratio where we stack up . . .

MS. LINDA PENNY: We're second-highest in the country for family physicians and we're highest in the country for specialists, and that's the latest CIHI data.

MR. DEWOLFE: Based on population. Wow, that's really is something.

MR. CHAIRMAN: Mr. Clarke, you want to add something.

MR. DOUG CLARKE: Just one thing I want to clarify on this. The numbers, we are high, but I also want to point out that the denominator that you're using here, we have to change it because we're not only serving the population of Nova Scotia. We have a huge number of physicians who are serving the populations of New Brunswick, P.E.I. and Newfoundland and Labrador. In the Children's Hospital, almost 30 per cent of the patients that they see are from outside this province. So, when you're taking the numerator of how many people are in this province and dividing it by the number of physicians, that's not what you have to do to get the proper statistics. We are one of the very few provinces that actually has a huge percentage of the population that we serve from outside the province. Whereas in Saskatchewan you can take the population, divide it by the number of doctors, you can't do that in Nova Scotia.

[Page 24]

MR. DEWOLFE: Just before I pass to my colleague, the member for Kings North - and thank you, Mr. Clarke, that's something that we can be proud of too, that we have the quality of physicians here at the Children's Hospital and so on, that attracts patients from out of province - I want to very briefly find out how many physicians have been recruited to Nova Scotia last year and how many have been recruited since the government took office? Can you give me those numbers very quickly so I can pass to my colleague?

MR. CHAIRMAN: Ms. Breckenridge.

MS. BRECKENRIDGE: I can tell you that through the physician recruitment coordination efforts within the Department of Health, 50 new physicians have been brought in since 2004. As Ms. Doiron mentioned in her opening remarks, that is a gross number and, obviously, the net number would be lower than that.

MR. DEWOLFE: Yes, because we didn't have any statistics in our binders on that. Thank you, I'm going to pass to my colleague, the member for Kings North.

MR. CHAIRMAN: With a little under seven minutes, the member for Kings North.

MR. MARK PARENT: I want to take a page from the member for Halifax Needham and talk about how proud I am of my own family doctor and of the doctors in our area who do very hard work. Not only do I have my own opinion to back it up, I found a biblical passage which - oddly, I look at the Bible now and then - to honour the physicians because God made them. I never knew that was in there but anyway. So physicians can claim - it's an Apocryphal book, The Wisdom of Jesus, Son of Sirach, or Ecclesiasticus, but it's still in there. Anyway, that being said - and the good news that my colleague for Pictou East talked about, I think, needs to be underscored.

I do have some concerns about certain billing practices that I want to ask you about. One is that, when a doctor applies to do a clinical study, for example, they also bill for the same patient, so they get money to do that clinical study and then using the patients that they have, they bill the department for a visit for them. Is that a common practice in Nova Scotia and is there a concern there?

MR. CHAIRMAN: Ms. Breckenridge

MS. BRECKENRIDGE: The payment that the physician would receive would have to be as a result of them providing a service to the patient, so the billing schedule is quite clear in terms of the fact that the service would have to be provided to the patient. That service would have to be provided in order for the physician to collect the fee through MSI.

[Page 25]

MR. PARENT: But my point is, they are providing that service but they are getting money to do the study on top of it, so in a sense, it's almost double-billing, isn't it? Is there a concern here?

MR. CHAIRMAN: Ms. Doiron.

MS. DOIRON: I don't believe so because based on what occurs with the study, often the dollars that are coming in to support that kind of research are for other things other than physician fees. For example, most of the studies would involve maybe some researchers that would be hired to support the process, or it may be to hire a nurse in order to participate in the activities of the study and not specifically for the patient treatment that the doctor would be giving. So that, in my experience, that has been allowable billings.

MR. PARENT: Do you monitor that, then, as a department?

MS. DOIRON: We are aware of many of the research projects that are going on out in the system and certainly through the Nova Scotia Health Research Foundation, there is a definite monitoring of any dollars that are provided through that or dollars that they leverage by bringing them in from other research funders.

MR. PARENT: Okay. I have a specific problem in my riding which may be replicated in other ridings. As, increasingly, doctors move to try and have a better lifestyle, what is happening is that we have doctors opting not to follow their patients through in the hospital. In my particular setting, the specialist has them for one or two days but then the physician takes over from there.

We have a clinic starting in Wolfville, for example. They will see their patients from 9:00 a.m. to 5:00 p.m. but they won't follow the patients through the hospital, so that other family doctors have to pick up the slack. They are frustrated with this because the fee that they get to cover a patient in the hospital is less than the fee that they would get to cover that patient in a clinic, simply because the negotiations by the family doctors put a higher price on the fee in the clinic. In the Metro area, where most of the doctors are, for example, they usually don't follow the patient through, the specialist takes over. Are you aware of that problem and how do you intend to solve it?

MR. CHAIRMAN: Ms. Doiron.

MS. DOIRON: Yes, we are aware of that issue and it's an issue not only in Nova Scotia but it's been a growing issue across the country. There are, again, some ways that we can approach that where the volumes of patients that are in that situation are great enough. Then we have, actually, in some provinces, introduced what they call a hospitalist or a GP who is kind of specialized in some areas, and basically will pick up on the patients that are coming in who don't have a family doctor following them.

[Page 26]

In some cases, I know there has been a combination of approaches, such as having a GP or a group of GPs who provide that coverage and, basically, do other things as well, like they may assist the admission/discharge people, in terms of review of people who could be discharged from a hospital bed. They may get involved with quality improvement work and things of that nature. I know we're currently in discussion with your district to have a look at what their situation is and if there is an approach that can be taken that would help to resolve it.

MR. PARENT: I'm glad to hear that because the family doctors were going to withdraw services from the orphan patients, and in my area it's estimated about 5,000, in February. Then they put that off until April to give the department time and the district time to meet, so I'm glad you're working at that.

In terms of the alternative funding plan which I am personally in favour of - but I was speaking - it was interesting - to a person who was on the District Health Board for the South Shore. They had a situation in New Germany where they could only put someone in on an alternative funding plan. The problem they had there is that there would be patients lined up at the doctors door but because he was on a salary, there was no sort of incentive for him to see those patients. He was building a new house. He would take off for hours at a time in the middle of the day. How do you intend to have your cake and eat it too here because there are real advantages but there are some disadvantages as well?

MS. DOIRON: I think that's part of the whole issue of defining deliverables in a manner that can actually be measured. That is some of the work that is currently going on. We need to have those things that are specific enough that we will be able to look at the performance and to be able to take action if, in fact, there are issues of that type that arise.

It has not really been our experience, where we have AFP, that this is what has occurred. I know there was some concern and trepidation, more recently, when the anaesthetist at Capital Health went under an AFP. I know that the entire group may not have been 100 per cent for it but the whole group had to go with it if it was going to fly.

So at the end of the day, despite some of the dialogue that went on beyond them and some concern about, people may be saying, well, if we go into an AFP I'm only going to work x number of hours, too bad, we haven't seen that occur. I think that what we tend to see more of is the kind of dedication of the professionals that we have in our system to respond to the demand of the need that is there. But we recognize, as well, that that has to be done in a manner that makes life liveable for the providers, as well as responding to the patients. It is a bit of a balance and I think we will get better and better at defining deliverables that will allow us to manage that more effectively.

MR. PARENT: Thank you very much.

[Page 27]

MR. CHAIRMAN: Mr. Clarke, would you like to add a comment?

MR. DOUG CLARKE: Yes, just to point out, Mr. Parent, the system that you're talking about, I think, is working. Is it perfect? Not at all. I think we have to look at things like blended payments so that people get a deliverable but if they want to work harder, if they want to put in those extra hours and see the patients that are lined up at the door, that there is a system to remunerate them for that.

The other thing that I think is important that we be careful of is, any time we go to a new system - and even under, I guess, the old system - the vast majority of people that work under the system work hard and follow the rules of the system. We have to make sure there are processes in place for those that don't, to be managed.

We, at Doctors Nova Scotia, have absolutely no problem with that. We believe that you have to have systems in place to manage it so that not everybody gets painted with a brush that says, the system or the physicians, or this, aren't working hard. The vast majority work extremely hard, and like any profession, you will find those that don't. The system has to make sure that it manages that.

MR. CHAIRMAN: Thank you very much. In view of the fact that we started a few minutes late in the opening statements and went a few minutes overtime, I've decided the next round will be 12 minutes. So the next 12 minutes belong to the member for Halifax Needham.

MS. MAUREEN MACDONALD: Oh, good. Thank you very much. I know when we started out, my colleague in the Liberal Party said - and I think he's right - he said that people don't care, really, in some ways of how doctors get paid, fee for service or the alternative way, they just want a doctor there when they need a doctor. I think that there is a lot of truth in that but I also think that it is our responsibility as legislators to make people care. It's our job to do that, to make people care about the payment and how it works because it's such an important part of the system. Doctors are an important part of the system and the amount of money we're talking about is significant. As we work to protect, preserve and improve our system, we really need the public with us to understand the changes that are going to go on. I think that's why this conversation today is useful, maybe as a beginning point to shed more light and get the public more engaged in this issue, which isn't going to go away, it's going to be, I think, a very important issue.

[10:30 a.m.]

Again, going back to the health expenditures, the estimates, I know that a great deal is made about the cost drivers in the health care system and we look at Pharmacare, for example, drugs, as being a cost driver but my math isn't probably the best in the world - I come from social science not the hard sciences - but over time, when I look at the kinds of

[Page 28]

expenditures I see that just in a three-year period, really, there's a 22 per cent increase in the expenditures with respect to medical payments. I'm not saying that that's bad but that's the reality and people have to pay for that through taxation and stuff like that. So, there are a number of questions I would have. One is around getting efficiencies in the system and I think my colleague, Mr. Graham, was going in that direction.

I have a very specific question about Yarmouth. I went to Yarmouth on a mental health outreach endeavour and the Mayor of Yarmouth came to a meeting. He said that his municipality was having to put up $18,000 - I think he said - as a way to attract a physician into that community. He wasn't happy about that, as a municipality they don't see that as being their job, to fund health care providers. I have to say, I have a large degree of sympathy. So why is it that a municipality like Yarmouth has to do that and in particular the problem areas that were identified, Strait-Richmond and Yarmouth, here, today. What specifically is the government doing to attract physicians into those communities and to prevent municipal units from having to pony up very limited municipal dollars that are needed for infrastructure that is rightly within their political arena?

MS. DOIRON: This is an issue that the department actually did become concerned about a few years ago because as we discovered, there was great competition going on among some of the communities in Nova Scotia to get doctors to go there. While I think we have a payment system that is competitive and was competitive at that point, getting certain types of doctors to go to specific areas was something that often the communities or the foundations of the health system, the hospital, for example, decided to provide some additional dollars toward attracting and keeping physicians in their areas.

One of the things that we did - I think you may recall a few years ago - was to introduce a regulation under the Finance Act that would contain the scope of what people could do at the local area within that competition, because we had discovered that we had a couple of contracts that seemed to be very unreasonably high. In an effort to kind of be fair to make the negotiated fees and amounts the kind of base, and to be fair to physicians across the rest of the province as well, we have tried to contain that level of competition. So, we're not encouraging that kind of competition. We have not stopped it entirely, but we are working on containing that and using other mechanisms that we can put in place, whether it's assisting them with recruitment, organizing with them and introducing them to the communities when they're visiting, doing a debt repayment plan, or a whole variety of other factors to say that those are the things that we should be making available throughout the province.

As has been pointed out, there are some communities where it is especially difficult to recruit to. We also have been leaning more in recent times to going to approaches which will place people in those communities with a return for service agreement. I think that it's not something that the Department of Health wants to encourage. I will let Mr. Clarke answer for Doctors Nova Scotia.

[Page 29]

MR. CHAIRMAN: Mr. Clarke, did you want to add something to that?

MR. DOUG CLARKE: Yes, please. It's a very important question. One of the things, if you look at it strictly from the doctors' point of view, it would be very beneficial to have all the different areas in the provinces competing. However, our board has said right out, they don't want that. They want provincial rates. What we would like to see is specific areas identified where incentives need to be put in. There may be a couple that you have to do that with but we don't want to see Antigonish having to compete with Yarmouth and then Amherst competing, because that doesn't do any good for the system. We would like some stability in that.

Having said that, there are going to be places in this province that are going to have a more difficult time recruiting. We have very little trouble recruiting to Antigonish. People like going to Antigonish. We don't have too much problem with people going up to the Valley. However, there are other parts that we do have to look back and come up with incentives to bring them there, all right? I think that is what we have to do. Rather than try to open this up and let all the communities compete, we have to say, okay, Yarmouth is one, or Strait-Richmond, here is the incentive to bring you there. I think that will work better in the long run.

MS. MAUREEN MACDONALD: I still have a bit of time?

MR. CHAIRMAN: Oh, yes, you do. You have four minutes left.

MS. MAUREEN MACDONALD: Okay, great, thank you very much. You know, one of the issues that is presented to me most often, I think, by people in my constituency and outside of my constituency that is a bone of contention for patients with respect to getting access to their GPs is the whole idea that they can only take one particular medical issue per visit to a physician. Now, I think that has a variety of problems for people, particularly people who travel substantial distances to see their family physician, or alternatively, people of limited means, for whom getting into the physician presents some challenges.

I'm wondering, to what extent is this a point of discussion between the government, or is the government aware of these concerns, number one, and Doctors Nova Scotia, and is there some way to deal with this because it is extraordinarily inconvenient and it is a complaint I hear very frequently, and probably with some growing frequency.

MR. CHAIRMAN: Who would like to start with that one? Mr. Clarke.

MR. DOUG CLARKE: Yes, a couple of things. A few years back, our board, working with the doctors, indicated that we would promote physicians if somebody came in to be seen with more than one issue. However, it's a balancing act. We have had people come in with a list of 32 items. A general practitioner gets paid $26.13 to see a patient; 32

[Page 30]

items, you can imagine how long that takes. The physician has to pay their staff, they have to pay for everything. Some of them could take over one hour. It doesn't work.

However, the problem that existed several years ago has decreased substantially. Most physicians now do not say, one problem, go away. It's still a problem but it's a balancing act and I'm not sure if it will ever go away. But we have promoted to physicians to attempt to try to accommodate within a reasonableness. That's the best we can do, given that scenario.

MR. CHAIRMAN: Ms. Doiron.

MS. DOIRON: Thank you. Yes, and this is another area where I think the AFP and, also, the collaborative practice models can be more supportive to patients who have a variety of issues that they need to have addressed. While the balancing act will go on with the individual physician visits, I think the growth on the other end, in terms of collaborative practice and other models, will also kind of make patients feel more comfortable with that.

MS. MAUREEN MACDONALD: My final question is to the deputy minister. It concerns extra billing for uninsured services. To what extent is the Department of Health tracking this issue and Doctors of Nova Scotia, as well, if you have any information on how prevalent this is, and what are those issues that are being extra billed for?

MS. DOIRON: We actually, as I think you know, have an audit system that is used and can be used at any point. Particularly, if we wish to call, if we are alerted with anything that could be of concern, we would definitely go in and do an audit. On the other hand, we need to do periodic audits just to kind of take a look at the issues that are out there at any particular time. We have not found a large number of concerns within that but we will be monitoring this kind of an area, I think, as we see the growth in terms of different models and ensuring that the models that are actually moving forward are done in a manner that does not bill patients for inappropriate measures and that, in fact, they are being provided with the insured services on a basis that they are not charged for. So I think that as we explore various models, it is incumbent upon us to make sure that that auditing and monitoring takes effect more actively.

MR. CHAIRMAN: Thank you. Mr. Clarke, you would like to add something?

MR. DOUG CLARKE: Just very quickly. It is interesting that this topic could come up right at the end. It could be a two-hour topic on its own. I think what is important from our point of view, a couple of things, but one of them is, we would argue that the right of the physician to bill for extra billings outside of the insured services, they don't follow it the way they should. They should be billing a lot more of uninsured services. As much as they are independent business people, they can't bring themselves to bill the people of this province for it. Having said that, there are situations where it is billing and there are a number of

[Page 31]

different models and, as Ms. Doiron mentioned, we have to manage those but the position of the physicians and of Doctors Nova Scotia is that the insured services are what they do on MSI and those things that fall outside, and they have to be clearly outside of insured services, they have the right to set the rates and to bill for but they also have to provide the service. That's the position that we have had in the past and that is the position that has been upheld across the country.

MR. CHAIRMAN: We will now move on to the Liberal caucus for the next 12 minutes.

The honourable member for Halifax Citadel, who no doubt wants to pick up where he left off.

MR. GRAHAM: I do and I have to say, first I want to apologize for not getting to my question in the last round. Hopefully in the 12 minutes that is available, I will get to the question on this occasion. That was the shortest five or six minutes I think I have ever experienced.

Mr. Clarke, I heard you speak about the challenges with respect to an alternative funding program. What you have described is not dissimilar to the vast majority of people who are paid in society generally. Almost everyone is on a salary of some sort. If they decide to go build a house or go golfing, then that is something that you deal with through the organizational structure, through the administration, through the human resources elements. I don't see that as being unique to doctors and I don't see that as an argument that can be advanced to suggest that the system is going to be any less efficient than the systems that we have and we try to improve on efficiencies every day.

I suspect after my little rant, your response is going to be that we are moving in the right direction and we seem to be moving with some speed. The position that I would take, or at least I would suggest to you is that this is perhaps - there are no silver bullets, there are no quick fixes - but this is perhaps an idea with the highest return for the investment of effort in terms of improving the system across the board on a wide variety of scopes. That is a proposition. If you disagree with that, then I welcome your response but I do think that this single move could change dramatically the way in which we treat patients on primary health care and it will also deal with a number of the cost issues. No quick fixes.

The challenges, however, relate to timing and leadership and what may be suggested by you is that we are moving the right direction, just be patient and it's best that doctors make the choice for themselves.

[10:45 a.m.]

[Page 32]

First to Mr. Clarke and I will follow to Ms. Doiron, on the question of leadership and who makes the choice, Mr. Clarke, isn't it the government's job to make the choice about when and how quickly we move in that direction, recognizing that you have a partnership here and that partnership needs to be respected and you can't drive something in some direction that people are unwilling to go in? Ms. Doiron, isn't it time for the government to show clear leadership on this issue? I say that specifically because in 2006 the Primary Health Care Transition Fund expires. This is the window that we have for us to move in this direction and after 2006 we may not have the funding to put together the kinds of initiatives that will bring about this sort of fundamental change. So I throw that to each of you.

MR. CHAIRMAN: We will start with Mr. Clarke.

MR. DOUG CLARKE: If you were looking for disagreement, you are not getting any over here. The first point that I would point out is that I still believe it should be an option. However, having said that, we think it should move quicker. As was pointed out earlier, 70 per cent of the doctors have indicated they would like to explore some other method than fee for service. We have currently about 30 per cent who are entirely on it but we have about another 15 per cent to 20 per cent who receive part of their income through alternative funding models.

Having said that, I am getting significant pressure from my board, from members in other parts of the province outside of Halifax to get on with making this model available to them. GPs want this done. So I am in total agreement with you but I do believe if there is one area that the Department of Health and the Doctors Nova Scotia have had some tensions about, it is the speed at which this is moving. We are in agreement that it should be moving. We are in agreement with the direction it should be moving but it's the speed that it is moving, I think is where you would get a little bit of a battle, I would have to talk to our members about demanding that it happen but I don't think that would be your issue because I don't think at the present time any system can keep up with the speed that the doctors want to move in this direction.

MS. DOIRON: I guess you have heard that we are supporting this kind of direction and I think the issue of timing has much more to do with the impact that this does have on resources than it has to do with the willingness of leadership to move it forward. If, in fact, we were simply moving to an alternative payment and that would satisfy the total situation, then there would be no issue and in cases where that is possible, then we certainly can go out and do that. There are, I think, a few areas where that is possible and we have not yet followed up adequately to put those in place but we can move forward quite quickly on those kind of areas.

What is probably of more concern for us is the desire for physicians to be working in teams and the way that the whole system will transition into that kind of a process. At the present time, what happens when we go out with collaborative practice models is that we

[Page 33]

tend to be adding dollars to the system as opposed to simply exchanging one kind of process or care for another. We have to, I think, get better at not only providing the resources that are necessary to kind of build that kind of system but also in finding ways that we can transition the system without it all requiring additional dollars. So to some extent I think the timing issue has been based on the availability of resources and that is our biggest struggle with it.

MR. GRAHAM: I would just like to go a little deeper on this transition question and what the potential obstacles are. We have the transition fund that has been set up. It expires in 2006. The focus of the department for some considerable period of time has been toward moving in the direction of enhanced primary health care. Funding health care in the Department of Health globally as a line item in this province has gone from, not too long ago, about a billion dollars to $2 billion. That's a big increase that has happened and the people of Nova Scotia who care about, not just health, but education, expect a response, expect something effective to come from this. So I think it's incumbent on the government to be as clear as possible about what those obstacles are and in particular, what they're going to do to set targets and whether or not you have targets in mind.

It seems there is an agreement in principle and I'd just like to understand a little bit more about what the obstacles are to getting to those targets in a specific time frame and if that means another increase in funding - we know that we've received a substantial increase in federal funding over the last period of time and some of that was dedicated to these kinds of issues - then surely, this is the window and the opportunity for the Department of Health and the government to say, here's our plan. This is when and how we're going to make this happen.

MS. DOIRON: I believe those are reasonable comments. One of the things that I think is not clear to people, however, in the public or even often in government - and if it is clear it's emotionally unacceptable - is what is happening to all of those new dollars in the system. Quite frankly, right now we are at a place where about - including physicians - 80 per cent or more of the cost of the health care system is salaries. Based on that and all the agreements that are struck, the collective bargaining processes that go on, that requires that on an annual basis there are substantial dollars added to the health care system to do nothing new.

In addition to that we know that the inflationary costs to health care are certainly much higher than normal inflation costs. Some would argue we are giving 7 per cent to the DHAs for their non-salaried inflation, but some would argue it's even higher than that and certainly, in the last year or two, we're seeing a number of provinces looking at it more as around 10 per cent.

So having said that, we require in the Department of Health - depending on what level of increases are coming through collective bargaining processes - anywhere from $150 million to $200 million a year just to do nothing new. You can imagine how quickly that

[Page 34]

adds up and when we go back and people are saying to us, can't you do something to control the growth in the health care costs? My standard answer lately has been, we can either take on the Canadian labour system or Nova Scotia can do it own their own, like B.C. tried, or we can redefine the Medicare basket because that, to me, are the ways that we can substantially change the growth in that health care funding.

When we say that there has been that much of an increase, it's absolutely true, but very little of it has been accessible to do new things. That is part of our challenge and part of trying to help people understand what is happening with it.

Having said that, we have done very good things, I think, with the primary health care funding we've had. We are still making moves in that direction. We are putting the electronic primary health care system out this coming year, all of the province will have access to that. All of the collaborative practices that we set up, we set up with the understanding that they're going to be using the electronic health record system or contributing to that larger record. So we do have some of those targets but some of the other targets that are based on resources would have to do with the business planning process.

Having said that, I think that one of the reasons why we have to add new people when we're moving in this direction, may also have a relationship to the supply/demand issues that we currently have in many of the professions.

MR. GRAHAM: I just want to follow up on some of what you said. When I asked the question I was asking about targets and timelines. Hopefully, you can give us a clear sense of what those targets and timelines are or what analysis has been done, what reports and research you've done to analyze the cost benefit of doing this type of work. It's not just a cost in terms of the increased expenses, there's a potential reduction in cost. I think most people have referred to their own family physician, I'll chime in in the same way. My family physician tells me that sometimes 50 per cent of the work that he does in the run of a day relates to something that a social worker, who is well trained, would be able to do instead of him, obviously, at a lower cost than he would be able to do it. That is where you get the savings so this is the transition period and Nova Scotians are asking what are the targets, when are we going to make it happen?

MS. DOIRON: We basically have a target that is also part of the national target to allow Nova Scotians, at least half of Nova Scotians within a short period of time, approximately 10 years or less, to have access on an a primary health care basis to the system and I think there are a variety of approaches to accomplish that. It would be a lot easier if, for example, a doctor spending half of their time doing work a social worker could do, then it would be really easy if we could say well for every two social workers we put out there, we can remove a doctor but the system is not working in that way at the present time and the supply is not based on that kind of a model. So for us to say that we are going to have a target for x number of collaborative practice opportunities right now is certainly something that we

[Page 35]

see being a thing over time. In the primary health care planning work that was done when the Primary Health Care Fund was initially available, if you read that, you will probably see it is projected to be a 10- to 15-year time period to make a full transition.

MR. CHAIRMAN: Mr. Clarke, you wanted to add a brief comment.

MR. DOUG CLARKE: Just quickly on that, kind of in support of it, each time we talk about social workers, we talk about nurse practitioners, pharmacists, nutritionists, they are all new providers to the system who aren't paid through the system at the moment. They are paid through private insurance plans, if you get them. So they are costs if you are putting them in the collaborative systems and you have to look at the benefit as Mr. Graham was saying.

The other thing with the transition fund is it runs out. A lot of physicians aren't willing to change their model of practice knowing that one year or two years down the road the transition funds disappears, where does that leave me. That is a big problem. You have to remember that right now the whole system is run on the backs of the GPs with regard to the incomes and their buildings are usually owned by them. The infrastructure is owned by them so there is more than just saying we are going into a collaborative practice and if you can't say that collaborative practice is going to continue to exist, the physicians aren't going to buy on because they don't know where they are going to be and I will tell you one thing about physicians is that they are scientists and you have to prove things to them and if you are going to say ride with me here, it probably won't happen if you can't guarantee that somewhere down the road this is going to be consistent and sustainable.

MR. CHAIRMAN: We will now move on to the Conservative caucus.

The honourable member for Kings North.

MR. PARENT: Just in response to the comment by the member for Halifax Citadel, I am certainly not opposed to the AFP program. In fact, I'm in support of it. It has always struck me as rather odd that you have a public medical system and yet the key component in it is independent business people, as Mr. Clarke said. Which is why I think that the inter-relationship between the two is at times very problematic and may be driving the costs up. So I certainly support that and I'm glad to hear that Doctors Nova Scotia support that as well.

Just some very quick questions, then. The average salary of doctors of $190,000, I believe, last year, that was the gross salary according to the stats I have. What is the net salary? Out of that, what do they usually pay to run the office?

MR. CHAIRMAN: Who would like to take that? Mr. Clarke?

[Page 36]

MR. DOUG CLARKE: I'll take it. First of all, I will start off, I don't think there is an average. It depends on how hard you work. I know there is an average number but the physicians all work. Roughly, we've seen overheads running in the 50 per cent to 60 per cent range but on average it is probably about 40 per cent or 45 per cent. So on $200,000 you are talking $80,000 or $90,000 overhead.

MR. PARENT: So it's not really in there. You see the number out there. The public sees it and goes wow, look at that. How about specialists? What is the gross and net on specialists? Is there some sort of average?

MR. DOUG CLARKE: The problem with specialists: GPs in some degree are a homogeneous group, specialists aren't a homogeneous group. You have surgeons, you have psychiatrists, I mean doing all kinds of different things. We have how many different groups?

MR. PARENT: Is there a mean that you can give me?

MR. DOUG CLARKE: Surgery, just to give you an idea, if you have a cardiac surgeon in this country, the average is probably around $500,000-something for a cardiac surgeon. For a geriatrician, which is also a specialist, the average is probably about $180,000. So it's very difficult . . .

[11:00 a.m.]

MR. PARENT: Those specialists wouldn't have overheads?

MR. DOUG CLARKE: Most specialists still have some overheads, it depends on where you practice. If you are a hospital-based specialist, which a lot in the Capital Health District are, because they teach and they're based there, their overhead is significantly less than an office based and almost every area outside the Capital district are office-based specialists in this province. So if you go up to your area, Mr. Parent, most of the specialists there have their own offices outside of the hospital.

MR. PARENT: In terms of international medical graduates, this is not really a question but a comment. I'm so pleased to hear, Mr. Clarke, the support of Doctors Nova Scotia because in our area, well, in really West Kings, the riding next to me, they have been working very hard to get doctors into Berwick, Cuban doctors and we find that the gatekeepers, the professional association being the gatekeepers, oftentimes don't make that process as easy as it should be. Engineers, for example, are doing a far better job of that as a professional association than the doctors are.

Of course, I know you want to ensure quality of care but it becomes almost a conflict of interest here because if the number of doctors is kept lower then the salaries of course are higher. I'm not suggesting that is what is going on and in light of your comments, it's clear

[Page 37]

that the doctors want to work but I would encourage you to do more in this regard and I'm glad to hear the comments because there are qualified doctors worldwide and we have had a tremendous problem with trying to get information, trying to get the process, trying to understand how to do it and it's not clear. More work needs to be done by the department on this and I'm glad to hear your support for it.

MR. DOUG CLARKE: If I could respond to that, because I think it's important. There is a segregation of duties here. There is a College of Physicians and Surgeons that set the licensing guidelines. Doctors Nova Scotia doesn't. If a physician qualifies to be a practising, licensed physician in this province, then they become our member but we don't set the guidelines on who it will be.

MR. PARENT: I understand that.

MR. DOUG CLARKE: There is a segregation of duties but I will tell you that the licensing body and ourselves are working together to make this happen.

MR. CHAIRMAN: I know Ms. Doiron wanted to add a comment as well.

MS. DOIRON: Thank you, I'll be brief. We are working very hard on this. We have several of our staff members in the department actively engaged with this activity, with the college, with people from outside the province. The other more recent development that we have started to act upon is to look for partnerships with other groups such as the new Department of Immigration. So with working with the Office of Immigration and the college and other partners like Doctors Nova Scotia, we hope that we will be able to make some real progress in this area.

MR. PARENT: Good, I'm delighted to hear that. One last comment, echoing the praise for the work that doctors have done in health promotion in the areas of smoking and the need for them to do the same thing in the areas of gambling addiction. I know that some is being done by Dr. Strang here in this area and I would encourage that sort of leadership. The labelling that we have on cigarette products, for example, I think was in large part by doctors pushing this. We need to recognize that gambling addictions are addictions, it's a health matter. So I just want to echo my colleague's comments and then pass it over to my colleague.

MR. DOUG CLARKE: Thank you both, Mr. Graham and Mr. Parent for your comments on that. I will take this back to our board and put forward the suggestion that you made with regard to gambling. I will just point out that we are a fairly small organization and we put a lot of money into this so we have to try to balance off whether we can put all of our resources into the healthy promotional lifestyle to get the bigger bang. So we have to balance that off. I will tell you that we don't hold meetings in any place where they have gambling

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and we support that. It's just a matter of what we can do for the public with the biggest bang for our buck.

MR. PARENT: I understand that. I do thank you for what you're doing.

MR. CHAIRMAN: We'll turn the floor over to the member for Waverley-Fall River- Beaver Bank, with five minutes remaining.

MR. GARY HINES: Mr. Chairman, I apologize for being late this morning. It's nice to see a team, I think we can benefit well from having both parties in here this morning to discuss issues that are pertinent to both groups.

I would be remiss if I didn't take the opportunity to say how pleased I am with the medical care system in my constituency of Waverley-Fall River-Beaver Bank. We have the Fall River Medical Centre, we have the government big in support of the new Cobequid Multi-Service Centre and in East Hants, which is adjacent to my riding, we have a service centre being built out there as well that our government has contributed to. So, I think we're faring quite well.

One of the things that happens, constituents listening to this program in the morning sometimes will hear acronyms, catch phrases, headings and so on, that they don't understand, so consequently they are somewhat left out of the conversation. Telehealth systems is one of the things that I know that my doctor's office has supported and is a big believer in. Could you give us a little briefing or an overview of Telehealth system?

MR. CHAIRMAN: Ms. Doiron.

MS. DOIRON: Yes. Telehealth has been around for a while, certainly became more active in the health care field, probably, during the last decade or decade and a half. That's when we saw the beginning of things like people coming together to form the Canadian Telehealth Association and the initiation of some projects in various parts of the country that would be supporting the concepts of what can be done through Telehealth.

This province took a very aggressive approach to seeing that there were Telehealth opportunities in every area of the province. So every acute care facility and even, you down to places like Advocate Harbour, or wherever, have access to Telehealth. So, it can be used for a variety of applications. A lot of educational work is done on that; a lot of continuing education credits through the College of Physicians and Surgeons, the College of Registered Nurses, various groups support the kind of work that can be done through Telehealth education.

It has also been used very actively in this province for meetings. It is not uncommon at all for us to bring in even Department of Health people in the field. If we have a general

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information session there is access to it through Telehealth. In other areas, similarly, for other groups that are holding meetings. The Canadian College of Health Service Executives regularly meet and bring in membership from across the province. We do that on a regular basis for meetings that involve people from across the province if they are not able to get to the meeting, so a lot of use from that purpose.

There is some use, as well, from the point of view of clinical applications. That is one area that we are now starting to see some more substantive growth in. There are places that have done projects around this that have pretty well demonstrated and proven that doing consultations, for example, through a Telehealth system can be very beneficial and, certainly, provide access on a much more open basis for people who would find it hard to travel.

There are applications that I think the QE II is now in the process of putting in the system that was developed in New Brunswick - I just happen to know about it because I was involved in it at the time - where heart patients, patients who have heart surgery, for example, when they're sent back to their communities can have a kind of daily check-up, with things like blood pressure, ECGs, O2 SATS and other things being monitored directly from their homes. Also, instead of having to travel long distances, maybe, for a six-week check-up, they can be with their nurse or their family care physician in some other area of the province, and have the consultation with the specialist in a manner that is satisfactory for all.

So we are absolutely encouraging more use of the Telehealth system. It has been rated very highly in a number of areas for mental health consultations and given some of the circumstances that we have, in terms of wanting to provide better access to the mental health system, I think that's a very important potential modality to develop further in this province in that area.

Those are a few examples of what we're doing with it. We have an excellent system and Telehealth now, of course, is kind of moved to being done over the Internet so it's much easier access for everybody.

MR. CHAIRMAN: Thank you very much. That brings to an end the question and answer portion of today's session. I would like to invite Mr. Clarke to make any concluding comment that he wishes to make, if, indeed, there is anything at all he wishes to say.

MR. DOUG CLARKE: Just very quickly. It was a note I had written down that - and I apologize, I'm not sure who actually brought it up - with regard to a comparison of education and health. I think it was the Liberals. One of the things I want to support is that our children are going to have this exact same discussion we're having today if we don't make sure that health promotion is involved in the school system and that the education is improved. We can talk about all the health care workers we want. If we don't improve the lifestyle and enhance the education of our kids, those determinants of health aren't going to change and our kids are going to be sitting here, having this exact same discussion, only it's

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not going to be $2 billion, it's going to be $4 billion and we won't know how to do it. So, as decision makers and policy setters, I think you have to look at, what can we do to stop this trend and change the lifestyle of our children?

MR. CHAIRMAN: Thank you. Ms. Doiron, any comments in conclusion?

MS. DOIRON: I would simply say, thank you, to the members for permitting us to be here today and to explore some of these ideas. I do believe that, perhaps, we have not communicated them as broadly as may be worthwhile to do. Based on some of the presentations and comments from you today, I think we'll take a look at that and see if we can provide for substantive information to the public.

MR. CHAIRMAN: Thank you very much for the information for members of our committee. Our next session is next Wednesday, 9:00 a.m., a briefing session with the Auditor General to help us prepare for some future sessions. It will be, of course, over in the Committees Office.

Is there any other business requiring the attention of the full committee before we adjourn? If not, a motion to adjourn.

All in favour. Any opposed?

This meeting of the Public Accounts Committee is adjourned.

[The committee adjourned at 11:12 a.m.]