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23 novembre 2005
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HANSARD

NOVA SCOTIA HOUSE OF ASSEMBLY

COMMITTEE

ON

PUBLIC ACCOUNTS

Wednesday, November 23, 2005

LEGISLATIVE CHAMBER

Department of Health
Audit on Performance Indicators

Printed and Published by Nova Scotia Hansard Reporting Services

PUBLIC ACCOUNTS COMMITTEE

Ms. Maureen MacDonald (Chair)

Mr. James DeWolfe (Vice-Chairman)

Mr. Mark Parent

Mr. Gary Hines

Mr. Graham Steele

Mr. David Wilson (Sackville-Cobequid)

Mr. Keith Colwell

Mr. David Wilson (Glace Bay)

Mr. Michel Samson

In Attendance:

Ms. Mora Stevens

Legislative Committee Clerk

Ms. Donna Chislett

Department of Health, Communications

Mr. Roy Salmon

Auditor General

Ms. Elaine Morash

Assistant Auditor General

Mr. Roger Lintaman

Audit Manager

WITNESSES

Department of Health

Ms. Cheryl Doiron

Deputy Minister

Mr. Allan Horsburgh

Chief Financial Officer

Ms. Barb Harvie

Director - Clinical Information

[Page 1]

HALIFAX, WEDNESDAY, NOVEMBER 23, 2005

STANDING COMMITTEE ON PUBLIC ACCOUNTS

9:00 A.M.

CHAIR

Ms. Maureen MacDonald

VICE-CHAIRMAN

Mr. James DeWolfe

MADAM CHAIR: Good morning. I would ask the committee to come to order, please. Before we start with introductions I want to ask the members, for the purpose of Hansard it's really useful if the Chair would recognize the members and the responders. I'm relatively new in the Chair and I'm attempting to learn the procedures that will help make this work for everybody, so I just want to remind you of this and that the conversation is directed through the Chair.

Today we have the Department of Health appearing, concerning the audit on performance indicators. Before we give the customary short period of time to the deputy minister for some introductory remarks, I would ask each member to introduce themselves, and then we will have introductions from the department so Hansard can get levels on the microphones.

[The committee members introduced themselves.]

MS. BARB HARVIE: Barb Harvie, Department of Health.

MS. CHERYL DOIRON: Cheryl Doiron, Deputy Minister, Department of Health.

MR. ALLAN HORSBURGH: CFO, Department of Health.

MADAM CHAIR: We also have the Auditor General and members of his staff and perhaps we will do introductions as well.

1

[Page 2]

MR. ROY SALMON: Roy Salmon, Auditor General.

MS. ELAINE MORASH: Elaine Morash, Office of the Auditor General.

MR. ROGER LINTAMAN: Roger Lintaman, Audit Manager, Office of the Auditor General.

MADAM CHAIR: Thank you. I'll turn the floor over to the deputy minister for some brief opening remarks, please.

MS. DOIRON: Madam Chair, today I'm pleased to have Department of Health staff available to discuss the June 2005 Auditor General's Report as it relates to performance indicators.

First I am pleased to note that the Auditor General was encouraged with the way the Department of Health prepared the report, A Measure of Our Health and Health System. This report was developed as part of the federal-provincial-territorial initiative, originally stemming from the 2000 Health Accord. Through this accord, the First Ministers across the country agreed to provide comparative, reliable information to Canadians about their health and their health systems.

Performance indicators play an important and vital role in managing our health system. They provide valuable information regarding how well our health system is responding to the unique needs of Nova Scotians, and over time they provide good information on where we need to target additional resources. This FPT initiative was the first collaborative process to develop meaningful and interprovincial indicators, and involved a network of experts and policy-makers across the country.

Performance indicators are a measure used to monitor an aspect of a system, such as health care. They help you understand where you are, which way you are going, and how far you are from where you want to be. Today, we know more than we ever have about our health system and the health of Nova Scotians, thanks in part to initiatives such as this. This national collaboration served as an opportunity for each province and territory to gain a better understanding of the strengths and challenges of their individual health systems. After all, our common goal is to improve the health of our residents and the delivery of health care. It's all about being able to make informed choices.

We know that some of the common challenges faced by all jurisdictions include lengthy wait times; an aging population and increased need for services; recruiting and retaining the right mix of health professionals; providing the right services in light of new technologies, tests and treatments that are always coming on stream; and the lack of standardized information.

[Page 3]

It is this particular need for standardized comparable information that I'm speaking about today. The FPT initiative on comparable indicators culminated in the September 2002 release of reports by each of the 14 jurisdictions on agreed upon indicators which provided information on health status, health outcomes and quality of service. The report that Nova Scotia published under this initiative was entitled, Reporting to Nova Scotians on Comparable Health and Health System Indicators. It was quite a large document that reported, in detail, 67 indicators and sub-indicators.

In February 2003, the First Ministers agreed to develop further indicators to report on their success in several key priority areas. They would be primary health care, home care, diagnostic and medical equipment, pharmaceutical management and catastrophic drug coverage, health human resources, and healthy Canadians. The development of these comparable indicators took almost two years and involved extensive collaboration among all jurisdictions and the Canadian Institute for Health Information.

These indicators, along with several measures from the September 2002 reports, were reported by each jurisdiction in November 2004. Nova Scotia's November 2004 report was entitled, A Measure of Our Health and Health System. It was very different from the 2002 report. It was much less technical and, at four pages, much more readable. It was written in a manner that was very easy for the public to read and understand. In addition, copies of the 2004 report were made available in public places, such as doctors' offices, to engage Nova Scotians in conversations around our health system and health status.

An important part of the report developed in 2002 and 2004 was the review of our data by the Office of the Auditor General. This has been a really important collaborative process that has improved the quality and accuracy of the information in the reports in highlighted areas where improvements in information systems at the department and the DHA level are required. Our work with the Auditor General revealed that Nova Scotia could report on indicators, in all but three areas, the number of patients receiving home care, wait times for coronary artery bypass surgery, and for knee and hip replacements. The Office of the Auditor General continues to work with us to ensure that we'll be able to report on these areas in the future reports. We value and appreciate this input and look forward to working with the Office of the Auditor General on future initiatives.

So what have we learned from the collection and reporting of this information? Perhaps one of the first things is that collecting and reporting comparative information helps everyone - those who use the health system, those who deliver care, and governments - as we continue to look for ways to improve and reform the health system and make sure that it meets the unique needs of the people we serve. It's about being able to make informed choices. For instance, the data shared in A Measure of Our Health and Health System suggests that while we face challenges, we are making progress. Fewer Nova Scotians are smoking, yet more than half of us say that we're overweight. Nearly all Nova Scotians have

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a family doctor, and more than 80 per cent of Nova Scotians are satisfied with the way that health services were provided.

As you can see, these comparative indicator reports provide valuable information which we continually seek to identify and address gaps in our system, and respond to the unique care needs of our people. These comparative national indicators, in combination with emerging provincial data, often provide solid evidence for good planning and decision making.

In Nova Scotia, good evidence has led us to establish and provide significant funding to Health Promotion to focus on helping people maintain and improve their health. This is a good social policy, but we hope it will also help to contain the cost of health care in the future. We are leading in areas of health promotion, tobacco reduction, healthy eating, active lifestyles and more. Our goal being to prevent increased incidence of diabetes, cancer and even orthopaedic surgeries for hips, which the research at CIHI found was on the rise due to the high rates of obesity.

Also, on the provincial front, Nova Scotia has moved forward with efforts to enhance and standardize health information. As this committee heard recently, we have many technology-based provincial projects underway to ensure more accountable decision making in health care. We are moving forward on elements of a comprehensive information management and technology strategy that involves the implementation of an electronic health record, including primary health care information systems, the Nova Scotia Hospital Information System, picture archiving or PACS, Telehealth and single-entry access in continuing care.

As you know, just last month, we launched our provincial wait times Web site. The Web site shares wait time information for scheduled tests, treatments and services for each district health authority across the province, making Nova Scotia the first Atlantic Province to publicly report on wait times. The information being shared on our Web site is the first accurate, reliable province-wide data on wait times that we have collected. It is the result of over two years of working collaboratively with district health authorities and the IWK, and the clinical community to develop standard ways of reporting and collecting the information. It provides the data needed to identify and address barriers to timely care across the province, and helps us to make good decisions about best allocation of resources.

This data also allows Nova Scotians to make informed choices on whether they would like to access services where wait times are shorter. This Web site is yet another tool that government can use to be accountable to Nova Scotians. Wait times are, of course, a challenge across this country. Nova Scotia is working with other provinces and territories to develop, by December 31st, a first set of evidence-based benchmarks for medically acceptable wait times in five priority areas. That would be: cancer, heart, diagnostic imaging, joint

[Page 5]

replacement and sight restoration. We are in the midst of identifying those now. We're making progress, and we will meet that commitment.

This work is a prime example of how a collaborative national approach will make sure that we're using the best evidence available on when a wait time affects a patient's outcome. This information helps us in making good decisions based on good evidence, to be accountable and to be transparent. Nova Scotians have come to expect up-to-date information regarding the health system and, more than ever, they want to be more involved in their care. I'll stop at this point, Madam Chair, and thank you for allowing me time to address the committee. We are now ready to take your questions.

MADAM CHAIR: We will have the first 20 minutes with the NDP caucus.

The honourable member for Sackville-Cobequid.

MR. DAVID WILSON (Sackville-Cobequid): I want to thank you, again, for coming before us. You're a regular at this committee. It just shows the importance of health care not only to this committee but to all Nova Scotians. You had mentioned in your opening statement about how far we are from where we want to be. I think that's an important statement, because I think it's important for government to indicate to Nova Scotians, where we want to go, what we want to see, and what progress we are making to get to that point. I think everybody would agree that we need to address some of the seriousness and crises we see in some of the areas of health care.

One of the things - reading through the Auditor General's Report and a lot of the material that was provided - was the indication around wait times. I understand and I know that government has taken some steps to try to at least project to Nova Scotians what they are around the regions of the province. At times, I believe some of those wait times are a bit lagging in being as accurate as they could be or as up to date as they could be.

One of the areas that concerns me that I've dealt with quite a bit over the last two years is in the area of home care. As you know, as a paramedic before being elected, I dealt a lot with patients being discharged from hospital, post-op, elderly patients in dire need of home care. I believe strongly that if government invests more money into home care and gives the ability for Nova Scotians who are in their own homes to remain there without entering the health care system again, it saves a lot of money in the end. I think that's definitely an area government needs to work at to provide better service with home care.

[9:15 a.m.]

In the Auditor General's Report, he mentions auditing the wait times around measuring home care. They were unable to track or separate continuing care pertaining to home care, because I think the computer program that they use can't indicate the assessments

[Page 6]

or services for home care. Why hasn't the Department of Health done a better job of ensuring that that computer system - for one - can indicate what the wait times are for assessment in home care for Nova Scotians who are waiting for that?

MS. DOIRON: A very good observation and questions. We agree with you that we need to be able to get that information system to the point where we can separate the categories that they're assessing, that interRAI system - which is probably at this point one of the best computer tools in the world for assessing individuals in various areas of continuing care - still continues to be under development. I think that in order to be able to get the kind of data that we want, that software has to be able to distinctly categorize the separation of people who are being assessed into home care, long-term care, adult protection, or other categories which at some point will be added to that assessment such as mental health and others. So while it's a very good tool, it's a tool that continues to be developed.

We are starting to be able to get a data bank that is giving us tremendous information that we never had before. There is a need to kind of go further, it's not so much the department's ability to do that as it is our need to work with the company that provides that software, to help them to design it in a way that's going to meet the needs of the health systems in a more accurate and better way. It is a tool that has been accepted in a lot of jurisdictions, not just in Canada but beyond that, as probably one of the best tools for us to continue to work with. I know that Ontario is just in the process of implementing it province-wide as well. But it is under development and until we have that software issue worked out, we will have some difficulty in terms of breaking out the categories. I'm going to ask my colleague, Barb Harvie, if she wants to add a bit to that.

MADAM CHAIR: Ms. Harvie.

MS. HARVIE: The deputy really has provided a good overview of what's going on with the interRAI software and the SEAscape which is referred to in the Auditor General's Report. We're certainly moving toward being able to measure wait times from that for home care and long-term care clients, much better than we would even a year ago. The vendor is actually in the department today meeting with some of the IT folks to talk about how to make improvements in it. It's a great case management software and we need to make some modifications so that we can get the type of answers that we need for how many patients are you seeing, how long did they wait.

MR. DAVID WILSON (Sackville-Cobequid): I can appreciate the process of what we're going through here and excuse my ignorance when it comes to IT and technology, but I do know that there are changes that happen daily in electronics, in computer data processing. Is it a matter of it's going to be an additional cost to implement what I think would be, in my view, a simple task of adding another column to a data bank, or to an indicator page, or whatever the terminology is, to add assessment for home care, or delivery

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of home care, or receiving home care? Does it come down to a matter of it's going to cost the government more money to implement changes to the system that we currently have?

MS. DOIRON: I don't believe that there will be additional cost, I think it's simply the users working with the vendor to help to define what kind of changes should be made to the software. That is an ongoing process and that's not going to add cost to what we're doing.

I appreciate your comment, however, that it seems like a simple request to do and at the end of the day, I don't think it should cause extreme complication for the company to be able to set it up on that basis, so we can categorize on the basis we wish to do, but we do have to work it out. I'm assuming that's going to be something we can work out on a short-term, not a long-term basis.

MR. DAVID WILSON (Sackville-Cobequid): One of the things that surprised me the most was we always hear about wait times in the emergency rooms, that seems to be the most prominent thing when someone feels they're in need of emergency care and there's a 12-hour wait at say, the QE II. That seems to grab the headlines the most when it comes to wait times, that and, of course, surgery and ortho surgery.

I was amazed in the last several months - this Summer actually - to deal with a case in my area where an individual who is in her late 70s had a stroke, was still living at home, able to maintain her home with her husband and found herself in need of home care. Her husband, who was older than her, I believe he was in his late 80s, was unable to pick up the slack. In that generation, the head of the household in most cases is the female of the relationship. She found herself in a very difficult position because her family is trying to help her with what she needs to be able to remain in her house.

I was amazed when I called the care coordinator for our area, the Bedford-Sackville area is how they designate it, and tried to get some information on how long the wait is, or how many people are on the wait list. I was surprised by the answer from the care coordinator, she said that she was unable to really tell me how many people were waiting, or how long this person is going to wait for home care. She indicated it would probably be two to three months in our area of the province which, in my view, is an added stress put on family members who, for the most part, have both spouses working, have two incomes. Here is an individual who I would say probably used the health care system at an increase over that time where she was discharged from the hospital.

You had said that the vendor may be in there now looking at implementing changes to this system. Can you give us a timeline? Can you give us a date? I know the Minister of Health doesn't like to give a date of closing because we'll hold his feet to it, but can you indicate to the members of the committee roughly when this process will be done where you can monitor the assessment and need for home care?

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MS. DOIRON: I'm going to hand this to Barb in a moment, but you've raised several issues here that I think are really significant issues. I want to say that I can certainly appreciate and sympathize with this couple and with the work you are trying to do with them, having a father myself who is into his late 80s and living alone at home, there are those challenges. It is important, I think, that we continue to work toward having services in the home when people need them. If we don't achieve that then we realize that we're going to cause issues, both in emergency departments, in hospital beds and so on.

We are making progress with that, aside from being able to define the wait list and the timeline exactly, which we do somewhat manually now, so we know what areas or jurisdictions in the province have wait lists for home care. The computer system is certainly going to help us to do that more efficiently and more accurately.

One of the problems that we had been running into over the last few years was that even though we had approval to enhance home care services or add more volume to those services, for a period of time we were having difficulty recruiting all the staff that we needed to enhance the programming. That's one of the challenges we're still into in a variety of areas.

Having said that, I think that the nursing strategy is starting to show some results, because this year we have been able to hire more people into home care, not all that we need yet, but we are, at this point, projecting about $3.5 million of additional home care that we had not been able to hire people into in the past year. So it's showing us, I think, some signs that we're moving in the right direction, but we don't have it where we need it to be yet.

In terms of your specific question on the timelines with the computer system adjustment, I'm going to ask Barb to respond to that.

MADAM CHAIR: Ms. Harvie.

MS. HARVIE: No specific timelines, other than to say that we are testing some programming right now and looking at the measures that we're getting from the system. We do want to get that information up on the wait time Web site.

MR. DAVID WILSON (Sackville-Cobequid): I think you also mentioned another area, especially when it comes to home care, that is in need of addressing, and that's the recruitment and retention that goes along with those health care providers who work in home care, whether it's for government or in the private industry. We know a lot of private home care services are on contract by the government to provide the services.

One of the things that I've heard, definitely over the last couple of years, is that lack of continuity when it comes to the health care providers who come into your home. A senior, the last thing they want is to ask for help. Finally the family or themselves have gone through

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the system, gone through the wait and they finally receive home care, and they think things will get better. When they start to receive the services, there are such differences when there's no continuity of home care worker, for one, and the services they provide.

Another case I was dealing with, a patient had had home care for roughly about a year or so and had that continuity of care for some time, and then all of a sudden had a different person every day; it had been mentioned they do different jobs, different tasks when they come in. The patient was finally told, well, if it's not in a book, if it's not written down, they don't know what their duties are.

Can you give this committee and Nova Scotians some encouragement that you're addressing that retention, recruitment of home care workers and the standards of care that people receive when they get these services?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Again, I think it's a very good issue, a good question. Basically, there is a lot of work that has started up now to try to assess that kind of continuity. There are some realities when you're going on with care for a period of time, to sustaining the common threads of people, particularly as they end up with days off for vacation and various things, but those things are generally understandable. We have had some cases brought to our attention where there has been, for some reason, a variety of careworkers going in that aren't related to those reasons. In those cases we have been going back and trying to address that around specific clients, where we've become aware of it.

Having said that, we have also done a fair bit of work in this arena to try to stabilize the system in terms of full-time workers, as opposed to part-time and casual workers. I think that will contribute to more of that continuity as well. It's very important in any part of the health care system that we look for as much continuity as we can, but I think even more so important in home care, particularly if the home care is delivered over an ongoing period of time, because it becomes an issue of relationships which end up as part of, really, the therapeutic value of the visit.

We are working on that and, in addition to that, during the last year we have done a major reorganization within the Department of Health of the Continuing Care branch. With that we have put people in position to pay more attention to policy, to also particularly pay more attention to standards and evaluation. We have a small section that's dedicated to that in Continuing Care, which means that for both home care and nursing home care we are going to be enhancing and putting more effort toward the work that should define the kind of standards that not only we need to practise, but the standards to which we will hold any caregivers which we contract.

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[9:30 a.m.]

MADAM CHAIR: Mr. Wilson, you have three minutes.

MR. DAVID WILSON (Sackville-Cobequid): I think that's definitely an important area. As I said, seniors who allow strangers into their home, it's a very hard thing for them to do. They really need to know that government is there to help them remain in their home, for one, and really stay out of the hospital. We all know the costs incurred by government when someone enters the health care system. I've stated this many times since I was elected that we need to look at prevention. I know government uses that terminology quite frequently, but I think government is behind the eight ball or is lacking in the home care initiative in the province.

When you have someone, an elderly person who may have broken her arm and needs some assistance in her home - we have another case that we were dealing with where she was assessed, it was deemed that she was going to receive home care and was placed on the wait list, and she was going to receive the help and the care she needed, but it was after she had her cast taken off. What are we doing wrong? Why is there no avenue for these individuals who need the help? Maybe a broken arm isn't that significant, but to an 80-year-old Nova Scotian who's living on her own, she needs that help. She needs that assurance that government is there to help her in her time of need. She has paid taxes her whole life. She's in need. Do you feel government is addressing their needs adequately? Do you feel home care, at the present, is addressing the needs of Nova Scotians in a timely manner?

MS. DOIRON: I think we need to do more to be doing that to the level that we think is appropriate in this province. Over the past number of years we have indicated that we do not feel that we are at the level of delivering home care that is actually consistent with the rate of home care across most of the country, and that it is appropriate for us to be going there. As I said, some of that struggle has been not the recognition that we need to do it but the ability to kind of get the staffing up to the numbers that we require. We've been working on avenues to deal more effectively with recruitment and retention.

We are not 100 per cent there. I think that we should acknowledge that because there are some issues that we are not addressing in the timely fashion that we should. We are aware of that. It is, in our view, inadequate that if you have someone in their 80s going home with a cast on a broken arm, that's the time when they need the support and the home care. We are continuing to work to kind of make sure that we are not only dealing more effectively with getting the staffing there to respond to everything in a timely fashion, but we also need to make sure that we're prioritizing appropriately around how we not only keep people at home but use the acute care beds more effectively. There are some issues there, and we're still working with it.

MADAM CHAIR: The honourable member for Glace Bay.

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MR. DAVID WILSON (Glace Bay): Good morning, everyone. Thank you for appearing before us this morning. It's almost like having a neighbour over for tea sometimes, Deputy, when you're here that often. I hope it will be on just as friendly a basis as if we were having a cup of tea. Let's try to keep it that way, anyway. (Interruptions) I will.

Madam Chair, I note, for starters, that according to the Auditor General's audit, one of the indicators audited for performance was the emergency response time for ground ambulance. In 2001, the government issued a tender for the evaluation of the emergency health service system, and that included response times for ground ambulance. At that time, there was about $100,000 spent on that report. Included in that report was information that stated that the emergency response time, for instance, in the metro area was nine minutes 90 per cent of the time. Then, only one year after that report that I think was entitled the Fitch report, you go back to audit the response time for ground ambulance service. My question is simple, straightforward, why would you ask the auditor to verify a performance indicator that the department paid $100,000 for just a year before, to complete?

MS. DOIRON: Well, basically, the review that was done by the Fitch report was a pretty comprehensive review. It did audit the response times, but it actually was an accreditation-type approach to the whole service. Of course response times for ambulances is one of the critical factors, so that was included. But looking at our response times is something we do on a regular basis, so it's not something that we would have a reviewer come in to do once every five years or more. It's something that, on a regular basis, is one of the performance requirements that gets reviewed annually or more frequently.

Particularly when we were put in a position, which I think we all found ourselves in at the beginning of the 2000 period, where we were looking for the indicators that can give us some information that's valid information, this, again, was brought up as one of those areas that we could measure. We do require, as well, through the contract that we have with EMC, which manages much of the ambulance service for us, there are performance indicators in their contract that, periodically, are required as well, which includes that response time monitoring. So that's done regularly.

MR. DAVID WILSON (Glace Bay): With respect to 24/7 care, there are other areas, perhaps, that could have been audited by the department instead of that, which had just been done a year earlier at a cost of over $100,000. The other areas, for example, I'm wondering why you wouldn't want to ensure that there was a performance audit that was in place to ensure, for instance, the consistency and the validity for the times that it takes to see a physician in an emergency room in the Capital District.

For example, some of the most recent data that comes from wait times, the average wait times, in Capital Health emergency departments, if you're waiting for Triage Acuity Level 2, which is somewhat of a potential threat to life, the national guideline says 90 per cent of the patients are seen in 15 minutes. In Hants Community Hospital, the wait time is

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an hour and seven minutes; at Cobequid Community Health Centre, it's two hours and 21 minutes; at the QE II Health Sciences Centre, it's three hours and 27 minutes; and at the Dartmouth General Hospital, it's five hours and 16 minutes. So taking a look at just those figures alone, why didn't the department audit that performance indicator?

MS. DOIRON: I think the observations are good observations, and it is important in emergency departments to break out the level of patient we're talking about. In terms of looking at the classification of the patient as Levels 1 to 5, it's relative to take a look at the wait times for each class as opposed to the average wait time in terms of looking at things that would be related to standards or health outcomes. We do work with the districts to understand their wait times in those areas as well. Certainly, we have been talking with the district health authorities about an approach that we might be undergoing that would take a look at all of the emergency departments across the province.

The other thing that we are doing on an ongoing basis at this point is actually working with the system to try to truly reform the whole approach to primary health care. We know that the volume of patients in emergency departments who could be seen elsewhere is by far the majority of patients who show up in emerg. I think part of our job is to work with the providers and the professionals to redefine how people are going to access the system in the future and where they go for different types of care. That's what the Primary Health Care Reform is all about, that's what looking at different models of care provision is about, it's about the collaborative practice approach that we should be making more accessible in the province so that that access does not always happen through the emergency department door.

Having said that, that will take a period of time to shift, because for many years the way the system was designed, and the way that hospitals were rewarded, and the way the federal and provincial governments provided incentives ended up, in a sense, driving people to hospitals and to emergency doors. So we are in that process now which will take some time to change the whole culture and character of how that occurs. At the same time, we're not ignoring the fact that various places are having difficulty at times with their wait times in emergency, and trying to look at other alternatives which are going to provide a different response.

For example, down in the South Shore area, the community health centre that's being built at Queens is one of those avenues that should take people and absorb people differently, other than people then going up to the emergency department in that area, or going to Bridgewater or places like that where it gets quite busy in emergency. So there's a variety of approaches of work going on to try to deal with that reality to which you refer. Do you want to add anything?

MS. HARVIE: The only thing I would like to add is that the Canadian Triage Acuity Scale, each of the districts are attempting to record their volume of patients according to each of those five levels. They have all done some internal reviews of whether or not their

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information is correct - if I'm assessing the patient would I be assessing the same way that another care provider would be - making sure that information is of better quality. There is also a lot of work at the national level.

As the deputy suggested, there's an information gap there that we need to address. We need to get more comprehensive information about what's going on in emergency rooms not just the wait times, but why are people being seen in emergency, what time of day are they being seen, and that's something that the wait time initiative is looking at as a priority.

MR. DAVID WILSON (Glace Bay): Those are great answers. The fact of the matter is you had an opportunity here to do an audit of that performance indicator and instead, for instance, you chose to audit something that was a year old, which everyone already knows we have one of the greatest ground ambulance services in the world, and we already know that. Doesn't the public deserve to know whether the information that is released by Capital Health District - as it pertains to wait times, for instance, in emergency rooms - is both valid and consistent? With those alarming statistics, I would suggest, why wouldn't you do an audit of that performance indicator?

MS. DOIRON: I think it's fair to say that it's not something we would not do, in fact, we are looking at doing a provincial review of the emergency departments which would include, obviously, looking at the wait times, as well as looking at the opportunities for making improvements or changes that would impact the wait times more positively. So there are a number of areas in which we have been collecting information and/or auditing. There are also areas where we know that we need to go further in being able to audit.

Part of the issue arises from the fact that for many years various hospitals, in particular, kept information on an independent basis and there were not the kind of appropriate standards to ensure that even in the same province, let alone across the country, that the approach to defining and collecting wait times was similar in any way. So often when you would start to get information gathered you would find out if you went into it deeply enough that you were, in a sense, comparing apples and oranges.

The process in all of the areas of health care of getting the systems to look at wait times in the same way, to establish a database which has a period of time attached to it that allows us to do some assessment, has been one that we've been working with over the last couple of years now to try to get in place. We don't have it there for every aspect of the system and that's why we keep taking pieces of it, whether it's emergency departments or orthopaedics or other areas, where we need to be able to standardize and keep going out into the system and working through those initiatives, so we end up with comparable indicators that can give us opportunity to audit it accurately. Yes, I think that's a strategic area to which you refer that we need to do that work in.

[Page 14]

[9:45 a.m.]

MR. DAVID WILSON (Glace Bay): The first performance indicator report that was issued by the department, you made reference to it already this morning, entitled Reporting to Nova Scotia on Comparable Health and Health Systems Indicators, and that was in 2000-01. It showed a growing problem with respect to wait times, with respect to radiation therapy. Did this report not show government that there was a problem with respect to wait times with radiation therapy that long ago and if that's the case, why didn't government do something at that point to stop the crisis that cancer patients in this province are facing today?

The data was a warning, I would suggest, for government five years ago, absolutely nothing was done. I know recently there are patients who have gone public, for instance, they have contacted us at the Liberal caucus with some horror stories when it comes to wait times to see oncologists and then wait times to have treatment in this province.

If you read The ChronicleHerald today you will see an article with the headline "Send some cancer patients out of N.S., doctors say" and it quotes Dr. Andrew Padmos and six other health officials who describe, ". . . it is an impossible task in a system that was already bursting at the seams."

Let me read you a recent e-mail - Madam Chair, may I ask how much time I have at this point?

MADAM CHAIR: You have until 9:53, so you have quite a bit of time.

MR. DAVID WILSON (Glace Bay): Thank you. Let me read you a recent e-mail I received from an individual who is battling cancer in this province. Madam Chair, I will say at this point that this individual - although I would be quite willing to give you her name - she would like her name protected for confidentiality purposes if that's okay. Here is her e-mail which was sent to us:

"I am a recently diagnosed breast cancer patient. I have experienced long wait times as I have navigated each step. I have learned to be patient, but the wait time I now face for adjunct therapy is pure torture . . . My appointment time with an oncologist is not only double the national average; it also exceeds the recommended safe wait time for adjunct therapy to begin. This is a disgrace. The emotional and physical stresses put upon me are phenomenal. My chances of long-term survival are being compromised . . . I have no control over the fact that I have cancer nor do I have any control over how our health dollars are spent . . . As a resident of Nova Scotia, I am being let down. Considering the province's high rate of cancer - why are we facing such a crisis in the area of oncology?"

[Page 15]

The letter writer goes on to say:

"Since my diagnosis I would have to say that I have maintained a positive outlook in spite of the emotional and physical scars of surgery . . . I accept that I have cancer but I cannot accept that I do not have the chance to fight this disease in the best way possible because of money issues and a lack of direction in the health care system of my home province. I am waging a huge personal battle, the last thing that I or anyone else with cancer needs to do is to fight for proper and timely medical care.

Our population is aging and as the number of cancer patients rises, so will the demand for continued care and follow-up for these people increase. When I have finished the recommended five years . . . I would like to know that an oncologist will be available to direct my treatment. I would like to know that I have a chance of being here in five years; if I do not have to wait for my chemotherapy to begin . . . We are above the Canadian Medical Association's Guidelines for the number of patients per oncologist. They will not come if they foresee burnout, a lack of research facilities and fewer colleagues with whom to collaborate."

In closing, the letter writer says:

"We need to make our province hard to resist - I think the effort is worth it. The only consequence will be a healthier population. The commitment to Cancer Care should be a priority for the province of Nova Scotia and the Department of Health, beginning with shorter wait times for cancer treatment."

How do you tell a person experiencing that type of battle with cancer that you had evidence that there were problems that were developing four or five years ago?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: First of all, I think I have to acknowledge the anxiety and distress that that individual is going through because I think those cases are very real. I know that I would have that distress or I know that my family would have that distress if they were going through it.

There are about four areas that we need to speak to relative to the cancer-oncology situation. First of all, is the differentiation between the radiotherapy and the other kind of medical oncology response. You mentioned that the radiation wait times back in 2000-01 were stressed, that is no longer the case, we have taken care of that. So for a period of time

[Page 16]

now, the recent statistics which are very current - within the past weeks - have illustrated that we're responding well to radiotherapy at this point.

The stress we have right now is getting to the medical oncologist. Basically, it is the growing volume, as well as one or two positions that ended up changing or being vacant. So essentially what we have done, and I think this information has been given publicly, is that we encouraged Capital Health to go ahead and, of course, recruit to their vacancy. They have done that, so they have somebody joining their staff at the beginning of January. We also approved three additional positions that they could recruit to, in advance of the actual renewal of their AFP. They are recruiting to that and at this time they're telling me they have another probable two individuals who will probably be joining sometime in the new year.

In the meantime what we have done is add the kind of medical associate, basically, a GP who has had experience, an interest in cancer, to augment the oncology staff, so they can try to bring together some of that wait-list issue. I think this issue that we're addressing right now, while it's a very important issue, should be a reasonably short-term issue once these positions get filled and operating.

There is another side to cancer that has caused some distress as well and that is the whole impact on all of the oncology operations at Capital Health because of the growing volume of cancer patients which are very clear to track. Because that has been growing and we've recognized it, we've been working with Capital Health and Cancer Care Nova Scotia, to make sure that we're putting together the right kind of plan to go forward in the business planning process this year, to build on those services and to add to the capacity that they'll have in the overall system at Capital Health, so that's all happening.

MADAM CHAIR: Thank you. The time has now expired for the Liberal caucus for this round.

The honourable member for Kings North.

MR. MARK PARENT: The question I have is, first of all, a very short question but then I want to ask some larger philosophical questions which may not be fair, and feel free to say that really, those questions are beyond the scope of what we should look at today.

The first very simple question is, we focus always on wait times as the indicator, is that a fair indicator? Are there other indicators that are just as good that we should be looking at as well?

MS. DOIRON: Thank you for the question. Basically, I think the challenge that we're having right now across the country is understanding what we should have out there as indicators, and we use a lot of words around wait times, we use indicators, benchmarks, targets, so there is a lot of different terminology that is used.

[Page 17]

We are trying across the country to get to terminology that is going to be more standardized so that a benchmark will refer to a wait time that is evidence-based, in other words, there is research attached to it that relates the wait time to the health outcome. We have very little of that kind of work across the world at this point in time, so that's part of the struggle as we work with this on a Canadian basis to say, what are the benchmarks that we can put out there publicly and work toward? However, we do have some of those and they will be some of the things that will be coming out in the report prior to the end of December.

There are other areas, though, where other indicators or targets need to be used where we don't have that level of evidence. For example, orthopaedic surgery is a good example because of the distress people have while waiting. Even though we may not have information that's linked to the health outcome for somebody who waits for three months versus six months versus 12 months, what we do know is that if somebody is in the more acute phase of an orthopaedic condition, then they are going to having some pain and suffering or distress or impact on their ability for everyday functioning that is a consideration that, even without the evidence, we should consider.

So in those cases the kind of discussion that's occurring nationally that will also apply here is what is a reasonable wait time. Should it be, for example, six months? We hope that the evidence will catch up with that, but in the meantime we will set targets. So we do think that wait times are extremely important.

The other thing that we feel we need to be doing better in regard to wait times, and again this is interprovincial discussion but it's something we're intending to act on here, is that it's bad enough to be on a wait list, but one of the things that we need to do better is communicate with people who are on the wait list. If you're sitting there for months on a wait list without hearing anything, I think your level of concern and question and distress is greater than at least if we were to check in with you periodically and be able to tell you what's happening and what you might come to expect. So there are a lot of considerations given to not only how we understand wait times but how we're going to address them.

MR. PARENT: That's a good point, because I have many people who are saying if I knew where I was on the wait list, if I knew I was still moving up, if I knew I was still on it, so I think that point is valid. One of the things about wait times - I was going to get to my larger questions but I do want to follow up very quickly on this one - is one of the problems that has come to my attention, in terms of wait times, is that you'll have - and you mentioned orthopaedics - certain orthopaedic surgeons who, for one reason or another, seem to be popular. So people will go to them, and they have a long wait list.

You have an orthopaedic surgeon who's practising right next door who has a shorter wait list, but the one with the longer wait list oftentimes won't tell his patients, or her patients, listen, the wait time with me is going to be a year, if you go to my colleague it will

[Page 18]

be three months. Do we overcome that by publishing on the Web? Is that how that's going to overcome that, so people can have a choice? Is that the purpose behind that?

MS. DOIRON: That will be part of the opportunity that the public will have, to look at that and then to go to their GP or whomever and ask questions about that and ask if they could be referred to somebody else, which is their right to do. One of the other things that is occurring is, essentially, work that's going on to not only engage doctors in helping us to define wait times, but to also work with the whole culture of thinking with the medical profession around wait times.

I know that Dr. Brian Postl, who is the CEO of the Winnipeg Health Authority and also a physician, is the physician that the federal government engaged as a consultant for a period of time around wait times. He has started to engage the medical community through all of the associations, whether they're colleges or whether they're the Canadian Medical Association, the more unionized approach of medicine, through the Deans of Medicine, and a whole variety of approaches to start to work with the medical community in terms of saying what the responsibilities are that physicians should see and have around wait times and helping to deal with that for their patient population.

With a whole variety of work going on and a shift in the view and culture around all this, with the availability of information that we can now measure on a more standardized basis and make publicly available, we hope that a combination of factors will lead to at least providing the opportunity of choice to the individual.

[10:00 a.m.]

MR. PARENT: Madam Chair, the larger question is, we're talking about, with all these benchmarks, with getting scientific evidence - and this is good and I think Nova Scotia is amongst the leaders in it, and I want to commend the Department of Health for the work they do - is improving efficiency in health care in large part driven by the fact that health care costs in every province that I know across Canada are exceeding the rise in provincial budgets? In Ontario I think it was almost 20 per cent that the budget went up by over a given period of time, and the Health budget by 40 per cent.

So we're trying to get more and more efficiency to get costs in line. It's a commendable thing and we need to do that, and I remain committed to it. However, in my short time in politics, no matter how hard we try to do that, the costs still keep going up. I wonder with the latest Massey Lecture - well, it's two years old - The Cult of Efficiency, if her arguments are beginning to have some play in regard to this.

I'm becoming increasingly concerned - and these are probably questions you can't answer - about the rate of the increase in the medical budget and the pressure that puts upon all the other budgets in government, and the fact that health care, as we know it in Canada,

[Page 19]

is not sustainable no matter how many efficiencies we wring out of it unless we either raise taxes, which is unpalatable to most people; move to some sort of public-private partnership, which is unpalatable to other people; or begin to think differently about health care. I go back to Ivan Illich, and you and I have had a few conversations about that.

I think that we need to put this whole discussion on efficiency within the context of that larger picture, because that's where it belongs. I don't have any answers for it, but I do know that it needs to be talked about and it needs to be put on the public agenda, that health care as we now have it is not sustainable. There are various reasons for this, the rising cost of medications, the technological advancements we have, salaries. One of the reasons is the growing expectations of Canadians for the health care system to cover many things that in the past weren't covered, and for Canadians to be unable to accept, I think, that death is part of life. That's why I've been such a big fan of the hospice movement, and trying to get a pilot hospice going in eastern Kings, which could perhaps help to bring that back into the health care system.

I remember as a young minister in North York one of my members had died, and when I got there the doctor was just so relieved to get out of there, because his work was over. He saw this as a failure, the patient had died, that's it, get out of there - he almost ran out of there when he saw me coming, thank God, you can take over - instead of seeing this as sort of a continuum. I'm not really asking a question but I'm making, I think, a remark that all of us, of all political Parties and the medical establishment, have to get the sustainability of health care as a topic of discussion, or we're going to wear out you people in the Health Department. You can only wring so much efficiency out of things. We're going to destroy the health care system that we have by not being willing to tackle this important issue.

Now it's not really a question, it's not really even a fair question, but it is something that I think we need to get in there because the efficiency question is part of that whole piece. If we just focus on efficiency and give the impression, I think, that by creating a little more efficiency here and there we're going to solve the larger problem, we're not going to. It's part of it, but it's only, in many senses, I think, a smaller part than other questions. I guess I'll just throw that out. You don't need to respond if you don't want to. It is something that I wanted to put on the record.

MS. DOIRON: Thank you so much for bringing that up. I want to respond. This is such a huge, important area that is something that we should not, collectively as a society and collectively as government, be ignoring. As you say, we do keep working at the incremental efficiencies and savings that can be made, and trying to find dollars here and there that could be reinvested, but having said that there is no way that that is going to address the continuing growing cost of health care at a rate so much higher than normal inflation.

[Page 20]

As you said, the drivers of that are twofold main things: the cost of collective agreements that are often settled far in advance or above the normal rates of inflation; and the second issue is the actual inflation on the very costly drugs, med/surg supplies and things of that nature in hospitals. So when you look at that, in order for us to move from one year to the next and not do one thing new, just to deal with those issues, we're now in the order of something like $200 million a year in this province. How do you continue to put that rate of growth and pressure on taxpayers from a population of less than 1 million people. But that's a comparative statement relative to every province and territory in this country.

At some point I think we do have to get serious about what then are the approaches that we can take that are going to substantially change the direction that health care is heading. I don't have the answers to that except I know the issue has to be addressed. It probably has something to do with wages, salaries, and physician settlements in the health care system, it probably has a relationship perhaps to what it is that we insure in health care.

We know that the Canada Health Act started out insuring only hospital care and physician care, but now when you look at the health care system, essentially we're insuring hospital care, physician care, long-term care, home care, drugs, and a variety of other things. While that whole sense of pride in this country is irrelative to what we do in our health care system, there's also that growing sense of, I guess, expectation, ownership, and the demand is there. I think it makes it very difficult for government decision makers to make those decisions that at some point are going to be very hard decisions to make. My view is this, we have an ethical responsibility to start considering this question, provincially and nationally, nationally preferably because I don't think we can do it alone, as Nova Scotia, but I think we need to start to prepare.

It's interesting that you bring that up today, because last week I had a two-day retreat with my senior leadership team and this was one of the subjects of our discussion because we're all quite distressed about it. Even though we may not be able to solve the issue, we decided that over the next few months one of the things we're going to do is put together a position paper and the position paper, at least to start with, will do nothing more than say that we know a lot of things about the projections of what's to come and if we continue down this road, in 10 years or 20 years, here's where we are going to be. Essentially, I think what that will do when we put that paper together is offer some good basis for discussion, that at least we can start discussion here and elsewhere to try to create that kind of interest to say we need to be serious about this.

I believe that we are either going to do that and make some hard decisions, or secondly, we're going to run into a total crisis and then we'll deal with it on a reactive basis. I appreciate the pressure that should be put on and maintained on us in the Department of Health and that we should carry through the system making sure we're doing the best we can with every dollar we spend. But that is not going to resolve the long-term issue and we need to collectively start to think about what that means.

[Page 21]

MADAM CHAIR: Mr. Parent, you have about five minutes.

MR. PARENT: Just a closing question and I'll turn it over to my colleague, the vice-chairman of this committee. Thank you for your comments, but the challenge needs to be not just for you to come up with a position paper but for us, as politicians. My wife works in the medical system, as you know, and she has said to me time and time again, the trouble is that none of you politicians have the guts - she uses another word but I won't use it here - to actually deal with this issue and to say that the emperor has no clothes, or is fast becoming an emperor with no clothes unless we do something now.

So thank you very much for your remarks but I think that really the challenge, ultimately, is going to be for politicians to rise above partisan interests and deal with this, but your help is needed, too. Thank you.

MADAM CHAIR: The honourable member for Pictou East.

MR. JAMES DEWOLFE: Thank you, again, for coming. I want to go back to a topic that my colleague for the Liberal Party brought up regarding oncologists, it's a subject that is a big concern to me and to the constituents in my riding and indeed, all of Pictou County.

Joanne Cumminger is a name that is familiar, I know, to you, Deputy, and Joanne happens to be a constituent of mine. I consider her a leading oncologist nurse and extremely dedicated to her job, her patients always come first. I have never met anyone quite like her in my life, she's just a wonderful person and a wonderful person in the community, involved in community centres, she's always there, I don't know how she finds the time.

She has brought concerns to me over the past couple of years regarding the medical oncologists and the lack of in Pictou County. We had medical oncologists coming from Halifax once a month and they would see 30 patients. That was of great benefit to the people in our area and they stopped doing that. I know all the reasons why - that they give, anyway - and I don't see a light at the end of the tunnel on this.

I understand we may be getting another oncologist from out of province and hopefully, that happens. There appears to be a shortage of these doctors and I know particularly in the Summer there's a backlog because of vacations, I expect, and so on, so there ends up being a backlog.

These cells divide and the length of time these patients have to wait is of major concern to them and to the health care system. I would really like you to address that situation we have in Pictou County and how we're going to resolve that. I understand Sydney is doing quite well because they have oncologists there, but there's a whole area of northern Nova Scotia that's lacking in that department. Would you please address that concern for me.

[Page 22]

MS. DOIRON: I appreciate what you're saying, it is a reality. Once the oncologists in Halifax became more stressed - they lost one of their members and then had a second one resign due to overwork and stress - they basically pulled back on some of the activities they had been engaged in, one of which was the clinic in New Glasgow. We have talked with them about that and we have - basically, with the agreement that we made - had them proceed to recruit several new additional positions. One of the conditions we put with that was as soon as they had a couple of additional positions in place, they were to resume the clinic.

Given my understanding in the past couple of days of the status of that recruitment, I would hope that we're looking at the first quarter of the year to be able to restore the clinic there. I've also talked with Dr. Padmos about the potential to interest somebody in actually making travelling clinics one of the priorities of their job. So we are exploring different approaches to say if we repackage the work would we be able to attract or keep somebody who might otherwise find it rather difficult at this stage of their career.

My expectation is that we will have worked through some of these issues and the intention is that as soon as we can possibly put it back in place, that the clinic will be restored. I will be happy to keep you informed about the progress with that.

MR. DEWOLFE: I would appreciate that. I'll continue this in the second round. Thank you.

MADAM CHAIR: The time has now expired and I'm going to remove myself from the Chair and Mr. DeWolfe is going to replace me.

[10:13 a.m. Mr. James DeWolfe took the Chair.]

MR. CHAIRMAN: We will begin with the NDP for the second round.

The honourable member for Halifax Needham.

MS. MAUREEN MACDONALD: Thank you for the opportunity to ask a few questions. I'm particularly interested in mental health. I know that mental health wait times have not been part of the targeted priority areas nationally for the development of health indicators, but nevertheless, I think it's an important area. I'm wondering, we had a situation here not so long ago where it came to the attention of myself and members of the Legislature that the Capital Health District has made a decision to book people for mental health assessments and once they were booked they were removed from the wait list, even though they were waiting for those assessments for some considerable period of time.

[Page 23]

[10:15 a.m.]

Now this, in my way of thinking, was not an appropriate way to measure whether or not someone was getting the mental health services that they require. I would like to know what the position of the government has been with respect to that practice? So I'll start by asking that question, Mr. Chairman.

MS. DOIRON: A good observation and question. As you said, we have not yet entered into defining how we're going to collect or understand wait times in mental health, but it is an area that we do want to get into. I think that when we get into that area then we will have various clinicians determine what is the appropriate approach and standard that we should be using to define wait times. It is, I think, unusual to have a practice, which we understand and as you came to understand, the practice that's occurring with that clinic at Capital Health. It's not one probably that we would have expected, so I think that it is important - sooner than later - that we also start to work with mental health in that regard.

One of the struggles that I think Capital Health has had, as you know, is dealing with that particular one clinic at Abbie Lane because when you look across the district at all of their clinics, it appears to be the only one having that kind of a major wait time issue. Our expectation and what I basically communicated to Capital Health is, we have to find a way to define the problems and address those problems.

As you know, we are making additional dollars available, we've had several years of additional dollars, not everything that is needed but good chunks of dollars into mental health. The way that we distribute those dollars is based on the standards that we defined with the system, but standards that they can then assess themselves against in terms of looking at their own gaps or problems. So what we expect to happen is that they take a look at where their greatest need is, and the dollars that are distributed to any particular district is based on their expression of that particular issue or need.

In this fiscal year, Capital Health, basically along with IWK, came in with a joint proposal around Crisis Response and Intervention, which was also a legitimate requirement. We are anticipating having dollars available again in the coming year for mental health and we would certainly like to see Capital Health make the clinic that they have at Abbie Lane a priority for resolution. So we have proposed that to them and I'm hoping that we will be able to work that out with them.

In the meantime, one of the positive things that's happening, not just for this province but nationally, at the last meeting of the Ministers of Health across the country, Senators Kirby and Keon presented to the ministers a proposal for a mental health commission, an arm's-length mental health commission on a federal basis, a national basis. I should say national, federally funded but at arm's-length. It would be a commission that would be there for at least a 10-year period, dedicated to looking at mental health issues, best practice,

[Page 24]

research and things that would assist us all across the country to kind of bring mental health to a new standard.

We've been recognized across the country for the standards that we've developed, but we know that we still have a challenge to be able to put everything in place to be consistent with them. So I appreciate what you're saying and I think that that is work that will come up in the very immediate future for the Department of Health, to work with those particular wait time issues.

MS. MAUREEN MACDONALD: Mr. Chairman, I'd like to ask the deputy if the government has communicated to Capital District their concerns about the practice of dealing with the calculation of wait times in the manner in which I had talked to. Have they been asked to track wait times, in fact from the time that the person is referred until they're seen rather than the time that they're referred until they're booked for an appointment?

MS. DOIRON: No. We became aware of it recently, as well. We haven't given them any instruction on it at this point. I think to give them an instruction to say, don't take them off the wait list is one matter, but I really think we also need to more immediately kind of get to how we're going to define wait times in mental health, and make sure that's the standard that we use across the province. So now that we're aware of that, I think we basically will be going back into the system, but that's more the approach we'll be taking.

MS. MAUREEN MACDONALD: I think it's very important, if we're going to be developing performance indicators, that the public can have some sense of confidence that they accurately measure the concerns that people have, which tend to be the period of time that they wait from the point of referral until they're seen. I think that this is why this is a very great concern to myself and members of our caucus as people who are here representing the public.

The second question that I would have in the area of mental health waits is the numbers of people who are waiting in the mental health system in inappropriate institutional care locations, like jails or expensive hospital beds, who don't need to be there, who are waiting for placements in the community. I think the case around the elderly lady who came into public view last week, Mrs. Rogers I think her name is, is a very good case in point. As I understand it today, there will be some form of review of her particular situation to try to identify an appropriate community placement for her.

This situation is not new, there have been people who have been at the Abbie Lane for four years. There have been other people in the past year in the forensic unit who essentially have been discharged but they wait for placements. In some ways I get frustrated around the notion that we have to develop these big complicated databases in order to deal with problems that are very clear, because people working in the system and people who are advocates have seen these kinds of problems for a long time. It's as if we have to get this

[Page 25]

whole big infrastructure in place until we can deal with problems that people are dealing with every day in their lives.

Why do we continually not have community placements in these kinds of situations? And what is the department going to do for Mrs. Rogers and some of these other people like her?

MR. CHAIRMAN: Ms. Doiron.

MS. DOIRON: Mr. Chairman, this is a critical issue. We have recognized for some time that we don't have adequate placement for individuals with these particular kinds of needs. We know that that is true for individuals or clients that we're trying to place both through the health system and also through the community services system. Health and Community Services are working together very closely on a whole variety of areas these days, which is really good and productive and something that should have been happening for a long time, but we are getting places with that.

This is one of the issues that we have tackled with and, as you say, we don't need large databases to understand that there are people who should be placed, that they are in the wrong places. We have received permission at this point to build a joint facility that I know doesn't create the solution overnight, but, in fact, we do need actual facilities in which to place some of these individuals, the right kind of facility. Nursing homes aren't the right kind of facilities for most of these individuals.

When the rehab centres - those long-term rehab centres - were closed in the metro Halifax area over the past several years, there were not enough beds retained and there was not a plan to put in the appropriate number of beds to respond to that particular population. We've done some interim things in Health, in terms of trying to develop supports for behavioural management in various kinds of settings, including homes and other locations, but that is not the actual appropriate and total answer.

We are now at the table jointly designing the building that will come forward in order to respond to this particular group of individuals that are being housed in inappropriate places. And for those forensic individuals, for people who are released and yet can't be placed outside somewhere in the community, it's totally inadequate and inappropriate. We have recognized it, and we're going to act as quickly as we can to get that in place.

MR. CHAIRMAN: Ms. MacDonald, with two and a half minutes remaining.

MS. MAUREEN MACDONALD: Well, in that case I would like to ask a question about the bottleneck in the transitional unit and the waits for long-term care on the South Shore. This has also been in the news in the last few days. I had an opportunity to be on the South Shore and speak to some health care workers in that area who are very concerned that,

[Page 26]

first of all, there is pressure to discharge people into the community, back to their homes and families, without sufficient home care but, at the same time, there are people who are in hospital taking up beds and people who need those beds can't get in.

So this is not a new problem. This problem continues. It's unacceptable, I think, that there continues to be a lack of long-term or continuing care placements. I can't understand, Mr. Chairman, why there isn't a plan. I want to know, how soon will that DHA see some relief?

MR. CHAIRMAN: I wonder if we could give a brief answer as time is closing in.

MS. DOIRON: We recognize that this is a problem that's actually throughout the province. For the last several years we've been trying to stabilize the nursing home sector, which really didn't receive much support over a period of a decade or more. That stabilization has occurred, to some level. What we now need to do is to turn our plan to actually developing more beds, because we know that no matter how well we plan and how many other things we do, there will still be more beds that are required. I think we're seeing some of that hitting us now. Again, we've got a major issue to address, but we are putting the plan together so we will be able to take that forward to government, hopefully for some decision to start moving on it very soon.

MR. CHAIRMAN: The time has expired. I'll move to the Liberal caucus.

The honourable member for Richmond.

MR. MICHEL SAMSON: Mr. Chairman, let me just start by saying it was quite interesting to hear a government member, in this case Mr. Parent from Kings North, allude to the fact that there is a crisis in health care in Nova Scotia. It's unfortunate that his speech was given here and not given to his government colleagues, because the fact is that there has been a crisis in health care here in this province for some time. When he mentions that politicians don't have the guts to deal with the issue - I think that's what his wife has told him - well, in 1999, our Party campaigned on a $600 million investment fund to try to stabilize health care, which he and his colleagues ridiculed. Since their time in office, after saying health care needed better management, $1 billion later, that is what has gone into health care. That's just not sustainable. Fifty per cent of the total revenues of this province go to one department.

[10:30 a.m.]

I can only imagine how difficult it must be for the deputy and her staff, knowing that health care is not sustainable, yet your political masters are telling you, do not look to make cuts, do not talk about any sort of efficiencies, don't do that and don't let out that we're even looking at this. That's the unfortunate reality.

[Page 27]

In the Spring when our caucus continued to question the Premier and the Minister of Health about the crisis in health care spending, what did we get back? Was it, well, let's have an open discussion about this? The Minister of Health accused us of wanting to cut services. The NDP accused us of wanting to raise taxes and having a hidden agenda. That's the reaction we got. It's unfortunate the member for Kings North wasn't there at that time to join with us and ask for a public discussion to take place on the crisis in health care - maybe from here forward. Let me just end that point by saying, when the budget was passed, while the Premier at no time admitted there was a crisis in health care, his one telling comment after the budget passed, what's your next objective, he said it's to deal with the crisis in health care spending. Now I don't know if anyone in this room can tell me where the Premier has mentioned it once since that time, and now he's retiring, so we're left to deal with it.

Deputy, let me bring a local issue to your attention. I know the member for Halifax Needham has mentioned the situation on the South Shore with long-term care. We're faced with the same problem in Richmond County. We have St. Anne Community and Nursing Care Centre and the Richmond Villa, two fine institutions, and yet we have Richmond County residents who are on waiting lists for extended periods of time, who can't get their loved ones into nursing home beds. Is it because there are not enough beds to meet the Richmond need? Not at all, the problem is the people from outside Richmond County who are occupying the beds. Because of this 100-kilometre rule that the department has, and because there are not enough nursing home beds in the Antigonish area, and there are not enough nursing home beds in the Sydney area, they are coming to Richmond facilities.

So my question to the deputy is, is your department prepared to review this 100-kilometre rule? Where Richmond is located, we pick up what's coming from Sydney because of that 100-kilometre rule, plus we pick up what's coming from Antigonish. At the end of the day our beds are being filled with people from outside our county while our own residents can't get into nursing home facilities within Richmond County. I have a few more issues to raise on that. Is the deputy and the department prepared to review that 100-kilometre rule, especially with the impact it's having on our facilities in Richmond County?

MR. CHAIRMAN: Ms. Doiron, I believe you have a couple of issues to address there.

MS. DOIRON: The department is reviewing and addressing the underlying problem, which is not enough beds in a number of communities. Basically, when we do that and address that, then we probably should not have that same kind of strain on a 100-mile radius rule, which is there, really, to address some of the use of the acute care beds in hospitals. That would work quite well during a period where we're stabilized with enough beds in long-term care. It gets into a situation you're talking about when we have the bed demand that we haven't been meeting. So that is the real issue.

[Page 28]

Now having said that, we have moved forward with some new beds. So this year we are moving forward with approximately 300 beds for long-term care. A number of those beds, about 100 of them, are out in the Cape Breton area. Once they're in place - and that process is already started, so they're underway - then there should be some relief on the Richmond Villa, I would think, because what you're saying is correct, there are areas that don't have enough beds in your jurisdiction.

MR. MICHEL SAMSON: And it's not just the Richmond Villa, it's St. Anne Community and Nursing Care Centre as well. I remember, I've raised it with you and I've raised it with the minister that the new Richmond Villa will actually have fewer long-term care beds. The answer that came back was, well, when we look at the demand in Richmond, we should be able to meet that. The problem is it will meet Richmond, but right now the problem is we're servicing the entire Island of Cape Breton and part of eastern Nova Scotia with our nursing home beds.

There are two issues that come out of that. First of all, I know that my colleague, the member for Clare, has raised the issue about French language rights for individuals in Acadian communities. It does not make sense to send someone from Isle Madame or from Richmond County, who is Acadian, to Neil's Harbour, it just doesn't make sense, or sending them to other facilities in Baddeck or Sydney where there are no French language services, which are readily available at both St. Anne Centre and at the Richmond Villa.

The other problem that is happening which I think is of extreme concern is that family members are now calling and saying, why should I continue to financially support at the fundraisers, at all the events, whether it's for St. Anne facility or Richmond Villa, when Mom can't even get into that facility, yet there's a lady from Antigonish who just took a bed, a lady from Sydney who just took a bed and how much is Antigonish or Sydney giving to keep those facilities running in our communities? That's where our big problem is, communities are starting to question whether they should continue to support their local facilities which they always thought would be there in their time of need, and they're not being there. Has the department considered the impact that is going to have on these facilities for the long term if communities suddenly no longer feel these facilities are there to address their personal needs when they'll require them?

MS. DOIRON: I think those are also reasonable observations and one of the reasons why we felt we had to move on an immediate basis with some beds in that particular area. When you get the additional 100 beds, I think you'll see some significant relief there. Having said that, that's not all the beds that are required in that area for a projected future of 10 to 15 to 20 years. As part of the plan that we need to take forward to government, we need to add to that 100, but I think you will see some immediate relief once those immediate beds get put in place. Basically, by the time that the new Richmond Villa is constructed and open then hopefully they will be mainly Richmond Villa residents that will be able to occupy it.

[Page 29]

MR. MICHEL SAMSON: That's certainly our wish and let me say, the people of Richmond are extremely generous people and in time of need are more than happy to be there to assist where they can. But the fine line gets crossed when all of a sudden you have people on waiting lists who are clearly in need of nursing care, have been approved, but are told, you are going to have to wait longer because we now have a lady from Antigonish who was sent from St. Martha's, we have a lady from Sydney who is coming from the Regional, and until they get placement in nursing homes in their area, that is going to change.

Is it safe to say at this point that until those new beds are constructed and in place, that we should expect that 100-mile rule to continue to be in place, or is your department prepared to say, if you're a Richmond County resident on a waiting list, you should have priority getting into one of the two Richmond County facilities?

[10:38 a.m. Ms. Maureen MacDonald resumed the Chair.]

MS. DOIRON: I will never say I would not go back and review something. What I don't want to do is to make a promise that I can't keep because I know there are lots of issues to be considered in terms of why we have a policy of that type. We do, however, I think support the position that people should be able to be kept at home as long as possible, kept close to their community or right in their own community. That is basically the premise of all the work that's going on in continuing care to say, what do we need to do to be able to make that happen into a longer-term future?

One of the challenges that we're going to have is dealing with some of the issues until we get some of this planning moved forward and get the actual, on-the-ground resolution to some of these things. We can't ignore, I think, that very pressing reality that it's much better for people to be connected with their own communities and their own families, so anything we can do to try to support that we must take into consideration.

I will go back and talk with my staff about that issue. I'm not sure that we will be able to walk away from that policy, but we'll have a very good discussion about it. I will assure you that once we have that discussion, I will actually get back to you to tell you the outcome and whatever position we have at that point, and why.

MR. MICHEL SAMSON: Let me just finish that issue by saying that I realize the objective is to keep people in their communities, but when I have residents calling me and saying they walk into St. Anne Centre and they don't recognize people and out of all the residents they knew one or two, something is not working. The same thing for the Richmond Villa. If we want communities to continue to support these facilities with fundraising and all of the generosity that the communities have shown, we need to start addressing this.

[Page 30]

Richmond is just one example and I'm sure colleagues from different parts of the province right now are bearing the burden for the lack of beds in other areas. We have enough beds in our community to meet our needs, and any excess beds, we're more than happy to assist others. Right now our needs are not being met and that's the significant problem that exists.

Let me just finish and pass my time to my colleague by once again pointing out Strait Richmond Hospital, the doctor is only there for six months. Those six months are coming to an end and we still don't have a long-term solution for that facility. I'm not sure how many more years I have left in my political life, but I'm hoping at some point we are going to have some stability for that facility. Traditional methods have not worked.

I know the deputy has indicated an interest in exploring new initiatives for that facility, nothing has happened yet. We need to do something or we're going to continue to have problems there and we continue to roll the dice with people's safety and people's lives, and that's just unacceptable in this day and age. With that, if the deputy wishes to respond, I will give the rest of my time to my colleague.

MS. DOIRON: Again, I think the position that this member has brought is very reasonable to continue to press on because it has been an ongoing and long-standing kind of problem. We have recently done a review of Richmond Villa to determine what could be the appropriate approaches that might work better there. We now have that report which is basically recommending a combination of looking at physician service differently during the day, but also the inclusion of nurse practitioner. We are defining in the department roles for nurse practitioners that we had not traditionally had such as nurse practitioners in emergency rooms or nurse practitioners in long-term care, and so on. So with a combination of those factors we think we can now come forward and start to work with Richmond Villa to see if we can try to stabilize that situation with a different model than we had in the past.

MADAM CHAIR: The time has expired for the Liberal caucus.

The honourable member for Pictou East.

MR. DEWOLFE: My colleagues to my left are making some comments and we'll try to ignore that. Madam Chair, to Ms. Doiron, the pressures in the health care system that were brought to light by the member for Richmond are not unlike those pressures of other provinces right across our great nation. I think my colleague, the member for Richmond, knows very well that this is true, and he is certainly being more of a reactionary member than a visionary. I would have to say that my colleague, the member for Kings North, is a visionary and forward-thinking person with regard to health care, and that was where his comments were coming from.

[Page 31]

Not that I have to sit here and say that to you, because you are in the forefront and you know very well that the pressures we have in Nova Scotia are, indeed, the same pressures that other Health Ministers and deputies are facing across this country. Would you not agree?

MS. DOIRON: That's correct.

MR. DEWOLFE: Having said that, a concern that was brought to my attention by a good friend, Agnes MacDonald, a nurse at the Aberdeen Hospital in New Glasgow, was something that I hadn't heard before but recently she brought it to my attention. There was a couple of weeks' wait sometimes for biopsy reports, so that would be a pathology problem. I don't know what the national average would be for getting these reports back, but it would seem to me that someone who has a biopsy and has to wait for two weeks, that's a tough two weeks sometimes to put in. I was wondering if you would comment on that?

MS. DOIRON: I don't want to comment too far because I'm a little bit away from my clinical days, but I do know that most pathology reports for the full report generally take up to 10 days. I'm not sure exactly what this refers to but I think we could go back to explore that to find out if there's another issue attached to that from a wait time perspective. I haven't heard that there is any problem or issue with the response time around lab and pathology testing.

MR. DEWOLFE: I don't think there was any one case and it was just the fact that she, as a nurse, felt that the results should come much quicker than two weeks for these patients who have a possible malignancy. I think it was more of a general comment that there should be a way that our system could speed this process up. I, of course, know nothing about how these tests are done or what time frame is indeed needed.

[10:45 a.m.]

MS. DOIRON: Two weeks does seem a little long to me, from my experience. I think seven to 10 days would be more the time frame that I would be used to understanding. So I'm not sure if there's some other issue attached to that, I think we would need to look into the issue, generally, to be able to comment on it further. We will do that and contact that location to find out what is occurring there.

In terms of saying, should we expect a turnaround time in 24 hours, sometimes there is the kind of testing that's done at the time of surgery and is a quick-review kind, to take a look at whether something is malignant, but it's always on a basis that it has to be confirmed by the full pathology report. Those pathology reports, just by the nature, apparently, of what has to occur to get to that diagnosis, so far have not been able to be turned around in less than a week to 10 days, I think it's just the process that they have to put the tissue through.

[Page 32]

MR. DEWOLFE: Thank you for that answer and I do appreciate you getting back to me so that I'm more comfortable with the time frames involved and that sort of thing. I know it's a tough time for patients waiting for reports and I have a very close friend who is actually waiting for a report now and I'm keeping my fingers crossed for them.

It seems like only a couple of years ago that we sat here in this very Chamber and I was discussing the concerns about orthopaedic care at the Aberdeen Hospital, and now we have a wonderful orthopaedic section. I became quite friendly with Dr. Chabra and there have been many successes now in Pictou County. We have a special event called Hip Hop Hooray and I am one of his patients myself, not surgery-wise, but he has treated me. Here we are, in Pictou County, very much appreciating what we have there and when you go to one of these events you realize how many patients show up with their new joints to do the symbolic walk at the start of this event, it's really something. All the families join in and we have fiddle playing, hot dogs and it's great fun. A couple of years ago it wasn't so much fun and both Dr. Chabra and Dr. Haider are doing a great job there.

At any rate, I'm hoping that the oncology - going back to that - that we will resolve that concern, and I brought that up in the first round and we're running out of time. I appreciate that it is of concern to you and your department, and a concern that you are trying to address on behalf of the constituents of Pictou County who have to go to Sydney, who have to go to Halifax. I understand Sydney is taking some of them, but they don't want to because they have enough to handle down there, as well. There is a great need for that service at the Aberdeen Hospital in Pictou County, which is sort of central to northern Nova Scotia.

Having said that, Ms. Doiron, I'm going to pass to my colleague, the member for Waverley-Fall River-Beaver Bank, and I thank you for all of the work you're doing. I know health care is improving, I've seen a great many improvements during my eight years as a legislator and I hope to see many more in the future. Thank you.

MADAM CHAIR: The honourable member for Waverley-Fall River-Beaver Bank.

MR. GARY HINES: Thank you for coming in today. I think the next time we invite your department in we'll just get Hansard to replay the tapes from the last three or four times you were in here because you're frequent guests and we never seem to stay on the subject. Today we haven't been on it very much and that's probably because the Auditor General's Report suggested that you were doing a good job.

I am going to go to an area of it that I wonder if you have any performance indicators or information on. It was prompted by a conversation I had with a friend of mine from Ontario. We were talking about health care and perhaps how we had to be visionaries in what we had to do in the future to be able to make health care affordable.

[Page 33]

He brought to my attention one thing that one of the hospitals in his area was doing and that was instead of booking appointments long-running, they were booking the first two appointments of the day and their operating rooms were busy the rest of the day. Have there been any studies done as to how much actual time we lose with our operating rooms sitting idle, and that's a good thing in terms of budgeting, because it doesn't cost anything to have that sitting idle. I'm sure there are some who believe that that is a good thing but I don't because of the backlogs, I think they should be busy.

This has seemingly worked in this hospital, according to the gentleman I was talking to. Has there been any indication as to how much loss time our operating rooms do have, because some people, unfortunately, can't make their appointments and are not able to cancel in a timely fashion so that they can re-book that space?

MS. DOIRON: We have some knowledge of that kind of information through discussions that have taken place. We don't usually have a problem with people cancelling out on their surgeries and therefore leaving the operating room unused. The questions and issues that we tend to look at more so is whether we're actually turning the operating room around quickly enough, if our procedures are adequate so that we're not wasting time in between cases, for example, and things of that nature. However, because it is such an important issue, we were actually talking about doing more work in this area.

The Wait Time Advisory Committee to the minister, which has been in place now for a number of months, has recently come back to the minister and the department with a recommendation that we do a review of all the operating rooms across the province. Consequently, we are going to be following that recommendation and sending that kind of review off, which will then address any of those kinds of issues around if we're booking the operating rooms appropriately, if we're using them adequately throughout the day and other periods of time. We know that they sit idle at times on weekends or on evenings and nights, although there are a number of emergency cases that are done in some locations.

In my career, when we have looked at the potential for using operating rooms at unusual hours, the challenge that we tended to have was the availability of physicians to carry on into shift work. Because of the critical mass that we have in any particular operative group, trying to make something like that work can sometimes be a challenge. We are certainly interested in looking at any of the approaches and actually bringing in external reviewers that would have had experience looking at OR systems in other jurisdictions, so that we can also kind of learn from practices from elsewhere, such as maybe what your friend may be referring to.

That review will be taking place sometime over the next year. It will be interesting to look at the results of that to see if we can become more efficient in our use of ORs.

MADAM CHAIR: Mr. Hines, you have approximately 45 seconds.

[Page 34]

MR. HINES: I'm going to make one comment. In your discussions with your colleagues across the nation, I think it's time that we look at changing the Canada Health Act that will allow public-private partnering and health care insurance because we can't afford the health care system, it's not sustainable in the direction we're going. I think it is time that we get private sector involvement and there are good cases across the world to indicate that that may be the place to go, although I realize that we have a socialist philosophy that doesn't have much to do with budgeting. Thank you.

MADAM CHAIR: Thank you and what a way to end our meeting. Ms. Doiron, you can now take a few minutes to conclude or summarize the discussion today, if you would like.

MS. DOIRON: Thank you very much, Madam Chair. I want to thank the members for inviting us to come on this topic because it is one of our most important strategic topics of the day. Wait times and indicators in health care are a very complex business, it doesn't sound like it when you look at the surface of it, but to try to then understand how you define them, frame them, work toward them, and understand evidence against them is a whole area that is just developing.

We are basically committed to going down that road and to being as open, transparent, and visible as we can be while we go down that road. We do want to make information available to the public and any other bodies that have an interest in exploring it, and also in providing us with advice as to where some of the priorities or most important areas might be. We are actually relying on the advice coming from the Wait Time Advisory Committee, which has representation from the delivery system and physician specialists, but also from the public members on that committee. So it's an area that's not just owned by professionals, in my view, it's a public issue, so we're open to that.

We also want to ensure that as we go through this kind of work, that we invite scrutiny against it. So we're extremely pleased to have the Auditor General's involvement up to this point. We think at some point in the future we will also be looking at other kinds of auditing from people who have content knowledge of the field or system that they're auditing. Essentially, we have much work to do into the future.

The systems and processes that are being put in place, including the information system support, is going to enable us to do much more of this on a better basis into the future. I expect that we'll have continuing discussion as we go down the road with this and I thank you for your interest in this topic.

MADAM CHAIR: I would like to thank the deputy and members of her staff for being here today. I would now ask for a motion to adjourn.

[Page 35]

MR. HINES: I so move.

MADAM CHAIR: The committee is now adjourned until next week.

[The committee adjourned at 10:57 a.m.]