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25 mai 2005
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Wednesday, May 25, 2005


Capital District Health Authority

Printed and Published by Nova Scotia Hansard Reporting Services


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


Capital District Health Authority

Mr. Bruce McLaughlin

Chairman - Capital Health Board of Directors

Mr. Don Ford

President & Chief Executive Officer

Ms. Barbara Hall

Vice-President - Community, Continuing & Restorative Care

Mr. Cal Crocker

Vice-President - Administration

Dr. Andrew Padmos

Vice-President - Research & Academic Affairs

[Page 1]



9:00 A.M.


Mr. Graham Steele


Mr. James DeWolfe

MR. JAMES DEWOLFE (Chairman): Good morning, ladies and gentlemen. I would like to call the Public Accounts Committee meeting to order. This morning we have with us representatives from the Capital District Health Authority. Before we go any further, I would like to introduce the members of our committee to you, beginning with the NDP, please.

[The committee members introduced themselves.]

MR. CHAIRMAN: Also with us today is the Auditor General, Mr. Salmon, and Mora Stevens, clerk for the committee. I understand, Mr. McLaughlin, you are going to start off with a few opening comments and I will ask you if you would please introduce your group prior to commencing your comments.

MR. BRUCE MCLAUGHLIN: Mr. Chairman, to my immediate right is Don Ford, our President and CEO. Sitting next to Don is Barbara Hall, our Vice-President responsible for community hospitals and centres as well as all of our community health programs and our continuing and restorative care programs. Next to Barb is Cal Crocker, Vice-President of Administration and our Chief Financial Officer. To his right is Dr. Andrew Padmos who is our Vice-President of Research and Academic Affairs, in addition to being the head of our cancer programs.


[Page 2]

Mr. Chairman, it is indeed a privilege to be here this morning. We are grateful for the opportunity to be accountable in such a direct way. In our opening statement, we will first answer the question you originally provided when inviting us to be here this morning. Secondly, we would like to give you some context and insight into all that is Capital Health. Finally, as overseers of matters involving public funds, there are four points that we believe to be important for your consideration. Then we are here to answer your questions on a complex subject that is not too often captured in sound bites and headlines. We look forward to a robust discussion.

I would like to turn things over to Don Ford, our President and CEO.

MR. CHAIRMAN: Thank you, Don. Go ahead.

MR. DON FORD: Thank you, Bruce. As Bruce indicated, I am first going to answer the question that was asked at a committee meeting back on April 12th concerning the late approval of our 2004-05 business plan. Quite succinctly, the late approval did not impact our ability to look after patients and continue toward our overall objective of improving health in our community. At the start of the fiscal year, we gave our managers what we called a provisional budget. It was based on expenses from the previous year, plus the 7 per cent annual increase for supplies that was committed to district health authorities, plus the increases that were negotiated in collective agreement contracts and any information we had about funding for new programs.

The revenue line in our budget was based on what we anticipated the Department of Health would fund plus the other amounts we generate from third parties such as insurers, hospital foundations and retail operations. So the provisional budgets that managers were working with through the year were, in fact, consistent with the budget that was approved by the department in March.

Our managers' diligence in managing their provisional budgets enabled us to end the year in a balanced position. Continuous communication with the Department of Health ensured that the timing of our budget approval did not get in the way of doing what was right for patients and the people we serve.

Now let me take a moment to tell you a bit about Capital Health. We are your largest district health authority, created through the Health Authorities Act in 2001. The Act brought together, under one structure, with one budget and one purpose, three organizations. Today, this includes 10 hospitals and health centres: the Nova Scotia Hospital; the QE II Health Sciences Centre, including Camp Hill Veterans' Memorial building; the Dartmouth General Hospital; Hants Community Hospital in Windsor; Eastern Shore, Twin Oaks and Musquodoboit Valley Memorial Hospitals; the East Coast Forensic Hospital; the Cobequid Community Health Centre; and the Nova Scotia Environmental Health Clinic. Public Health, Addiction, Prevention and Treatment Services, and the Mental Health Services complete our

[Page 3]

service offerings. All of which would not be possible without our seven foundations and the auxiliaries whose staff and volunteers raise vital dollars for hospital equipment and health programs.

Our services are provided to almost 0.5 million people, who live in the Capital Health District, and because the QE II is a teaching hospital offering highly specialized medical services, we have also served people from elsewhere in Nova Scotia and, indeed, from all parts of Newfoundland and Labrador, New Brunswick, and P.E.I. We employ about 10,000 people, including approximately 1,000 doctors, who have privileges at one or more of our hospitals. At any given time, we have over 1,000 students in our midst, working alongside our care providers and with patients.

We are the only academic health district in Nova Scotia. That means we provide training opportunities for doctors, nurses, physiotherapists, pharmacists and many other health care providers. We support and facilitate research into new treatments, cures and concepts that improve results and ultimately health. This gives Nova Scotians access to cutting-edge treatments and to a broad array of specialists who treat the most rare and threatening of medical conditions.

The seven community health boards and community health teams that represent neighbours from West Hants through to Sheet Harbour are an important part of Capital Health. They keep us grounded in the health needs of the citizens we serve. Our annual operating budget of approximately $600 million means that we are spending $1.5 million a day, almost all of it from the public purse. A 15-member volunteer board of directors meets twice a month to ensure the effective governance of our operations. So that's a quick snapshot of Capital Health.

Now to the four points that are an important part of Capital Health that often don't get told, either accurately or in context. First, we take stewardship very seriously and continuously strive to run an efficient operation. We spend public dollars as prudently and as wisely as if they were our own, which, in fact, they are. When I first became CEO, I asked an independent agency to give our major clinical operations a rigorous review to ensure we were up to national standards of efficiency. The results of that review gave us an opportunity to become more efficient and enabled us to reduce our expenditures by $10 million. This helped us balance our budget for that fiscal year and provided an adjusted base for future years.

At Capital Health, 4.4 per cent of our budget is spent on administration. This is the lowest in all district health authorities in the province, and well below the national average of 6.1 per cent. By most indicators, we are an efficient organization, and we continue to strive for further efficiencies. That being said, it's fair to ask why, then, if we've taken so many costs out of the system, does our budget continue to grow? Simply put, the dollars we

[Page 4]

achieve in efficiencies don't fall to the bottom line, as they would in the private sector, where you can control and influence supply and demand.

In our business, we don't get to decide how many surgeries we'll perform or how many people we'll see in our outpatient clinics. We respond to the demand that presents itself. When we are able to save money by implementing more efficient processes, this creates opportunity to see more patients and do more procedures. Improved efficiency rarely means savings. It almost always means doing more. Demand - legitimate demand - continues to grow, and with that demand our expenses grow.

To my second point, even with our efficiencies, there never seems to be enough money for health care. For Capital Health, I would suggest to you it's a bit of a good news and not-so-good news story. The good news is that through the efforts of the government in recent years to stabilize the health system, we are seeing that this impact is working. Its commitment to stable operational funding year over year has enabled us to plan and manage with predictability. Not only does this make business planning a meaningful exercise, but, importantly, it builds confidence in our patients and staff that we will be able to meet the obligations.

The not-so-good news for Capital Health is that the operating funding appears to be short by what we believe to be about 2 per cent. Budget after budget, no matter how well we manage the finances, there is approximately a 2 per cent gap between the funding and the expenses that we believe we need to incur to meet the demand. That 2 per cent, I would propose to you, is a result of many factors. It is a cost of being a referral centre that provides highly-specialized medical services to a province and a region that is the unhealthiest in the country. Not only are these services unique, they are expensive. As the referral centre and safety net for the province's health care system, we also serve as a backup for other districts when they are short-staffed.

It is the cost of training the next round of health providers and pushing the envelope of discovery that leads to treatments. Access to a teaching hospital with hundreds of medical specialists, a research facility like the Brain Repair Centre, and teachers for the medical school is good for health care today, and it helps ensure a sustainable health system down the road, but it comes with a price tag. We believe it needs to be recognized in our annual funding and has not yet been reached.

This leads me to my third point, the 2 per cent gap that I've spoken about is in our operating budget not our capital budgets. The capital side of our organization, and that includes our buildings, equipment and information technology, is a huge concern. Like hospitals around the country, funding for maintaining buildings and replacing equipment has fallen dramatically behind in recent years. Now the cost of catching up is increasingly a safety concern.

[Page 5]

When Capital Health was surveyed last Fall by the National Accreditation Agency, the state of our buildings and equipment was such a concern that a report was issued, giving us one year to demonstrate improvement in this area. In the Auditor General's Report, tabled in December, this was illustrated quite dramatically. It quotes that in 2001, the need for capital was identified at $53.5 million, contrasted with the $9.2 million in actual funding received. In 2004-05, that need rose to $106.6 million, compared to the $19.4 million that was received. That difference of $87.2 million in just one year manifests itself in a number of ways.

Building renovations, such as roof repair and window replacement, almost always cost more when it's done to fix a problem than when it's done according to a planned maintenance schedule. Over one-third of our equipment in our diagnostic imaging department is deemed to be beyond its useful life. That means equipment such as MRIs, CTs and X-rays are either unreliable or their software is no longer supported by the manufacturers.

None of this comes as a surprise to our colleagues at the Department of Health. The problem is as serious at Capital Health as it is at other hospitals in the province and across the country. The federal government has made some investments, and we know our provincial government is doing what it can, yet this is not enough. The problem needs more than a band-aid solution. We need to work together to build a solution that is as resourceful and substantive as the problem is big and serious, and sooner rather than later.

The final point I'd like to make is that you, as policymakers, and we, as deliverers of that policy, have got it right. By that I mean that the legislation that created Capital Health and the other district health authorities with a focus on the population's health and not just hospitals is right. Today, all people who work in health, from those working in community health and health promotion through to specialists providing quaternary-level hospital care, are working in the same organization and toward the same goal, healthier people living in healthier communities.

Consolidating administrative structures and budgets was the right approach. Removing duplication and overlap made sense. Offering physicians the opportunity to work under alternative funding models has helped to ensure the needs of the population are considered first and foremost. The Health Authorities Act has helped to tear down silos and broaden perspectives, so that now we look at the whole picture of health and not just hospital care. These were and are the right things to do.

The Health Authorities Act also made community health boards an integral part of our perspective. Through their work, there are literally hundreds and hundreds of projects underway in our neighbourhoods, all finding unique and compelling ways to improve health for all ages and stages of life. So unique is their contribution to health that they were recognized by the new Health Council of Canada in their first report to Canadians. With

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federal funds transferred to the province for primary care renewal, we have developed new prototypes for care in place, like North Preston, Musquodoboit Harbour and here in metro's Duffus Street Clinic, where we have an opportunity to change the way primary care is delivered. The community's needs determine how health care is delivered, not the needs of the provider or system. But, if we're going to be successful, we need to find ways to sustain what we are building. The federal funds do not allow for ongoing operations, so funding from provincial coffers will need to be found if these initiatives are to continue.

The youth health centres located in HRM's high schools are funded by Capital Health. Here we celebrate the important relationship between health and education. We put in place our belief that by swimming upstream and working to educate and promote health today, we will reduce the need for hospital beds and medical interventions down the road.

When it comes to accountability, we genuinely understand how valuable each dollar is and how important it is that we report openly on how the money is spent. On any given day you can go into our Web site and find out how long waits are in our emergency departments, how many people are waiting for beds, or how many surgeries have been cancelled.

[9:15 a.m.]

We recognize there is much yet to be done to strengthen our performance reporting, but this degree of transparency, I believe, is unparalleled in the country among other health care organizations.

I could go on for a great deal of time telling you about the many achievements and points of pride at Capital Health and I hope we'll have some opportunity to share more of them as the morning progresses. I would like to conclude by saying that Capital Health is on the right track. Yes, there are financial issues that we have to come to terms with, but relative to six and seven years ago, these are much healthier days financially and organizationally.

I acknowledge and applaud the staff, the physicians, the volunteers who work at Capital Health, and our colleagues in the Department of Health who helped us achieve this improved state of organizational health. The foundation is strong and the framework is well designed. We're going in the right direction, but we do have much to do to shorten wait times and improve health outcomes. The fundamentals are right, they and the people who are working on them deserve continued and enthusiastic support. Thank you for the opportunity of being here this morning and we look forward to answering any questions.

MR. CHAIRMAN: Thank you, Mr. Ford and Mr. McLaughlin, for your opening comments. I know our members are anxious to have you address some of their concerns and we will begin immediately with a 20-minute time allotment to the NDP.

Ms. Maureen MacDonald.

[Page 7]

MS. MAUREEN MACDONALD: Good morning and thank you very much for being here today. I want to start by acknowledging and lending my support to your closing comments, about the high-quality staff, volunteers, all of those who are involved in providing health care services. As a person who has had family, neighbours, and constituents in the Capital District health care system, I hear a lot of very positive comments about the experiences that people have had, but that's not going to be my focus here today. I am going to really focus on those areas that you have outlined as being areas of concern and also areas that are brought to my attention as areas of concern.

I would like to start with your business plan and aspects of the business plan that you have spoken to here today, particularly the extraordinary shortfall on the capital side of what is required to maintain adequate equipment, buildings, and what have you. You indicated that a year ago there was an independent audit or a certification process, accreditation, and there were safety concerns and you were given a year to improve. Perhaps you could indicate what you have been able to do in the past year to address what those safety concerns were. Maybe you could elaborate a bit in terms of what the details of the safety concerns were.


MR. FORD: The concerns that were raised were raised recently, they weren't a year ago, they were recently raised with the accreditation process that we went through. We have been given a year from the point of receipt of the accreditation, which is into next year, to address the issues.

The primary concerns that were raised related to the state of the physical plant, particularly at the Nova Scotia Hospital, but recognizing there were also some concerns of the physical plant at the Victoria General Hospital. I think it's important to remember that these facilities were built at a point in time when the programs and services were fundamentally different than they are today.

Over the last many years we've been in the process of retrofitting buildings to address changing programmatic approaches, clinical interventions, technologies, so that buildings that were built at a point in time for the service that they provided, now are having to provide services for very different activities. For example, in an operating room that was built at the VG for a particular range of operative procedures, now with new diagnostic equipment, new X-ray equipment, the facility and the building don't always match, so you're also doing a little bit of retrofitting. So those were the kinds of issues that were raised.

The other issues that were raised related to some of the concerns around the age and stage of some of our diagnostic equipment, and concerns that the age of the equipment was affecting our ability to process patients at the pace that other jurisdictions with newer equipment are able to process patients. So for example, in our MRIs or RCTs, if you have an older generation piece of equipment, a procedure may take, presently, with that piece of

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equipment, 40 to 45 minutes where with the newer pieces of equipment it may only take 15 minutes, so you're obviously not as efficient as you might otherwise be. The recognition of the accreditation council was to see what we could do to address those issues.

Since we've received that accreditation report, we've obviously shared it with the department, it reflects the requests that we had before them already for some of the physical plant concerns that we have at the Nova Scotia Hospital and the VG, and it also reflects the concerns that we have with some of the clinical equipment.

Since that report came out, we have been informed that we will be receiving some new pieces of clinical equipment. The Dartmouth General Hospital Foundation has graciously been able to fund a CT that will be in place, which will be a newer version. The Department of Health has indicated to us a replacement of an MRI at the VG site, which will obviously address the concerns. So I think we'll be able to demonstrate to the accreditors that we are moving in the right direction.

In the one year we will certainly not be able to completely demolish and rebuild the Nova Scotia Hospital, but I think as long as we demonstrate to them that we've taken their concerns seriously and we are making every effort to address them, in concert with the department, that we will be able to satisfy them.

MS. MAUREEN MACDONALD: Has the Department of Health indicated that they're going to pony up any additional resources to deal with these safety and structural issues? It's great that the charitable foundations are prepared to put in money to address some of the shortfalls, but ultimately the foundations only have so much ability. Really, it's government that has to come to the table, so what concretely has been the response of the Minister of Health and the department?

MR. FORD: Our dealings with the Department of Health, as I said, we have received indication that we will be receiving an MRI for the VG site, which is one of the pieces of equipment that we require. We just recently received indication that an interventional angiography unit that we need to replace will be funded. As these issues are brought before them, we are receiving approvals to proceed.

The challenge is that we are well aware of the fact that the appetite in health is insatiable and when these funds are made available for capital investment in the health facilities, they're not therefore able to be made available in schools, roads, bridges and all those other things the province is juggling with. We realize that we're competing for those capital funds with a very large pool of other competitors, all probably equally meritorious, so we're working also with our foundations and others to try to do what we can do through fundraising vehicles to also address some of those concerns.

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MS. MAUREEN MACDONALD: I notice in your business plan, on Page 6, it indicates that Capital Health was only able to fund emergency capital funding requests and that planned replacement of aging equipment is almost non-existent. So the two instances that you have just cited, they would fall into which of those categories, emergency or high-ticket items is what you called them?

MR. FORD: One would have fallen into the plan. The MRI has been on the list and it has been made aware to the department it is one of our priority requirements. The interventional angiography would fall under the emergency, because the unit failed to perform to the standard that we required so we took it out of service and we are now replacing it.

MS. MAUREEN MACDONALD: You've indicated that in particular the Nova Scotia Hospital site is one of the buildings that is in serious need of intervention in some way. Mental health has been an issue of concern, as you will know, with the long waiting times and what have you. I note that you had an outside consulting firm in about a year ago to do a review of your operations and that they had made recommendations, and there is now an action plan. I'm wondering if there is any part of that action plan that would see the elimination of any mental health beds in the Capital Health District?

MR. FORD: There is no indication for any elimination of any mental health beds at all.

MS. MAUREEN MACDONALD: You can guarantee that the few beds we have will stay in the system?

MR. FORD: That's correct.

MS. MAUREEN MACDONALD: That's certainly good to hear, because I know that frequently people from our district end up being hospitalized in other health districts around the province because of a lack of access to beds. I'm wondering if you could indicate whether or not the Capital District has a planned maintenance program. You indicated when you started that what was really required was not just crisis management but, in fact, having a good maintenance plan. Do you have one?

MR. FORD: We have a maintenance plan for IT, for physical plant and for equipment replacement. We have all of those plans in place.

MS. MAUREEN MACDONALD: Can you elaborate on what they would contain, and the cost of doing this, and to what extent government is supporting planned maintenance?

[Page 10]

MR. FORD: The plans that we have in place are designed that in order to provide to the Department of Health a quantification of what we believe the ultimate needs would be, we obviously had to sort of say, in IT we believe this would be the replacement schedule, in our clinical equipment we believe this would be the replacement schedule, in our buildings this would be the obvious replacement/refreshment schedule. The total cost to do all of that would be approximately in the $150 million range, if we had the availability to do all of that.

We have, before the Department of Health, at any point in time, lists in each of those areas, and we go through the normal channels that they demand of us with respect to applications for clinical equipment, for capital replacement, et cetera. As I said, we obviously respect that we are being considered at the government level with many other demands that are before them for all the other jurisdictions. Many of the jurisdictions, if you believe, as we do, in the determinants of health, are probably just as important, obviously schools and areas like that that need input are important to the determinants of health, so we obviously feel strongly that those issues are equally meritorious.

So it would be in the range of probably $150 million, if all of the funds were available that we would be able to demonstrate in each of those three venues, we'd be able to have a plan to address. What that would allow us to do is do some catch-up, and then hopefully provide us a base budget that on an annual basis, in the order of probably $25 million to $30 million of our budget, we'd be able to get onto a regular cycle of replenishment and replacement. So, for example, if you had ultrasound units and a fifth of them were replaced every year, you would never have ultrasound units that were more than five years old, and you'd always have a fifth of them that were brand new. That would be more than adequate to meet the needs, and more than adequate to cover the requirements of our clinicians. So it would be in that order of magnitude.

MS. MAUREEN MACDONALD: I want to ask you about the issue that has been in the news recently, and that's around the privatization of some aspects of health care. There is very grave concern about the opening of several private health care clinics, and one of the concerns is about the impact this would have on the public system, in particular with respect to draining away health human resources, such as nursing staff, anaesthesiologists and what have you. To what extent is this a concern for the Capital District Health Authority? What would you recommend to government as a way to deal with this?

MR. FORD: Well, it would be presumptuous of me to recommend anything to government because they're the policy-makers and it's their responsibility to set the policy. The issue of, obviously, monitoring it at this point, Capital Health is watching. We do not know what the impact will be. We can't project what that will be. It would be only an assumption that would lead us to anything, so we're watching it closely.

I think it's important to remember that the clinics that are being considered in the public domain are offering non-insured, non-medically necessary services. So from the

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standpoint of the activities of Capital Health, we are there to provide the medically-necessary insured services, and that's where we're focusing our attention. We're just watching with interest to see what the impacts may be, if any.

MS. MAUREEN MACDONALD: Well, I don't know that I would agree with you that the clinics are only offering non-insured services. Certainly what is proposed for the eye care clinic, I've heard the physician involved interviewed, and he has expressed a real desire to be doing insured services. The private MRI that has been here for some time is providing,

in the private sector, what is available or should be available in the public sector. So, perhaps you could indicate whether or not the private MRI has had any impact on health human resources, as far as you can tell . . .

[9:30 a.m.]

MR. FORD: It has had no impact on us.

MS. MAUREEN MACDONALD: It has had no impact? You've monitored this?

MR. FORD: We have, and it's had no impact on us.

MS. MAUREEN MACDONALD: Well, that's certainly reassuring, I suppose, on one hand, because this is very much a concern that people have, about the bleeding away of personnel from the public system. I want to ask you how many vacancies do you have right now at Capital District, in terms of anaesthesiologists?

MR. FORD: I believe the number right now, we are recruiting for six more anaesthetists, and we have a number of anaesthetists who are interested in coming and filling those positions. So, we have six positions to which we're recruiting, and we have candidates interested in each of those positions. So our anticipation is that by some time over the Summer, we will be at our complement in anaesthesia, which I think is important in the sense that at the national level there are probably, at any point in time, in excess of 400 positions available for anaesthetists. We've a great deal of success in recruiting to the positions that we have, so our anticipation is we'll be at complement by sometime during the Summer months.

MS. MAUREEN MACDONALD: Can you comment on why these vacancies occur? Why is it so difficult, in your view? Why has it been so difficult, in your view, to either retain or recruit people to these positions?

MR. FORD: A lot of factors contribute to the challenges that we face. As I said, I think one of the greatest factors is that there are 400 positions across Canada that are available. So, when a graduate is available, they have a great deal of choice from which they can choose where to go. They may choose to go to another jurisdiction because of a different

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program structure, a different set of activities that they can be involved in and they might be able to be involved in here, maybe something to do with the compensation. Each organization is effectively after the same pool of graduates, when they graduate.

Our hope is that those graduates who have gone through our program will stay. I think one of the important things that's happened recently with the signing of the alternative funding plan is that in previous years when our graduates would graduate, they would frequently not stay in Nova Scotia but in fact go to other locations, and this year we've had three of our graduates who are coming to the end of their program training course indicate a desire to stay and practice in Nova Scotia. Some of them will be here for several months and some will be here for half a year. They will then go away, do a sub-specialty training with the anticipation of coming back and filling one of the spots that is now available, because of the AFP. So I think our stability through our AFP has been a starting point and, as I say, we're competing with a very large and aggressive market. I think it's a myriad of factors that contribute to where a clinician will ultimately decide to settle.

MS. MAUREEN MACDONALD: Throughout parts of the United States, in fact many of the states in the U.S., have nurse anaesthetists. I'm not sure that we do yet here in Canada, although we may be moving in that direction. Is this something that you would consider?

MR. FORD: It's certainly something that's been discussed. I think the important thing is to make sure that if we moved in that direction, we had the right conditions in place to ensure that the care and the activities that the nurse anaesthetist or others might be providing was properly supported and managed so that patient safety was the paramount consideration. Certainly it has been discussed, and it is an option that I think, across the country, people are looking at from the standpoint of this terrible challenge that we have, particularly in the area of anaesthesia.

MS. MAUREEN MACDONALD: Your business plan makes reference to the report or recommendations from Corpus Sanchez International. You also make reference to a 100-day action plan with some priorities for action. You've made reference here this morning to a report that was just done on accreditation around the capital side of your operation. I'm wondering if you could make those reports available to this committee.

MR. FORD: They are publicly available on our Web site.

MS. MAUREEN MACDONALD: Thank you. I think my final question would be with respect to the strategic planning process that just occurred on mental health. Can you indicate what the cost of that process was, the external consultants?

MR. FORD: I'll ask Barb to respond to that, it's in her jurisdiction.

[Page 13]


[Page 14]

MS. BARBARA HALL: As you know, Maureen, we had several phases to that strategic planning process that went all the way back to last October. I think the total cost to date is around $200,000, and that would include all of those forums, the breakfasts and all the planning and the citizen support.

MS. MAUREEN MACDONALD: Coming out of that process there's now a plan for an alternate model of mental health care delivery, is that a fair characterization of what you have?

MS. HALL: I think that's a good characterization, it would set the tone for our mental health services and the direction for the next five to 10 years, sort of the vision of where we would like to go and with some practical implications for our whole mental health system, including those outside of our traditional mental health services, so we were very inclusive.

MR. CHAIRMAN: Thank you. Time has expired for the NDP caucus. I will recognize Mr. David Wilson, the member for Glace Bay for the next 20 minutes.

Mr. David Wilson.

MR. DAVID WILSON (Glace Bay): Thank you, Mr. Ford and others for joining us today, I'm sure you're thrilled to be here, we all are as a matter of fact. I meant that in a good way, Mr. Chairman.

I want to bring to your attention first of all, I guess it's rather troublesome when we sit here as members of the Legislature and we hear phrases like never enough money, insatiable appetite for health care, and we hear them time and time again. When we hear that our main medical facilities in this province, as you stated, you are a training hospital, you are a regional hospital, you're a referral centre for Atlantic Canada, but yet you appear before a Public Accounts Committee in this province and you say that over one-third of your equipment in diagnostic imaging is out of date. That's a rather startling statement to me because if I'm somewhere in this province and I'm being referred by a doctor to the QE II, I'm usually of the opinion that I'm going to Halifax to get the best treatment possible in this province and indeed, in Atlantic Canada. How can I get that treatment if your equipment isn't up to scratch, if your equipment is out of date, if your buildings are falling apart?

If you are telling us here in the Legislature that you would need $106 million to bring your buildings up to scratch and you were offered $9 million, that discrepancy is huge. That would lead me to indicate there's no way the QE II will ever catch up, it's impossible. You will continue to fall behind unless the proper amount of funding is there in terms of capital construction.

[Page 15]

The operational funding shortfall that you indicated is about 2 per cent on a continuous basis. Again, that would be very worrisome. The demand, as you said, your budget is growing and why does it grow? Because you can't play the game of supply and demand, you can't guess when the demand it going to be there, you just have to play the supply game. When the demand is there you have to supply the services.

I guess my first question, Mr. Ford, would be to you. I know from the few meetings that I have had with you that you're a person who takes your job very seriously. You are a professional person who takes a great deal of pride in what you do. I've given you my MRI and that's what I have come out with. So as that professional person, you tell me, please, how can your facilities continue to operate with outdated equipment, with buildings that are falling apart, and what would you like to see done today, by this government that is in place, to remedy the current situation that you're in?


MR. FORD: The challenges that we face are as you have outlined and they're not challenges that are new, they are challenges that have been existing in the health care system for years and probably will continue to exist for years to come. Clearly, when we talk about a third of our equipment in diagnostic imaging being beyond its useful life, we would not place patients at risk. I think you can be assured that should a piece of equipment not be safe for patients to use, it's taken out of service.

Clearly, equipment is changing regularly and almost daily. New procedures are being discovered, new pharmacological interventions are being created and to keep up with that pace is the challenge of health care, it's not unique in this province. As I said earlier, we are competing and we understand that we are competing with the demands that exist in this province for all the other capital needs that are out there.

Understanding the determinants of health and the importance of those, we appreciate that investments in schools, investments in universities, investments in housing, and the ability for people to have meaningful work, those are all important to the health and well-being of the population. So we know we are competing in that area and the responsibility that we take is to continue to work with government, to continue to identify those concerns, to continue to provide the prioritization. We also continue to work aggressively with our foundations so that, where possible and when possible, we're able to also add their funds to the ability to replace and replenish equipment, it's an ongoing and continuous challenge.

MR. DAVID WILSON (Glace Bay): Mr. Ford, I'm not casting any aspersions upon yourself, the administration, or anyone else at the QE II, but if you're continuously falling short, you can't catch up. I know it's an ongoing problem that you're having with funding, obviously it's getting worse. You are saying operating funds are short by 2 per cent on a continuous basis. You're also saying that, again, your capital construction is falling behind

[Page 16]

every budget that comes out. You're faced with a situation where you start the year with a provisional budget because you have no idea from this government exactly what you have to look forward to.

I know it's on an ongoing basis and I'm not talking about people at risk, but if I'm referred to the QE II for whatever the case may be, whether it be cardiac, whether it be cancer, whatever the case may be, I'm expecting to be referred to the major, the premier medical institution in this province and indeed in Atlantic Canada. If I'm walking into an imaging unit with an MRI that's outdated, I'm not getting the best medical attention that I should be getting. Is that not true?

MR. FORD: I think when you present, obviously the clinicians that are involved will determine which piece of equipment is most appropriate for your care. I think it's fair to say that the results that we've seen from satisfaction and from following our discharge activities and discharge data, is that the care that the citizens of this province and, in fact, Atlantic Canada are receiving, is meeting the standard that it should be meeting and that they're being cared for in a compassionate and efficient way. I think from the standpoint of saying that you would necessarily always go to that one piece of equipment, no, that's not the way it happens. I'm just telling you that on balance, we have this challenge continuously that we face. I don't think you can make the quick jump from that to the fact that the care that is being received is not meeting the needs of the individuals being treated.

MR. DAVID WILSON (Glace Bay): That challenge is, as you said, on a continuous basis, and the challenge is to get the funding from government. You just said today that you are getting from a foundation a new piece of equipment that is being donated. That's not government funded, that's the people of Nova Scotia being charitable towards your organization, but that government funding is not there in that instance.

I know from the district health authorities across the province, for instance back home in Cape Breton, the regional hospital foundation does a tremendous amount of work and donates a tremendous amount of money towards the operations of the Cape Breton Regional Health Care Complex. But despite the fact they are public monies, it's not government funding, that's sort of like the cream - is it not - that you get?

[9:45 p.m.]

MR. FORD: I don't understand that last question.

MR. DAVID WILSON (Glace Bay): In other words, that's the icing on top of the cake. When you receive a piece of equipment from a foundation, it's a gift.

[Page 17]

MR. FORD: It's a gift, yes. It's made available through the generosity of the citizens of the province or the district or wherever the donors may be, or corporations, or other organizations. It is part of what we are expected, as an organization, to do to ensure that we provide the services. So yes, some of the equipment is made available through that route. It is all equipment that is part of our overall plan, it is not equipment that is not necessary, it is part of our overall plan and we're just able to find alternate sources of funding for it.

MR. DAVID WILSON (Glace Bay): That's what I meant, that's alternate sources, it's not government funding. As a matter of fact, continuously, the Capital District is underfunded, is it not?

MR. FORD: We have what we believe is a systemic shortfall of about 2 per cent and we have the challenges continuously in the Capital District.

MR. DAVID WILSON (Glace Bay): In your estimation, why is that? Why is it continuously 2 per cent?

MR. FORD: As I said earlier, I think there are a number of factors that contribute to it. We are an academic teaching centre and with that comes a cost that other jurisdictions may not bear. I think we are obviously a port of last call for many patients in the province, so that when it's a specific clinical intervention that is required, we may be the only ones who offer it so it comes to us. We obviously, I think, have the challenge of demand and expense. Our volumes and our costs for some of the activities go up and we can't control those. For example, in the area of orthopaedics, the equipment is very expensive, the prostheses, the tools, and the implements that are used are very costly. They may not always be at the 7 per cent that we receive for operating supplies and expenses. So it's a combination of many factors that contribute to the pressure that it is that we feel we're under with that 2 per cent shortfall.

MR. DAVID WILSON (Glace Bay): Let me change topics, Mr. Ford. My colleague, the member for Halifax Needham, made reference to the subject of the anaesthetist situation at the QE II. I know you're aware and as the public is now aware, one of the top cardiac anaesthesiologists at the QE II, one of the top in the country, is leaving the QE II at the end of June. Is that correct?

MR. FORD: I believe that's correct, yes.

MR. DAVID WILSON (Glace Bay): What impact is that going to have on the QE II and in particular, what impact is it going to have on your cardiac wait lists?

[Page 18]

MR. FORD: In discussion with the division head for that area, he is indicating to us that some of the candidates we're recruiting will be able to help us replace that individual. Our anticipation is that we will be able to adjust accordingly and cover the clinical needs as they present themselves.

MR. DAVID WILSON (Glace Bay): According to a press release that was made by the district back in February, there was a full-time anaesthesiologist scheduled to start in March. Did that occur?

MR. FORD: Yes, it did.

MR. DAVID WILSON (Glace Bay): And another was scheduled to start in May, did that person start working full time in May?

MR. FORD: Yes.

MR. DAVID WILSON (Glace Bay): You said you had six?

MR. FORD: I believe there are presently six that we're recruiting.

MR. DAVID WILSON (Glace Bay): You had anaesthesiologist residents who were scheduled to leave at the end of next month. Have their contracts been extended?

MR. FORD: Their contracts haven't been extended because they're leaving to continue their post graduate education, but the expectation with each of those individuals is that they will be getting educational training, in anticipation of returning to provide that sub-specialty service in Capital Health.

MR. DAVID WILSON (Glace Bay): You've had three new anaesthesiologists hired from January to May, is that correct?

MR. FORD: Yes.

MR. DAVID WILSON (Glace Bay): Three more scheduled on short-term assignments?

MR. FORD: Yes.

MR. DAVID WILSON (Glace Bay): Three residents have agreed to stay through the Summer? I read that in a news article at one point.

MR. FORD: They are staying for various periods over the Summer and into the Fall.

[Page 19]

MR. DAVID WILSON (Glace Bay): And a new one starting in July?

MR. FORD: That's correct.

MR. DAVID WILSON (Glace Bay): So that's a total of 10?

MR. FORD: It's hard to use those numbers because at this point we have the six that we're trying to replace, which we have leads on all of them, and we are anticipating that we will have the complement of anaesthetists that we need by the middle of the Summer.

MR. DAVID WILSON (Glace Bay): According to my figures - and I'm not really great at math - that should fill all of your vacancies, from the indications I've had, but you have indicated there are still more. Anyway, I'll leave it at that.

I want to know, in your opinion, all of this discontent that seems to be out there, and you may take offence to that, but I'll use that word anyway, regarding anaesthesiologists, is that related to the new alternative funding agreement?

MR. FORD: Is there discontent related to that? Is that what you're asking?

MR. DAVID WILSON (Glace Bay): I'll give you two questions. One, is there discontent? If there is, is it related to the alternative funding agreement?

MR. FORD: I think there has been some discontent, and I think it's related more to the fact that with the shortage of anaesthetists, the workload has been excessive. They're obviously unhappy with the excessive workload. With our ability to recruit, we're hoping that we're going to be able to bring those workloads back into a more normal expectation of what an anaesthetist should be doing on a weekly and a monthly basis. So I'm hopeful that with the replacement of the positions that are coming onboard, some of that perceived discontent will diminish.

MR. DAVID WILSON (Glace Bay): They're unhappy with the workload. Are they unhappy enough to go to a private clinic or a private hospital?

MR. FORD: I can't predict what a physician would choose to do.

MR. DAVID WILSON (Glace Bay): I'm sure that physicians talk to you from time to time. I'm sure that if you have a physician who's not happy at your facility that at one time or another Don Ford's door has opened and that physician has gotten it off his or her chest, I'm sure. Have they indicated that they're not happy to the extent where they're maybe thinking about leaving.

[Page 20]

MR. FORD: They've indicated, as I said to you, that they're not happy with the workload, in some cases, and we've indicated to them that we're endeavouring to replace vacant positions which will hopefully address that concern.

MR. DAVID WILSON (Glace Bay): In comparison to other jurisdictions, when you're talking about the alternative funding agreement, comparing it to other jurisdictions in the country, how does the salary component of those agreements compare? In Nova Scotia, are we the lowest, are we mid-range, where exactly do we fall?

MR. FORD: I would suggest we're probably mid-range.

MR. DAVID WILSON (Glace Bay): And is that a factor in recruiting?

MR. FORD: It's a factor in recruiting some individuals, yes.

MR. DAVID WILSON (Glace Bay): A negative factor in recruiting?

MR. FORD: It's a negative factor is some cases, and it's a positive factor in others. We've obviously had some success in recruiting. So, I would suggest to you that the amount of money that's made available to the individuals we're recruiting is satisfactory to what they're looking for. Clearly there are some individuals who would choose to go places where they might be able to make more.

MR. DAVID WILSON (Glace Bay): Back to the person, and I'm not dealing with personalities here but, your top cardiac anaesthesiologist, who's leaving, how difficult is it going to be to replace someone of that calibre?

MR. FORD: Specialists in all areas are a challenge to replace. So, certainly, somebody with a subspecialized skill is a challenge to replace. Some of our residents, as I indicated, are going away and training in subspecializations, and that's how we continue to replenish those who are either retiring or moving or choosing to leave the profession for other reasons.

MR. DAVID WILSON (Glace Bay): For instance, how many other cardiac anaesthesiologists do you have on staff?

MR. FORD: I don't know that specifically. I could find that out and let you know.

MR. DAVID WILSON (Glace Bay): Because, as you said, that is a subspecialty, right? I noted that last week there was a spokesman for the Capital District who indicated the elective wait list is going to taper off during the Summer, because - the comment was - people don't want to have surgery over the Summer months. I found that rather strange, because, I thought to myself, well, isn't that rather an artificial reduction in wait lists. After

[Page 21]

all, at some point, those people are going to require surgery, are they not, just because they're not having it in the Summertime? I'd like your opinion on that. Which surgeries are going to be affected during the Summer months? Does that actually occur?

MR. FORD: I'm not really sure what your question was, I'm sorry. You kind of didn't . . .

MR. DAVID WILSON (Glace Bay): There was a spokesperson for the Capital District, last week, who indicated that the elective wait list is going to taper off because some people don't want to have surgeries during the Summer months.

MR. FORD: Right.

MR. DAVID WILSON (Glace Bay): Why is that?

MR. FORD: People who have a procedure scheduled, when we contact them, there are individuals who will say, I'm not going to be available, we're off on Summer vacation, we're going down to the cottage, we're doing things. So, they defer their scheduled procedure to a later time.

MR. DAVID WILSON (Glace Bay): I think my point was that the point was being made that that's going to reduce wait lists, but it doesn't.

MR. FORD: It doesn't reduce wait lists, but individuals choose, if it's an elected procedure, they, as individuals, have the opportunity to choose. Some individuals, when contacted, would prefer to defer that scheduled procedure until the Fall.

MR. DAVID WILSON (Glace Bay): Back to your anaesthesiologist situation, indeed, is that impacting on the ability to perform surgeries at all?

MR. FORD: Absolutely. When you don't have enough anaesthetists, you obviously can't run the same number of ORs, so we have had, over the last several months, a reduction of OR availability because of anaesthesia availability.

MR. DAVID WILSON (Glace Bay): Because of that reduction of availability, how many surgeries, for instance, any idea, have been cancelled?

MR. FORD: I don't know the specific number of surgeries. We've probably had one room out of about 40 that hasn't been able to work regularly.

MR. DAVID WILSON (Glace Bay): Pardon me, would you give me that figure again?

[Page 22]

MR. FORD: We've had one room that we haven't been able to run, out of about 40.

MR. DAVID WILSON (Glace Bay): So that would indicate - any idea? Maybe you could provide . . .

MR. FORD: It would depend on the subspecialty that's being done. Depending on what's being done in that room, there are a different number of patients who could go through that room at a point in time. So, to say how many it would be, it's hard to quantify in that sense. It might be for orthopaedics one day, for cardiac one day, for general plastics one day. So it would be variable - the numbers would be somewhat variable. It's hard to pick a specific number.

MR. DAVID WILSON (Glace Bay): There's a situation where you are cancelling surgeries, are you not?

MR. FORD: Yes.

MR. DAVID WILSON (Glace Bay): Is that what you're saying? You're cancelling surgeries because of . . .

MR. FORD: It may be that a surgery is cancelled or it may be that knowing that that room is not going to be available, the surgeries are not booked. So patients aren't always cancelled, but they may not be able to be booked for that procedure because there's no available space.

MR. DAVID WILSON (Glace Bay): I believe my time has expired.

MR. CHAIRMAN: The time has expired for the Liberal caucus.

The honourable member for Kings North.

MR. MARK PARENT: Thank you for the presentation. I listened with great interest, because although my riding is in the Annapolis Valley and we have an excellent DHA there and a wonderful regional hospital, the Valley Regional Hospital, in my riding, nonetheless, we all know that as a referral centre, we depend upon the work that you do in the Capital District Health Authority. So the whole province and, as you indicated, the Atlantic Provinces have an interest in making sure that the Capital District Health Authority is working well.

I was struck by the positive nature of your comments, particularly the comment that compared to six years ago, that we're in a much healthier state. I've heard that comment in other fields as well. It's music to my ears, because six years ago there was a government change and I was part of that.

[Page 23]

[Page 24]

I also listened very carefully to your four points, because I think that they're points that are probably similar to other health authorities, in terms that you're efficient - I know our health authority is a very efficient health authority - that in spite of the efficiency, there's not enough money, that the capital cost, the infrastructure costs are falling behind, and that's typical. I come from a church background, and whenever our budgets were tight, we didn't do the necessary repairs, knowing that it would cost double that amount in the future. Health promotion needs to be foremost if we're going to tackle the problem of sustainability of health care, which I think is what a lot of your comments alluded to, and that's what I want to ask some questions on.

In light of the fact that you're efficient, you quoted the figure in terms of administrative costs, and yet even then there's this shortfall. The Leader of the Liberal Party suggested that $140 million might be taken out of health care and put into education.

MR. DAVID WILSON (Glace Bay): Mr. Chairman, on a point of order. That comment was never made, never suggested, and it should not be brought up in this meeting.

MR. PARENT: I'll rephrase that. In light of the media reports that the Liberal Leader suggested $140 million be taken out of health care and put into education, and in light of comments like that, and behind those comments are suggestions that the administrative costs are out of control, that efficiencies aren't there, in light of comments like that, what effect would it have on your budget if - since you have the lion's share of the budget as the largest health authority - that amount of money was taken out of your budget? How would it affect you?

MR. FORD: Well, it's somewhat hypothetical. If the province was reduced by $140 million, where we're about probably 45 per cent of any distribution, and if it all came out of acute care, that would be in the range of $60 million, which would probably mean a substantial reduction of programs, closures, staff layoffs, and it would obviously drive up wait lists and would make us far less responsive than we would ever want to be. It would have a huge impact, obviously, a reduction of that magnitude, on the health system in the entire province.

[10:00 a.m.]

MR. PARENT: Coming in then, in terms of the fact that there's certainly no savings to be made through efficiencies, that the loss of any money would have a very detrimental impact. Yet, there isn't enough money, as you stated, for sustainability and it's not just our health system in Nova Scotia, it's across the country. What sort of alternative ways of funding, or what solutions do you see to this? Certainly, health promotion is one, but that's going to take time. As we get a healthier population, hopefully, some of the costs will go down, although that will be offset somewhat by the fact that we have an aging population at

[Page 25]

the same time, which drives up the costs. We know that as people age they see their doctor more, they depend on the hospital more.

What options are out there? That may not be a fair question to ask you, that probably should be a question you should throw back at me as a politician. But I'm interested from your perspective as a health administrator and from any of the doctors and other health administrators who are there, we know we have an efficient system, I agree with you on that - and I was perhaps taking a bit of a poke at my colleague here - but you can't have it both ways, you can't say the province isn't funding it enough and say you want to take money out. But we know we can't meet the demand financially, and I do worry about capital infrastructure falling behind because that's an easy place not to spend while you're trying to keep up with the other, so are there some creative ways that we can meet that shortfall in infrastructure funding?

MR. FORD: I think that the system, over the last 20 years, has been continuously looking for increasingly creative ways to meet the demand and meet the need. Clearly, the agenda, as you say, of health promotion and prevention is critical to that. It is a long-term investment but if we don't make that investment soon, we'll never get out in front of this wave.

When you look at the rates of inactivity, when you look at the rates of obesity in our youth, when you look at the kinds of diseases that we're seeing now, 12-year-olds with type II diabetes, the prognosis on that is frightening from the standpoint of what that's going to cost to the system, quite apart from the reality of what it costs that individual and their family, and society as a whole. It's critical that we aggressively tackle the prevention and promotion initiatives. It's critical that we stay on top of things that are known to make a difference, fetal alcohol syndrome, fetal alcohol effect, getting young women to appreciate and understand that not consuming alcohol while pregnant is the absolute 100 per cent guarantee of not having a child with fetal alcohol effect, or fetal alcohol syndrome, it's a guarantee. Very few things in health care are, that's one that is. The fact of bike helmets; helmets when you're skateboarding, skiing, et cetera; the issue of seatbelts; the issue of not drinking and driving; the issue of activities, all of these things are investments that are not costly to make but are huge as far as the downstream effect. So as much as you're stating the reality that it's a long-term investment, it's an absolute investment that we have to make, so that's the one thing.

The second thing is that we continue to look for efficiencies in the way the system is run and the way we do procedures. We're always looking to see whether or not a procedure that's done in an operating room can be done in an ambulatory clinic, or an ambulatory clinic can be done in a physician's office. So, we're obviously always looking for capacity to find greater efficiency, so that we're able to meet the need within the available dollars.

[Page 26]

I think the last area that's important is to provide education to the public so that they can make informed choices. We have a very informed population and with the right information made available to them at the right times, when they're making the decisions, I think that's part of the solution, and supporting our primary care part of the organization. Eighty-five, 90 per cent of the population is really dealt with in the primary care arena. We see a very small percentage in our district health authority, hospital-based part of the organization, so supports to the primary care physicians, thinking about whether or not primary care practice is reconfigured, so that primary care physicians have access to pharmacists, have access to physiotherapists, have access to extended practice nurses, have access to social workers, so that as a collective group practice, the primary care physician can manage a population in a much more creative way and in a much more aggressive way.

Those are the kinds of things that again, are an investment, yes, those practices would need to have those resources made available, but a family practice with those kinds of resources could have a huge impact on the wellness of the population that they are serving in the district that they're responsible for. With the right kind of interventions at the right time, with the right kinds of resources, they don't show up at the hospital doors.

MR. PARENT: We've actually seen that in the EKM in Wolfville, which has taken on the model of a clinic, where they have drawn in a wide array of health professionals, and it is working. It allows the physician to draw upon their expertise, but also to devote his or her time to the area that he or she should be devoting it to. So, yes, I appreciate you ending on that.

My colleague for the NDP raised the issue of privatization and you mentioned that these clinics were non-essential services. When Medicare was brought in it was brought in to cover a certain scope of services and that has widened over time. Are there any other models in other countries where they have said okay, the public system can handle this amount of services but non-essential services will be handled through a different model? I'm told that in Sweden they perhaps have a model like that, is that true? I'm not aware of other models.

MR. FORD: There are models across the country and across the world where jurisdictions have looked at the range of programs and services that are offered and have put certain limits on what they consider to be insured service and what they consider to be non-insured services. There was an historic model called the Oregon model in the United States where they went through a very active process of trying to define a threshold below which funding was not available, so that wasn't covered, and things above it were.

I think most jurisdictions that have tried that have found it is good at a point in time but medicine and clinical interventions are changing so rapidly and so drastically that it's almost out of date the day it is printed. A new clinical intervention, a new determination of how to use an existing pharmacological agent for a new application, the fact that we have

[Page 27]

genomics and we can now precisely define the genetic blueprint and create drugs that specifically target aberrations in that genetic blueprint.

Those things are changing so quickly and the expectation of the public therefore is changing so rapidly, I'm not sure - to be quite honest - that the models that were used at a different point in time have still the same applicability, because it's moving so fast, it's changing so quickly, new diagnostic therapies, the idea of laparoscopic cholecystectomies, that was not even on the radar screen 15 years ago and now, we do very few open gallbladder removals, they're all done through a laparoscope. The effect on the patient is huge, it's great for the patient, they're in in the morning and they're home at night, as opposed to being in hospital for seven days. The reality of that means that over seven days we can deal with seven patients, as opposed to before dealing with one patient for seven days. So the efficiencies have created all the challenges that I spoke about.

I think as a result of those kinds of factors it would be very, very difficult to use some of those pre-existing models, although I think, clearly, and we do regularly, look at jurisdictions across the world to see what's new, what's different, what are they doing, what can we learn from that, what can we apply? Some of the things we can apply well, some of the things we can't. Some of the things in some of those countries, the health system is so closely tied into their social services system, that the synergies of the two play off each other. So the applications of those ideas and those models have to be very carefully reviewed to see whether or not they really do have the ability to make the difference in our reality.

MR. PARENT: My colleague has some questions to ask, and I'll turn it over to him. One last - it's not really a question, but it's a comment, maybe it's a question, I've always wondered why the Windsor hospital is in the Capital District. I know that's where they want to be, but many of the services gravitate the other way. That's really not a question you can answer, because of the boundaries.

MR. FORD: That's where the line was drawn.

MR. PARENT: I just put it, to get it on the record.

MR. CHAIRMAN: The honourable member for Waverley-Fall River-Beaver Bank.

MR. GARY HINES: Welcome, ladies and gentlemen. It has certainly been an informative session, as it always is when we get the opportunity to listen to Mr. Ford talk. One of the statements you made regarding the need for large capital amounts to bring your equipment up to date and so on, I had a little problem with the suggestion by one of the honourable members that you don't have the money to bring your technology up to perhaps the top-of-the-line equipment. You were not suggesting by any means that that equipment was incompetent and not able to do the job. It would be my understanding that you were

[Page 28]

suggesting that this equipment can do the job, but perhaps in terms of time and that kind of thing, that's what you'd be gaining by having the newest and most modern technology.

MR. FORD: Absolutely. If a piece of equipment is deemed by the clinician or the physician who's involved with using it is not a safe piece of equipment or a piece of equipment that meets their needs, they basically take it out of service. They tell us that they can no longer use it and they don't use it. So we have vintages of equipment at various stages, and they, obviously, are always making that clinical determination. But if it reaches the stage where it's not safe for the patient, they are the first to remove it from service.

MR. HINES: Certainly, I've said it before and I'll say it again, the strength in our health care system is in the providers. I had the opportunity - after a little wobble here in the Legislature in the Fall - to see the care you get when you go to the hospital, firsthand. There certainly was no evidence there with the use of the equipment and so on and with the process that they put you through, that we're suffering from proper treatment as a result of equipment or the ability to operate it. It was just incredible, the service I got there.

I had the opportunity at the end of my stay there to talk to the chief neurologist. One of the things he indicated to me is something that I want to compliment you on, that you've done, and that is to insist that those who have stroke or heart conditions remain in the hospital and get the full gamut of observation and treatment that you can get rather than, well, yes, you're safe to go home now, I'm going to trust you to go to your local practitioner for the remainder of these tests. I think that's been a big step. He asked me to comment on what I thought of that, and I said, well, having had no more experience in your hospital, I don't know. But since then, I have had friends go in for triple bypass, just recently, and so on.

I commend that decision, to encourage individuals to stay and get the whole gamut, so that when they leave that hospital, they know that all those things related to heart and stroke are being addressed rather than trusting the individual, who, as soon as he feels healthy, like myself, will walk away from further treatment. I wanted to make that comment.

I want to go to another issue. I read in the paper just recently, there was a doctor in Australia who was able to practise for some 20 years, despite the fact he came from the United States with condemnation. He practised for 20 years and was responsible for the death of some 60 patients. What do we do in this province when we're recruiting professionals to come to this province from away? I know there's a new generation, to have recognized individuals coming out of this country. What are we doing to make ourselves safe, so that this type of thing doesn't happen here?

MR. FORD: When physicians are recruited to any of the districts in this province, there's a very clear protocol that's required. The first is that they obviously have to receive licence here to practise in the province, through the College of Physicians and Surgeons of

[Page 29]

Nova Scotia. They're the body that looks at the professional designation, they're the ones who look into whether or not the standing of that individual is, as they state, in good stead, they're the ones who correspond with their counterparts in whatever jurisdiction the individual is coming from, to be sure that there's nothing of any concern in that individual's history or in their background.

We clearly, also, from the standpoint of recruitment, do our due diligence. The chiefs and directors of those areas usually know colleagues who work in those areas, and they are in touch with their colleagues to ensure that the individual is as they are presenting themselves to be. So we go through the process of ensuring that their qualifications are what they are said to be. We make sure that they are able to perform the procedures they say they are able to perform, and conduct themselves in the manner in which they are purporting they are able to conduct themselves. So we do that through our usual processes as well, through both the department channels and through the hospital health district organizational channels, so that when the individual arrives, we know they are fully qualified and are here without any concerns following them.

[10:15 a.m.]

MR. HINES: In my community, I'm fortunate to have the medical care available that we have there. In fact some of the statements that you hear in other areas about never getting a doctor and those kinds of things, I don't have that problem, because the Fall River Medical Centre has been a tremendous asset to our community and for the areas surrounding, as has the Cobequid Multi-Service Centre. When I go to the Cobequid Multi-Service Centre or drive by that new facility, I have to look at it with pride.

There's been some rumour out there, or suggestion, that in fact when they open, they're going to be like the hardware store that doesn't have the shelves full. Can you elaborate, are we going to be fully operational when they do open the doors? When can we look for that opening?

MR. FORD: The opening is scheduled for January 14th, and will they be fully operational, no. There will be components that we have obviously built with the anticipation of being able to grow into our new facility. I think it would have been irresponsible not to do so. Clearly we have identified that there is a need for some enrichment in some areas, and we've heard from the Department of Health that those will be funded. So we will be able to open our emergency bays to their fullness. Some of the diagnostic activities may not be at their full complement when we open, and we will continue to work with the department to receive the necessary funding for those pieces of equipment and for the staff who are necessary to operate them.

The other activities, obviously, are that as the facility is opened and up and running, we will be looking at the range of services that are offered throughout the rest of the district

[Page 30]

to see whether or not it's possible to start to offer clinics in that area as well. Once it's up and running, we will be translocating some of our clinics from the HI site or the VG site or the Dartmouth site out to Cobequid for visiting clinic activities. So we'll be ramping up as we live in the building a little bit.

MR. CHAIRMAN: The time allotment has expired.

The honourable member for Halifax Needham. We'll have 12-minute rounds.

MS. MAUREEN MACDONALD: I have three relatively quick questions. You have approval now from the Department of Health for the replacement of one of your MRIs. At what stage are you in securing a new MRI? When can we expect to have that?

MR. FORD: I believe the RFP has gone out and is under review, and I believe the target - and I stand to be corrected on this - is to have the new MRI in place by the Fall.

MS. MAUREEN MACDONALD: I think it's fair to say that there is confusion around AFPs. We've just had a report on AFPs in the Capital District, and I think we'll have an opportunity, this committee is going to examine this a bit further. I want to ask specifically with respect to anaesthesiologists. AFPs, you say, are tools that assist in retention and recruitment. What are the measures that are put in place in terms of deliverables under AFPs? That may be too lengthy a question, in some ways, to get into at this stage. Can you just, in terms of dollars, tell us what would anaesthesiologists get under an AFP versus fee-for-service, ballpark?

MR. FORD: I can't answer that, because the AFPs have an element called the practice plan, whereby the physicians, with the revenues they receive, determine the relative share for each of the members of the AFP. That's done by the department. It really reflects the activity profile of that individual, so it's not a standard. I think it's fair to say that on average it's in the range - and this is the average - of about $265,000, that would be the average of the range but it would be variable depending upon the individual.

The deliverables component of the AFPs is an important part of the AFPs, and the report that I think you're referring to is the one that was recently done on the Department of Medicine by North South Group, and within that there was a very clear recognition that work needs to be done to clearly define what those deliverables are. In fact, in the most recent negotiation, in which I was intimately involved, we spent a great deal of time struggling on what are those deliverables. The challenge is creating a definition of that deliverable somewhat in the absence of a benchmark.

There is a history of using the fee-for-service as a proxy for the activity but as an example in medicine, using the shadow billing, which means if the physician is on AFP, they continue to bill as if they were on MSI. One of the examples that came to our attention as we

[Page 31]

were looking at deliverables was a concern that there had been a huge drop in an activity as reflected by the MSI billings. In fact, when we looked into that, there had been and the reason was because that practice had changed and the reason it had changed was because on the AFP there was an opportunity to do a very good analysis of whether or not that practice was in fact indicated for that population group. When it was determined that it wasn't, the physicians stopped doing it. In stopping it, they obviously stopped shadow billing and it therefore looked like they weren't working as hard which, in fact, was not the case at all.

So the issue of defining those deliverables is a critically important part of those AFPs. It is a huge challenge and what we are trying to do is establish benchmarks as to wait times, benchmarks as to responsiveness, benchmarks as to the numbers of procedures that a various group will do within each of the divisions of which there are, in medicine, I believe 16 different divisions. It also has to define that individual's contribution to research, to education and to their administrative responsibilities. Each physician has a different profile so that when you do the sum total of all of that, you get the departmental profile of activity and service and events that take place and then you can look at the dollars that are made available and do the assessment as to the value for the money, which is what North South did.

MS. MAUREEN MACDONALD: My final question - and I want to turn over the remainder of my time to my colleague - is with respect to the shortfall, the 2 per cent operating shortfall annually. I would assume that by far the largest proportion of your operating funding goes toward staff and salaries. How do you manage a 2 per cent shortfall? This doesn't sound like a big deal but 2 per cent, I would assume, is significant. Do you do this by casualizing your labour force, reducing cleaning staff, do you do it by across-the-board cuts in all departments or do you focus on particular areas, for example, allowing wait times for orthopaedics to lengthen? Can you explain that to me?

MR. FORD: The 2 per cent systemic shortfall that we are discussing, about 70 per cent of our budget is salaries and benefits and effects related to that. The remaining portions would be operating supplies and expenses, drugs and other expenses such as our electrical, et cetera. One of the areas that we use to find some of that shortfall is that historically, out of our operating budget, we have endeavoured to set aside approximately $4 million into a capital account so that we have funds available for capital acquisitions. We are not able to do that so there's $4 million of it right there. We just leave that in the operating accounts and offer the programs and services.

The other areas are obviously efficiencies so we continue to look at whether or not we can get better deals with our group purchasing. We use national group purchasing processes. We look to see whether or not, with our various suppliers, we can go into longer term arrangements where we can get better pricing points and so we are looking at those regularly, looking at all of our contracts and all of our services. The other area is that if we have a vacancy, a position that is looking to be replaced, we may not replace that position.

[Page 32]

If we have a 0.5 physiotherapist in a program and we would like to have 1.0, full-time equivalent, we may not be able to proceed with making that a full-time equivalent. In our support areas, for example, in our information technology and areas like that, where we know that we would like to have perhaps four or five full-time equivalents to deal with our PC maintenance, we clearly don't proceed with that because we just can't do it. So therefore the maintenance on the PCs falls a little bit behind and our responsiveness to people who are having problems isn't what we would like it to be.

Those are the kinds of things that we do to manage it. It is a myriad of activities. Each and every time we do this, we appreciate that it has an impact on the staff that are providing service and it ultimately has an impact on our ability to be as responsive as we would like to be. It therefore has an impact on patients and their families and we take that very seriously and it's a great concern to us but it's that ongoing balancing act that allows us to achieve a balanced budget which we, in fact, had last year. We had a balanced budget the year before, a balanced budget last year and we are presenting to the department a balanced budget for this year.

MR. CHAIRMAN: The honourable member for Sackville-Cobequid.

MR. DAVID WILSON (Sackville-Cobequid): Thank you, Mr. Chairman, and thank you for coming before the committee. Some of the questions I have - I know I only have a short period of time - really pertain to some of the concerns I've heard as the elected official in my area but also concerns that I've seen and witnessed over my career in the health care sector over the years, especially pertaining to emergency room wait times, and access to diagnostic equipment. There seem to be concerns with Nova Scotians when they enter the health care system - not pertaining to the care they get from the health care professionals because I think we have some of the best in the country, if not in the world, in our province, we are very lucky and I rarely hear concerns about what care we get - it's the access to the services.

You had mentioned in your opening statement about a new MRI that you are hopefully going to obtain and a CT. One of the things in our area, I'm fortunate to represent an area that has seen a growth, I think, in capital project, the Cobequid Community Health Centre, and the construction of the new facility. In the plans, I know that it stated that there is going to be a CT put in place there. Could you inform us, is this an area where a new CT is going to go and will it be in place when the doors open to the new facility?

MR. FORD: There is a CT going to be there and the anticipation is it will be there when it opens, yes.

MR. DAVID WILSON (Sackville-Cobequid): That's good to hear because I think the new facility can definitely play an important role in addressing some of the concerns with wait times, especially in Capital Health but across the province, as many of my colleagues

[Page 33]

said, Capital Health and the QE II and Dartmouth, they play an important role in delivering health care to the rest of the province.

One of the concerns we heard is around the bone densitometry. I understand we have the only facility here that has that. Has there been talk about improving or increasing the unit? I think we have a wait time of about 10 months for that service and I'm just wondering if you could address that for a second.

MR. FORD: I will ask Barb to address that one.

MS. HALL: The province actually has embarked on a process to look at bone densitometry for the whole province so that instead of each district doing their own thing in bone densitometry that there is a provincial plan that has been suggested and put around and looking at where bone densitometry should be, so we will be working with our Department of Health colleagues as they roll that out throughout the province. I'm not really sure of all the details of it but it will be a provincial plan and not a district plan.

MR. DAVID WILSON (Sackville-Cobequid): Good, because I think we all recognize the need for up-to-date, state-of-the-art equipment, especially when it pertains to diagnosing potential health risks and the cost of patients and hopefully saving the cost of health care in the province. The other question would be, have you considered the impact the new Cobequid Community Health Centre could have on wait times in the Capital Health District, especially when it comes to the crisis we see often in the emergency room at the QE II? Have you looked at what extended hours or what maybe 24 hours would do in that area of the province, or especially in this area, with the crisis we see sometimes at the QE II?

MR. CHAIRMAN: Short answer for that, please.

MR. FORD: The short answer would be yes. We certainly have looked at the impact of the Cobequid Community Health Centre. Clearly it will be an important part of the continuum of services within the Capital District Health Authority. The emergency room is part of the district emergency room set-up so that the physicians that are in charge of the various emergency rooms are working together to understand what the logical model of continued care for a patient would be through the various emergency rooms. Having the diagnostics out there is going to be a huge advantage because many of the cases that are transferred are for that diagnostic intervention. So having the diagnostic capacity out there will be a great deal of help to us in hopefully resolving some of that pressure that is felt at the QE II or at the Dartmouth General Hospital.

[10:30 a.m.]

Obviously the issue of extended hours is one that continues to be discussed and I think it is one that when the business case is sufficiently there to justify we will be bringing

[Page 34]

it forward. I think it is fair to say, though, that when you look at going with a 24-hour model there versus taking that same amount of money and investing it in other activities in that district to address the needs of that specific population, I think there would have to be a very robust discussion to be sure that should new funds be made available, the investment is made where it is going to have the greatest payoff and it might, in fact, not be to go 24 hours at Cobequid, it might be to invest in some other free-standing clinics, as we discussed earlier, with the right kind of configuration to meet the needs of that population in a more immediate fashion.

MR. CHAIRMAN: I'd hate to hear the long answer. I'll turn now to Mr. Wilson, the member for Glace Bay.

MR. DAVID WILSON (Glace Bay): Mr. Ford, I know we brought you here today under the premise of talking about business plans, I know we strayed somewhat but we're allowed to do that at the Public Accounts Committee from time to time. Let me just clarify a couple of comments that may have been made. I, at no point, have suggested that you don't get the proper care when you go to the QE II, indeed, I'm living proof of the fact that you do get the proper care which enables me to stay here and keep members, such as the member for Kings North in check, from time to time. Having clarified that, let's talk about business plans.

I noticed that the supplementary estimates for this year's budget show a total for the Capital District is forecast to come in at $498.5 million. I also noticed that a news release indicated that the plan included a balanced budget of $517 million. I'm wondering which amount of those two is more realistic, is it the $498.5 million or is it the $517 million?

MR. FORD: I think I'll ask Cal to address these issues, if that's okay.

MR. CHAIRMAN: Mr. Crocker.

MR. CAL CROCKER: The component of the budget, and I don't have all six on me because I thought I was dealing with 2004-05, our total budget - which we took to our audit and finance committee last night - is $618 million and that includes the provincial component and the portable, which includes portable and non-portable. So our total balanced budget is $618 million from all sources of income, that's the provincial component and the other source of income such as insurance companies, workers' compensation, federal government, everything.

MR. DAVID WILSON (Glace Bay): Is it fair to say that consistently, the Capital District has been overbudget according to the budget documents we get on an annual basis anyway? Is the Capital District consistently overbudget and if that's the case, what accounts for the increases in spending?

[Page 35]

[Page 36]

MR. FORD: I would suggest that we're not overbudget. The year before last and last year we had balanced budgets at year end and this year we are proposing and submitting to the Department of Health a balanced budget. So we are not overbudget from that perspective, no.

MR. DAVID WILSON (Glace Bay): The business plan, which was approved in March, this fiscal year, I noted that the copy we received through the Freedom of Information and Protection of Property Act, the copy that is included in this week's binder is missing some schedules. In particular, a full-time employee analysis, business plan initiatives, and an analysis of cost drivers. Is there a reason for that?

MR. FORD: I don't know where you received it from so I don't know the answer to that, I'm sorry.

MR. DAVID WILSON (Glace Bay): Through freedom of information. Is there anyone who could answer that question?

MR. CHAIRMAN: Mr. Crocker.

MR. CROCKER: There is no reason why you can't have it. I wouldn't know why it isn't in your package. I didn't put the package together.

MR. DAVID WILSON (Glace Bay): It may just have been missing.

MR. CROCKER: But it's available.

MR. DAVID WILSON (Glace Bay): If I may request then perhaps we could have that information made available to us. I'm not trying to uncover some scandal here, gentlemen, just looking for the information. Let me ask you this question, currently, how many full-time nurses do you have working in the Capital District? Any idea?

MR. FORD: I don't know that number offhand, we could provide that to you. That's not detail that we brought with us.

MR. DAVID WILSON (Glace Bay): And I understand that you came here, as I said, to talk about business plans. If you provide us with that information, as well.

MR. FORD: We'll certainly provide that.

MR. DAVID WILSON (Glace Bay): And could you please provide us - you may not have this with you as well either - the overtime that has been spent, the cost of overtime, in particular relating to nursing overtime, how much was spent on overtime this year in

[Page 37]

comparison to the overtime costs that were incurred by the Capital District for 2003-04 fiscal year as well? Could you please include that information?

MR. FORD: Yes.

MR. DAVID WILSON (Glace Bay): Let me get back, Mr. Ford, if I could, to a comment that you made. You said about 4.4 per cent is spent on administration, which is the lowest or one of the lowest.

MR. FORD: It's the lowest in Nova Scotia and one of the lowest in Canada.

MR. DAVID WILSON (Glace Bay): I take it you've left no stone unturned trying to find efficiencies within facilities?

MR. FORD: We continue to try to find efficiencies. To say that there's no stone unturned would be an overstatement. As I said earlier, as processes change, as protocols change, as interventions change, we obviously continue to look for improved efficiencies and we never stop looking for efficiencies. I would suggest to you, interestingly, that we are hearing from some of our union representatives and others that we are too thin on our administrative structure, and the consequence of that is we're not able to provide the supervision and the mentoring that our newer staff would always like to have available to them, and that we're not able to, obviously, always keep up with our activities such as performance appraisals. So there's a point beyond which administration can go so low but then it really gets to a point that it's almost too low. I think we are at the point where we are hearing now, from among our staff members, that they would like to see us investing a little bit more in middle management so there are more supervisors available to them day in and day out.

MR. DAVID WILSON (Glace Bay): You touched on my line of questioning, I wanted to ask you next . . .

MR. FORD: Sorry.

MR. DAVID WILSON (Glace Bay): If you are thinking like me it may be a dangerous sign, though. What sort of input do your employees have, in terms of contributing towards looking for efficiencies towards the operation of your facilities?

MR. FORD: We ask and actually expect, day in and day out, that every member of Capital Health is consistently and continuously trying to make sure that we do what we do in an as efficient and effective way as we possibly can. We do receive very, very good suggestions from our staff around methods of doing things, around protocols. They are the ones who day in and day out are doing it and they're the ones who have the best view of how things can improve. So we certainly try as much as we possibly can to create a culture that

[Page 38]

allows them to bring those ideas forward, to suggest changes that need to be made and equally, to comment on changes that we're thinking about, from the standpoint of whether or not they're in fact doable. Some of the things, when you actually try to implement them, just don't make sense, so it's a two-way street.

MR. DAVID WILSON (Glace Bay): You said 70 per cent of your budget goes toward salaries and benefits?

MR. FORD: Yes, that's correct.

MR. DAVID WILSON (Glace Bay): That's a huge amount, first of all. So in regard to taking advice - let's call it that for lack of another word - or listening to your employees who are there, is that done on a regular basis? Are you actually involving them in the decision-making process?

MR. FORD: To the degree that it's possible to involve 10,000 people in decision making, yes. Everybody can't be a decision maker but everybody should be able to have a voice. They may not have a vote but they should have a voice. When you have 10,000 people, we do everything in our power to make sure that we have processes and channels in place, whereby they are able to make their concerns known. One example would be, in our Intranet site, there's an "Ask the CEO", and people can send me a comment, a question, a concern, an issue, and, in fact, they do. Every one that is sent to me we endeavour to respond to, either I respond to it directly, or I ensure that the individuals who have the information respond. So we've built as many channels as we can, our managers, our directors, our supervisors are constantly in touch with their staff. We are trying as much as we can, in a very large organization spread out over a very large geography, to provide people the opportunity to have a meaningful voice and a meaningful input into doing what it is they do in the interests of the patients that we serve.

MR. DAVID WILSON (Glace Bay): Like a computerized suggestion box?

MR. FORD: It is.

MR. DAVID WILSON (Glace Bay): Mr. Chairman, how much time do I have left?

MR. CHAIRMAN: About three minutes.

MR. DAVID WILSON (Glace Bay): Let me ask you this, Mr. Ford. In terms of the amount of time that is spent, the amount of services that are there, the money that's spent in taking care of out-of-province patients by the QE II, is that becoming somewhat of a strain on your resources, in your opinion?

[Page 39]

MR. FORD: No, it's not. We have a mandate to be a Maritime resource. The budgets are struck in such a fashion that when there's a patient from another province seen in this province, there's an interprovincial reciprocal bill that's generated. The province, when they calculate our budget, have factored in those events, and have compensated us for them. When we reach a threshold above which that compensation has been made available, in many of our programs, we've negotiated with the department that should we see above that threshold, the revenue that comes to the province will come to us to offset our costs, so that it's not a cost beyond which we would expect to be able to bear.

The other part of that is that for some of our very highly specialized programs, having a Maritime pool from which to draw gives us the critical mass that allows us to keep those programs up and running and viable. So, it's really a mutual benefit.

MR. DAVID WILSON (Glace Bay): Well, as you indicated, you're not just an everyday hospital, so to speak, you stand out.

MR. FORD: Well, for part of our operation, we are. We are the primary care provider for HRM, and we do the primary and secondary care. So, we are actually everything from prevention, promotion, right straight through to the quaternary bypass and transplant.

MR. DAVID WILSON (Glace Bay): You're trying to be everything to everybody, in other words, which is a difficult position to be in, which brings me . . .

MR. FORD: And our staff does a wonderful job.

MR. DAVID WILSON (Glace Bay): . . . back to my final question, probably. How can you continue to do that, if you're continuously underfunded by government?

MR. FORD: As I said earlier, we continue to manage within the budget that we're provided. We continue to challenge ourselves to be as efficient as we can possibly be. We continue to make sure that we're meeting the needs of the people we see, and we recognize that we're not able to meet the needs of all those who we'd like to see. And we continue to bring those issues before the government and before the department to hopefully receive some recognition and some new funding.

MR. CHAIRMAN: The honourable member for Kings North.

MR. PARENT: I'm glad that our health system has improved over the past few years, and want to assure my colleague that I'm glad that it was there for him when he needed it. I guess my comment was really borne out of the fact that I find it frustrating, and perhaps this goes back to comments your chairman made, that it's difficult to get the sort of in-depth debate on the sustainability of health care that we really need in this country. I find it frustrating, if not hypocritical, to complain that government's underfunding and then to

[Page 40]

advocate that more money should be taken out of health care. Those sorts of mixed messages, I don't think, are helpful in regard to this very important issue of the sustainability of health care, which I think we're struggling with, all of us across the country. I noted your comments were good comments in terms of promotion, in terms of primary health care clinics, et cetera. I think we're on the right track, the question is can the two lines converge in time.

Just a very quick question, and then I'll turn it over to my colleague. In terms of the need for specialists versus family doctors, where is the greatest need, in specialties or in family doctors? If it's in specialties, in which areas?

MR. FORD: I'm not sure there's a particular pressure, one or the other. We probably have about a 50/50 split of specialists, general practitioners, in the province. I think there are certainly some parts of the province where general practitioners, family practitioners, a family practice program with enough of a critical mass that the physicians who are there can cover the bases and live a reasonable life, I think those are probably opportunities that are there to be seized upon.

As far as our specialty areas, which would be predominantly the Capital District Health Authority, we have, as I said, approximately, probably 1,000 physicians. I would say, at any point in time, we might have 20 to 25 that we're in the process of recruiting as a result of retirements or those kinds of activities or new positions coming on as a result of the AFP and the physician manpower plan that allows more physicians to come in. So it's a fairly close balance. Clearly, there are some areas that are feeling the pressure more than others. I don't think there's a glaring gap.

MR. PARENT: Do you see the clinical assessment for practice program to help assess the educational qualifications of doctors trained outside this country, do you see that as being a way in which we can help meet the physician shortfall?

[10:45 a.m.]

MR. FORD: I think that's a very important part of helping to meet it, yes. I think when physicians who have trained in other than Canada or the U.S. are being considered for practice in Nova Scotia, the Clinician Assessment for Practice Program is a very good way to assess their clinical skills and their competencies, and their ability to function in our system. The application of your skill, the language, the use of the various terms that we have, those are all important parts to being successful day in and day out on behalf of your patients. I think the CAPP program is a good component to allowing a rigorous review of that in a very standardized way and a very fair way, so that individuals who are given licence to practise on an ongoing basis, there's a confidence that they have demonstrated the right competencies and they feel comfortable that they've demonstrated the competencies.

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MR. PARENT: Thank you. I'll turn it over to my colleague.

MR. CHAIRMAN: The honourable member for Waverley-Fall River-Beaver Bank.

MR. HINES: Mr. Chairman, well, rightly or wrongly, we get our information from the news media. We're all open to our own interpretations, and obviously there's a difference in the interpretations of particular pieces of information where the media has stated that Liberal Leader Francis MacKenzie said that to fix education . . .

MR. DAVID WILSON (Glace Bay): Mr. Chairman, on a point of order. And I will raise points of order until I'm blue in the face, if the Progressive Conservative Party continues to bring this up at the Public Accounts Committee. That statement was never made, and should not be raised in a political nature in this meeting right now with these guests. The members of the Progressive Conservative Party know that.

MR. CHAIRMAN: That's not a point of order. It's a disagreement between two members. We haven't heard any comments as of yet from the members, so we'll address them as they come up.

MR. HINES: Mr. Chairman, I will bypass the figure suggested that we needed to take from health for education, because I think the part of the media report . . .

MR. DAVID WILSON (Glace Bay): Mr. Chairman, on a point of order. Again, I would like to bring to your attention, on a point of order, the comment was never made that money be taken from health care to go to education or anywhere else. That is erroneous and the member continues to make erroneous statements.

MR. CHAIRMAN: The member did not, as I heard it, say that the information, the comment, came from your Leader, only that it was in the paper. I'll once again say it's a disagreement between two members. I'll go back to the member, and perhaps ask him to ease his way through this, please.

MR. HINES: Mr. Chairman, I think the most galling part of the media report, to me, was to suggest that more money couldn't fix health care, when you sit here and tell us that it can. It was a suggestion that money is being spent wrongly. I think that's a direct attack on you.

MR. DAVID WILSON (Glace Bay): Mr. Chairman, on a point of order. The member continues to make inaccurate statements, and I take exception to them. That's not true, the comment was never made.

MR. CHAIRMAN: Thank you, member. I still maintain it's not a point of order.

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The honourable member for Waverley-Fall River-Beaver Bank, please continue.

MR. HINES: Mr. Chairman, I'd like to ask the committee what the direct effect of a $140 million health care cut would be on your ability to perform health care in this province?

MR. FORD: I think I responded earlier, obviously, $140 million coming out of the health budget in this province, if it was out of the acute care sector, would be a serious reduction that would obviously affect the ability of any of the districts to provide the services they're presently providing, and it would result in reductions in programs, activities, services and, likely, if it was that serious, would result in the reduction of the human resource that's necessary to provide the services.

MR. HINES: I would like to move now to public versus private. Presently in the province, what percentage of health care delivery would be by private sector through clinics and those entities that are not covered by insured health care provisions? What would the percentage be?

MR. FORD: I wouldn't have any idea what that percentage would be.

MR. HINES: Mr. Chairman, I'll pass back to Mr. Parent for final statements from the Party.

MR. CHAIRMAN: Mr. Parent, you have several minutes left if you would like to continue.

MR. PARENT: I want to pick up on this question of referrals, since you are a referral centre. I appreciated your comments, because I've had the same sort of perception that perhaps we're not getting the amount of money that we need from the other provinces. You've cleared that up, that we are, that you feel comfortable with that. How about within the province itself? How does one work out where the money goes? You get people crossing boundaries because the wait lists are shorter in one area, or whatever. Is there a problem there, or how do we keep track of that and compensate the authority properly?

MR. FORD: The only way that a funding of that nature can be created is for the province to have a funding formula. The province does not have a funding formula, so in the absence of a funding formula, the majority of the funds that each of the districts have is a reflection of the historic amount that was in those districts prior to regionalization or districtization.

Should there be a funding formula created, the funding formula in other jurisdictions where they exist, does have an element which they call import-export. Effectively what they've done in other jurisdictions is they've said that there's an amount of funds that the

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population demographics, the gender breakdown, the age distribution, the burden of illness would indicate that district needs for its funding. Each district gets its amount but then at year end they reconcile those patients from other districts who went to a different district and they reconcile the dollars. So a funding formula would be the only way that that would be able to be addressed and in the absence of a funding formula, the funding that we have is based on historical record.

MR. PARENT: Did I hear you right that that's adequate from your perspective?

MR. FORD: In the absence of a funding formula it's hard to know whether it is adequate, to be quite honest. I would suggest to you that as a regional district and as a regional centre, and as a provincial centre, we're mandated to provide services that are not able to be offered in other districts - and probably, legitimately shouldn't be - at the Capital District Health Authority. If a funding formula was in place then two options exist: one is for the province to say as a provincial centre, these are the costs that we attribute to you to offer those services, and you cover the whole province; as a district centre anybody who comes to your district from another district at year end we'll do a reconciliation on an import-export. But as I say, in the absence of a robust funding formula, our funding is based on historic record and is based on new program additions in the intervening periods.

MR. PARENT: As the main referral centre for the Maritime Provinces, would this affect the cost of medications as well? Would your costs be higher because you handle the most acute cases?

MR. FORD: I think it's fair to say that when you're dealing with the more acute patients and the more complex cases, that your cost per case is probably higher. When you are dealing with burns - we're the regional burns unit, we're the regional trauma unit, we're the regional transplant unit - obviously the drugs and the technology that's required to support those programs is very high. We're the regional cancer centre - we have outreach areas but, clearly, a lot of the cancer treatments are done here. The cost of the technology, the cost of the skilled staffing, and the cost of the pharmacological agents that are necessary in each of those areas, would obviously be vested in the Capital District Health Authority disproportionately to any other districts.

MR. PARENT: In closing, I'll come back to my opening statement, that in spite of disagreements here, I'm sure we're united on all Parties in wanting the Capital Health District to work well and wish you the very best. Thank you for what you've done because you are the referral centre for many of our constituents, so I wish you the very best success.

MR. FORD: Thank you.

MR. CHAIRMAN: Thank you and indeed, I want to thank each and all of you for your input and for providing us with a better understanding of the work that you do, and the

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work of the Capital District Health Authority. I also want to thank members of the committee for their work here today and as you can understand, we're representing our constituents and each brings to the table particular concerns. Sometimes you may wonder where we're coming from with the questions but there is a method to our madness.

Before I ask for you to make any closing comments, I just wanted to remind you that you have agreed to an undertaking to provide certain information to this committee. Mr. Ford, you did shake your head to the affirmative that you would also provide the overtime comparisons that Mr. Wilson requested. I'll ask you to provide our clerk, Ms. Stevens, with any information for the committee's use.

Having said that, I would like to allow you or any member of the Capital District Health Authority who are here today, to make closing comments.

MR. FORD: More than anything we'd just like to say thank you very much. We appreciate the importance of this and as we said in our opening remarks, we take our obligation to accountability very seriously. We will endeavour to make sure that we provide that information that we didn't have at our fingertips so that you have that information. As always, we remain open to any questions that you have throughout the rest of the year that, if they are directed to us, we will do our very best to make sure that we provide the answers in a timely fashion. So we thank you very much for your interest and your support.

MR. CHAIRMAN: On behalf of the committee, I want to thank you as well. Thank you very much.

The meeting is adjourned.

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