House of Assembly
Nova Scotia
HALIFAX, MONDAY, APRIL 8, 2002
COMMITTEE OF THE WHOLE HOUSE ON SUPPLY
5:31 P.M.

CHAIRMAN
Mr. Brooke Taylor

MR. CHAIRMAN: The honourable Government House Leader.

HON. RONALD RUSSELL: Mr. Chairman, would you please call the estimates of the Department of Health.

Resolution E9 - Resolved that a sum not exceeding $1,980,235,000 be granted to the Lieutenant Governor to defray expenses in respect of the Department of Health, pursuant to the Estimate.

MR. CHAIRMAN: The honourable Minister of Health.

HON. JAMES MUIR: Mr. Chairman, I'm pleased to rise today for the third time to talk a little bit about the budget for Health for year 2002-03. I want to say in the beginning that I'm very proud of the health care system in Nova Scotia, and I'm also proud of the progress that we've been able to make in the two and a half years since we've been in government. I just want to say that if we're reviewing the health system in our province, we would say that we have an excellent health care system for the most part, that is sometimes very good, and it would be our objective as government and mine as Health Minister, along with that of my staff, to be able to say that at all times we have an excellent health care system.

Mr. Chairman, my perspective on the quality of our health care system, I think, is shared by just about every member of this House. I don't like to get too particular but I will for this time. In the two and a half years since I've been in this chair we have had a number of members in this House who have had rather somewhat serious conditions treated by our health care system and, if you were to ask them to a person, I think they would all indicate how well they have been treated by our health care system.

I talk about my colleague to my left, the honourable Minister of Finance, who had surgery last year; I talk about the honourable member for Glace Bay, who stood up in this House last week and commented on the excellent service he received from the health care service up in DHA No. 8; I think of my colleague, the honourable member for Dartmouth South, the government caucus chair, Mr. Olive, who also had a bit of a scare not that long ago and was treated in the Dartmouth system excellently.

I think also of my colleague, the honourable member for Chester-St. Margaret's, who had a brain aneurysm and is back in this House after a short period of time, thanks to the quality of care in this system; I think of the honourable member for Cape Breton Nova, the longest-serving member of this House, who had an aneurysm last year, and because of the quality of medical care in this province is back in his chair and, as we heard in his resolutions last week, he's getting back to 100 per cent, close to 100 per cent.

Mr. Chairman, I would be remiss if I did not mention the Premier who today, has undergone surgery, although I have not had a report I expect the quality of care that he received was excellent.

What I want to say is that I am proud of the health care that is delivered in this province and I am proud of the health care workers that we have in this province. I want to say that we are doing all we can to see that this characteristic of excellence, which is known across Canada, does continue.

Mr. Chairman, as we all know, this government has undergone, like other governments in Canada - all provinces and territories have had tremendous fiscal pressures on their health systems. I'm pleased to say that we as a government are not only gaining ground with our fiscal agenda, but the progress that we've made in getting the finances of the province back in shape augur well for the future stability and improvements in our health care system. I'm pleased that my caucus colleagues and my Cabinet colleagues agreed with the people of Nova Scotia and we were able to retain health as the number one priority during budget deliberations.

Mr. Chairman, months ago the budget process formally began. The starting point of the budget process was the same as it was last year - all departments and agencies were asked to prepare scenarios if they had to either live with the same budget that they had this year or if their budget was reduced by 2 per cent. This was across departments, and in the case of Health we went to the district health authorities and to our other agencies and asked them the same thing. At the end of this process the government put $134 million more into health care for the 2002-03 fiscal year. Budget to budget or estimate to estimate, that represented about an 8.8 per cent increase; forecast to estimate, it represents about a 7.374 per cent increase. This is indeed significant and does indicate that this government has health care as its number one priority.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 3

We have a bit of a problem in Nova Scotia. Clearly no agency, no district health authority, no other component of the health system got the dollars it would like to have. Indeed, none of those agencies or divisions received the amount of money, the increase that I would have preferred to have given them, but the increase that they did receive means that quality health care will continue to be delivered in this province and, indeed, in some cases it will be enhanced.

Mr. Chairman, it means, for example in the case of the district health authorities, that they all received increases and there will be no facility closures. It means that an additional $22.7 million will go into the home care, nursing home, and other components of the continuing care sector to help ensure that the care of seniors and others who need assistance at home will continue to be met.

Mr. Chairman, we are also adding an additional $1.5 million as an investment next year to help children and youth who are afflicted with mental illness; we have an additional $1.8 million for services to help women and youth with addiction problems; we have increased the renal dialysis capacity in the province to meet what I will call an unfortunate growing demand; and there is increased access to orthopedic services with the reinstatement of a program in northern Nova Scotia.

In 2002-03, we will continue to work on the implementation of a health human resource strategy which will help recruit and retain doctors, nurses, and other health care professionals.

We will begin to introduce the most comprehensive and modern hospital information system in Canada, and that is a good thing. We will work to develop a new and objective funding formula for district health authorities. We will continue to further develop the DHA accountability framework to promote quality of service delivery, efficient use of resources and measurement of final results in business plans. We will introduce legislation that together with our comprehensive tobacco strategy will help to address high rates of youth smoking and will also significantly reduce exposure to second-hand smoke in public places. We will look at how treatment is provided for certain diseases.

These are just some of the examples of initiatives we can look forward to this year due in large part to last year's accomplishments. Let me take just a few minutes to recap. Let's start with the recruitment efforts for doctors and nurses. We are extremely pleased with the response to the nursing strategy. This strategy was developed by nurses, for nurses, and it has really turned out to be a very, very good thing. The situation with the shortage of nursing personnel in Nova Scotia is not unique to this province, it's not unique to this country and it took many years to develop. The strategy that was developed by nurses and their other members, stakeholders group, is a long-term, comprehensive approach and, as I've said, I am very encouraged by the results that we have accomplished so far.

[5:45 p.m.]

I would like just for a minute to acknowledge the work of the provincial nursing network. This was the group that developed the strategy. Those people have been a tremendous resource and the strategy has not only seen more nurses come to Nova Scotia, but it has given practising nurses other opportunities for professional development and continuing education that they did not have before the strategy was in place.

I just want to tell you since the nursing strategy began there have been 150 RNs, student nurses, who have completed, who are set to begin co-op work terms. Just for what it's worth, yesterday afternoon I was at a festive event in actually the constituency of the honourable member for Hants East and met a young person who was there .. .

AN HON. MEMBER: Helping him out.

MR. MUIR: Helping him out, yes. I met a young woman who was graduating from the Dalhousie nursing program this spring and I asked, have you a job? She said yes, I am going to work in the Cardiology Department at the Dartmouth General Hospital - I thought the member for Dartmouth East might be interested in that. We're even helping you out, not that you deserve it, but helping him, doing what we can.

Anyway, this is an example of the things that we're doing. Over 200 RNs and LPNs have received or are receiving educational bursaries. The RN bursaries come with a one-year¬in-return-service agreement, meaning that they work in Nova Scotia for at least one year after graduation. We have had 90 nurses from outside the province - 90 from outside the province - who have used the relocation allowance that's in the nursing strategy, to take positions in Nova Scotia, and that's a good thing.

The strategy is meant to support employers and that includes the district health authorities, the agencies which employ home care workers and, of course, long-term care facilities in their efforts to recruit and retain nurses. There have been some of the DHAs that have increased the impact of the nursing strategy by adding their own incentives. I'm pleased to say that 80 per cent of the $5 million nursing strategy has gone for its orientation and continuing and specialty education for registered nurses and licensed practical nurses.

As I've indicated, many of the agencies and districts have added their own incentives, thereby increasing the impact of the nursing strategy. For example, in January the Capital District Health Authority announced that they were working in tandem with that strategy and had recruited 60 new RNs since June, and 41 new graduates have been also guaranteed jobs with them.

In terns of physician recruitment - and, by the way, just before I get into physician recruitment, I want to indicate that the LPN programs in the province, and I believe they are located in four sites with community colleges, they are all subscribed to capacity. The ability to recruit LPNs to staff not only the acute-care facilities but the long-term-care facilities that participate in home care is increasing. I suppose I should add, just to refresh memories of members of this House, when the LPN legislation and the RN legislation were passed here last spring - I would like to congratulate all members for supporting those pieces of legislation - they have modernized the profession of the LPN and the RN professions and now enable the members of those professions to do things which are more appropriate to their competencies.

In the area of physician recruitment, I can say that we continue to have one of the most successful physician recruitment programs in the country. We are the second most successful recruiter in Canada.

AN HON. MEMBER: We were first last year.

MR. MUIR: No. second. So despite the fact that we welcome new physicians - we encourage new physicians and we are very successful in recruiting physicians comparatively speaking - unfortunately we still have some gaps to fill and we will work with the communities and with the district health authorities to try to fill in those gaps.

So far this year we have been successful in recruiting new physicians in Elmsdale, in Parrsborro, in Barrington Passage, in Amherst, in Berwick, and in Inverness. By July we will have others locating in Yarmouth, New Glasgow, Kentville, and Tusket. We're ahead of last year in recruitment and we are also ahead of last year in site visits by physicians, with 18 scheduled and 20 more being negotiated. All in all, despite the fact that we don't have as many physicians as we would like, our program has been a success. It doesn't mean that it can't improve but, relatively speaking, it's been as good probably as any program in Canada, given our resources.

We've started a consultation process with physicians across the province as part of a new physician resource planning initiative to ensure that we plan and recruit for our needs five and ten years down the road. Our incentive positions are being examined to ensure that we're offering the right kinds of packages to attract and retain new physicians for our most under-serviced areas. As pleased as we are, Mr. Chairman, with our success to date, we will continue to keep our recruitment and retention efforts as one of our top priorities for the coming year.
Additional examples of successful recruitment efforts have to do with the paramedics, the partnership with Holland College, which saw a program put in the community college campus in Truro and, of course, that program will rotate around the province as it is needed. I am pleased to say right now, Mr. Chairman, that I have been informed that we do have a

sufficient number of paramedics. The interest in that program is really phenomenal. They are offering it over in Dartmouth, for one place, for the P 1 level paramedics and it's one of the most competitive programs, I think, of any program in higher education to get into; it's really phenomenal the interest in that program. I know that the member for Victoria had mentioned last fall that they did have a couple of vacancies up there, but I think even those have been taken care of, and I am optimistic. The honourable member for Richmond may be able to tell me that for a fact. (Interruption) I think he's agreeing with me.

Additional examples of the department's achievements to date include the implementation of our single-entry access program to continuing care. Staff from the continuing care sector have worked very hard and continue work to help make it easier for seniors and others to access the long-term care that they need. As a matter of fact, Mr. Chairman, just last week we began with one toll free number to replace a complex process that has been a challenge for seniors and others for many years.

Mr. Chairman, the district health authorities and 37 community health boards are stronger than ever. A new approach in developing and implementing health services planning was started last year, emphasizing the use of hard evidence in making decisions about how acute and continuing care services will be made available to individual communities across the province. Last year, we established a solid foundation which will enable us to continue our work this year on plans to help enhance our programs and care for those among us who are mentally ill. Efforts to improve the health of the overall population were made evident by the introduction and implementation of the province's first tobacco strategy, by advancements which enhance breast screening and pap tests and, of course, our annual flu immunization campaign. This year, work will continue in the area of primary health care and emergency health service.

Mr. Chairman, I could go on and on, but suffice to say that we have made great headway this past year and we are looking forward to many more successes this year. The budget of $1.98 billion will help make that possible. That's not to say that next year or this year will not be without its challenge, because we are going to have them. We are going to have them in our department and in every other department as well. But we were very fortunate to have an additional $134 million this year. Of course, we could always use more because the demand for health care services continues to rise, and managing the costs continues to be a challenge.

I just want to tell you, Mr. Chairman, some of these pressures. I want to go back to the year 1994-95, which was about the last year we had a reasonable contribution from the federal government in terms of health care dollars. In the year 1994-95, our budget for home care was $21 million; in the year 2001-02, it was a $108 million; our long-term care costs in 1994-95 were $60 million; in 2001-02, they were $181 million; the bill for our hospitals in 1994-95 was $638 million. Despite the reduction in a significant number of beds, last year

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 7

the cost of delivering hospital services was $925 million. Clearly, a lot of pressures on the health system.

Fixed costs are increasing as well. There is probably somewhere around 5 per cent just to maintain the system that we have in terms of, sort of, I guess you would call them inflationary costs. About 2.5 per cent for pharmaceuticals overall; about 1.5 per cent for inflation and medical surgical supplies; a 1 per cent increased cost in utilization. Despite the fact that that comes up to about 5 per cent, we are looking at the district health authorities. In addition to picking up negotiated salary increases, their operational budgets were increased by about 10 per cent. This was the largest portion of the $134 million dollars, additional dollars going into health care service this year is going into the budgets of the district health authorities.

Despite the fact, Mr. Chairman, and this is a point which we have not been that successful in communicating and people tend to think of a health system in Nova Scotia and other provinces consisting of acute care services plus physicians. They fail to understand the costs of home care or the component of home care, the component of pharmaceuticals, the components of long-term care, all of these things. More than 50 per cent of our budget is allocated to services which fall outside the acute care sector. Yet, when you talk to people about health services they tend to think of their own acute care services. We need the support of all members of this House to get the population to understand that health services are more than hospitals. (Interruption) You're going to help us. I can tell that.

Now, despite the increase, Mr. Chairman, there are going to have to be changes in the way health care services are delivered. Our intent is to continue quality with greater efficiency. So quality and efficiency tend to be two watched words, as does care. Quality care in the most efficient way is what we are looking for. People will continue to get the care they need when and where they need it, hopefully by the most appropriate provider. Change to care will be made based on clinically sound benchmarks and best practices.

You might be interested, Mr. Chairman, in the time it takes me to read one sentence here, probably about $500 of health care services has been expended in Nova Scotia. Our health services cost just about $3,800 a minute, more than $225,000 an hour, and nearly $5.5 million a day. That's. what Nova Scotia spends as a government on health-related programs and services and, of course, that does not count the other health services which people either pay for themselves or are insured services of some outside agency.

[6:00 p.m.]

Nova Scotia is not alone, Mr. Chairman. Provinces all across this country are battling increased health costs, the rich provinces and the poor provinces alike. Some wealthier provinces, for example, Alberta and British Columbia, have gone the route of health premiums and so far we've been able to avoid that.

8 HANSARD COMM. (SUPPLY) MON., APR. 8, 2002

Mr. Chairman, I will be meeting with Mr. Romanow later this month to speak with him directly about our concerns about the sustainability of our health care system in Nova Scotia and I would encourage all members of this House who have an interest in health and health care to present their ideas and their concerns to the Romanow Commission. Now, appreciating that provinces and territories have somewhat different views and that members of this Legislature and different Parties might have some different views about health and health care delivery, we still have to work together to ensure that Nova Scotians continue to benefit from a good quality, unsustainable health care system.

Mr. Chairman, although we may have some differences, I do believe that all members of this House are committed to quality care and will be anxious to see that our citizens continue to receive it, not only this year, but into the foreseeable future and will recognize that things have to change and that we also need a better support from our federal government to see that many of the services that we have now can be continued and enhanced.

Just before sitting down and inviting the people on the opposite side of the House to offer observations and to ask questions, I would just like to comment that when the Medicare system first began, it started off first free hospitalization, then it was free physician services, but today all governments in Canada have assumed a far greater responsibility than when the Canada Health Act, when these federal decisions were made. For example, you would just have to look at the Health budget and what we expend for others whereas when that first came in, you would see two lines. You would have seen one for hospitals and you would have seen one for physician services. Now we see pharmaceuticals, long-term care, home care, catastrophic drugs, and all of these things. We have just all of the services that the government contributes to and people expect the governments to contribute to that were not part of the fundamentals of the Medicare program in this country.

If we are to continue to do those things, Mr. Chairman, we have to work together as provinces and territories and as legislators in Nova Scotia to convince the federal government that, the Canada Health Act has to be re-examined and many of the services which are not deemed as insured should be insured and we have to have the support of the federal government if the province's contribution is to increase.

MR. CHAIRMAN: Minister of Health, is your staff available now? Okay, before I start the Opposition's time, I am going to allow two minutes for your staff to take your seat, please. The time being 6:05 p.m., one hour is allotted the NDP caucus.

The honourable member for Halifax Needham.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 9

MS. MAUREEN MACDONALD: Mr. Chairman, I want to start off by thanking the minister for providing us with some insight into how well he thinks he's doing. He has given himself an A-plus on this and I trust he will understand when we don't give him such a generous mark for his performance in the job.

Mr. Chairman, I would like to start by saying that in many ways this government probably has done more to harm the long-term health of Nova Scotians than any other government. If we were to look at the attention that has been paid to the determinants of health by this government, which is just about nil, this government has not taken the kinds of measures that would be required to address income distribution and inequality which are probably some of the largest determinants of health that we know. This government hasn't improved the educational status of Nova Scotians and we all know that the better the education status, the better the health status of the population. This government has not paid attention to some of the really important issues, pressing environmental issues like the health of people in Cape Breton around the Sydney tar ponds area. So I think that in terms of rating this government's performance and this Minister of Health's performance vis-a-vis the determinants of health, then we would have some very serious concerns about what this government has done or failed to do, more precisely.

Mr. Chairman, when I look at this budget, it is clear to me that of any of the new infusion of dollars in this budget, there is little or no money in this budget that will transition the health care system in Nova Scotia into a more proactive system that will deal with issues of population health and equity. I think that that is truly unfortunate and that is the real failure and really in many respects the test of whether or not this is an adequate public policy response to the long-term health and well-being of Nova Scotians, but having said that, I would like to focus a bit on some of the aspects of the health care system, the system that the minister took up, and I would concur with him.

In his opening remarks he indicated that we have a high quality medical care system in the Province of Nova Scotia, that Nova Scotians, quite justifiably, have confidence in their health care system, have pride in that health care system, that there are many dedicated, competent and qualified professional health care providers working in that health care system, and that the quality of their work and the care that's delivered needs to be acknowledged publicly and they need to be supported in the work that they do. I concur with that and members of this caucus certainly concur with that view about health care providers in the Province of Nova Scotia.

However, Mr. Chairman, while it is true that most people get excellent care when they get into our medical care system, the problem for many people increasingly is the getting into the system, if you will, and I think that, if you look at what the minister had to say, there were two weaknesses in the claims that he made about our health care system. The first weakness in what he had to say is that he certainly glossed over and, in fact, I didn't hear him really acknowledge that increasingly there are people who are unable to get into the system

and they are consequently not able to get the care they need, certainly not without many long waits, delays, cancellations and difficulties. I would like to review a few of these situations, because I think that as members of this House we all have people in our constituencies who have presented us with some very clear examples of the difficulties they have had with respect to cancelled surgeries and the growth of the length of waiting times, for example.

On a regular basis I receive contact not only from members of my constituency but from members of other constituencies, constituents who live around the province, who contact me to discuss the difficulties they have with cancelled surgeries. This has been a problem that we have seen grow to rather significant proportions under this government. I don't think there's any question about that from my perspective. Having been here now in this Legislature with two governments, clearly the waiting times for surgeries and the number of cancelled surgeries, cancellations, if the number of times I hear about these situations is any measurement, certainly some of the research that has been done in the NDP caucus would indicate that the number of cancelled surgeries is something that has grown and continues to grow. We all know that, for example, the Capital Health District, not so long ago, indicated that they're carrying a deficit in excess of $13 million. This means that they, in fact, will not be able to deal with the waiting times they have and cancelled surgeries will continue to occur.

The problems that people have experienced in the last year in Nova Scotia will not only continue but they're going to get worse. Let's be clear about what's occurring in terms of the cancellation of surgeries. The surgeries that are being cancelled are often surgeries that are absolutely critical for people's health and their well-being, for their ability to be able to participate in work. I had a gentleman from one of the Dartmouth constituencies call me. He had been off work for several months. He was in a huge amount of pain. He was unable to participate in the labour force and support his family. He was the sole breadwinner in that family.

He was in a situation where he wasn't employed in an industry where unemployment insurance or employment insurance existed, and his family was rapidly running out of their own personal financial resources that they could draw on to support the family - he had young children; he was a young man - while he was waiting for surgery. His specialist was essentially telling him that the waiting time for the procedure was going to be six to nine months. For this particular gentleman, that was just a horrendous idea, that he was going to be in a situation where his family was financially destitute as a result of the situation.

I've had calls from people in my own constituency where their mother had a blood clot and had surgery scheduled. That surgery was cancelled three times. Throughout this whole horrendous situation, not only was this mother in a great deal of pain, but she had to be monitored extremely carefully on a regular basis by physicians because, in fact, this blood clot could have been a life-threatening situation. So there was a lot of anxiety in that family as to what was going to occur with their mother.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 11

These kinds of situations have presented themselves to me over and over again in the past year as the MLA for the North End of Halifax but also as the Health Critic in the NDP. I must say that I don't remember ever having this number of people coming to me to talk about the length of waiting times and the cancellation of surgeries in the past. This is one very good example, Mr. Minister, of where people may have a very excellent experience in the medical system, but it's getting into the medical system that is the problem. There's no doubt in my mind that once these people are admitted to the Dartmouth General Hospital or the QE II or whatever facility that they're going into, they'll get excellent care, it's getting into the facility to get the care that is highly problematic.

This is one serious weakness in your claim that health care and the medical care system has enjoyed some sort of a renaissance under your watch. Another difficulty with people who can't get the care they need is home care. The waiting times to get a home support worker, as you probably know, can be months. People can literally wait for months to get the home care they require, and quite often there's a disconnect between people being discharged from hospital and getting the home care into their homes when they need it immediately upon being released from hospital. Often they are sent home and they are told that home care will be arranged, but in fact home care doesn't occur, maybe for days or weeks. I've had many examples of this as well. Again, this is a very good example of the system not being there for people who need it when they most need it.

[6:15 p.m.]

Long-term care, I think, without any exaggeration is a system right now that is causing a lot of despair and a lot of concern among people who are in need of long-term care. Tomorrow morning I will be meeting with a gentleman in my constituency whose wife is in a nursing home here in Halifax. He has approached me because of the way the assessment of long-term care has occurred, in terms of his financial ability to pay, the appeal procedure, which has not worked for this family. As you probably know, the Province of Nova Scotia, we're one of four Atlantic Provinces that fails to pick up the cost, the health component cost of nursing home care, but in fact we off-load that onto the families to pick up the health care component of long-term care.

This is placing an extraordinary financial burden on many people in the Province of Nova Scotia. Certainly I hear from people, members of this caucus hear from people all the time who have loved ones in a long-term care facility and who are feeling the extraordinary financial pressures of exorbitant costs, not only for the room and board part of the long-term care facility's cost but also the burden of costs for the medical component - the nursing care component. This government has completely lacked a plan for long-term care that has been open, that has been clearly articulated, that has invited the public to have any input into the long-term care development and where it's going in this province.

I think in many respects and I know that around the single-entry point, which this government likes to talk about, there is a feeling, there is a concern, there is some skepticism that the downside of the single-entry point - and there certainly are some positives around having a one stop, a one-place entry point I suppose into the health care system, or the medical care system, but there is a concern for many families that their family member will be placed in a facility where there happens to be a bed available but it's not close enough to the family to be able to visit.

For example, I had a call last week from a woman in my constituency whose father has been placed in a nursing home in the Windsor area and this woman is a student and she has transportation issues and certainly would like to have her family member closer to the family so that they can visit their father on a regular basis. This is a very big concern for many people as they see this single-entry point system developed without a great deal of input from families.

There are other places where people require care in our health care system that they're unable to get care. Increasingly, senior citizens are unable to comply with the prescription drugs that they are given from their physicians because they can't afford them; increasingly there are drugs that are required for certain kinds of illnesses like Alzheimer's and arthritis that are no longer covered under the Pharmacare Program in Nova Scotia. Here again are people who require services but, unless they have the personal financial means to access these services, they're in a situation where they just simply cannot get these things.

The minister failed in his statement to address the issue, to acknowledge the issue, of closed emergency room departments. It may very well be true that we have seen physicians attracted to certain parts of Nova Scotia, but let me tell you there are still many parts of this province where there are not enough family physicians. I read something from the Yarmouth Vanguard last week, a letter to the editor I believe from a local municipal councillor there who was saying this is a very big problem. We have many people in this community who are unable to get a family physician. You have the whole situation in the Weymouth-Digby Neck, that area, where the medic group have been unable to get family physicians into that area, and this government has taken away from those areas the incentive program that they would have used to attract people to that part of the province.

We have heard the physicians, the doctors from the Annapolis Valley, here in front of the Nova Scotia House of Assembly last week, come and talk about their concerns and some physicians in the Valley have indicated that they will leave the Annapolis Valley if cuts in that region result in any further deterioration in an excellent health care service, and their concerns about the inadequacy of the funding formula to recognize the particular conditions that they face in the Annapolis Valley. As one doctor told me outside the House when I had a chance to talk to him, he said you need to understand that it's like dominoes - we're a team, we need a very diverse group of practitioners, and when you start pulling out one or two in particular specialty areas the whole thing can fall in. Certainly, on some level, we've already

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 13

seen that with the suspended liver transplant program at the QE II. When you lose one or two key people in a specialty unit, it has a profound impact on other aspects of medical services that are available.

So these are very serious problems; they're very serious deficiencies in our current medical system, and they're deficiencies that do not rest on the shoulders of the health care professionals themselves, but they rest on the shoulders of the Minister of Health and this government in terms of what their plan is to address and deal with these various issues.

The last - and I am sure there are many, many weaknesses that I haven't touched on here - the one last area of care that is required that has certainly caused me some real concern is the fact that we do not have a comprehensive health care strategy for people with brain injuries in the Province of Nova Scotia.

I don't know if people here heard the Kathy Large CBC piece that she did a few weeks ago on a family from the St. Margaret's Bay area with a brain injured, dependent daughter. This piece really spoke to the difficulties that people with brain injuries have in the Province of Nova Scotia and the fact that in spite of the rigorous advocacy on behalf of people with brain injuries, by brain injured people themselves, we still have not addressed their needs.

Also, in terms of people with disabilities, the need for technical aids and in-home supports, Mr. Minister, I have to say when I go through this budget - and we'll have a chance to talk about this in more detail - I'm unable to find the in-home supports program and I want to know what the department's plan is for people who need in-home supports and the various technical aids and services that are required.

So this is sort of an overview of some of the conditions that people with various needs face in our health care system, and these really are the challenges for government in terms of addressing the health care needs of Nova Scotians with respect to the medical system.

These are areas where people can't get medical care when they need it, but I would be remiss if I didn't raise the fact that there are growing numbers of stories and there are growing numbers of concerns that make me concerned about problems that exist in the medical system when people actually are able to get services in the medical system. Yes, on balance, perhaps most people who go into the medial system get excellent care and they appreciate this; nevertheless, there has been a deterioration in the quality of health care in numerous ways that people point to.

[6:30 p.m.]

I know that the Premier certainly has received letters from well-respected physicians in this province about the quality of meals that are provided now in our acute care facilities to people who are sick and not just nutritional supplements. If all that was required was a nutritional supplement, then people could have a vitamin tablet placed on a plate and it could be given to them. But people need nutritious food, wholesome food. They need food that is comforting, quite often, when they are sick.

These kinds of services have deteriorated and they're disappearing in our hospitals. People tell you stories about how profoundly horrible the meals are. Family members have to cook and bring meals into the hospitals because no longer are the kinds of meals that are tolerable being served in hospitals, right at a time when people are undergoing chemotherapy and various kinds of procedures, when they really need a little comfort and the kind of warmth and caring in a half-decent bowl of soup or a hot breakfast.

We also know that more and more surgeries are being performed on a day-surgery basis or an outpatient basis. The minister may know, in fact, of situations where people who have had day surgery have actually complained about the quality of the care that has resulted from being moved in and out so rapidly in that kind of process. I know of a person who has a friend who also works in the health care system who had a mastectomy on a day-surgery basis and had quite a terrible experience, being discharged in the day, way before her arrangements for transportation or a place to go were put in place. Her physician had communicated this on to the unit, yet none of these communications were taken seriously.

The way she understands what occurred is not to blame the nursing staff and the personnel on that unit, but to talk about the enormous pressure that people are under when they work in those kinds of situations where they are required to turn around a large number of people in their day surgery unit in a way that makes it increasingly difficult to do. Quite often, the nursing staff are people who have been up all night and are working many overtime shifts.

So the first thing I want to ask the minister is if he would respond to my concerns about in-home supports?

MR. MUIR: Mr. Chairman, the honourable member has raised something that has been a great concern to the department. The in-home support program, I am pleased to say that we will be admitting more people to that in the not-too-distant future. This was an example of one of the difficulties our government faced, and that I assume the previous government faced as well, in trying to get a handle on the total health care system and map out an appropriate go-forward position. The in-home support program was right across the province, but like the Home Care Program, the in-home - well, I guess it is a form of home care - one of the things was a lack of consistency in the delivery of services and benefits from

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 15

one community to another. The reason that the department did, I guess, stop new admissions to the program was simply so we could get a handle on what did exist in the province and establish a go-forward position. That go-forward plan has now been developed by the department and we will be announcing that in short order, Mr. Chairman, with the intention of admitting new persons to that program in the not-too-distant future. We should soon be ready.

MS. MAUREEN MACDONALD: Mr. Chairman, I would like to thank the minister. The in-home support program has been a program that many families rely on. I would like to say that it can't happen soon enough that this program get reinstated; people are very anxious about this and they are very upset at the loss of this program. I want to ask the minister - because one of the things that we have been very aware of, I guess, is that there doesn't seem to be a real reduction in the numbers of people who are working in bureaucracy and on the front lines. I want to know from the minister, what number of people has been seconded into the Department of Health into administrative positions?

MR. MUIR: Mr. Chairman, I am going to have to get that information. I am sitting here and conversing. For example, our nurse policy advisor, I believe, is seconded from the Capital District Health Authority. The person who has just come with us was with us, and he was seconded or in contract - or lent to us, I guess would be a better way - by one of the long-term care facilities. If your question is, do we have additional people who would be in addition to scheduled positions, the answer to that, basically, is no. The people who we have brought in on sort of a secondment basis are to fill regular positions as opposed to provide extra people.

MS. MAUREEN MACDONALD: My question isn't about whether or not you have people seconded and what are they doing. My question is whether or not you have people seconded into the Department of Health, not the DHAs, but into the Department of Health itself, who do not appear in the budget? So that is a question I have and whether or not there may be as many as 20 of these people?

MR. MUIR: No, all of the people we have are in approved positions. If you are talking about people who might be contract or consultant service, if that was the group, I don't think we have anybody there now doing that.

MS. MAUREEN MACDONALD: So, in other words, you wouldn't have anybody seconded into the department from a regional health board that no longer exists, by any chance?

MR. MUIR: We have a person who was with a regional health board, Dr. Ripley, if that is the person to whom you are referring, but he is filling a regular position and he had been with the Northern Regional Health Board. That board is no longer there. He's filling a regular, full-time position. His position is in the budget, if that's what you're asking.

MS. MAUREEN MACDONALD: One of the things that we noticed in looking at the budget for the Department of Health, Mr. Minister, is that in this particular budget, in total, there's about S12 million that has been allocated for capital improvements. It's our understanding that at the QE II alone the requirement for capital improvements is much more significant than that, probably in the vicinity of $60 million, and that diagnostic imaging, for example, is dangerously outdated in some facilities, and that province wide there could be a shortfall of as much as $150 million in terms of capital improvements, what's required. Can you indicate what, in fact, is the capital requirement for facilities across the province, and how you intend to allocate that $12 million?

MR. MUIR: Mr. Chairman, I'm going to ask the honourable member for clarification on the $12 million, I'm not sure about that figure. If she could direct us to that, we might be able to .. .

MS. MAUREEN MACDONALD: It will take me a minute to find that. Perhaps, while I'm doing that, we could move on to another area, and then we can come back to that, if the minister wishes.

MR. MUIR: Mr. Chairman, I think I know the money to which you're referring now, and it's for ambulance purchases and IT purchases, that's what it's for, that $12 million that was in there from the Department of Finance. That's the figure to which you were referring, I believe.

MS. MAUREEN MACDONALD: I would like to go back then to my point, that there's a substantially greater requirement for capital improvements province-wide and at the QE II. I guess the first question I have is, what exactly is the total sum of what's required, as estimated? And then, how will this measly $12 million be allocated within the larger needs?

MR. MUIR: Mr. Chairman, we've allocated an additional $30 million for capital projects and, of course, there's the $15 million equipment fund, which appears in the budget, in addition to that $12 million figure to which the honourable member referred. So that would be about $57 million.

MS. MAUREEN MACDONALD: I think I'm going to have to look at that a little closer. Mr. Minister, the method for accounting for hospital construction has changed in the budget so that there's an announcement that three projects will proceed, Highland View, Cobequid Multi-Service Centre and Yarmouth. But they don't appear in the list of capital projects on Page 23 of the Budget Address. They're being treated as DHA capital spending, not government capital spending. The change is evident - it's on Page 15.21 of the supplementary estimates. Instead of reporting the cost of hospital capital improvements including equipment in the estimates, the government will now simply show them after year's end on the consolidated Public Accounts for the year the capital project is concluded. Only the equipment purchases that are too small to qualify as a tangible capital asset remain.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 17

The government's budgets for DHAs will cover the annual amortization for the approved capital projects. The Public Accounts will show the increase in DHA's assets, and a capital expenditure by the DHA. I want to ask, what is this year's hospital infrastructure spending, and how does it break down compared to last year?

MR. MUIR: I think the total is $30 million. The redevelopment of the Yarmouth Regional Hospital is $1.1 million; Phase II of the Dartmouth General Hospital is about $186,000; the Yarmouth Phase II is about $4.9 million; the Highland View Regional Hospital, the contribution this year is about $8 million. That's a total of about $13 million. The Cobequid Multi-Service Centre is about $1 million; the Dartmouth General dialysis unit is about $800,000; the dialysis unit at the Cape Breton Health Care Complex is about $700,000; miscellaneous capital projects, which would include bone densitometry is about $200,000; and the infrastructure repairs, and this is to bring certain facilities and whatnot up to code, is about $1 million. In addition to that, we have $15 million allocated for medical equipment. So the total in that thing, I guess in terms of that, is about $38.4 million total.

If I could, with your indulgence, Mr. Chairman, when the honourable member was talking about in-home support, she was talking about equipment, and I failed to tell her that one of the things that we are doing this year is we are in the process of working out an agreement with the Red Cross to set up an equipment-lending depot, I guess that's what you would call it. Some of the things the honourable member had mentioned about lack of equipment when people need it intermittently, we hope that will take some of the pressure off.

MS. MAUREEN MACDONALD: Mr. Minister, can you tell us - you've itemized the infrastructure spending, amounting to about $38.4 million - what that was last year, what the comparative number is?

MR. MUIR: Mr. Chairman, the revised forecast for 2001-02 was close to $34.1 million. I guess if you're looking at it this year, the increase would be about $4.2 million.

MS. MAUREEN MACDONALD: Mr. Minister, thank you for that. I guess we've heard in the news in the last couple of days that the federal government has been unable to figure out where the money went that they allocated, I think probably, in the last year or two to update medical equipment. In some cases it went for lawn mowers and things like this. (Interruptions) Yes, lawn mowers. I was reading this article and I'm sure that people in Nova Scotia would want to know how we're investing in updating medical equipment, and whether or not the gap between what we have and what we need is widening, so that we don't allow our hospitals and our medical facilities to become like our schools, where we completely neglect the infrastructure and the equipment inside it that's required to provide up-to-the-minute diagnostics and treatment.

18 HANSARD COMM. (SUPPLY) MON., APR. 8, 2002

I want to ask the minister, how much will the DHAs borrow this year for their approved capital spending, and when will that borrowing show up on the province's net debt?

MR. MUIR: Mr. Chairman, the districts aren't allowed to borrow.

MS. MAUREEN MACDONALD: Have the business plans for the DHAs been approved yet by the department?

MR. MUIR: Yes, Mr. Chairman, they have.

MS. MAUREEN MACDONALD: Would you table the business plans for the DHAs for this year, please?

MR. MUIR: Mr. Chairman, we would be pleased to do that, I guess, although I personally think that the business plans should come from the DHAs because they are theirs as opposed to ours. I would have to say it will be - what we have done is gone back, in the cases where there have been revisions to those plans, and asked them to recreate a final document, and I would prefer not to table it until we get the final document.

MS. MAUREEN MACDONALD: The business plans have been approved, though, by the Department of Health at this point in time, so they're back in the DHAs for whatever modifications were recommended by the Department of Health, is that correct? (Interruptions)

MR. CHAIRMAN: Order, please. I am having problems hearing the debate.

MR. MUIR: There has been considerable discussion between the department and the individual DHAs, Mr. Chairman, about - I guess you would call it tweaking or fine-tuning the business plans. There has been an agreement on that, so it wasn't necessarily things that the department - one of the things is that there was a budget figure agreed on. There was no more money, so it's a refining. Obviously, they're going to have to put together a "final document" and I would be pleased to share it with the honourable member when we get that "final document."

MS. MAUREEN MACDONALD: I think it is very important for the people in Nova Scotia to have the business plans for the DHAs, especially since, as I understand it, many of the DHAs are having to introduce mechanisms to raise money in various ways, be it introducing parking fees, charging more money for meals in cafeterias or for, some procedures, like the collection of blood, in some areas - charging people for coming in and having those services provided. So I think it is important that we get some idea of how it is that the DHAs, without significant increases in their operating budgets and without the increases they perhaps require to meet the demand in their areas, are going to go out and find

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 19

those alternative sources of funding which the department has encouraged them to go looking for, and then what that means for people in the areas.

I want to switch gears a little bit and look at spaces in long-term care, because a piece of the budget has been to talk about the allocation of some new resources into long-term care. I want to ask the minister if there are going to be additional spaces allocated in long-term care or if the number of spaces will remain the same in Nova Scotia?

MR. MUIR: Mr. Chairman, there have been additional dollars allocated and there has been some redistribution of beds. The absolute number has not been changed. There has been no increase in the actual number of beds, but in the case of Halifax, there are a couple of major facilities that have been renovated, which is adjusting the capacity of those downward. To bring it back up to capacity, there is a new facility opening before too long out in Clayton Park, and I believe there are probably some people living there now. In the case of my home community of Truro, there was a building there that was basically condemned, and they've built a new facility which is replacement bed. But no, we haven't increased the number of beds up to this point.

The single-entry system - you know, we're moving along with that. It appears that, although we occasionally do get a bit of backlog, the capacity problem, we will probably know by the end of the year or have a better perspective on capacity than we have right now, and once we feel comfortable with the information we have, then we can make other decisions. Now I can tell you, notwithstanding that, we get - you know, there's a whole file of requests to add beds and there are a lot of requests from all parts of the province to add beds, but the question is, do we really need them? Quite frankly, in the last couple of years I think we've gotten better information than we've ever had before, particularly with the single-entry access system going into place. Although we may have to make an upward adjustment, Mr. Chairman, it's certainly not going to be anywhere as significant as people would indicate.

It's meeting care requirements, but what we did this year, as opposed to extending capacity - there's no question, Mr. Chairman, that the long-term care for quite some number of years has been chronically underfunded. We've increased the spending in long-term care this year, but it was better to provide stability to those homes that were in existence now, to put them on a stable footing, than it was to expand at this particular time. So it was a case of choices. Long-term care - some of the facilities had not been adequately funded for some years, and for benefits and a number of things that they had been asked to absorb in their budgets, the dollars hadn't been made available to take care of that. I guess I don't say with any degree of pride that there were a number of our long-term care facilities that had calls from the bankers on a weekly basis.

20 HANSARD COMM. (SUPPLY) MON., APR. 8, 2002

MS. MAUREEN MACDONALD: Mr. Chairman, the situation, I think, in the long-term care area is that there is concern that there are still waiting lists for many facilities. I have to tell you that one of the worst things that this government has done in its term was deny the Sisters of Charity the licence for the Mother Berchmans Centre, and that is a very sorry saga in the provision of long-term care services in the Province of Nova Scotia. It's a particularly sorry scenario when you consider the politics that were played by the Premier and members of the government benches when they were over here on this side of the House and the Liberal Party was the government and the Sisters were attempting to get a licence.

[7:00 p.m.]

I stood here on the floor of this House and I watched members of that Party howl about the denial of the licence to the Sisters of Charity, and to see that this government essentially crossed the floor and took up the same position that had been taken by the former government is not a pretty picture, Mr. Chairman. I have to tell you that, certainly, the feedback from members of my constituency to me is that they don't like this one little bit. They see this as being a fairly mean decision. They are not fooled. They know what the Tory position was when they were in Opposition. So they see it as being a very crass opportunist position that was taken in Opposition that wasn't followed through on when in government.

I think, Mr. Chairman, it is particularly disturbing if you consider just how many providers of long-term care services are private-for-profit businesses compared to the numbers of facilities that are providing long-term care that are, in fact, non-profit organizations. The Sisters were operating their Mother Berchmans Centre as a non-profit organization and to displace those elderly women who have dedicated their lives to the welfare and the well-being of people in the Province of Nova Scotia is really quite disgraceful. Notwithstanding what the requirements are province-wide for long-term care expansion, stability or whatever, I think we all recognize that there are always choices that government has to make, but I think we all want to see our government, when the chips are down, be able to make some decent choices once in a while, based on a sense of moral accountability and a moral compass. I don't think that occurred in this case.

Now, I would like the minister to explain in the time that we have left what in fact the thinking was at the Department of Health and in his department and for himself in terms of this decision to turn down the application of the Sisters who, after all, had invested not only a fair amount of time, but also who had invested a fair amount of money into the development of a facility for their own members, but as well were providing 15 additional beds for this community.

MR. MUIR: Mr. Chairman, I guess the decision and the discussions between the representatives of the Mother Berchmans Centre and the Department of Health were going on for, I expect, I think, I was told, for 10 or 12 years. This was not a new issue. I can't comment from direct knowledge of the financial situation of the Sisters of Charity, but it is

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 21

clear when the Order felt that they had to request assistance to keep Sisters at it, that it probably wasn't very good. They also made the decision and later on they made it public that their intent is to divest themselves of that property. The honourable member is well aware that they made that decision.

I am pleased to say and I think the Sisters have requested of the department that public discussion of this matter cease. I would hope that the member would honour that request, but to say that as a result of negotiations between the department and the Sisters of Charity, they are .. .

MR. CHAIRMAN: Order, please. The time for the member's debate has expired. The honourable member for Dartmouth East.

DR. JAMES SMITH: Mr. Chairman, I am pleased to have the opportunity to speak on the estimates of the Ministry of Health and to recognize the great windfall of money that is just coming this minister's way. What a fortunate minister he is to be realizing the good fortunes of the Department of Health and how excited he must be and how he will be able to move in the right direction and keep the promises that this government made prior to the last election - the promises to having health as a priority, quality health care, not just health care, but quality health care with a balanced budget.

So they started out with new resources from the federal government and resources from the economy and now we have seen the resources, this last budget seeing many new taxes and this has been channelled into Health. So Health has done reasonably well within an expanding budget of this government and I guess throughout this, we will get some indication of how the minister feels if things are looking so much better from a financial point of view, why does there seem to be, I would say, in all fairness, increasing problems? Why was it necessary to cancel programs like the liver transplant program, those types of initiatives? I know those are complicated. They involve university, hospital administration and the Department of Health. So you have three bodies. So maybe that's not a financial decision. Maybe this is people working together.

We have moved from four health regions into nine district health authorities. We see a very large region here, tertiary care, in this community in the Capital District Health Authority. Yet, we see in some areas in the Valley, DHA No. 3, a financial officer being audited. Maybe the minister could clarify this. There has been some talk about well, that was a mistake and the media reported it wrong, that fact that the financial officer in that particular district was relieved of that particular position. It certainly looked bad in the media and I brought that to the House before. It was like something was going wrong with that area and the department was going to jump in and do something there. But this was all, in moving to nine district health authorities, to bring decision-making back to the communities.

Under this government, we formalized the community health boards and I have congratulated the minister different times on that initiative. I think that is very positive. It followed the Goldbloom report. But the Goldbloom report did not recommend moving to nine health districts. I think what has happened, Mr. Chairman, is that this, again, has destabilized the system. Whether you are in manufacturing or resource industries or whatever, you have a system and you try to keep it in a bit of stability. I think what has happened, moving in that direction, maybe the minister sometime would share why that was done and why we went to nine district boards, health authorities. Was it the lobbying of certain people who wanted to return to the old style of hospital board management and was this a saw-off, a bit of a move in that direction to sort of satisfy those persons that obviously had the ear of the Premier and probably other people in government, as well? It certainly did destabilize the system and continues to do so. A lot of people felt the move to regional boards had certainly destabilized the system, as well, but that was achieving a large measure of stability. There are improvements that need to be made.

Now we are at the time, the promise of the government that we have a quality health care system and a balanced budget. There are certainly concerns about the quality of health care, as we speak here this evening in Nova Scotia, throughout the land, and there's certainly concern about the balanced budget, about the thin margin that it is, but also the validity of some of the figures. Time will tell about that.

Across the country this last while we've had several studies bumping into each other back and forth. We have Mazankowski and Romanow and Senator Kirby and there's little flyers going out about privatized care, and I will come to that when I speak about the equipment fund, because that's certainly a concern and we see provinces actually using some of that fund to fund private clinics.

Along with the clinical footprints and all these studies, the minister must have a terrible job keeping up with his reading. I'm sure he's up to date on the Mazankowski - remember Mazankowski? He was part of that great Mulroney Government so he must have a lot of great - and the influence of Klein - ideas on privatization. What more can be privatized within the health care system? Of course Romanow we know wanted a forum to travel the country and the Liberal Government thought that would be a great idea to have a socialist and show their largesse and might even come up with a few ideas. Whether there's anything new going to come out of that - Senator Kirby was quite taken with privatization in Sweden and all of these types of initiatives.

But anyway, last year, I'm sure it's in the minds of people when we come back to this Legislature, remembering Bill No. 68 and maybe someday during these estimates, maybe not only in terms of dollars and cents and monies, but in the goodwill that really Bill No. 68 cost this government and this health care system. It was a bill that was draconian to say the least, so if we tend to be critical on this side of the House, we have to say well who's making these decisions over there?

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 23

The Premier, before he was Premier, during the election said he was going to fix health care - no problem. Administration wasn't going very well, we'll just take some money out of administration, S46 million was going to fix health care. But who advised on Bill No. 68? I know the minister took a lot of heat day after day here, hour after hour, night after night. He couldn't have been too pleased about that - I don't know if he ever caught up with those people who brought Bill No. 68 in that said you couldn't take matters arising from that to the courts.

So if they wonder why people are upset around this province - and letters to the editor are not as generous as they might be some days - I think the shadow of Bill No. 68 is still there. I think it's something that this government will be known by. So if we tend to be a little bit critical over here and a little bit cynical on the bad days, the bad dog days, the black dog days, then (Interruptions) well the Minister of Justice, mind you, the rumour mill had it that he was one of the big ones for Bill No. 68, so maybe he would like to sometime explain what he thought the cost of goodwill for this government was from Bill No. 68, where the Cabinet had the final decision to make.

MR. CHAIRMAN: Order, please. It would be nice to hear the member talking. Thank you.

DR. SMITH: I'm not sure that you would get a unanimous decision for that, Mr. Chairman, but I appreciate the thought.

Is there a similarity? Are we still sending the audit into the Valley, District 3 Health Authority - is that really the failed Bill No. 68 still at work? The bill that had to be set aside, still hanging out there, Mr. Chairman, though.

I'm not going to dwell on that. This government has made those decisions and will have to live by them, but we do have the relationship with the federal government. I think it's very interesting at this time where the increased monies that are being transferred in, but the lack of any initiative and co-operation with the ministries at the provincial level with either home care or Pharmacare - those were big topics back there a few years ago.

[7:15 p.m.]

I think one of the most disheartening ministerial and federal meetings that I saw, where this minister was front and centre, was on this getting together and sharing the federal government and have valuation of medications or whatever it was called. I remember some of those discussions. It was going to be an Atlantic Region and that was a great forethought and I've never seen the spin doctors spinning so hard to try to put a positive spin. How, when you look across this country with all your studies and all the challenges, and that's what came out of a federal and ministers - I mean, Minister Rock himself must have been embarrassed that he had to put his name on that.

If that was what we're to expect from those types of meetings, I would say that there's just a dearth of ideas how to address - maybe we do need all those studies that are going on. Certainly it looks like getting the ministers together at all levels is not achieving any great manoeuver. When you're really getting together with a single voice saying, no, thou shalt not have Alzheimer's drugs. I remember the time in the Atlantic Region we had some agreement to work together on these particular initiatives, the valuation of drugs and new medicines. We decided and we advised the other ministers in the other provinces that we were going to move on Betaseron with multiple sclerosis and that they were actually angry with us because they thought they had an agreement that we would all stick together and say no.

That's one of the points I'm trying to make here. I think when you see those types of agreements come forth, it's not to enhance the pharmaceutical supply to seniors or whatever it is, it's a way to say no, because this government is still arguing that we're not really sure about the effects of Alzheimer's drugs - it needs a little more study. Well I think that's been quite proven to be false.

So, the issue, where are the problem areas? Certainly in primary care we look at those initiatives. I've been reading up a little bit about it, some articles, CMAJ in the last issue or two had several articles - I got it from the library. It was interesting to look at how the last decade or so that primary care in this country, particularly with participation of family physicians, has become far less comprehensive. The need in this decade is far more urgent to develop a primary care system. The minister has alluded to that, the four pilot projects, and perhaps sometime the minister could share with the House what they've learned from that, and when we can look forward to expanding the primary care initiative.

As the minister himself, in his opening comments, shared with the House as he went around - I was wondering if there's anybody that hadn't been in the hospital in the last year as he went down memory lane, but in all seriousness we've had some very significant (Interruptions) Port Hawkesbury had a little scare, yes. Well, we hope his heart's good for the next election because he might get scared again.

Anyway, not to treat that lightly, but we've had, right in this House, we've had magnificent care delivered to some people who have been very ill and they're very appreciative. It's a very positive thing and I believe that when we speak of our health care system we think of the acute care in many cases, sometimes too much perhaps to focus on hospitals, but the fact is the care is good in those hospitals. That's why it's so important the QE II is functioning well, and I hope that we do get a very capable CEO like we had before in the person of Bob Smith. I think one of the tragedies of the last month or so has been the announcement of his resignation, effective in June I believe.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 25

So we have the primary care initiative, but now that there is money falling out of the skies and projected to evolve into the budget, the initiative of primary care. We mentioned long-term care, and you can't dispute the minister in his solemn wisdom pontificating about the stabilizing of the long-term care, the adequate funding. That's commendable, but I think you should be very clear with the people and tell them there aren't going to be any more beds.
What's happening is we're getting calls from people who are going for financial planning, and the financial planners are telling the senior citizens, well, you know the rules are changing here, things are changing, we're not sure what's happening, but you better go and find out about what all this talk is about. People are looking at the single-entry system and they're being told, well it's like a divorce, and you're going to have to really split your income here. There was a piece in the seniors' information newsletter that I clipped out and sent to some of my constituents, because I thought it was a good article and it described that very clearly.
I think the rules have been in place over the years, I just think, perhaps, they have not been adequately or rigidly adhered to or put in effect by the nursing homes themselves. Now the department has taken a much more active role and has sharpened the pencils. Really, it's caused a lot of concern there for a lot of people; it's more than I've heard for quite a little while. Anyway, we can tell them there's not going to be any extra beds, but there's going to be a reallocation and, hopefully, some improvement in the quality of those that are present. We shall see how that goes.

A year or two ago the Premier had this as one of his main initiatives, long-term care. He was going to increase the beds then, as my memory serves me. Now we learn this evening there are not going to be any new beds, and that was one of the questions I had. Maybe I will just go to some questions.

On Page 15.10 of the Supplement, the Children's Dental Program. I would like the minister to just describe how that's going to work. I can't figure that out. If you're setting out rules for that, where MSI will not be the insurer of first order; if someone has a plan and it's optional to that plan, will they have to take out that dental plan? If you have a single mother with two or three children and she's working, say in a restaurant, and they have a plan, the dental is optional, is she going to be required - or he or she - to subscribe to that plan? How are you going to determine all of this, as to who is covered by MSI and who is not?

The other thing - the minister said that they were lobbied by the Dental Association. MR. MUIR: I said some doctors.

DR. SMITH: By some doctors. Some dentists? (Interruptions) Not so. Okay. It has not been the position of the association or the society (Interruptions) The big moneymakers here in Halifax are the ones who were lobbying me at the time, and I gather they have lobbied you, and maybe they effectively got through. I'm sure it wasn't you, Mr. Minister, it must have been somebody else, one of the more elite members of the Cabinet who were lobbied by their rich friends here in Halifax.

In rural Nova Scotia, small-town dentists value MSI, and they're very concerned about prevention. I've spoken to some as late as today and this is a major concern. Can the minister share - I don't think there are specific questions I can ask now, because there's so little known about it - what's this program going to look like? How is the department going to administer it?

MR. MUIR: Mr. Chairman, before I answer the question for the honourable member, I realize, and I do apologize, I didn't introduce my department staff who are sitting here with me. On my left is Cheryl Doiron, who is the Associate Deputy Minister of Education - Health - again, that's three times I've done that in two and a half years, and unfortunately all in places where it would have been better if I hadn't done it. Byron Rafuse is the CFO of the Department of Health. Up in the balcony, the gentleman with the moustache is Gary Glessing, and the person sitting next to him is Allen Horsburgh. They're also a part of the financial team in the Department of Health. (Interruptions)

Mr. Chairman, the Children's Dental Program will remain as it has before, and there will be no change in that. What we have done is we have written to all of the dentists and we've notified the insurance companies, and I think the dentists are getting the copy letter as well, indicating that we're moving to insurer of last resort. We will rely on the dental fraternity to help us with that. They would know, obviously, if a person is insured or if they're not insured. We will rely on their help to see that this is implemented.

You asked the question that if the person works and there is a dental plan available, whether they would have to take it out. We are interested in people who have the plans. The only thing that's going to change is the fact that we think we're going to take close to $5 million off the books of the Department of Health and transfer it to people's insurance companies, and they, of course, are being paid already for providing those benefits.

DR. SMITH: Does the minister anticipate that the insurance companies may put the premiums up when they realize what you're doing? Has there been any agreement with the insurance companies that they will not put the premiums up? People will cancel their insurance. Then, would they still be eligible? If your dentists are going to monitor the program and they have identified somebody having a program, and then they cease it. As you know, one of the reasons the rich dentists don't like the MSI is because they have to accept what MSI pays, but with the other companies you have your extra billing and your top-up

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 27

billing. What about if a dentist knows somebody has a program and they say, oh well, I'm going to cancel that, it's going to be better the other way around?

MR. MUIR: I guess I really can't answer that, Mr. Chairman. I do know that like everybody else in this House, I suppose if we had the option of either opting into the dental plan or opting out of it, I suspect we all have to belong to it. The ability to opt in and opt out, with many of those plans, is once you're an organization that takes a plan, I think in most cases you take it or you don't take it, that would be entirely up to you. There would be very few cases - I can't think of any - where somebody would have a dental plan simply for children. It would be a family dental plan. Children are generally an add-on to a dental plan. If you have children you take out the insurance. You think it's going to be a little cheaper for you. It's not necessarily for children's dentistry, it's for other things. Don't forget there's very limited service, it's not a comprehensive plan, the children's dental plan.

DR. SMITH: Mr. Chairman, I'm very upset with this. I don't think it's really quite sunk in what's happening. I know when I turned 65, I had to provide (Interruptions) I've modelled myself after the honourable Deputy Premier, the good life. He said it was because he grew up in New Zealand. I only spent a couple of weeks there, and it worked for me. I would suggest maybe (Interruptions) Seriously, Mr. Chairman, I didn't want to get into a debate this evening about the merits of the impact on your health, growing up in New Zealand, but I suspect it's a very positive indicator, probably more so than growing up around the tar ponds in Nova Scotia. I think we just have to come back to the Children's Dental Program another day.

[7:30 p.m.]

I started to say that when one turns 65, if you can show proof of another program, then you're not billed. I see this, with children, maybe the other way around. You're going to have detectives in the dental office, and if somebody has a program, then that's going to be billed. It's like the superannuates, the federal program on the seniors. They wanted to have that program be exempt from the Seniors' Pharmacare, which took place, but I see a little problem with administration here in fairness and I just hope that - we fought so hard for this program and there have been real efforts made to sustain that program even with some reductions, but it is a preventive issue and it's a statement of a government that says that we believe in preventive dental care.

It's one of the few areas firstly in my health that was deficient and the only one so far. I've not been one of those listed that used my health card, but I think that was the price you paid for growing up in rural Nova Scotia during the times I did. I feel very strongly about this and we've worked hard and I've tried to work hard as the minister and we made changes to that.

We made this minister's job easier. I just don't want to see him take this one step to further dismantling that program, and I want it to be clear to the people of Nova Scotia and I think the dentists may want to do this, as to where they stand on this particular issue, because it is their profession, they know and the hygienist and the dental assistants, they work with these families and they'll be able to tell you. I just hope it works out, but I have no problem if people who can afford to pay and with insurance programs and that, but on the shoulders of the groups, there's going to be some groups there that could well fall by the wayside.

I wanted to go to the equipment and the $30 million two year, or the $15 million one year, and there's no allocation that we can find as to date for this past year that ended March 31st and where does that show on the books or where is the money? Is it in a trust fund somewhere in the feds? Has it come into the province or where is that money, that $15 million, that while people are waiting for tests and all the various equipment - and some of it within 5 to 7 years becomes antiquated really in the computerized diagnostic testing - why hasn't the province used that $15 million?

MR. MUIR: Mr. Chairman, we received as a province $30 million over two years. The first $15 million was basically expended this year. The bracketed figure of $15 million which appears in those accounts is money that's available and will be expended in this coming year.

DR. SMITH: So it's being expended in the year after the feds made it available. That's what it would be because the year now has ended on March 31st. So for some reason it's not being used, and it can't be just the ingenuity of this minister because it seems to be going on a bit across the country, so I gather the reluctance would be to have the operating money kick in, new staff or whatever arises, but the replacement issue, I can see that shouldn't cost a lot more money to replace some of the equipment. I know there's been a wish list and I know last year I had some calls from some of the radiologists and this year now I haven't heard from them and I haven't called them yet, but it might be worthwhile. They usually have a wish list and last year it was fairly extensive. I'm sure there's ongoing discussions with that.

So it doesn't show. I gather the minister said it doesn't show anywhere in the book or maybe he can point it out?

MR. MUIR: Mr. Chairman, that $15 million is there. It shows up in the Department of Health amortization of equipment. There's a $15 million figure there and the House might be interested where the first $15 million went. I can tell you that some of the equipment is not in place yet simply because it takes a period of time to get it and to install it. Down in DHA No. 1 they got a radiographic/fluoroscopic unit which was $0.5 million.

DR. SMITH: I have it here.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 29 MR. MUIR: Oh, you have it, okay.

DR. SMITH: No, if the minister did want to read it off to be read into the record, I wouldn't object to that, but we do have copies of that. I guess our question is this past year that ended on March 31st

MR. MUIR: I would accept the honourable member's invitation to read this into the record because some people do read Hansard and, once this is made available, it will give a broader awareness of how this money was used.

I mentioned DHA No. 1 and DHA No. 2, again a radiographic/fluoroscopic unit; in DHA No. 3 is a new CAT scanner, to the tune of $1.2 million; in DHA No. 4 there was a CAT scan upgrade - with the trade-in it was $640,000; in DHA No. 5 there was a $160,000 CBC analyzer; in the IWK there were volume metric infusion pumps, anaesthesia monitoring, diagnostic ultrasound, and that was just about $1.5 million; in DHA No. 6 there was a radiographic in the trauma unit, and I guess that's an X-ray sort of in the emergency department; in DHA No. 7, a $950,000 radiographic/fluoroscopic unit and a radiology unit, and that went into the Strait-Richmond Hospital; in DHA No. 8 was a radiographic/fluoroscopic unit, and that went into the Cape Breton Health Care Complex; and the DHA No. 9, the Capital District Health Authority, $5.65 million, a neuroangiography biplane unit at the QE II and an HIQ CAT unit at the QE II; a radiographic/fluoroscopic unit at the Dartmouth General, a radiographic/fluoroscopic unit in the Cobequid Multi-Service Centre; and a radiographic/fluoroscopic unit down in Kentville.

MR. CHAIRMAN: The honourable Minister of Health, just one moment, please. Although you read that into Hansard, we would also like to have a copy for the record as well.

DR. SMITH: Mr. Chairman, I just want to really be thankful for the $100 from the federal government, the largesse of the federal government on these matters, but I'm still a little bit puzzled. I haven't been able to find out, I don't know if anybody else understands where that is. So this was the first year. The second year, which has now passed us, has not been allocated any of the $15 million that I am aware of. I have one little outstanding matter, it has to do with the forensic unit and $700,000 on that. Maybe I should go to that directly. What did that buy at the forensic unit, that $700,000, because those are ones that we couldn't determine?

MR. MUIR: Mr. Chairman, it was start-up equipment for that forensic facility. I would have to get a detailed list of it. I can't specify what it was used for other than it was equipment that was needed as we started up that unit.

DR. SMITH: So, Mr. Minister - through you, Mr. Chairman - you could say that it was not for furniture, it had to do with equipment, it was definitely (Interruption) Okay, because one thing that is happening across the country with this and I would like assurance from the minister tonight that these monies will not in any way - and this new S15 million that's still there to be used - find its way in matters that in other provinces are being indicated, at least in the media, that Lisa Priest has written several articles, and I know we've been talking with the feds a bit on that, and they certainly have concerns about where this money is being used and I think we all should because if it's not used appropriately it just gives the federal government another chance to beat up on the provinces again and say, well look, we trusted you with this; we gave you this money. Number one, you're not using it, and number two, we're finding out that you're putting it into some private clinics, ride-on lawn mowers and goodness knows what.

As I prefaced my comments earlier, if I do seem to be a little bit cynical and suspicious at times, and the forensic unit - I want to make sure that that went appropriately because we don't want anything, in any way, to cause the federal government to have any concerns about where the money goes. That is one of their criticisms, that they put it into roads and it goes somewhere else or something like that - it's in the cost sharing. In this way it's a 100-cent dollar, so I think it's important that we know where it's going. Can the minister explain why this equipment is not being used? Is it because of the operating costs associated with it? Why isn't it being taken up in the year it's been allotted for?

MR. MUIR: Mr. Chairman, a lot of it has to do with the capacity for procurement, getting the equipment and getting it into use. It just - as the honourable member would know - some pieces of equipment, it takes time. You have to order it, then it has to be installed; sometimes there are some physical modifications that have to take place to accommodate new pieces of equipment.

The other thing, which I haven't mentioned and I know the honourable member wouldn't want to leave the impression, is that the other part of the health system that I talked about, the long-term care sector, it also received a portion of that. I do want to assure all members of the House that our Health Department in this government is fully complying with the reporting requirements from the federal minister and all of this money, 100 per cent of it, is going to where it is supposed to be going and is providing equipment for residents of the facilities and serving the residents of Nova Scotia.

DR. SMITH: Mr. Chairman, could I ask the minister again for clarification as to where he said it was - if he can give me page and line that the $15 million is. I know he said it was amortized there in some line. Also, the fact is where the $15 million is sitting. I think the S15 million that is in the budget must be the S15 million that has been drawn down, and I'm using round figures here. Then where is the S 15 million sitting for this year that has not been used - the year that has just gone by?

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 31

MR. MUIR: there is a line called Medical Equipment Trust Fund, and in 2001-02, there is a $15 million item in there which has brackets around it. That was the estimate which showed and then the forecast had $15.6 million. It means that that money is in a medical equipment trust. Now, I can't fully talk about the bookkeeping practices of this thing, but I am informed by our finance officer that now that that money has basically been booked, the money is transferred to the Department of Finance because it handles cash flow.

What we will do is keep a running account of the cost of these items that were approved to be purchased through that money, but the money will then come out of a trust fund and will be distributed from the Department of Finance next year as opposed to the Department of Health. The money came to the Department of Health this year. Because we didn't use it all, we put it back with the Department of Finance. That's got something to do with accounting principles, and I don't fully understand but I know that's where it is.

DR. SMITH: Thank you, Mr. Chairman. I think I am clear, but I think we will leave it for now anyway. I think we are talking about - are we talking about last year's $15 million or this year's - the first lot or the second lot?

[7:45 p.m.]

MR. MUIR: The first $15 million, by and large, has been expended, Mr. Chairman, and the honourable member for Dartmouth East has indicated that he has that list. I don't know what the bottom line on it was, but it was pretty close to $15 million and it's the money that we received this year but hadn't expended. It has been booked to be spent next year. It will be going out in this coming year.

DR. SMITH: Okay. Thank you, Mr. Chairman. The minister was kind in speaking about the various nursing initiatives, and I was wondering if the department keeps a running total, up-to-date, now of the nurses and how many nurses are - rather than full time, maybe let's just say how many nurses are working as full-time equivalents? That might be the best way to say it - full-time equivalents or however the minister might have it classified so that we'd understand some sense of the nursing supply availability in the province.

MR. MUIR: Mr. Chairman, I don't have those numbers. I think I can probably provide them. What I do know is that with the nursing strategy, which is one of the things, obviously, in the department that we are keeping track of, 60 student nurses have completed the co-op work terms and 90 more are beginning those co-op work terms this spring. There are 75 RN students who have received bursaries and have completed or will soon begin - if they get the bursaries then they agree to return to service - those folks have either begun their services or their return of service will be. I know that 46 LPNs have begun or will soon begin their return of service agreements at facilities around the province, and there are 95 more who are in that bursary process. I also know that more than 90 nurses have returned to Nova Scotia or have been recruited from outside the province.

I would say the nursing strategy is something, Mr. Chairman, that seems to be having a very positive benefit for the province in terms of recruitment and retention of nurses. I will endeavour to find out the numbers of RNs and LPNs that we have on the registers now.

DR. SMITH: Mr. Chairman, I think that is pretty well what the minister said earlier on, and we know there are some initiatives. I guess it's just who's staying, what jobs are opening up and, with the increased funding to the regional authorities, whether that is going to be adequate to keep their beds open - like in the Valley and the other areas - and to allow expanded programs in the community, too. I think that's a real initiative. You hope the initiatives are working; you like to see the nurses staying here in this community, and that's why I think it's so important that the environment is a healthy one so that they will want to stay in this beautiful province.

Mr. Chairman, I would like to move to the special drug program and learn a little bit more about what Page 15.10 means there on the special drugs. Yes, on Page 15.10 there is a Special Drug Program. There is an increase there and I wonder if the minister can share what that is all about.

MR. MUIR: There is a drug, Mr. Chairman, called Clozatine and that was originally, in the past year, provided through the Capital District Health Authority. We have moved that into the department's budget this year.

DR. SMITH: So I gather that is one of those special expensive ones because you are looking at an increase of above forecast, but we will just say estimate - but say forecast even a couple of million there. Would that drug be that expensive? I am not familiar with that. It is not one I am familiar with.

MR. CHAIRMAN: The honourable minister will just wait until he is announced. Thank you.

MR. MUIR: My apologies, Mr. Chairman, I am just so anxious. It is Clozapine and the estimate of that drug is $5.2 million, which is $1.7 million more than we spent this year.

DR. SMITH: I wonder if the minister could share more about that drug? Does the minister have information as to what it is - I don't want to get too technical here, but this is a pretty significant medication and I should know what it is, but I don't.

MR. MUIR: It is a mental health drug that was previously dispensed through the Nova Scotia Hospital and that is what it is. It is one of those drugs prescribed for people with mental illnesses that enables them not to be hospitalized.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 33

DR. SMITH: I probably didn't get the name down right, and I think I recognize it now. What I was thinking was that there are some of those medications that are life-saving - often by injection - and there are a few people throughout the province who require medications that, generally, are not even talked about, and most Nova Scotians don't even know that it is being done. But I was just wondering if there was one drug that was particularly more popular or more required, but I see this would benefit a fair number of patients. It is not a selected, small group. It would be quite a large group. So I thank the minister for that.

I wonder what sort of advice he is getting from the department these days on the Alzheimer's drugs and if he could get us up to date from last year as to what his position might be as minister. I am sure I can't ask his personal opinion, can I, Mr. Chairman? Probably not. It has to be a policy of the department - what sort of advice he's getting and what it looks like. Can we hope to see some of the Alzheimer's medications that are out now before the election?

MR. MUIR: Mr. Chairman, I guess perhaps what the honourable member is referring to is that in some cases when those drugs did go on the formulary, they went on during election campaigns as election gimmicks. There wasn't the evidence at that time to support, really, their inclusion. I believe that is what the honourable member is referring to. We have a very good formulary advisory committee here, and it is made up of gerontologists and pharmacists and other people who know about pharmacology and its benefits. There are now three of these drugs, by the way. There are Aricept and Exelon, and there is another one which I heard of this morning. I was actually speaking to a person who happens to be involved with one of those. We have really taken the advice of our expert advisory committee, and they are reviewing these drugs and re-reviewing them on a regular basis.

I can tell you, Mr. Chairman, that for the most part - and, as a matter of fact, I don't think there has been a case where I have not accepted the advice of our expert advisory committee, and the advice that it has continued to give the minister is that there is not sufficient evidence at this particular time to put it on the list, although I do know that the evidence continues to mount and seems to be getting better. I have confidence in our formulary advisory committee, and it provides good advice. Indeed, I will just go on to that because the honourable member had mentioned something that he kind of smiled about when he was talking about Health Ministers getting together and proposing a single Canadian formulary with the exception, basically, of Quebec because they won't participate in it.

I don't want to cast cold water on the honourable member's thoughts, but I just want to tell him that the First Ministers, not the Health Ministers, have endorsed that proposal. That is going to be functional as of August 1" and it is the model that we are using. The procedure and the process that we are using here in Atlantic Canada are being looked at nationally because of our excellence here. Mr. Chairman, I am pleased to say that we appear to be leading the country in our approach to the management of our formulary. Clearly, the

other Atlantic Provinces are looking at Nova Scotia to take a lead in this, so I am glad he asked that question. He is casting aspersions on all those First Ministers. I don't think he really meant to do that. That just kind of slipped out.

MR. CHAIRMAN: I wonder if the member for Dartmouth East would allow for an introduction?

DR. SMITH: Most certainly.

MR. CHAIRMAN: The honourable Minister of Education.

HON. JANE PURVES: Mr. Chairman, we have some visitors in the east gallery tonight from my riding. They are members of the Halifax 36th Scout Troop. Their leaders are with them, and they are Stanley Fage, Marshall Giles, David Copp, Dean Dimmerick, Keith Johnson and Ben Fage. So I wish the members to give the Scout troop a warm welcome, if you would stand and receive it. (Applause)

MR. CHAIRMAN: The honourable member for Dartmouth East has the floor.

DR. SMITH: I forget how I was going to answer that question now, but I was going to at least say that I was not going to withdraw my comments. It is just amazing; Aricept and Exelon and the other drugs for Alzheimer's, that over 70 per cent of the people in Canada have access to - and he is going to join up with the rest of Canada and show them how it is done in the Maritimes. I am a little puzzled here. I seem to be missing a step. Excuse me if I am cynical about that, but I don't think we have much to show them in that way. (Interruption) Oh, yes, Reminyl. Well, it doesn't matter if you can say it or sing it. If you can't get it at the cash register, it is not going to help you much. We are dragging behind. I am not going to delay this debate in this particular matter because it is a very serious matter. I think this government could have stepped up to the plate.

It is not easy. I was wondering if the minister said, and I couldn't quite hear him, that there were some drugs approved prior to an election once? Was that something to do with multiple sclerosis drugs or something? It wasn't that. I am sorry.

MR. CHAIRMAN: Excuse me. Mr. Minister, can we have the questions through the Chairman. Thank you.

MR. MUIR: I am told, Mr. Chairman, by more than one source, including representatives, occasionally, of the pharmaceutical industries - not necessarily those who are selling the products - that there have been occasions in the past where drugs have been put on formularies perhaps before the evidence would indicate that they should be placed there.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 35

DR. SMITH: Well, it is good to know that we are going to show Ralph Klein and all the Tories in Ontario how to do it, that they made mistakes, that they have been covering Aricept and they probably shouldn't have been because here in Nova Scotia, we don't do it and they are going to adopt our ways. Hang onto your hat, and we will see how that runs.

[8:00 p.m.]

Mr. Chairman, in all seriousness, I couldn't quite follow Page 15.21 of the Supplement, in the hospital infrastructure the money's there. I think the minister said it was transferred to the district health authorities. I didn't follow where it was showing up in their budgets, it's not mentioned there. You have to excuse this because you try to sort these things out. I know he has backup information, but here, just looking at it, it's really impossible to find it or hard to find it.

MR. MUIR: Mr. Chairman, it was in our estimates last year, $15 million for that. What we did was we expensed it this year, we didn't spend it. What happens is because it's been booked, it now becomes cash flow. When it becomes a matter of being cash flow, then it is put on the books of the Department of Finance. In this case, I believe it's set up as equipment fund in trust, and it's managed by the Department of Finance. So what happens is that you will find, somewhere in the Department of Finance, an accounting for that $15 million. We will determine, in conjunction with other people, how it will be expended, and basically send them the bill.

DR. SMITH: I was just wondering - my time is pretty limited now but just briefly - the cutbacks to Cancer Care Nova Scotia. Can the minister just advise the committee as to what areas he felt the cutbacks could best be achieved? I know expanding the program navigator, and one of the things we hear from our patients - any patients, but particularly those with cancer - is the issue of finding their way through the system. Maybe we could talk about the information system that we're still waiting for. We see some budget accommodations for that.

What area in Cancer Care Nova Scotia does the minister see - is he going to transfer some areas to some other part of the health care system? It's quite a hefty chunk of change that's being taken out, $900,000, almost $1 million out of that budget. What's the advice that the minister has received, that it's not worthy of funding within Cancer Care Nova Scotia?

MR. MUIR: Mr. Chairman, that figure came up earlier, and unfortunately it was a wrong figure. It did appear in a stakeholders' meeting, I guess. I think it was the Leader of the Opposition the other day who was talking about a reduction, and he used the same figure you did. Basically, Cancer Care Nova Scotia's budget - they were under-expended last year, which is not a good thing or a bad thing, I'm simply saying that they were, so the reduction is actually about $270,000, and what it really reflects is the amount they spent last year. It's

probably better to report that, in terms of the actual dollars, as zero as opposed to, you said, a -20 or something like that, that's not the case.

DR. SMITH: I somehow knew there was some controversy about the numbers, that I wasn't quite aware of. That's encouraging. Dr. Andrew Padmos has come to this province from Ontario, and I think along with him followed several other cancer specialists. I think we have led that along with alternate funding mechanisms in place.

MR. CHAIRMAN: Order, please. The honourable member's time has expired. DR. SMITH: We will come back to that another time.

MR. CHAIRMAN: The honourable member for Halifax Fairview. (Interruptions) A minute break? Yes, we can have a one minute break.

MR. GRAHAM STEELE: I move that the committee adjourn for two minutes, Mr. Chairman.

MR. CHAIRMAN: Two minutes.

[8:05 p.m. The committee recessed.]

[8:10 p.m. The committee reconvened.]

MR. CHAIRMAN: The honourable member for Halifax Fairview.

MR. GRAHAM STEELE: Mr. Chairman, I am rising today in the Health estimates to address the topic of ambulance fees. Many members of the House will be aware that there is a group of Nova Scotia citizens who have challenged the government on the legality, and not just the legality but the reasonableness, of ambulance fees that are charged in Nova Scotia. In the Financial Measures (2002) Act that was introduced in this House on Friday, there are provisions dealing with the legality of ambulance fees, and you say, okay, that's not entirely unexpected. When I was asked at the time what I expected the government's response to be, I did say I didn't expect them to do the right thing, I expected them to retroactively legalize what they've been doing. But that's okay, because it's important once in a while to give our governments a sharp reminder that they can't tax their citizens and they can't impose fees without legal authority.

The whole system of ambulance fees in Nova Scotia had developed with no legal authority. The government's going to introduce this legislation and make it fully retroactive, well, not fully retroactive, retroactive back to April 1, 2000. For reasons that may become clear later and may not, the government didn't make it retroactive back to the beginning of the public ambulance system, which stretches before April 1, 2000. At any rate, April 1,

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 37

2000, would put it conveniently a month before the earliest of the cases of the people who are challenging their government. So maybe that's as good a reason as any for them picking that particular date.

But there's still the issue of the reasonableness of ambulance fees. The whole challenge wasn't just about validity, although these citizens felt their government needed to be reminded that it had to be legal. The whole reason for legality is that then everybody knows the rule book, and the problem in Nova Scotia today is that nobody really knows what the rule book is around ambulance fees. The government can do whatever it wants because there's no piece of legislation setting boundaries around it, there's no regulations setting boundaries around it, in fact there's nothing at all. Nothing at all setting boundaries around when and how and under what circumstances it's reasonable to charge ambulance fees.

One of the people challenging ambulance fees in Nova Scotia is Ann Hudak of Dartmouth. Ann suffers from multiple sclerosis. She has no practical way other than ambulance to get to and from the hospital. On December 29th last year, she took a trip to and from the hospital and was charged $85 each way, which under this budget will now be $105 each way. Ann's situation underlines it for people with chronic illnesses, ambulances are not a luxury but a real necessity.

So my first question to the Minister of Health is this, under the proposed scheme of ambulance fees, which is enacted in the Financial Measures (2002) Act and laid out in this budget, is any allowance made, in any way, at any level, for medical necessity, and whether that is a legitimate factor by which ambulance fees can be reduced or forgiven?

MR. MUIR: Mr. Chairman, I have some reluctance to answer the honourable member's questions dealing with ambulance fees. As you know, not as an MLA but as a lawyer, he is representing a number of people, and he just referred to them. The last letter I had from the honourable member for Halifax Fairview was as a lawyer. The instructions in the letter he gave me was, I want to be treated as a lawyer representing these people, although he wrote it on NDP letterhead. I really would feel uncomfortable - if he is acting as a lawyer in those cases - responding to those questions. I can't.

MR. STEELE: Mr. Chairman, first of all, he knows perfectly well it wasn't on NDP letterhead, it was on House of Assembly letterhead which doesn't refer to what Party I'm from, just the fact that I'm an elected member of the Legislature. The other thing is that the minister is refusing to answer questions, apparently under the much-abused and over-used rule that the ministers can't discuss cases that are before the courts. These cases are not before the courts. There is no legal action underway, except from the Department of Health, who has sicced their collection agency on these people who can't afford ambulance fees and are charged ambulance fees vastly out of proportion to the services that are delivered. (Interruptions) We will get into that a little bit later.

38 HANSARD COMM. (SUPPLY) MON., APR. 8, 2002

The minister does not have one leg to stand on, he doesn't have one toe to stand on in refusing to answer questions here today. There is no legal proceeding underway on these cases. These people simply refused to pay their bills because they were illegal and unfair. As a lawyer and as an MLA, I helped them to do that, but that is certainly no reason for him to refuse to answer that question. I would like to ask the minister the question again. In any way and at any level, is medical necessity treated as a reason for reducing or forgiving ambulance bills?

MR. MUIR: Mr. Chairman, I would like to go back to what I just said. Inasmuch as the honourable member for Halifax Fairview has indicated he is the official legal representative, and he went out and solicited these clients, I would really feel uncomfortable. Now if you as the chairman, sir, can solicit or get an opinion that would make me comfortable, I don't mind answering the questions. Really, because he is the lawyer, he's acting as the lawyer, and I have correspondence from him saying that, I just don't feel this line of questioning is appropriate from that member.

Mr. Chairman, you might want to recess or something to get an opinion on that, but I just really feel uncomfortable. (Interruptions)

[8:15 p.m.]

MR. CHAIRMAN: Just one moment, please. Order, order. The chairman recognizes, much the same as in Question Period, during budget estimates, the minister is not required to answer any question if the minister chooses not to respond to a particular question. The same applies here as elsewhere. Now for the member for Halifax Fairview, if you wish to continue this process then you continue it with the assumption that the minister may or may not respond to the question.

MR. STEELE: Mr. Chairman, that's fine. If the minister chooses not to answer, let's be very clear that he is choosing not to answer legitimate questions. Just because I happen to be a lawyer, he's standing up and saying he's refusing to answer these questions, just because I happen to be a lawyer. I've always thought that the so-called sub judice rule is much abused in this House, and it has just gone another level, that just because I'm a lawyer the minister is now refusing to answer my questions.

Let me ask another question, but let me first tell a story. On March 20th of this year, a gentleman and his son were driving in Halifax. Now this gentleman, I should add, was from the fine Town of New Waterford, Cape Breton. A couple of weeks earlier he required emergency medical attention because of cardiac arrest. He was saved at the New Waterford Emergency Department. (Interruptions) There's a real question about whether that man would be alive today if there had not been an emergency medical department at the New Waterford hospital.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 39 AN HON. MEMBER: The one he's trying to close.

MR. STEELE: At any rate, while in Halifax to prepare for open heart surgery, the gentleman was in a car accident. He and his son were in the car, and the car accident happened at the corner of Robie and Jubilee in Halifax. I won't ask the minister if he knows where the nearest emergency department is to the corner of Robie and Jubilee because it is literally across the street, across the street and around the corner is where the emergency department is.

An ambulance came and this gentleman, this pensioner, I should add, and his son, a laid-off coalminer, got into this ambulance, and they went, literally, around the block in the ambulance to the emergency department. They were both billed $500. For this incident where they were taken, literally, around the block, a total bill of $1,000 in that household, because they do live in the same household, the pensioner and the laid-off coalminer.

Mr. Chairman, my question, flowing from this particular case is, is any allowance made - and this is not one of the people I wrote to the minister about, is not one of the people I wrote to the minister about, let me say that again, it is not one of the people about whom I wrote to the minister - by the Department of Health or by Emergency Medical Care when sending out ambulance fees, in any way, at any level, is the distance travelled taken into account?
MR. MUIR: Mr. Chairman, it used to be. It used to be that distance was taken into account. As a matter of fact, like the person from New Waterford who had to be transported to Halifax from the New Waterford Hospital to the cardiac care unit in Halifax would have been charged a per kilometre fee, which may have been, I suppose, $500 or $600. Under the system that we implemented last year, the cost would be $85. We've standardized that, a postage stamp rate, I guess, effectively. (Interruptions)

MR. STEELE: Mr. Chairman, does the minister consider a bill for $1,000, in the circumstances I've described to be fair and reasonable?

MR. MUIR: Mr. Chairman, it's like any type of insurance plan, and basically what it is, in this case, a certain amount of money goes in. The honourable member might very well know that he's covered by the medical insurance plan, at least I assume you are, that's available to all members of the House of Assembly. So I can look at my good friend from Cape Breton Nova, last year, and I could just simply say, sir, that I'm probably paying the same rate for medical insurance as the member for Cape Breton Nova. We do know that, unfortunately, his medical costs were a little bit more than mine last year, but because we are all for one and one for all, I'm willing to share his burden, he's willing to share my burden. We do it collectively.

40 HANSARD COMM. (SUPPLY) MON., APR. 8, 2002

I will tell you, Mr. Chairman - and this was borne out by the Auditor General as well as an independent thing - the ambulance fees that are charged here in Nova Scotia are well set and do basically reflect the cost.

MR. STEELE: Mr. Chairman, apparently the minister didn't hear my question. In the circumstances that I've described, is a bill for $1,000 fair and reasonable?

MR. MUIR: Mr. Chairman, the honourable member for Halifax Fairview obviously wasn't listening. I did answer his question. What I said was that we basically have a flat fee, a postage stamp rate. I explained - the member for Cape Breton Centre, if somebody came down from New Waterford to here, and actually if they came from New Waterford, the facility at New Waterford to the facility in Halifax, there would be no charge because that was an inter-facility charge. If he came from a home in New Waterford to here, it would be the same price as from where my apartment is, which is one block from the VG. I would pay the same rate to get to that hospital as the person from New Waterford would.

MR. STEELE: Mr. Chairman, I don't hear the minister answering my question, not in the least. If he's answering, apparently it's yes, but apparently in this House we all learn that when we mean yes we actually say something else that's difficult to interpret. Apparently that's part of the occupational training for being a Cabinet Minister.

One of the real irritants in the system of ambulance fees is the so called third party billing, where when there's somebody to bill, like the Workers' Compensation Board or a private insurance company, the rate goes from $105 - which it will be if this budget passes - to $600. Well, okay, it's just insurance companies paying it, except at this time when auto insurance rates are going up as much as they are and the insurance companies are getting stuck with these $600 bills, it's not hard to see that this is one of the factors leading to higher insurance rates.

Be that as it may, the problem is, and the problem that the Department of Health simply does not seem to be ready to deal with is, just because a motor vehicle is involved does not mean that private insurance will pick it up at no cost to the person insured, it simply is not the case. When I talked to people at the Department of Health about this they say, oh well, insurance will cover it. The problem is insurance does cover it sometimes, sometimes. I spoke to people at the Insurance Bureau of Canada, who, when this story first came out, were quoted as saying, oh no, no, it will have no impact on people's insurance rates. Well, on further investigation and further discussion with the Insurance Bureau of Canada, I have to say they've retreated from that position and that they now acknowledge that yes, indeed, people's insurance rates will go up or can go up. In fact, they can and will and do go up by more than the bill itself.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 41

So people are faced with a Hobson's choice of either paying the $600 themselves or submitting it to their insurance company and watching their insurance go up by more than $600. Of course you know what they're going to do, they're going to pay it themselves. Any rational person would. But what's hard to understand is that in those circumstances that I've described, which are very real, it's going on out there, why will the Department of Health not reduce the bill from $600 to $105 because there is no third party insurer there to pick up the bill? Why will the Department of Health not make allowance for those kinds of circumstances?

MR. MUIR: Mr. Chairman, the policy that has been established is that the Department of Health and indeed you and I and everybody else, we subsidize individuals for ambulance transport. That's the $85 charge from home to a facility, or no cost if you're travelling from one facility to another. On the other hand, it's the policy and it has been that in the cases where there are accidents involving third parties, insured, we bill Workers' Compensation, we bill insurance companies. They are billed for basically the full cost of the transport.

I can't enter into a debate with the honourable member about what insurance companies are and are not doing, simply to say that the information he has stated is different than the information I have gleaned from the same sources.

MR. STEELE: Mr. Chairman, I really suggest that the Department of Health go back and talk to the Insurance Bureau of Canada, because they've changed their tune talking to me. The fact is that out there in the real world people are being stuck with these $500 and soon to be $600 bills, and the insurance company will not pick it up, or if they do pick it up the premiums will go up by more than that amount of money. That's really happening out there.

The minister said something interesting. He said, well, we bill the insurance company, but they don't. They don't bill the insurance company, they bill the individual. Then it's up to the individual to try to get the money from their insurance company. Mr. Minister, it would be okay, I think personally that it would probably be acceptable, if the department and EMC billed the insurance company. If you get the money from the insurance company, all's well and good; but, if you don't, when you turn around and try to collect the money from the individual you don't stick them with a bill for $600, you stick them with a bill for $105 which, in most cases, people are willing to pay. It's the shock of that $500 bill, soon to be $600, that they simply cannot get back from their insurers. They cannot get it back, okay, they cannot. That is really happening out there in the real world.

[8:30 p.m.]
Mr. Chairman, I would like to move on to the issue of the department's collection methods. I use the word department loosely, I know it's really EMC, but the money collected goes to the department so it's difficult for me to draw any meaningful distinction between the department and EMC, but EMC uses some pretty heavy-handed collection methods. They've been known to send collection letters to children. They've been known to repeatedly phone a person. I know of one case where they repeatedly phoned a person who was under a mental disability which is a legal term for somebody who is not legally able to manage their own affairs and even though the collection agency was told that, they continued to call that person who had a legal guardian, who was not able to manage her own affairs.

So my question to the minister is, what control, if any, does the department exercise over the collection agency that collects ambulance bills and the methods that that collection agency uses?
MR. MUIR: Mr. Chairman, the ground ambulance and the air ambulance is operated by EMC and indeed part of the contract is the collection of bills. What I can say, and I think everybody in the House knows, is that if somebody is unhappy with the bill that they receive - and by the way I do apologize, the honourable member is correct, the bill is sent to the individual as opposed to the insurance company, I wasn't trying to imply that it wasn't, it was bad terminology on my part - there is an appeal process. I can also indicate to the House that in the cases which I have learned about of people having difficulty paying their bills, is that EMC, they're willing to work with people to get a payment schedule put in place that meets the person's ability to pay. The fact is that the policy regarding ambulance services, we subsidize services to individuals in auto accidents and others, workers' compensation. Where there are basically third party people who are eligible to pay, then we would expect the full cost to come.

I should also add, Mr. Chairman, although we have increased the fees this year, I think they're still amongst the most reasonable. The cost of our ambulance transport in terms of individuals who are asked to participate in the cost of transport and as well as companies, I think are very reasonable in terms of the rest of the country.

MR. STEELE: Mr. Chairman, when I wrote to the minister about a month ago .. . AN HON. MEMBER: As a lawyer .. .

MR. STEELE:... as a lawyer, I wrote about seven cases and dozens of more people had contacted me. This is a real sore point out there, Mr. Minister, I hope you know that. So I want to tell him about one of the other cases. Probably the saddest case that I heard is not one of the seven so if the minister has any reservations about answering the question here in the Legislature, he can drop them this time.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 43

It is about an older couple and one of them had a mother in a nursing home, even older. This is a retired couple, you see, this is a couple who are themselves old and have a very elderly mother in a nursing home. They were not at all pleased with the quality of care being provided in this particular home which I won't name because that's not the point of the story. One day when they visited their mother and found her lying in conditions which they found completely unacceptable, they took her home. They took her home. The home was over on the Halifax side. They took her home to Dartmouth because they could not leave her the way they found her in that home. The mother was a woman with Alzheimer's. It's very difficult to handle. She was completely unable to care for herself and this couple found that evening when they had their mother home and they tried to bathe her and wash her, that they themselves were not up to the job. They're older themselves and it was very, very difficult for them to do what they wanted to do, to clean up their mother and give her a place to sleep, and they realized in the middle of the night that they could not keep her. They were just unable to tend to her very significant needs.

So it is the middle of the night, they have only one place to take her and that's back to the nursing home. So they called an ambulance. It was the only way they knew of getting their mother back to that place where there were staff who could care for her. They had no choice. They felt they had no choice and in real human terms, they did have no choice. It's all they could do and they received a bill for $500 because it was classed as a non-emergency trip, $500. There was no insurance company to pick this up. This elderly couple have contributed to their city, their province, their country. They don't have a lot of money. They did enter into one of the minister's payment plans, you know, for something like $35 or $45 a month. Every penny that they had, that they felt they could spare, they paid towards the ambulance bill because there was no allowance anywhere in the rules or regulations for doing anything different.

The department's policy book said this was non-emergency, bang, $500, no choice. Is there any allowance anywhere at any level in the policy on ambulance fees to take into account these kinds of circumstances so that kind of fee could be reduced or forgiven?

MR. MUIR: Mr. Chairman, I wouldn't comment on that case if I knew anything about it, but I guess, I don't know how they did it, but obviously if she was going from home back to the facility, they must have got her from the facility to the home and if she was transported by car, I don't know how she or he was transported. I can say that if somebody has extenuating circumstances or other things, there is an appeal process which is in place and they can make their petition to an appeal committee.

MR. STEELE: Mr. Chairman, there is an appeal process, but it is not well publicized. I have seen a number of pieces of correspondence from EMC and their collection agency and none of them specifically refer to an appeal process. People kind of have to dig to find out that there is one and when they do there's no rule book because all of this was done completely free of any governing law or regulations. So nobody was too sure, even if they

knew about the appeal process, about what rules applied. This is why it is so important, if you're going to impose these kind of fees, to have a regulatory framework, precisely so that there is a rule book.

Now, under the Financial Measures (2002) Act which was introduced on Friday, there is a provision to pass regulations dealing with the appeal process which is good. It is good to have an appeal process for this kind of thing and there's also provision for regulations dealing with the fees themselves. My question to the minister is what plans does the department have for consultation with interested people in the development of these regulations before they are enacted into force? What process of consultation is planned?

MR. MUIR: Mr. Chairman, the regulations obviously would probably be put in draft form by people in the department in consultation with those in EMC and people, as appropriate, would be consulted.

MR. STEELE: People as appropriate would be consulted. I wonder if the minister could elaborate on that and explain what that means. Is there going to be any consultation outside the department and EMC? Is the Insurance Bureau of Canada going to be consulted? Am I going to be consulted? (Interruption) Well, just for the record, the minister said no, no, I'm not going to be consulted. I am a member of the Legislature and I have had dozens of people contact me with stories about how unfair and unreasonable ambulance fees are in Nova Scotia and listen, Mr. Minister, I've got a lot to tell you. I've got a lot to tell you and I think it is insulting that you would sit there and say from your chair that you are not going to consult me because of what - because I am representing citizens who have the nerve to challenge their government and say that what you're doing is illegal and not just illegal, but unreasonable and unfair?

MR. CHAIRMAN: Order, please. If I could remind you, this is about a question and answer of the estimates and I would ask you to keep in line with that request.

MR. STEELE: Okay, well we are talking about the estimates. How much money exactly does the department forecast it is going to take in this year from ambulance fees and how much of an increase is that over last year?

MR. MUIR: Mr. Chairman, the estimate this year is about S5.9 million and the increase, which will be to the Department of Health, because these fees are shared, is a little over $1 million to the department.

MR. STEELE: If I understand that answer correctly, the department is taking an extra $1 million just from the increase in ambulance fees. That is not how much they are taking in from ambulance fees. That is the increase, an extra $1 million. So I think it is fairly legitimate, Mr. Chairman, to ask the minister what process he has planned for consultation in the development of the rules about who gets charged and who doesn't. I have two more

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 45

questions. I keep telling my colleague over here, just one more. I have two more. How much of the new ambulance fees are going to go to EMC, the private entity that runs the ambulance system?

MR. MUIR: The EMC is scheduled to get an additional S67,000-plus.

MR. STEELE: Mr. Chairman, ambulance fees in Nova Scotia, as they are currently structured, result in some cases - I would even go so far as to say many cases, I have only seen the tip of the iceberg - that are, in the way they are applied to the facts of the case, unfair and unreasonable. The department has a certain number of rigid rules that it will not bend to take into account real human need, real human circumstances. This is all taking place in an environment where there was no rule book. There was no framework of rules. This is what happens when you charge your citizens millions of dollars without any supporting law, without any supporting regulation, with a rule book that you make up yourself and then keep to yourself, which is essentially what has happened here.

It is a good thing that the government, in the Financial Measures (2002) Act, is going to provide the legal framework around this. It took them a few years to get around to it, but it is a good thing that they are doing it. But in the meantime, there is real unfairness going on out there. My last question to the minister is - and I am going to need to explain this a little bit, so I am going to ask the question and then one sentence of explanation - will the Department of Health consider suspending collection of ambulance fees until the new rules and the new appeal process are in place and the regulations have been passed? The sentence of explanation, Mr. Chairman, is that I am not asking the department to forego eventual collection of those bills. I am not asking the department to forgive those bills. What I am asking right now is will the department suspend collection until the rules are in place?

[8:45 p.m.]

MR. MUIR: I guess, just for clarification, the department does not collect these bills, Mr. Chairman. It is kind of like insurance companies and individuals. That is the point I am making. No, clearly, the department will continue to operate under the policy that has been in effect for a number of years now and appropriate bills will be sent out to those to whom they are supposed to go.

MR. CHAIRMAN: I would like to recognize the honourable member for Halifax Needham, with 24 minutes, in turn.

MS. MAUREEN MACDONALD: Mr. Chairman, I want to thank my colleague for Halifax Fairview for bringing to the floor a very important issue. I think that most of the members of this Legislature have had to deal with this very serious problem. I have my own number of cases that I worked on. Just to impress on the minister how unfair these scenarios can be, I had a 90 year old gentleman in my constituency, a senior who speaks very little

English, a Chinese gentleman with no family members here, who was struck at the Willow Tree just outside the crosswalk. He wasn't actually in the crosswalk when he was struck. He received a bill for $450. He had been taken from the Willow Tree to the emergency department at the QE II. He was most distressed and had absolutely no ability to negotiate a process of trying to even ascertain what a repayment schedule would look like. It was a very difficult situation and I have had a number of situations like that. I think that it is very important that we make as transparent as possible what these appeal procedures might be because in situations like this, people need to have access to those steps and they need to have them very clearly articulated.

So there are other areas also, I think, where the collection of fees that we are now seeing creeping into our health care system are creating problems. Disputes between consumers of health care and providers of health care are rising and sometimes the mechanisms to resolve these disputes don't exist. I would like to raise the issue of the $50 a day fee that is being levied against people who are in an acute care facility, who have been discharged from the acute care facility, but do not have either a long-term care bed available to them or are unable to go to their home or a family member's home because the level of acuity that they have is such that they require nursing home care.

I would like to give you a specific situation and perhaps from this, not responding to the individual situation but to speak generally about what the department has in place or intends to put in place to deal with the following kind of scenario. So I have a gentleman who contacted me whose father was elderly and had Alzheimer's Disease and was at the QE II. At some point, the decision was taken that his father no longer required acute care. The family was contacted and they were told that he would have to be discharged. There is an elderly mother and a son that is elderly. They were unable to care for this person at home and there was no long-term care bed available to them. So their father remained in hospital and the $50 a day fee started to apply to this case. Well, in fact, the father died. He died within a very short period of time and they have been charged $450 for each of the days past the discharge date. Frankly, my office has been having one heck of a time trying to get someone to explain why the son now has to pay the $450, and how the decision was taken in the first place to charge this particular family $50 a day. It wasn't as if bringing that person home was a reasonable alternative. There was no reasonable alternative for this person and this family - after all, the father expired in a very short period of time.

Just to negotiate a bureaucracy where you try to get an answer for how that decision was taken is next to impossible, and I've been going through it, my constituency assistant has been going through it - this family is very frustrated and it seems to me that there needs to be a place for a serious, sober second look at a situation like that that a family could take their situation to for a fair and impartial review and seek some remedy. Is this in place? If not, why isn't it in place? Will there be consideration to putting something like this in place, particularly now that user fees of this nature are creeping into our medical system?

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 47

MR. MUIR: That's a good question from the honourable member. The intent of that policy - and it was suggested by representatives of the DHA and we accepted the suggestion - is not really to hurt anybody, but if you are medically discharged from a hospital and you're awaiting long-term care, then in a good many cases this $50-a-day fee kicks in for those people who can afford it. So, what you have is a financial assessment. I have no idea of the case that the honourable member was speaking of. I don't know anything about that and, of course, I wouldn't comment on it anyway, as she appreciates.

On the other hand, I must say - this is me speaking and I guess it is reflected now in department policy, or policy of DHAs - that if a person was in long-term care, they're awaiting long-term care, they're in long-term care, then they would have to contribute to that care as they were able, having gone into it. The issue of this is that they no longer apparently require the acute care that they're given in hospital, therefore they are now basically in a long-term care situation and the principle is that basically they would be asked to contribute to that as they could afford it, except that it's capped at $50. The average cost of a long-term care facility in the province is about $140 a day, so if the person was immediately moved from acute care and there is a space for them and they're moved into long-term care, then it would be - I'm talking about the average - about $140, depending on where they went. The issue of, is $50 a reasonable fee if you're going to go into long-term care, I believe the answer to that is yes.

MS. MAUREEN MACDONALD: So is the minister saying that an income assessment has already been done in this situation like this, and the income assessment is the standard assessment that would have been done for the long-term care facility and that those are the guidelines then that are the determining factor in setting the $50-a-day fee? Therefore in a situation where there is an assessment that there is little or no ability to make a financial contribution to long-term care, then in these cases the $50 a day wouldn't apply, is that what's being suggested?

MR. MUIR: The situation - I suppose it varies somewhat from DHA to DHA, but I do know that in cases where people cannot afford it, they don't have to pay. That I can tell you.

You asked whether the financial assessment would have been completed on these people, and in some cases it would have been completed and they refuse to go to a long-term care facility, therefore they remain in the acute-care facility. In some cases the financial assessment would be partially complete. In any case there is a discharge plan written for the person at the hospital, and the social worker at the particular acute-care facility obviously would have some input into this. If a person can't pay it, it's like going into long-term care, I think we provide subsidy fully or partially - well, I guess, not a whole lot fully because you get Canada Pension and all those things now, there's some revenue comes in and only a portion of it would go. What I'm trying to say is that if a person is not in a position to pay

that S50 a day, or couldn't even pay any portion of it, then they would not be asked to pay it; that would be my understanding.

MS. MAUREEN MACDONALD: There's still a problem though with the administration of this policy, whether or not you agree with the S50 a day which many people don't agree with. It seems to me that the critical question is who's deciding and whether or not there is a review about whether or not that decision - what are the criteria being used in determining who has to pay and who doesn't have to pay? Who decides and what are the bases on which they decide? Then if the family or the individual disagrees with the assessment or the decision, is there any recourse to have an independent review or an appeal? I guess that's my question.

In most administrative areas of public policy that involve an assessment of need, and an entitlement to having that need met in this province, as far as I know there are quasi-judicial kinds of processes put in place - principles of administrative law for some kind of a review to occur. That basically is all I'm asking. Where is the review process to ensure that there has been a fair and uniform standard applied to all of those people in this kind of situation in the acute-care facilities so that it doesn't become random, discretionary, and quite uneven. Then you get people who are really feeling that the system is failing, because the elements of fairness that are required in the application of the levying of these kinds of fees rest on discretion and are subject to arbitrary decision making rather than some sort of uniform standard.

MR. CHAIRMAN: I would like to advise the member that we have 10 minutes left of NDP caucus time. While we're waiting for the minister I would like to ask the Chamber members to quiet down a little bit. It's getting rather noisy in here. This is a very important time and you're here to have a clear understanding of the estimates. If you would like to have a conversation, please remove yourself from the Chamber and go outside. Thank you.

[9:00 p.m.]

MR. MUIR: Mr. Chairman, basically there is a standard, medical discharge from a facility, as far as I know, is uniform across the province. The billing matter is a matter for the district health authority. Clearly the intent is that if somebody is going to go on long-term care, this is basically what it is, or there are cases here where people are kept in acute-care facilities because their condition is such that they cannot be looked after in a long-term care facility, in any event they would basically go through the test of eligibility or how much financial participation a person should be required to make or be a part of if they're going into long-term care.

I guess I can't directly answer your question about the individual facilities, about an appeal process. I know that clearly, as the honourable member is well aware, when a person enters long-term care there is an assessment process and, to be quite frank, I believe there's

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 49

a considerable amount of give and take over items which are clear or not clear. There is - what is it? - the Social Services Act, I believe, is the guideline that they use in ascertaining the participation of somebody and the cost of care.

MS. MAUREEN MACDONALD: I understand that in some DHAs there is a backlog in the assessment that is being done from the department in terms of getting to people and assessing them for long-term care for all of the financial details, and that often people are caught in that process where they haven't been assessed but they are being medically discharged, and a determination is made then that they do have an ability to pay although the assessment hasn't been done. It hasn't been established yet whether or not the person has an ability to pay and it just strikes me as unfair to those individuals unless you have a standard procedure and you have in place uniform guidelines, income guidelines, so that each DHA isn't establishing a different level in terms of who they feel has an ability to pay or not.

It seems to me this is something that needs to be looked at, and so I would ask you to comment on whether or not you're prepared to look at that and have some flexibility, so that people aren't in these situations where they genuinely have no ability to pay but they're looking at these bills. I would suggest that as budgets tighten, the potential for systematic abuse because the financial sort of entities of these larger institutions are so fixated on the bottom line, the human element is in danger of getting lost, and so you need to have some checks and balances in place to make sure that that doesn't occur. The first place to do it, it would seem to me, is to have some uniform income guidelines and maybe some direction to these DHAs that if an assessment hasn't been done on someone, they shouldn't be levying fees prior to an assessment establishing whether or not there is an ability to pay.

MR. MUIR: Mr. Chairman, when that policy was introduced there was provision for a review and it's about the review period now, or around time, and I guess I can say we haven't formally gotten into the review process, and certainly the points which the honourable member makes are interesting ones. Yes, I can tell that the feedback from the people from the districts, they feel it is a good policy and should be continued, but that's not to say that if there are glitches in it - we don't like the glitches any more than anybody else does - we will certainly try to work with the DHAs to try to straighten them out.

MS. MAUREEN MACDONALD: I know I don't have very much time left, but I did want to raise a couple of questions about the changes around the Children's Dental Program. Specifically I wanted to know what the costs will be. I understand that when the budget was introduced, information was provided that the change in making private plans the first payer for children under the age of 10 would result in an increase of $400,000 a year to the Province of Nova Scotia in increased premiums as an employer, but I'm wondering what analysis the department has done with respect to what the increased costs will be to government employees, and also what it will cost in the broader public sector or the private sector.

MR. CHAIRMAN: We have approximately two and a half minutes left in the NDP caucus turn and then we'll be recognizing the Liberal caucus, and I believe we will be recognizing the member for Cape Breton Nova - no, not yet, I'm, just getting you ready, filling in some time waiting for the Minister of Health, but it's nice to know that you're alert and ready tonight, member, indeed.

MR. MUIR: Mr. Chairman, there obviously will be, over the course of time, some increase I expect, well particularly to the government, because they are going to become the first payer on children's dental and they aren't now. I don't know what the cost to the government is going to be. I know clearly that was certainly a subject for discussion in the budget preparation, and you may wish to address that to my colleague, the Minister of Finance, in his estimates.

The amount of money that's going to accrue to the department means that we aren't going to pay it out, and I believe the saving was (Interruption) We are going to go down, the reduction is going to be about $4.3 million in the cost to the Department of Health in that Children's Dental Program. The net of that is there will be obviously some increase I suspect in insurance premiums for the government, because I think we participate in dental plan insurance too. I mean I know I pay it and I assume - we may pay it all, I know in some places where they have a dental plan that the employees pay it all. So I don't know the answer to that, but you may wish to ask the Minister of Finance during his estimates for a more comprehensive answer.

MR. CHAIRMAN: You have approximately 25 seconds, member. If you would like to ask a quick question, I will allow it; if not, I will have to ask you to take your seat.

MS. MAUREEN MACDONALD: A quick question. Did the department do any study of the impact on children's dental health, of this shift?

MR. MUIR: A quick answer is that it is the belief of the department that the program will remain intact. Everybody is going to have their services.

MR. CHAIRMAN: It's time now to turn over to the Liberal caucus, and I would like to recognize now, formally, the member for Cape Breton Nova. The time being 9:10 p.m., at 9:31 p.m. the time will expire for tonight's session.

MR. PAUL MACEWAN: All right, we'll try to get it wrapped up within that time. Now, Mr. Chairman, the minister seemed just on the verge of a very extensive answer to the question just raised by the honourable member for Halifax Needham. I would like to give him some of my time so that he could answer that question.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 51

MR. MUIR: Mr. Chairman, I believe the last question from the member for Halifax Needham was, basically, is there going to be any effect on the oral health of children because of the change in the program? The best information we have in arriving at that decision - the answer to that is no. I guess if I was to put it into another decision, which I think you may have been a party to because I believe the change was made before I came into office, it had to do with the Seniors' Pharmacare Program. A number of years ago, your government, and appropriately so, made the decision to make the province the insurer of last resort, and people who had private medical plans that covered pharmaceuticals were required to make the insurance companies the first payer and if somebody chose to opt out and they put in some petitions about re-entry into the Seniors' Pharmacare Program. To me, that would be the closest analogy.

MR. MACEWAN: Mr. Chairman, because the turns at bat here oscillate back and forth between the two Opposition Parties, I am sure that line of questioning will be further pursued at a further time. I was stimulated to want to get in on this discussion this evening by the points raised by the member for Halifax Fairview about ambulance costs. I am not a lawyer. I am a former school teacher. I attended the institution presided over by the honourable minister in his previous career and graduated from there in 1963, so that is my background. I did not go to law school and I do not practice law without a licence, although I have frequently been accused of doing so, but that is another story.

Let me say this about that. I am inclined to reflect on the case of John and Brayden Chiasson of 76 French Street, 76 rue Francais, in Whitney Pier. Brayden is the son and John is the father. John is an unemployed steelworker recently put out of work by the honourable government opposite. Brayden is his son and is a young gentleman approximately 20 or 21 years of age. Brayden was out driving the family car on Seaside Drive. That is the name of Union Highway when you cross the new bridge at River Ryan. When you get on Seaside Drive and it is a slippery day, like it has been some of these days recently because the road is covered with slush and ice, a car can go off the road. Brayden drove his car off the road into the ditch.

He couldn't back it out; he couldn't get it out, but he did get out of the car himself. He was not injured. There was no broken bone. There was no blood flowing. He was poised and alert. He wasn't suffering from a concussion or from any of those other nasty things that can happen in a motor vehicle accident. He went to a nearby garage and called his father to come out and get him in the other family car and take him home, so Poppy got into his car and proceeded out to the site of the accident. But, in the meantime, some well-meaning bystander had seen the car go off the road and the young man get out of it and, I guess, concluded that he was all shook up and so called the ambulance.

The ambulance came down and the chaps got out of the ambulance saying, you must get into the ambulance. We have to take you to the nearby hospital to have you checked over. No, no, he said. I don't want to go into the ambulance. My father is coming to get me to take

me home. Go away. But they were persistent. They said, you must come into the ambulance. Well, he gave up. He said, all right. If you say so. I will have to leave word for my father to come up to the hospital to pick me up. So the ambulance took him up to the hospital, which is quite nearby. It is the New Waterford Consolidated Hospital. The minister is well familiar with it because he wants to close it down and transform it into an urgent care centre, but I won't get into the urgent care centre right now - later.

The young man was taken up to the emergency centre at New Waterford and given an X-ray, and the X-ray showed no broken bones so he was discharged. His father, by that time, had arrived and so took him home. End of story, or it should be the end of the story, because the ambulance ride, which took about three minutes, just like the other case that was mentioned around the corner - this is a little longer than around the corner. It was turn around and go up the hill and turn right over a very bumpy road - and I should get into that one on the Transportation Estimates - but, in any event, they arrived at the hospital, which is, I would say, about two miles from where the accident took place. It is not far. (Interruption)

Oh, you want it in metric? Three kilometres, how's that? So the father gets the bill in the mail a day or two after for $500 for taxi fare, I guess you could call it. His son was not injured, or bleeding, had no broken bones, was not unconscious, was alert, talking, lucid and coherent. That is more than you can say for this government, Mr. Chairman. So they came to me because I am the MLA for the area where they live, and I looked over the correspondence they had received. There was something on it like an assessment notice, saying if you don't like this assessment, you have the right to appeal within 30 days to the Assessment Appeals Court. Only this said, you have the right to appeal within 30 days to the ambulance bill committee, the remissions committee. I forget what it is called. The committee of mercy, I don't know. It is in Bedford, I know that much. I don't have the file on the subject of which I am speaking; I am just going by memory. But it is in Bedford.

[9:15 p.m.]

There is a gentleman who is the secretary, who is in charge of it, and you write to him and say, I would like to have my bill reviewed. So they came to me and asked me to do that on their behalf and I did. We sent the letter off and we sent a copy to the Minister of Health with a little covering tag saying, Dear Mr. Minister, if there is anything you can do to help, considering all the circumstances, we would be most pleased for any help you could give us. Well, none of those items of correspondence, so far, have been responded to, so I can't tell the House just what the final outcome will be. If they won't remit the bill or reduce it, it stands at $500. I am advised, in my non-lawyer capacity, that there is no law to support that kind of billing.

AN HON. MEMBER: Oh, but there will be.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 53

MR. MACEWAN: There will be, says my learned friend. Well, I am sure he is right. But there isn't right now, and I don't know what the collection remedies are because you have to have legal grounds for a bill.

AN HON. MEMBER: Isn't that called a gouging bill?

MR. MACEWAN: A gouging bill. My honourable friend from Lunenburg suggests that the bill that they have prepared up their sleeves is called the gouging bill. Well, we will debate the gouging bill when it comes to take us for a ride. But, in any event, I just want to relate this experience because the net effect that this has had on the Chiasson family is not positive. They say, my God, what is going on in this province when you can get a bill for $500 for a two-minute ambulance drive?

Now, I know that there is a philosophy that you have to charge for the ambulance. We don't have that philosophy for the fire department. God knows what the results would be if every time you had a fire and called the fire department, the next day you got a bill because a fire truck had to come down to your house; $500, please, or $1,000. We don't charge that way for fire protection services, but we do for the ambulance. I am maybe a bit defensive on this subject because I can tell you that when our Liberal Government was in power, we did a great deal to reform and revise the ambulance services in Nova Scotia. When Donnie Cameron and that bunch were in power - I just call them that bunch; that is not too abusive, is it?

MR. CHAIRMAN: We will allow that this evening.

MR. MACEWAN: When Donnie Cameron was in power .. . AN HON. MEMBER: You didn't say a bunch of what, though.

MR. MACEWAN: It could be a bunch of scholars and gentlemen, for all we know. When they were in power, I think if you had a bucket of white paint and a van and you painted your van white, you could say you were in the ambulance business and set yourself up as being available to the community and come and take people and put a red cross on the side. I know you do that part, too. So you needed a bucket of white paint and a small can of red to be in the ambulance business back then.

AN HON. MEMBER: Liberal red.

MR. MACEWAN: Well, I won't get into that, but I will say this, that from that time until now there has been a considerable change in what kind of vehicles are on the road and what kind of personnel are in those vehicles, what kind of training they have, what kind of knowledge they have of paramedic technology and procedures, first aid and all the rest. It's a great improvement, thanks to our good Liberal Government. Now that that government is

temporarily not in office, we want to see that those gains are maintained and not lost because of the frittering away of this crowd across the way.

If they're going to be charging people $500 or S1,000 to use the ambulance, I think that's something we have to take a look at, this committee. I know the minister has already answered questions on this, some of them anyway. Because the other member who asked those questions is a lawyer by training, there was some problem in answering. I would like to give the minister the opportunity to answer the subject in a broader way, if he wishes to take advantage of it, by using some of my time to tell us the straight goods on this subject.

MR. CHAIRMAN: Thank you, honourable member, for the story from Cape Breton, Whitney Pier. We certainly enjoyed it, and I'm sure the members in the Chamber have as well. Mr. Minister, you can take some time, he's giving you the floor.

MR. MUIR: Mr. Chairman, I would just like to go back in history a little bit with the honourable member for Cape Breton Nova. (Interruptions) No, I'm going to go back before we get into the bucket of white paint. I just want to tell the House that, indeed, he was a graduate of the Nova Scotia Teachers College, and he holds that institution in high esteem. I can only say that it was very unfortunate for education in Nova Scotia that his colleagues, including two sitting there on the front bench, did not hold that institution (Interruptions) in that regard.

I just want to tell all members of this House that one of the encouraging things to me through that horrible ordeal that was put upon us by that bunch - and two members of the front row who were in Cabinet at that time to make that horrendous decision - is that I did get a letter from the honourable member for Cape Breton Nova supporting me at that time, and I have never forgotten it. Thank you very much. (Applause) I did not get one from either of those two members sitting in the front row. (Interruptions)

He is absolutely correct, he knows the history of the ambulance service in Nova Scotia, probably far better than I do. I rode in an ambulance one time. I used to be, a number of years ago - more years than I probably should recite - a high school football coach in Truro. I actually started a high school football program there. I had a young man who, one day, on the field, lay down holding his leg. I didn't know what to do, so I called the ambulance, which was a good thing to do. Anyway, the guy that came, driving the ambulance, happened to be in Grade 11 at the school. (Laughter) The good old days. (Interruptions)

MR. CHAIRMAN: Order, order. Order, order. Could I have some order, please. Order, please.

MR. MUIR: I believe he was in Grade 11 at that time, and he was a student in one of my classes. I knew him well. (Interruptions)

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 55

MR. CHAIRMAN: Mr. Minister, just a second. I would ask the members in the House to be quiet, please. We would like to hear the minister's story about his youth and his experience with the ambulance service in Nova Scotia. Mr. Minister, you have the floor.

MR. MUIR: I'm going to tell you about my ride in the ambulance. Anyway, we got this young chap in there - and he actually went on to become a school teacher and still does that. I know his brother too - anyway, he was a big guy. He was about 6'4". He was the biggest guy I had on the team, I remember that. As we got him in the ambulance and put him on the thing. Now, this was some years ago when the streets of Truro were probably a little bit better than they are now, but they were still rough then.

We came out of the athletic field - and they drove fast in those days, in these old ambulances - we took the first corner and the buggy kind of slammed, and the guy was in there moaning. We went up the street, I suppose it must have been about half a mile, and we had to make a right turn onto Willow Street - we were going west - to turn down towards the hospital, and we slewed around that corner with the siren screaming. He was just writhing in pain; he broke his leg badly. (Interruptions) Coming down, in Truro then there used to be two sets of railway tracks before you hit the hospital, and I can still remember him saying: Jimmy, the tracks, Jimmy, the tracks. (Laughter) Jimmy was the driver. It was an ordeal.

That was my first experience. I do want to say, though, with all due respect to the standards and whatnot then, the ambulance service in my community of Truro, when the changeover was a model, they had an extremely fine and well-run, well-trained, well-equipped ambulance service in Truro. Indeed, I understand, I think the person who ran that was actually the one who went around the province to see if other ambulance services were meeting the standards.

That was my first experience in an ambulance, and I wanted to tell that. I also wanted to make the point that we had an excellent ambulance service in Truro prior to the changeover. We have an excellent ambulance service now, the same people are running it. You would all know who they are. They do a very fine job.

Anyway, you're right, we had ambulances in Nova Scotia, I'm told, that didn't run - they had no motors in them, yet they were counted as ambulances. I'm told there were some situations where there were ambulances that didn't have any wheels on them, yet they counted as ambulances. People were being subsidized for those. In general - or in a lot of cases - ambulance service was an adjunct to a funeral home. The ambulance service that I first remembered in Truro, indeed the one where I had my initial ride was an adjunct to a funeral home before it became an independently operated service. Indeed, the standards sometimes were not so great, but people were well equipped.

56 HANSARD COMM. (SUPPLY) MON., APR. 8, 2002

The government over there, when they made the decision to go to a high-performance ambulance service, they put in a good one; indeed it should be good because we spend about $58 million a year on our ambulance service. We have an expensive ambulance service, it's probably about three or four times what it cost before we had the high-speed one. (Interruptions) Well, they were changed by the previous administration; they went to this very high-performance and high-cost ambulance service. We have some very well-trained people, and we have a performance-based ambulance system. You can pretty well be guaranteed, if you need to call an ambulance in Nova Scotia they're going to be at your door pretty darn quick and you're going to have somebody in that machine, when it arrives at your door, if there's something the matter with you, they can help you.

The cost. What was decided. Everybody understands that ambulance service in Nova Scotia is not insured. It's not insured in Nova Scotia; it's not insured in Prince Edward Island; or Newfoundland and Labrador or any other province in Canada. It's not an insured service under the Canada Health Act; neither is home care nor long-term care nor a variety of other things that we talked about earlier.

My experience with Nova Scotians is Nova Scotians don't mind participating financially in a good service. Indeed, I've had I don't know how many people in the last number of years come up to me and say - well one of the things - I would be happy to pay a fee at the doctor's office or a fee at the hospital, it's what we call user participation. (Interruptions) No, not this year, sir. No, no. We turned that down, and I said that the other day in response to a question from the member for Halifax Needham.

Anyway, this high-speed ambulance system, when they brought it in there used to be a wide variety of ambulance fees across the province. What they used to do, the member for Cape Breton Nova, is that if you lived up, and let's take Meat Cove, which is on the northern extremity, and you had to be transported to Halifax, you would get a whopping big ambulance bill, because they charged you by the kilometre. On the other hand, if I lived where I live here in Halifax, which is one block away from the VG, I would get charged whatever the minimum charge was, and I don't know what it was.

[9:30 p.m.]

You could go into bankruptcy under that old system. What our government has done is last year is we reviewed this thing, looked at the flaws in it, and we got into this, what I will call a postage stamp thing. If you're transferred between accredited health facilities there's no charge. No charge. On the other hand, if you go from home to hospital, or from hospital to home is a flat fee. I will give you an example . . .

MR. CHAIRMAN: Order, please. Order. The time has expired for tonight's estimates. As much as I would like to stay here longer, I believe we're only allowed four hours.

MON., APR. 8, 2002 HANSARD COMM. (SUPPLY) 57 The honourable Government House Leader.

HON. RONALD RUSSELL: Mr. Chairman, I move the committee do now rise and report considerable progress.

MR. CHAIRMAN: There's been a motion to rise; hearing that we will. [The committee adjourned at 9:31 p.m.]