HALIFAX, MONDAY, MAY 2, 2016

 

COMMITTEE OF THE WHOLE ON SUPPLY

 

5:20 P.M.

 

CHAIRMAN

Mr. Keith Irving

 

            MR. CHAIRMAN: The Committee of the Whole on Supply will come to order.

 

The honourable Deputy Government House Leader.

 

            MR. TERRY FARRELL: Mr. Chairman, would you please call the estimates for the Department of Health and Wellness.

 

            Resolution E11 - Resolved, that a sum not exceeding $4,132,209,000 be granted to the Lieutenant Governor to defray expenses in respect of the Department of Health and Wellness, pursuant to the Estimate.

 

            MR. CHAIRMAN: I now invite the Minister of Health and Wellness to make some opening comments and introduce his staff members.

 

            HON. LEO GLAVINE: I'd first like to introduce staff with me today. On my right is Deputy Minister Dr. Peter Vaughan. On my left is Kevin Elliott; Kevin is the chief financial officer for the Department of Health and Wellness and the Department of Seniors. I certainly want to commend our finance department under the leadership of Kevin for the work they've done over the last number of months. His staff, I know, have worked late into the day, well beyond the regular hours, and have certainly done a remarkable job dealing with the finances that were given to the Department of Health and Wellness and the accounting process that will come out during estimates here on the budget.

 

            It is my privilege to introduce the estimates of the Department of Health and Wellness for the 2016-17 fiscal year. First I want to say, when I appeared in this Chamber last year I spoke about the tough choices needed to ensure Nova Scotians continue to enjoy a quality health system. As a government and as partners in the delivery of positive health outcomes, we continued to face those challenges over the last 12 months. I'm pleased to say that the results we achieved have been positive and have built the foundation of a stronger health system for Nova Scotia. Nova Scotians have told us that health care is one of the areas that truly matter to them. We know that providing quality care to our aging population is a significant challenge, one that has consumed an ever-growing proportion of our provincial budget over many years. Over the last 15 years, the budget of the Department of Health and Wellness more than doubled from $1.8 billion to just over $4 billion. That far outstrips the rate of inflation, which was about 29 per cent over the same period.

 

            Mr. Chairman, you might think that for that kind of investment, we would have significant results to show for it. Well, you'd be wrong. According to the Conference Board of Canada's most recent assessment, Nova Scotia's health outcomes are among the worst in Canada. Our D score is in just seventh place among the 10 provinces. "Could be worse" is not an acceptable goal for Nova Scotians when it comes to their health care.

 

            The department's estimates for 2016-17 project that the budget of the Department of Health and Wellness will see real growth of 0.93 per cent. In fact, this is the second year in a row that health spending will grow by less than 1 per cent. It's the first time in recent memory that any government can say that. I've heard some say that this is not something to celebrate, that when it comes to care, government should be spending more and more. Sadly, we have 15 years of evidence to demonstrate that throwing money at the problem has done little to achieve the results we want.

 

            Mr. Chairman, when our government was elected, one of our key commitments was to unify our province's health authorities which we did under the umbrella of a new Health Authorities Act. When I was here one year ago, the Nova Scotia Health Authority was only a few weeks old. We now have one full year to reflect on, and I am pleased to say the results have confirmed that our decision was the right one. In fact, both the Nova Scotia Health Authority and the IWK Health Centre have forecast that their spending for the last fiscal year will come in at or under their budgets for the year. Most importantly, the Health Authority's success in delivering on their program goals has demonstrated the benefit of a coordinated, integrated approach to health administration in Nova Scotia.

 

            The Nova Scotia Health Authority is able to act more quickly than nine local organizations to make needed changes. Best practices are now easily shared across the organization and more quickly adopted.

 

            The lack of artificial boundaries in the province has also resulted in more flexibility in managing budgets. With corporate services working together with the Department of Internal Services, the NSHA has been able to reach targeted savings ahead of schedule.

 

            Too often, we equate savings with reduced service. But NSHA has been able to improve care while achieving those savings. For example, the MRI wait-list has decreased by 12 per cent since September 2015. Hemodialysis patients in Yarmouth continue to receive treatment in their community with resources deployed from Halifax at a moment's notice. Collaborative practice teams are offering better support to patients in communities like Guysborough - Clare has been established for a while - Middleton, and others that are in the works for other communities. A clinic program for seniors in the northern area of the province is offering quality coordinated service to seniors in Colchester, Cumberland, East Hants, and Pictou areas.

 

            Another commitment I made one year ago was that the Department of Health and Wellness would review its mandate to find opportunities to better align with the new health care system. It was clear to us that with the NSHA and the IWK taking on more responsibility for the delivery of health care, the department needed to operate differently. Starting April 1^st, we transferred many programs that were focused on the delivery of front-line health care to the Nova Scotia Health Authority and the IWK. The redesign reduced the number of staff in the department and devoted new and existing positions on developing policies that will contribute to reduced wait times and improve health outcomes for Nova Scotians.

 

            In 2016-17, the Department of Health and Wellness will see a reduction of more than 144 full-time equivalent employees over the previous year. Last year, the department had almost 448 FTEs. This year we will have just over 303, a drop of about 32 per cent. The vast majority of these skilled professionals have transferred to other organizations.

 

            Thirty-six positions, together with $33 million in program funding, have moved to the NSHA and the IWK. The positions represent important work in public health; mental health and addictions; primary, acute, and tertiary care; and infection prevention and control. Also transferred to the NSHA is the responsibility for six provincial health programs: Cancer Care Nova Scotia, Cardiovascular Health Nova Scotia, the Diabetes Care Program, Legacy of Life, the Nova Scotia Provincial Blood Coordinating Program, and the Nova Scotia Renal Program. The Reproductive Care Program and the Nova Scotia Breast Screening Program have shifted to the IWK.

 

            The Active Living Branch and its important programs supporting sport, recreation, and healthy living has moved to the Department of Communities, Culture and Heritage. The Active Living Branch has 24 positions and a budget of $11.8 million.

 

            A total of 14 health inspectors moved to the Nova Scotia Department of Environment.

 

            Outside of these transfers, there was a net reduction of 28 FTEs: 52 positions were eliminated while 24 new positions were created to support the administration of the redesigned department. This included four new senior executives and an additional 20 positions to support the department's new mandate.

 

            Mr. Chairman, through the redesign of the department, we have saved a total of over $2.6 million, and that's just in the department. This amount represents a reduction in compensation and administrative operating costs as a result of the net reduction in positions I spoke about. Of course, these are ongoing savings, and we will continue to identify opportunities for new efficiencies as we move forward.

 

            There was a cost of $1.8 million accounted for in 2015-16 for redesign planning and severance costs. These costs relate to employees whose positions were eliminated and who did not accept offers of transfer. This was a one-time cost that will not be repeated in future years.

 

            As a result of these savings and the transfer of positions to other organizations, the budget of the Department of Health and Wellness for 2016-17 is $4.132 billion. This is actually a reduction of 0.13 per cent - the first time in 16 years the department has seen a decline in its budget. To be clear, as I mentioned before, that reflects the transfer of positions and budget to the Health Authority and other organizations. When those transfers are excluded, our remaining budget represents an increase of 0.93 per cent. As I said before, it's the second year in succession that our budget increase has been virtually flat, with growth under 1 per cent. I believe, Mr. Chairman, that this is a remarkable achievement and attribute it to the sound management of Dr. Vaughan and Mr. Elliott, their colleagues in the department, and our partners in the health authorities.

 

            As a result of that strong management, we have an opportunity to make some strategic investments towards a stronger health system for Nova Scotia. One of the commitments I am most pleased about is the commitment to add $3.6 million to the budget for the Early Intensive Behavioural Intervention program, EIBI. EIBI is a very successful program which is offered to children with autism spectrum disorder before they start school at age six. Early diagnosis and early treatment are incredibly helpful in helping children with autism spectrum disorder, or ASD, to adapt better to a school environment and in preparing them to learn. 

 

With this additional funding, the province will now invest nearly $14 million every year to provide EIBI to children with autism spectrum disorder before they start school. This will add up to 56 new spaces for children who need intensive treatment and more spaces for children who need less intensive treatment so they will be better prepared to learn once they start elementary school. Any child diagnosed with ASD can qualify for EIBI therapy in Nova Scotia, unlike other provinces where only those with the most severe symptoms can access treatment. The focus is on developing children's communication skills as well as their ability to play and interact with others. Parents report great success. One parent told staff that her daughter used to put her fingers in her ears when she walked into a crowded room. After taking part in EIBI, she was able to handle crowds and in fact loved the attention. She had a seamless transition to school. We all want what's best for our children, Mr. Chairman. We want them to get the best start possible in life. EIBI provides that great start, and we are proud to support it.

 

            I want to stay with the subject of mental health. We know that there are many people in Nova Scotia who are in need of mental health services and support. Government continues to make investments in mental health and addictions services a priority. This year we will invest $274 million in mental health funding. This includes services to those living with mental illness, payments to physicians, and pharmaceuticals. Over the past two years, we have worked to strengthen training for health care providers and the supports available to those living with mental illness. As a result of the department's redesign, we have moved an additional $5.4 million to the NSHA and the IWK to support mental health services. The Health Authority is working to study the needs of communities and better match mental health services to those needs.

 

            We have invested $700,000 to expand the sexual assault nurse examiner program, or SANE. The NSHA has issued a call for proposals to increase services in Cape Breton and the western region and to appoint a provincial SANE coordinator. Mr. Chairman, our goal is to see services offered in a number of locations across those two areas of the province. I'm looking forward to seeing expanded SANE launched later this year. The SANE program has already proven its worth in the northern and central zones, and represents the commitments I believe we all share to better support the victims of sexual assault.

 

            Another significant investment in this year's budget is part of our ongoing effort to reduce surgical wait times, particularly in the area of orthopaedics like hip and knee replacements. We've invested an additional $1.9 million to help the many Nova Scotians who are waiting for surgery. The Health Authority has been working to make the best use of its operating rooms and clinical teams to reduce wait times. They will have the opportunity to direct these funds where they will do the most good.

 

I want to be clear, Mr. Chairman, about this commitment that truly will make a difference. Since 2013, we have invested a total of $8.1 million to improve orthopaedic surgical wait times. Last year, there were 675 hip and knee procedures performed in addition to 19 spinal procedures over and above the average number that had been performed. With this additional funding, we expect that as many as 160 additional procedures could be performed for a total of 835. Overall, wait times for many procedures have stabilized. Hip and knee replacement wait times are improving, with a 14 per cent decline in wait times for knee replacements since Fall 2014. We are very close to meeting national wait time benchmarks for hip fracture repair, radiation therapy, and cancer surgery. This is another step among the many incremental improvements we have seen in wait times across the health care system.

 

            I don't want to minimize the challenge. I know we are all aware of examples where wait times are still too high. We continue to work with our partners to see improvements in all areas. Much work remains to be done, but I believe our progress is both measurable and sustainable.

 

            Continuing care: seniors have worked hard to support their families and contribute to their communities. We need to help seniors stay healthy longer and offer services to protect their well-being as they age. That's why we are adding $14.4 million for home support and nursing, the caregiver benefit, and wheelchair programs. Nova Scotians have told us clearly they want to remain in their homes as long as possible, and we are committed to helping them achieve that desire. We have put an extra $59 million into home care, including nursing care and home services, since 2013, bringing the total to $255 million a year. This year we are adding an additional $7.4 million in home support alone. 

 

We've also recognized that moving resources to support home care means transitioning from our traditional long-term care model. This year we have added a number of long-term care homes to manage a 1 per cent reduction in their operating budgets. Many have already identified innovative ways to increase their efficiency and reduce costs, things like taking advantage of group purchasing, shared administrative services, and joint contracting for insurance. But we know, Mr. Chairman, that this is not a problem money can fix. We need to look at better communication with clients and improving how services are coordinated. The NSHA and home care agencies have been doing that and have already demonstrated impressive results. In fact, within the last six months, they have succeeded in virtually eliminating the wait times for home support in Pictou County and in Yarmouth County. The lessons they have learned are now being applied in other parts of the province, and progress is already being made.

 

            The Department of Seniors: Mr. Chairman, older Nova Scotians are a diverse population and represent a valuable source of knowledge and experience. Nova Scotians over the age of 65 continue to be active in their communities and contribute to the well-being of our province. We have the highest volunteer rates among seniors in the country, with 44 per cent engaged in volunteer work. Nova Scotians over the age of 65 represent nearly 4 per cent of everyone employed in the province. Given our demographics, government's focus on older adults is more important than ever.

 

The team at the Department of Seniors is committed to its mandate. We need to consider this perspective in policy and program development across government, and we need to continue working with communities and partners to advance age-friendly approaches. Staff will lead the development of policy options that recognize and encourage the economic and social contributions of Nova Scotia seniors. Recently a very successful summit was held in Pictou to achieve that very end. The department will engage with our partners across the province to promote and support older adults in paid or volunteer work, create the conditions so they can age well in their own homes and communities, and help them live healthier lives.

 

We will continue to collaborate with our stakeholders and other departments to align our efforts around helping Nova Scotians age and live well. The department continues to offer various programs to support community-level projects which are led by municipalities, law enforcement, not-for-profit organizations, and community groups. We will continue to lead coordinated efforts to ensure that the issues, opportunities, and contributions of older Nova Scotians are considered in government decision-making. Mr. Chairman, I'd like to thank the staff of the Department of Seniors, who support these important programs every day.

 

            Every decade Nova Scotia's health care spending has gone up, but we aren't becoming healthier as a result. Fully 42 per cent of our provincial budget is devoted to health care, well above the national average of 38 per cent. Yet we continue to see some of the poorest health outcomes in Canada. We believe it's time to change that by focusing on setting priorities and measuring results so we know where our health care system most needs to improve. That is the goal of the changes we implemented over the last two years. The measures contained in our 2016-17 budget reflect the positive outcomes we have already achieved as well as our vision for the future. The announcement of a new model for the province's major teaching hospital, the QEII Health Sciences Centre, is perhaps the most significant example. In building a health system that will meet the needs of Nova Scotians for the next 50 years, we recognize that we couldn't simply repeat the old ways of doing things. The result is a plan that leverages existing infrastructure in Halifax, Dartmouth, and other nearby communities like Windsor with strategic new construction that will move services closer to communities where people live.

 

            Before I conclude, Mr. Chairman, I want to take a moment to express my personal thanks and the gratitude of the Government of Nova Scotia to the thousands of dedicated Nova Scotians who work tirelessly every day to help Nova Scotians achieve better health and better health outcomes. These are the doctors, nurses, clinical specialists, and other health professionals who are on the front lines of care. But it also includes the administrators and policy-makers who toil behind the scenes to create the foundations of a modern, effective health system. We must not forget the thousands of volunteers who devote themselves to building a healthier Nova Scotia, fundraising, assisting clinicians, and supporting patients and their families. Without the contribution of every one of these competent, caring individuals, the health system in our province would be much diminished.

 

            With that, Mr. Chairman, I will conclude remarks and open the discussion. With the assistance of Mr. Elliott and Dr. Vaughan, I'm pleased to answer any questions about the department's estimates and operations.

 

            MR. CHAIRMAN: We will now move to the Progressive Conservative caucus for 60 minutes of questions.

 

The honourable member for Argyle-Barrington.

 

            HON. CHRISTOPHER D'ENTREMONT: Thank you to the minister for those opening comments. I want to welcome Deputy Peter Vaughan and Kevin Elliott for being here today to provide him with the background information he's going to require over the next number of hours here during estimates for the Department of Health and Wellness.

 

            I too want to lend my voice to thanking the people who toil behind the scenes, actually in front of the scenes - the doctors and nurses and health care professionals who provide a phenomenal health care system, a phenomenal level of health care in this province each and every day. They're the ones who, I would say, provide us with the patient care that Nova Scotians deserve. They're the ones who probably put up with far too much negativity sometimes on long wait times and inability to access services and those kinds of things. But quite honestly, they do yeomen's service in providing each of us and our loved ones with the health care system that is robust and yet could use a whole bunch of improvements as well.

 

            Mr. Minister, $4,132,209,000 is a big number, being 42 per cent of the total budget. When I had the opportunity to sit in your chair, I brought a budget forward of $3,205,939,000, so in a short eight years this budget has grown by leaps and bounds. Yes, you've kept it to under 1 per cent . . .

 

            MR. CHAIRMAN: Order, please. Just a reminder not to speak directly to the minister but to make your comments through the Chair.

 

            MR. D'ENTREMONT: The minister has boasted that he kept it under 1 per cent. I don't know whether to celebrate that or not, because as we go through the budget lines to try to understand what's laid out before us, I think we'll find, Mr. Chairman, that there are a number of places that will be lacking, that will not have the investment that they did require to provide the services that are needed by Nova Scotians. I mean, $4 billion is a large amount of money, but if we look at the services that are required and expected by Nova Scotians, I think we'll also find that improvements need to be made. Will they amount to the annual 3 per cent increase that we had seen over the last 20 years or so, even more in some cases? We saw a 0 per cent increase once by a previous government. That didn't bode well because the next year it did go up farther than it needed. There's always that danger that if we hold it one year, there's an added cost to the next year. Hopefully as those projections are worked and we look at what's actually invested by the Nova Scotia Health Authority, by the IWK, and by the other provincial programs, these will be realistic numbers.

 

            When $4.1 billion gets invested in health care, that means there's $4.1 billion that can't be invested in other parts of the province, in other parts of the budget, whether it's in transportation, whether it's community services, or whether it's labour and advanced education. There's a whole bunch of places where of course, that dollar is being asked for by different departments of government. We know that we're keeping it short here, we're keeping it tight, hoping that some other dollars are available to those other departments. Yet there's a big number being taken up here.

 

            We had done some projections, and I remember having this discussion with my CFO on a number of occasions that if we did nothing - and this was back in 2006-07 - and just let it grow, the Department of Health would be the only department of government by 2020 or 2021. I think was the drop dead date if it continued to grow by that amount.

 

            Many times we talk about how, even though there has been this huge investment in health care over the last 10 or 20 years, none of us feel any better served than we were back then. We're still talking about some of the very same things that we were talking about before. We were talking about those wait times. We were talking about access to care - long-term care and home care, those kinds of things. Even though I know money is not all of it, money is a big part of it as well.

 

            Over the next number of hours, we'll have the opportunity to go through this departmental budget, and I'm sure we will speak philosophically about each specific item, whether it's mental health, whether it's Pharmacare, whether it's seniors' long-term care and home care, whether it's wait times, or whether it's construction of a new VG/Infirmary. We'll talk about the added investments, I'm sure, in different programming.

 

            What can say to you, Mr. Chairman, and to the minister is the layout of this budget doesn't tell the whole story. It's really hard to see where the investments are, to see where the department's investments are in specific programs. You talk about EIBI, making 56 new seats available, which is a wonderful improvement, but nowhere in it can I find it says EIBI in the documents that we received.

 

            I'm going to start going through some lines. We'll actually do a budget review here. I know Kevin will be very happy about this one. We'll actually take the pages and go page by page. I'll get the minister to explain the headings as they are. Of course, General Administration, we understand; Office of the Minister, we understand; Deputy Minister and Associate Minister. But as we start moving down, I'm sure there will be some questions specifically for estimates of 2015 and estimates of 2016 and maybe why money was spent or was not spent in our forecast.

 

            The first one that I do want to bring up is on Page 13.4, which talks about the Chief Medical Officer of Health, who of course provides leadership and funding for communicable disease prevention and control. We do see a $4.9 million decrease to that budget. I'm guessing it got transferred somewhere else in the budget. Maybe we'll start off by talking about what the Chief Medical Officer of Health does and how the programming is being transferred, or what's being held by the department and what's been transferred to the health authority.

 

            MR. GLAVINE: I thank the member opposite, the member for Argyle-Barrington, a former Minister of Health. It's been a wonderful opportunity for me over the past two years to have former ministers really drilling down on this huge budget and all its implications.

 

            One of the areas that I said I would be involved with over my time in office was foundational work. The new Health Authorities Act is foundational work. The real transformation, while it has begun - we'll really see the fruits of that work, the value of that work, the impact on Nova Scotians, probably five, six, or seven years down the road. In many ways, the first question asked by the member relates now to the realignment as well, in the health department.

 

            If there was one area that provinces like Alberta and New Brunswick were absolutely emphatic about, it was making sure you aren't too far along with your provincial structural change of going to one or two health authorities - we have two health authorities, of course, the same as New Brunswick, only they're along linguistic lines, and we are with the iconic IWK and the Nova Scotia Health Authority. They said one of the realities is that you need very, very clear lines of demarcation between the Department of Health and Wellness and the Health Authority. To that end, we've also now carried out a major realignment, as I said in my opening remarks.

 

            One of those areas that's now tasked fully directionally is the public health of Nova Scotians. In many ways, that role had picked up a number of other areas along the way. I can't think of a position more critical to better health outcomes and to the prevention of disease and promotion of health, although there is some separation there. A good part of public health and its day-to-day operations has been moved over to the Nova Scotia Health Authority.

 

            Again, rightly so, we put our emphasis on vaccine and biological warehousing cost, CDPC program delivery. These are now the areas that Dr. Strang and his department will be focusing on, whereas the day-to-day delivery of public health is in the domain of the health authority.

 

            MR. D'ENTREMONT: As we remember, when I left that position, we had Health Promotion and Protection, so there was actually a whole other department that provided services of health policy, Chief Medical Officer of Health. It actually had the community grant. It was trying to really separate the wellness piece from the sickness piece at the time. The previous government did put that back together to call it Health and Wellness.

 

            In this 2015-16 budget, there were 65.7 FTEs in that department. It went down to 16.4. I'm just wondering what's staying with this department and what is going to the health authority.

 

            MR. GLAVINE: To review the numbers for the member, moving out of the department were 13 FTEs. These were internally transferred due to redesign, 13 positions to the NSHA. Fourteen were transferred to the Department of Environment since the Department of Environment now is carrying out all of our inspection services. As a core group, focusing and concentrating their services and abilities inside of that whole inspection process I think will prove to be of great value in terms of the work in the department, monitoring and managing the health status risk by addressing health inequities and setting strategic direction.

 

            What we will have now in the department is four directorships. Those are now in place. They'll do coordination in the department to work in a team concept. As opposed to taking an issue, a policy, or a program and moving through each little section of the department, one of the big changes that will take place under the direction of the four new directors is a coordinated approach to making sure that policies, implementation of standards, and then monitoring by that group takes place on an ongoing and regular basis. This is one of the big internal changes that has happened at the department.

 

            MR. D'ENTREMONT: If I am to understand that, there's a bunch of numbers being moved around, but strategically what you're saying is that we have the Chief Medical Officer of Health - that position remains the same. But that person will now have a team of four other sub-officers of health, or whatever those positions will be called, ranging from I'm guessing the different districts of the health authority.

 

            MR. GLAVINE: In my zeal to get the bigger picture of the operations of the department talking about the four directors - that is four directors where there used to be probably 12 to 16 now down to four. That's the operations of the department.

 

            Dr. Strang and his team will obviously work with the zones as well as a number of people in the department. One of the big areas that is part of the change here is Dr. Strang and his team working across a number of departments. We know that the determinants of health can't be confined to the Department of Health and Wellness; they need to move across Justice, Community Services, and Education and Early Childhood Development. So his work now is in fact to give those good policy pieces and ideas out to a number of departments and work on a more coordinated approach to deal with those deficiencies that we have faced in our province for some time.

 

            MR. D'ENTREMONT: So the numbers as I see them, under Chief Medical Officer of Health, there was a drop of about $4.9 million in that budget. So I'm guessing that gets picked up by the health authority of an equal number or close to an equal number.

 

            There's about a $5 million loss here, and there's a $4 million gain there. That's Page 13.13. It just shows Public Health Services, $30.9 million in the estimate last year and only $34 million for this year. There's about a $1 million discrepancy in what was lost out of it to what was gained by the health authority. Did we lose any programming, or is that just simply trying to get rid of some of the bodies we weren't actually using in there?

 

            MR. GLAVINE: In terms of drilling down a little further here, some of that sum quoted is made up of 11 FTEs that were eliminated due to redesign. Also, the biologicals program budget is to reflect the historical spending, and that is close to $400,000. Those two would make up that $1 million.

 

            MR. D'ENTREMONT: Before I move on to the next thing, this is the department or division within government that talks about disease prevention and also talks about the possibility of disease outbreak as well, whether it's avian flus or Zika viruses; it goes on from there, the things that they are going to monitor. What kind of monitoring will be going on over the next year or so when it comes to some of these diseases that we've been hearing about a lot in the news? Again, Zika seems to be the big one of the day, but we know that there's a number of issues that are going on, the determination of what flu strains we'll have this year, those kind of things - maybe just a general statement on what's coming up.

 

            MR. GLAVINE: One of the four directorships that I had mentioned is now headed up by Ruby Knowles. That is system performance and strategic developments that will work across our Department of Health and Wellness as well as other departments and obviously having to deal with acute care, tertiary care.

 

            But in terms of looking at possible outbreaks of disease, the member is right to identify a flu or Zika or diseases that were also a concern as refugees came into the country. Our department, again under Dr. Rob Strang, is a lead often in the country in these areas, working with federal partners and provincial partners on an ongoing basis. I've been in on a few of those discussions, when there was the first case of a disease and the possibility of others and how quarantine measures would be taken, and were staff all professionally prepared. Dr. Strang and his department, now under the direction of Ruby Knowles and with more strategic planning right across all departments, I believe puts us in a very, very good place to be able to handle these communicable diseases that could indeed have an outbreak.

 

            MR. D'ENTREMONT: On Page 13.4, Communicable Disease Prevention, I see there's an increase of $531,000 versus $713,000 this year. I saw an article yesterday or a couple of days ago, an Alberta story about the increase of STIs in that province. I think it was due to dating websites and things like Tinder. Are we looking at some of the same things here when it comes to that? What are we increasing the communicable disease prevention budget for? Is it for things like that?

 

            MR. GLAVINE: Part of that amount of money identified is, again, some of that internal shifting that has taken place. I knew, as we went into Budget Estimates, that there would be a lot of explaining about the redesign. It's really two FTEs who have moved under the Chief Medical Officer directly to communicable disease prevention in the DHW transfer. There may be a small amount - when I went through the Budget Estimates looking at some of the details, we had a great pickup in flu vaccination, and I think there's a small increase this year as we move to quadrivalent vaccination in the coming year.

 

            MR. D'ENTREMONT: I'm guessing the immunization program is in that as well, the flu immunization. If we're going to be vaccinating with pharmacists versus doctors - I'll probably talk about that in the pharmacy section - I'm wondering if there is going to be any further work on getting more pharmacists to do that. I know the pharmacists have been having a really good time of doing flu shots. It seems to be a very convenient place for Nova Scotians to get their flu shot. I'm just wondering what kind of effect that has had to the uptake of the flu vaccine. I still hear when I go out, oh my God, I don't take that because I get sick because of it, and all kinds of crazy things like that. What has the uptake been since pharmacists have taken on the job? Has it actually increased the uptake, period?

 

            MR. GLAVINE: As the member probably realizes, we've been a leader in the country in terms of percentage of our population who do get the flu shot. Even though two years ago the selection for the vaccination was perhaps a little bit premature, and it didn't go quite as well, this year, I think we've had a very, very good year in terms of preventing flu. Also the number of deaths from flu is again dramatically down. We've seen roughly about the same percentage of Nova Scotians over the last few years, but there has been a shift of about 20 per cent from doctors' offices and clinics to pharmacies, I think a couple of hundred pharmacies across the province. They don't have to wait very often in the queue. Pharmacies are becoming, for many people, the place of choice to get their flu shot.

 

            MR. D'ENTREMONT: I said that would be the last question on that one, but how has the selection of strains been this year as we're working towards flu season again? It seems like we're always working toward the flu season, and we have to wait to see the effectiveness of it. I believe this year we had three different strains in the flu vaccine. Are we looking at the same three strains? Are we looking at something different? Are they adding a fourth? I don't know - the sky's the limit on what can be done in that respect.

 

            MR. GLAVINE: I know this is always one of those difficult areas to be able to say how successful the selection of strains in a particular year will be. I know H1N1 remains in the flu shot since there are still some cases being reported. This was a question actually posed recently to the World Health Organization to look at, if at all possible, tracking a bit later before making the decision on what strains would be included in the flu shot. Very often, we're looking at what's emerging in the southern hemisphere, and then that will move across globally.

 

            Again, we're trying to create the art of the possible, best outcome, so it certainly embraces science. But obviously if we have four strains of the flu covered this year, we're in a better position. We've been working on getting the quadrivalent vaccine. I'll have to check and see if in fact that is planned for this year.

 

            This year, the budget for the flu shot will be $9.1 million. That's because, again, we have exceptional take-up in our province. Some of that as well could reflect our aging demographic, where seniors are very, very susceptible to the flu and also the chance of more severe health issues as well.

 

            MR. D'ENTREMONT: Let's move on to something that looks a little less exciting. Nonetheless, we'll move on as we go through the budget document. On Page 13.5, we talk about Client Service and Contract Administration, which has a total budget of $5.4 million. Could I maybe have the minister explain exactly what's in here? I see emergency health services, telecare, and pharmaceutical and insured services - maybe a better explanation of what those lines are?

 

            MR. GLAVINE: Included in this area are client services, contract administration, contract management, eligibility review office, insured services administration - which is responsible for interprovincial reciprocal billing, out-of-country claims, third-party liability claims, travel, and accommodation - and pharmaceutical services admin for developing policies and strategies for the appropriate use of drugs to ensure access under the public drug programs.

 

            MR. D'ENTREMONT: So the thing that stands out in this list is the Client Service and Contract Administration line. That basically had no input for last year and then had an input for this year, so I'm guessing that's either a brand new heading or it was transferred from somewhere else. Maybe you could just give an idea on what exactly that is.

 

            MR. GLAVINE: Again, this is part of the department redesign. One of the areas where we realized that we have to get much better is drilling down on our contracts, especially our large contracts. A number will undergo, probably for the first time in years, a very significant review and analysis of those. Now we're clustering those so that best practices can be derived. We've had some examples from the NSHA as well this year where when contracts were renewed, much more stringent deliverables were included. Over the next number of years, I believe we'll see much better contracts that will be part of the future. Evaluation and compliance, when we're talking about millions and millions of dollars in contracts, I think, need the kind of analytics that perhaps we haven't always had in the department.

 

            Earlier today I spoke about 20 new positions that will be hired in the coming year. A number of those will be analysts, people who can take a look at how our contracts are performing to meet the desired goals and better outcomes for Nova Scotians. I think this redesign will help move us in that direction.

 

            MR. D'ENTREMONT: Moving to Page 13.6, which I would qualify another boring bureaucratic headline, Corporate Service and Asset Management, this one here is a little interesting because there is a drop in what we're actually spending here. We're losing 55 people. Some of it is under IT Systems. Some of it's under Health Services Emergency Management and Administration Services. That one's taking the biggest hit, I think, about $4 million. Maybe you could just give a little bit of a rundown of what this heading is and maybe what's getting axed or moved out?

 

            MR. GLAVINE: Again, as part of the redesign in the health department, when we look at the corporate processes quality area, 31 people from the Department of Health and Wellness moved over to the Department of Finance and Treasury Board. Some other positions moved to Internal Services as part of the whole redesign that took place. Health Services Emergency Management and Administration Services had a couple of positions as well.

 

            MR. D'ENTREMONT: I see that year over year IT Systems is going down. What's included in that? I know later on we'll probably talk about EMRs and patient computer systems and all that stuff. Is this just sort of the basic stuff in the department that's being transferred to Internal Services, or is this something else?

 

            MR. GLAVINE: This is not really the actual system itself, the IT system, but rather those who are in planning for the OPOR personal health record, these are the areas that come under this heading.

 

            MR. D'ENTREMONT: Okay, because it seems to pop up in the next one. Investment Decision Support, which is the next heading, "Provides health information management and analysis for government to enable evidence informed, health system decision making." This one is a $3.7 million item which has three headings. You talked about analytics, which is something we've been doing year over year - it has taken a little bit of a hit - but I'm guessing something got moved for Health Information Management and Investment Decision Support Administration. Maybe you can round that one out a little bit for us.

 

            MR. GLAVINE: That's what I like about former health ministers: they get down to some of that granular level of asking questions. This will be investment decision support administration; analytics, which I alluded to earlier and you mentioned as well; and health information management. This really is drawing upon the tremendous amounts of information that are collected in the department. We often hear about how much data is collected, and this is the area then where, when we make investments, it is supported by the analytical work, the data that's collected, to give us the best areas of both policy and program that we can implement in the department.

 

            MR. D'ENTREMONT: I'm just wondering what kind of investment decisions would be caught up in this. Is it investments in the purchase of equipment? Is it decisions in certain programs? Is it getting data on wait times? I need a little more data on this.

 

            MR. GLAVINE: This really strikes at the heart now of what the department's redesign is all about. That is taking not just the information that is collected and looking at what can be a change in policy but very much really taking the data and making the necessary plans for improvements in the system so that if we need more work directed towards, let's say, type 2 diabetes, then as part of disease management we can start to direct some more funding in that area. We actually do have an amount of money that this year will in fact roll out for disease management. Gathering that information and making the planning both in the short and the long term are part of the work that will go on here.

 

            One of the areas that is often brought up here in the Legislature, of course, is what's happening to a whole wide variety of wait times. We hear first and foremost about the long wait-lists, the ones that CIHI monitors and gives an annual report on. What are those six major areas? What are the benchmarks that are to be achieved? This is the kind of information that will help us look at - if it's a CAT scan, do we have enough capacity in some areas of the province? We know, for example, the need in Cape Breton for a new linear accelerator because of the high cancer rates that have been recorded over the last couple of decades. That got us moving to have state-of-the-art equipment, just in time, when one piece of equipment, one accelerator, was reaching close to its life cycle.

 

            We're constantly monitoring the kind of areas around disease prevention. We know that in our province we have pockets of very, very high chronic disease. One of the most startling statistics that hit me when I was taking a look at chronic disease across the province was to find areas at the eastern tip and the western tip of the province with anywhere from 7.5 per cent to 8.5 per cent of the population that had five or more chronic diseases. It's getting this data but then designing a policy and a program to work on that management, as well as reductions.

 

            MR. D'ENTREMONT: Maybe at a later hour, we will talk a little more about analytics and how we gather that data. I know we do rely on other sources to get a lot of it. But as we roll around and talk about a real electronic medical record, there's a whole bunch of subsets of that record that you can get a whole bunch of data off of as well. I think that's more of a discussion for later on.

 

            Within this one, though, there is a gain of 23.5 FTEs on this. Are these all new hires, or were those movements? We lost 55 people in the other heading; did some of these people just get moved around?

 

            MR. GLAVINE: This is perhaps one of the more exciting areas that I see the department moving towards. In the big Department of Health and Wellness, which had over 400 employees, we often worked in little sections and silos, really, within the department. This now will be some of our existing personnel who will be clustered together as well as some of the new hires who will be brought together to work in a team in that collaborative integration of skills that we feel will, in fact, start to show results as early as this Fall, despite having gone through an enormous change and having our lead and our deputy minister and associate deputy minister deal with those cuts and changes and exiting of personnel to the NSHA; the IWK; and Communities, Culture and Heritage.

 

            I took the time to do some exit interviews. I wanted to know what people were thinking and feeling. With every one of them, there was excitement about the change even though they weren't necessarily going to be directly part of it. They were maybe going off to the NSHA or another department, and some, of course, were retiring. They all saw that this was a needed development in the department to bring the skills into a coordinated way to work on the many substantive issues that we have in Health and Wellness and Seniors on an ongoing basis. Even now, there's very strong discussions, and around within six months, we'll start to see some of their work borne out. We will see some of that policy development and some also will be part of future legislation as well.

 

            MR. D'ENTREMONT: If we go on to the next bureaucratic heading, which is System Strategy and Performance, Page 13.7, "Responsible for development of system strategy to manage and mitigate risks to the health of Nova Scotians across the continuum of care . . ." There have been a number of drops within this one, so I'm guessing either we're not doing risk management, or it's actually being caught up in some of those new headings. We're down $4.4 million on health promotion and risk management. We're down $1.3 million on continuing care risk management. We're down $3.3 million on primary and acute care risk management. Could the minister maybe give us an idea of where risk management has gone or how it's going to be addressed in the new redesign?

 

            MR. GLAVINE: I know that's where there's a pretty significant drop in that budget area. Really, again, it measures and captures those people who have moved to other departments. Under Risk Management - Health Promotion, 23.6 FTEs were transferred to Communities, Culture and Heritage. Thrive! grants were transferred to CCH. Eight FTEs were eliminated due to redesign. Six FTEs went to the NSHA in this area. In Risk Mitigation - Continuing Care, there was an internal transfer of 10.5 due to redesign.

 

            I know you would certainly have read Dr. Raymond LeBlanc's piece around the whole area of that quality assurance, that whole area of monitoring how the system works. I know Robin McGee also wrote a piece that those who monitor the system were moving to the NSHA. Yes, in terms of looking at the quality of work, measuring the standards, having people who could provide some oversight directly to the NSHA in looking at all of our care from a provincial perspective with making sure standards are in place, some personnel were moved to NSHA. One of the areas now that will become the whole central focus of the department is where I know a few of the people commented publicly on losing those positions, and one even asked how we are going to make sure that the system is functioning at the highest quality day-to-day.

 

            Now this is really one of the biggest focuses of the health department, to make sure that we have high standards of care in place and monitoring of those standards. That kind of vigilance now becomes the work and one of the main focuses of the department. I know that over the next year, we'll see the department relating that monitoring to actual events that take place in the system and how they're moving to make sure that quality assurance - high standards of care - is there at every turn. That really is now a major focus of the department, and we'll see some other developments during this fiscal year.

 

            MR. D'ENTREMONT: Moving right along, I kind of wanted to get this one done in my first hour so that we would go back and maybe take specific issues as we went along, but I'm quickly running out of time already.

 

            The next page, Physician Services, Page 13.8 - here's where we talk about the funding that we provide for physicians' services, pharmaceutical services, emergency health services, and continuing care. More specifically right now, on the physicians' services side of things, we know we're in negotiation right now of the master agreement.

 

            I know the minister probably doesn't want to be saying a whole lot, but we have a flat budget here. There is really very little change. As a matter of fact, there's actually a little decrease in what's going on here. In light of some of the questioning that has gone on in this House of meeting doctors across the province in different places, and we get into the debate of ratios and all that, I think this tells a lot about where the department is going right now when it comes to paying physicians. Why are we taking a decrease or at least keeping this flat when there are so many needs across the province?

 

            MR. GLAVINE: I guess with the master agreement still an outstanding issue, perhaps I shouldn't say too much on this one. But in reality, we have started - really under the previous government - a practice through the collaborative model that I believe is going to see some reduction in physicians' services. We've opened a number of practices this past year, and the goal, of course, is to have a patient in front of the right provider at the right time. Going to a nurse practitioner or a family practice nurse will extract less dollars from the system, and more physicians going on contract versus fee-for-service brings about a reduction. We did have a movement to the NSHA of dollars for recruitment for the physicians' service budget.

 

            MR. D'ENTREMONT: I'm sure I'll come back to that one as we flow along. Like I said, I just want to sort of get the general budget out of the way first.

 

            On Page 13.9, we move on to Pharmaceutical Services and Extended Benefits. In this one here, we see Family Pharmacare Program, Insured and Extended Benefits Programs, Seniors' Pharmacare Program, and the Special Drug Programs. We see all of them to be getting modest increases I think in most cases here. I'm just wondering about the outlook for the subscription rates over the next year or so. Will they be adding to the formularies on these ones? What kind of general issues are you seeing in pharmaceutical services this year?

 

            MR. GLAVINE: Giving a perfect guide to an important service like pharmaceutical services is certainly challenging. We have a drug come along that has a really significant impact on just one medication. We had that in the past year and actually had a little further utilization increase this year of a drug called Kalydeco. Kalydeco looks after a subset of cystic fibrosis patients. Just to look after either eight or nine patients in the province who now get Kalydeco, that annual cost is about $2 million.

 

            Last year we brought on Harvoni, which is an actual cure for hepatitis C. So this year, we have a much stronger utilization and pickup of Harvoni. The results have been nothing less than astounding for patients who have been able to get Harvoni. The idea, of course, is to have more get it this year.

 

            If the member opposite would allow me the indulgence of one of those good moments in the Minister of Health and Wellness's chair - and we do have those good moments for sure - it was last year just the week before Christmas when I had two phone calls from two people who four, five, or six months earlier had started that course of treatment. Yes, it's $60,000 a person to get Harvoni. These two people were calling to say, by signing off to provide Harvoni to the formulary, you have given me the best Christmas present in years; I am completely free of hepatitis C. But that just really signals the kinds of developments that are going on in the pharmaceutical world, the biologics that will be introduced and the new oral cancer drugs.

 

            We know the rate of cancer in our province, based on one in four Nova Scotians being in the baby boom cohort, just by the natural factor of so many in that one age group, roughly 52 to 67, we're seeing the incidence of cancer go up; therefore, the drug formulary needs to respond. That's why every year there's a call for more money to be added.

 

            We've had an unbelievable beneficiary in Nova Scotia and other provinces of the work of the pan-Canadian Pharmaceutical Alliance that has allowed for a number, I think somewhere between 16 and 20, of drugs now, molecules, that have gone on the formulary that are about 18 per cent of brand. This has been a savings of millions and millions of dollars to our health care system and to the benefit of those who require pharmaceuticals of any age across Nova Scotia.

 

            I'm sure I'll have more specific questions around that, whether it's the Family Pharmacare or the Seniors' Pharmacare, and I look forward to those in the next hour.

 

            MR. CHAIRMAN: Order, please. Time has elapsed for the hour of questions by the Progressive Conservative caucus. We will now move on to the New Democratic Party caucus for 60 minutes of questions.

 

            The honourable member for Sackville-Cobequid.

 

            HON. DAVID WILSON: I want to thank the minister and his staff for being here today to talk about what I often have said is the most important department in government. It touches everybody's lives in our province. I think that's why this process is important for us, to dig into the line items of the budget and make sure that Nova Scotians understand the ramifications of the provincial health budget.

 

            I listened intently to the minister in his opening statements, in his opening comments. In this budget this year, we see what I've described as pretty much a freeze. At times I've described it as a cut. I know I've had some members of the government say, no, it's not a cut. But when you factor in inflation rates in our province - last time I read the Canadian inflation rate, it was maybe 3 per cent or around there, whatever it is, well over 2 per cent - and you see a 0.93 per cent increase in the health budget, it really reflects a cut. If you were to just maintain the services we have, with the inflation factored in, you would need those additional funds to just maintain services and stuff. That's why I indicated in some of my comments that it is a freeze, it is a cut, to the operating budget.

 

            I know the emphasis of the government over the last couple of years has been to try to curb health spending, which I think is something that governments need to look at. I know we spent time when we were in government looking at that and trying to make sure that the investment we made in health had the benefit of improving services and improving outcomes for Nova Scotians. When you see in the budget other departments seeing the increases and seeing the investment, I'm concerned about what ramifications there will be for services out there. As was noted, there's a number of former ministers in the House - my colleague who just spoke, myself, and there are two other ones, if I'm not mistaken. We've been through this process, and we know and I know about getting ready for the budget knowing that even a percentage cut in health means that there need to be some savings found within the districts or within the new health authority.

 

            I want to start off with the December forecast. That was the budget update in December of last year. It was noted in that update that the budget for the Department of Health and Wellness was going to be $3.7 million over budget. Four months later, we see in the budget line item that it doesn't actually reflect that; it was actually underspent from estimate to forecast last year of about $23 million by my calculations. How in four months do we go from a forecast update from the finance minister in December projecting $3.7 million over budget to underspending that budget by $23 million? I'm just wondering if the minster could give us some comments on that change in the last four months or so.

 

            MR. GLAVINE: I thank the member for his opening comments. Certainly, when we talk about the total health care budget and its big sweep and projections made back in December and where we ended up, it does allow to make the statement about why we really needed to do business differently in the province. We know that no matter what happens in terms of the new health accord, and there will be a new health accord, it's not likely to be anywhere near the traditional 6 per cent that had been coming on an annual basis. We will see probably about half of that. Plus we're all hoping for some additional monies, I know committed through home care, which will help our province. But $3 billion being divided across the country and the territories will certainly end up being a small amount. So as the new health accord is developed over the next year, we certainly hope that we will get the right amount for our province.

 

            Overall, we knew that we could not rely on the same amount of money coming from Ottawa. That caused us to start to look at doing business differently. First of all, I do need to give the strongest accommodation to three of our financial officers: Kevin Elliott in the department, Allan Horsburgh in the NSHA, and Stephen D'Arcy in the IWK. They were tasked by the Premier and the Minister of Health and Wellness and Seniors to look at how we would operate differently and to project out probably for a decade how we would undergo health change, health transformation.

 

            We know that we have to have the right amount of money in the health care system to look after the health needs of Nova Scotians. We know that we have some infrastructure challenges, the biggest, of course with the VG and the Centennial and a few of our community hospitals that also will need revitalization.

 

            But how would we go about doing day-to-day business in the province? First of all, I'd like to have the budgets in front of me passed for the IWK and the health authority because those are going to be so insightful to Nova Scotians about the kind of efficiencies and the changes that have gone on that have not impacted health care and, I would say, made our system stronger as we took down the borders and the barriers to moving doctors across the province to deliver care and starting to develop centres where greater amounts would actually be done with best practices. This has been one of the great sharing stories, integrated stories, that we will hear more about.

 

            We all need to point out here that when the health authority started, the debt of the nine districts did not evaporate. That debt of $29 million went on to the new health authority. When we finally officially pass their budget, we will have a lot of good news, a lot to celebrate.

 

            It truly is about doing business differently. The business around when we look at procurement and when we look at contracts did not have the kind of due diligence, the kind of oversight, to award a contract that would have deliverables built into it. That is probably some of the kind of change areas that I believe are making an enormous difference. They will be able to point to certain contracts where a saving of $500,000 was made, for example, with ordering one particular piece of medical equipment for every district across the province. But I'll allow them to share in some of that good news.

 

            It's one of the exciting areas where again we'll save dollars in the years ahead; in fact, we may be able to have, hopefully, a series of years of bending the cost curve yet and actually doing more while carrying that out. I think that will be a new reality. It's good timing, since the member and former health minister may have in fact engaged in some of these early discussions.

 

            It was just a matter of weeks into office when the Minister of Health for P.E.I., Doug Currie, who was the minister of the day, reached out. He was the longest-serving minister in the country. He wanted to bring me up to speed on how things were operating in the Atlantic area and how they were operating nationally. More importantly, he said, let's our two provinces start to co-operate. I said, well, that's kind of easy, Doug; we have the same Parties that are in office. I said, this needs to be a New Brunswick, Newfoundland and Labrador, and Atlantic approach. We have started, I believe to the credit of the deputy ministers in the province. I know Deputy Minister Vaughan said let's start to look - and I certainly was a proponent - beyond partisan politics because there were two Progressive Conservative Governments and two Liberal Governments. Let's embed in our departments a new way of doing Atlantic co-operation.

 

            We know there are gains to be made on the procurement side. But there's also gains to be made if, for example, we look at coordination of physician fees or if we take a look at common formulary for drugs. We've started a lot of discussions, a lot of work.

 

            In May of this year, there will be an Atlantic order for the next generation, if you wish, of ultrasounds - an Atlantic order. Why we hadn't been doing this for years I don't know. I hope that we will be able to achieve a lot of cost savings as we move forward just in the context of this Atlantic co-operation. Deputy ministers and department people are meeting on a regular basis. They're outlining the future. They have short-, medium-, and long-term goals that they want to achieve. I think what we're doing in the province now is starting to be really replicated across the Atlantic Region.

 

            I see a lot of value. I am convinced and convinced as much and more by the medical community. Many of our physicians and nurses across the province have reached out to say that we can do things differently. In doing them differently, we can do them better, and we can do them more cost effectively. One area that I hear about from the man on my right every day is that we must never, ever relinquish the goal of a better quality of care and stronger outcomes in our province. That's what we want to embed and incorporate in doing the work of the health department differently. It certainly is different and starting on a path completely in many ways different from what I experienced in my first months in office.

 

            Budgets tell a lot, as the former minister said. They represent the work and the delivery of the necessary care, the ongoing primary care. I believe that is central to what we need to do more of in our province, and that is to get all patients, all people in the province, in front of the right primary care provider. I know that that will be a team model of delivery, and I'm sure there will be questions about how we formulate it and how we bring that into practice right across Nova Scotia.

 

            MR. DAVID WILSON: I appreciate the comments from the minister, but he didn't answer the question about how you go from $3 million over budget in December to $23 million under budget four months later.

 

            I need to maybe burst the minister's bubble a little bit here on the co-operation of health ministers not only in the Atlantic Region but across Canada. It didn't start when a Liberal Government was elected in Nova Scotia. That work has been going on for many, many years. In a province like P.E.I., for example, with Minister Currie, who I've worked closely with, it didn't matter that we were with different Parties; we worked together to try to improve emergency health services. Minister Currie was here in Tatamagouche and in Springhill looking at the CEC model that they had here and they adopted in P.E.I. They were here talking and working with Nova Scotia when we expanded the 811 phone line service to P.E.I. That was done previous to a Liberal Government here.

 

            Of course, the generic drug pricing had taken place across the country, which included all three main political Parties, including the Saskatchewan Party. The work didn't start just when the Liberal Government was elected in 2013. A lot of good work had been taking place long before that. I'm glad to see that the minister is continuing that.

 

            But the question was on the difference in the budget from December to today. I'm just wondering if you could be a bit specific about where those savings were found. He indicated that they had to absorb the $29 million deficit from the district health authorities. I would assume that was known in December, so that may have been part of the forecast - to four months later. Is there anything specific? Is there just savings that were found within the health authority that changed those figures? It's quite a bit of money. You're looking at about a $26 million or $27 million swing in four months with the budget. I wonder if the minister could be a little bit more specific on why we're seeing such a swing in those funds.

 

            MR. GLAVINE: We all know that forecasts - as well, we saw quite a change in the total budget from December probably reflecting more the first six or seven months of the year when that update is given, somewhere in that line. We had some capital projects that did get a bit behind. We know that it's really a small percentage of the total budget that we're talking about here, but it is important that we note what was in the forecast and how we were able, by year's end, to have some of the savings. We'll see that a tremendous amount of the savings came from the new provincial health authority. Capital didn't go out the door quite as quickly for a few of the ongoing projects that we now have under way.

 

            MR. DAVID WILSON: Thank you to the minister for being a bit more specific on that. I would agree: $23 million - or if you look at what was made up, kind of a shift of about $26 million or $27 million - isn't a huge amount of money when you look at the overall budget. What concerns me is those under-spent dollars. Of course, those funds just go back to general revenue, or the treasury will re-evaluate the following year's budget. Last year's budget had a similar amount of money under spent, about $22 million. So over a two-year period, you're looking at about $50 million within health spending.

 

            Knowing a number of programs and the asks that I'm sure the minister is getting and that I received when I was there, was there opportunity to maximize the opportunities to support maybe a new one-time program or funding of some sort? Like I say, over the two years, it's close to $50 million. I know it can change daily. Was there any discussion on maybe tightening those figures up? I know it's very difficult to do with the number, but was there any discussion of trying to tighten it up so we don't see multiple years of $20-plus million under spent in a department? There's groups out there and organizations and services that could help with a boost, maybe, a service that was overextended last year. I'm wondering if there was any discussion to try to tighten that number up.

 

            MR. GLAVINE: The member opposite really does ask a very sound question about when savings are realized, could we have put them into other programs and other requirements of the health care system. Again, some of those choices that are made and some of the ones that we've made with our government - we know that we've been able to make some investments this year that we knew, while running a deficit budget, were certainly not possible. So this year we could say that perhaps some of those moneys now - there's 38 million new dollars that are in the budget this year, and hopefully some of those allocations will go into those areas where the member thought perhaps some should have gone in the past year. We all know that capital projects in particular are ones that do get behind schedule, and those dollars do show up on the ledger as not being spent in a particular fiscal year, but eventually they will have to be part of that envelope that the health department has to spend.

 

            MR. DAVID WILSON: In his opening comments the minister mentioned health transfers from the federal government and how do we move forward. In the last health accord, the Conservative Government of the day felt no need to negotiate with the provinces and the territories to come up with a new health accord. As the Ministers of Health across the country were meeting and trying to get to a point where some negotiation and work would take place, of course, the former federal Minister of Finance, I think it was, just brought out a new formula for it. There was no negotiation within the jurisdiction of the provinces and territories, which is concerning. I've mentioned a number of times in debates in the House other provinces that will benefit from the new formula. One of course is Alberta. They may take a little drop this year as we've seen a slump in the oil prices and that, but they're the ones who are really going to benefit over the coming years.

 

            I'm not too sure about the minister, but I know the Premier and the Liberal Party were vocal about challenging the federal government, and there needs to be pressure from the provincial government to make sure that the government revisits that.

 

            I believe the current Prime Minister indicated that in the last federal election. There has been some feelings that the federal government has been backing away a little bit from that. I'm wondering if the minister could indicate if he has had any discussion with the federal minister and/or the Premier with the federal government on continuing the pressure to say we need a new accord, we need a negotiated accord, and we need it to reflect the needs of the residents, no matter where they live, and it shouldn't be just based on the population of a jurisdiction. I'm wondering if the minister could give me a little update on any of the discussions that have taken place.

 

            MR. GLAVINE: First of all, I'm not sure how the member for Sackville-Cobequid embraced the former federal minister of the day and how many discussions they had about what the member rightly often says when we talk about health care as being our most important concern that we can talk about and address here on the floor of the Legislature.

 

            Really, the member opposite was right, and I should have provided a little bit more credit there to his work with Prince Edward Island especially and how we've continued to move that forward because we all know that we have a collective responsibility in the country to do whatever is possible in raising the bar on health care delivery and health promotion.

 

            One of the areas that I know we all had a moment to celebrate as Ministers of Health, in January of this year when ministers and deputies and support staff were in B.C. for the provincial, territorial, and federal ministers meeting, was to have the federal minister, Dr. Jane Philpott, sit down with ministers from across the country in a shared agenda, a very open dialogue on a whole number of areas, and in fact even added indigenous health to the agenda to make sure that we heard from the Aboriginal community from across the country about some of their very, very pressing health care needs.

 

            One of the big areas that we were all very concerned about, very wondersome about, was whether there would, in fact, be a new health accord. The minister did commit to signing a partnership with the provinces to investigate a new health accord. I think it's Ontario and Saskatchewan that have been tasked to bring forward ideas for a new health accord as early as September or October of this year so that a next round of discussions will actually have a framework for a health accord to meet the needs of Canadians. It really went beyond the money to potentially start to target areas that would address all Canadians. If some of the equity can be recaptured in a new health accord for a province like ours, which represents the aging demographic to the highest extent along with New Brunswick, then I think we could be in a better place once the new health accord is signed.

 

            MR. DAVID WILSON: I want to thank the minister for giving a brief update on that. I hope the government continues the pressure on the federal government every chance they get. There needs to be a broader look at what the needs are of jurisdictions and residents across the country, and it needs to be reflected in those federal transfers. As we know, well over 50 per cent of the health budget came from the federal government not too long ago, and it has definitely been reduced significantly over the last number of years.

 

            The federal Canada Health Transfer fund that's transferred to the province, we've seen about a 5 per cent increase this year compared to last year. There was some $896 million, and now there's $943 million this year. That's an increase of just over 5 per cent if my math is correct. Why does that not reflect the increase in spending in the provincial budget? If the federal infrastructure fund is going up by 5 per cent, and we're seeing an increase of not even 1 per cent, why would we not see similar? I would think you would see a similar increase in spending in our province when the federal government's transfer is about 5 per cent more than it was last year.

 

            MR. GLAVINE: I thank the member for that question. We know that it's part of the social transfer, and some, not all, of that money would come to health specifically. We know that this year, we have taken considerable millions to raise the income assistance of those citizens who rely on that program. I believe that's one that starts to address, in a small way, some of the determinants of better health for Nova Scotians. I believe that we can see value and spread some of that money across the departments that deliver social programs. I'm convinced that we have to look at many and varied ways of improving the health of Nova Scotians. When I look at the additional monies that will be required for an 18-month checkup in the province, these are some of the investments that I believe can lead to significantly improved health outcomes for our population. I think that command of doing work differently is catching on across our health care system.

 

            I believe the $38 million added to our budget this year, when used well, will meet some of our more-pressing needs. The investments that I have outlined in the budget are targeted and will deliver strong results for Nova Scotians, I think, and for those who need very specific health requirements with reduction of wait times. I believe as we look at doing things differently, we will find new ways of delivering health care. This is going to shed a light on how we've always done things in the department and how we've done things across the districts.

 

            I think we have the right amount of money in our budget this year. We know we need to be preparing for significant investments. We know the dollar figure for Dartmouth General. We're now scoping out the work at the Halifax Infirmary. We're going to have to make some pretty significant investments here over the next five or six years. So doing some cost containment around operations will put us in a better place to both borrow and invest. Hopefully with good economic performance, we'll actually have some dollars for a number of critical infrastructure pieces to give us the kind of care that our province will need delivered for well into the future.

 

            I feel very confident about the budget that we have to work with. I know the three financial officers that I've mentioned earlier, with their teams, are committed to making the dollars work.

 

            I think that over the next number of years, we will have to invest further, with the aging population in particular, the burden of chronic disease that we have in the province. However, if we address new models of care, I think we can realize the right amount of dollars to bring care to Nova Scotians.

 

            MR. DAVID WILSON: I was asking specifically around the Canada Health Transfer, and it is $943 million. There's a Canada Social Transfer of $349 million. That line item is very different. The social transfer, I don't think it was even a 3 per cent increase to Nova Scotia, but definitely the health transfer was a 5 per cent increase. We take in $3 billion in transfers alone, and the largest portion of that, of course, is equalization of $1.7 billion.

 

            There was an increase of 5 per cent to $943 million from the health equalization form. I'm going from information that's public from the federal government. Anyway, what I was trying to get at is, why would we not keep our budget at least at that percentage of increase, so continuing to support services in our province when the federal government is increasing the money going towards health services for our residents? What I see with that and what the province is doing - I understand the minister's comment is that it was a choice. It was a choice for the provincial government of Nova Scotia to underspend the increase in health transfer or not keep up with what the federal government is giving or transferring to our province. Of course, that's a choice, and I think they'll have to answer for that as Nova Scotians wonder why. Why wouldn't it even just keep pace? Then it's not a cost. The provincial government doesn't have to find that money somewhere; it's coming from the federal government.

 

            I'm just wondering on those health transfers if the minister could indicate specific requirements from the federal government on certain areas of care. Is there a breakdown that you could provide the House on any of those funds that are specifically designated for certain services that the federal government will give to the provincial government and they have to spend it on that specific service? I wonder if the minister could give us a bit of a breakdown on that.

 

            MR. GLAVINE: First of all, I guess when we reference a 5 per cent increase from the federal government, it really is a small percentage of our total health budget. I believe looking at 5 per cent overall on the health budget would be in the vicinity of $200 million. Yes, perhaps there are areas where some additional monies could be spent, but when I look at the areas in which savings were made this year, we were able to reduce some wait-lists. As we start on a quality improvement path to have better outcomes, we are seeing, and more and more in the health care system are saying, that we don't always need additional dollars to be able to provide outstanding care in our province. Our commitment is to do that. We're hearing from many clinicians who realize that we can do our work differently and not require that 5 per cent or 6 per cent increase that became pretty traditional - not every year.

 

            I know when the member opposite was in government, they had a year with probably close to a zero per cent increase in health care, and I don't think in that year Nova Scotians suffered as a result of that change. But to go over 15 years to have big increases year over year has not given us the health outcomes that we require in our province. Again, I believe it's taking a look at areas in our school system, across the life cycle, asking Nova Scotians to do as much as they can to improve their personal health and to have a strong system when they do get sick because all Nova Scotians at some time will need the health care system.

 

            There are many areas where despite the fact that as the former minister knows we get the flash points in the health care system but we're also fortunate to see some of the great work that is done in our province and how fortunate we have been to attract some of the top clinicians in some of the fields each year in our province to execute the surgery, the cancer intervention, the diagnostic work that goes on.

 

            I think it's finding that right balance that we need to be creating our thinking around - just as the new VG model. Many were thinking in terms of another gigantic edifice much like the VG and the Centennial. We know that care has changed dramatically. We can take 15 to 20 surgical procedures, operations, that used to be a week to 10 days in hospital - a friend of mine just had a kidney removed laparoscopically. Many procedures are day surgery or one or two days in hospital. We're doing things differently.

 

            Every day that somebody isn't in a hospital bed is a reduction in cost to our system. I believe that's the kind of change in health care delivery that we are seeing and will continue to see and put in a lot of emphasis on ambulatory care. I think doing health delivery differently is absolutely the way we have to go.

 

            Our investment in home care is very significant: $55 million over three budgets. The federal government sees home care as the only way in which we will be able to deal with one in four Canadians who are in the baby boom cohort. I look forward to even less requirements in hospital and more on day procedures that are less costly to the system. I know as we start to move out home care contracts, as one example, they will have required deliverables in them, something that hasn't been done in our province. They have sharpened their pencils, and we're going to see some wonderful contracts come out of the department over the next few years. It's about a time of change, and how we do the business of health care is in a great ferment in our province. I believe it's absolutely for the better.

 

            MR. DAVID WILSON: I didn't get an answer from the minister again. Maybe I'll be a little bit more specific. He mentioned, in what he was just talking about, the federal government's commitment to home care. I heard that from the Prime Minister in the last election, and he's committed to that. My question was, in the federal health transfer to the province, are there specific programs that need to be funded? Here's a direct question: the federal government is committed to home care; were they specific in an amount of money that was put into the health transfer to the province that needs to go to home care?

 

            MR. GLAVINE: I wasn't sure if the member opposite was wondering if we were back to looking at some of the targeted dollars that were in the very first health accord, which was to look at wait time reduction. We certainly know that that did not work very well. Provinces right across the country seemed to put dollars into general revenue. So I can appreciate the question, are there dollars targeted for certain health care work? It is basically a transfer to the province this year with no targets in particular areas except that in home care, there is $3 billion to be spread among the provinces. Of that $3 billion, we will make an Atlantic Canada proposal around innovation, and in fact, we hope to get a little better than what may be just a straight per capita share of that dollar simply by having an innovative approach to that particular $3 billion fund.

 

            MR. DAVID WILSON: Is that reflected in the budget this year? I know you will be making a proposal. Can the minister give a timeline on that? I would assume that $3 billion in the current federal budget is earmarked for this. My concern is, here we are today in session in the province, and I'm sure P.E.I. and New Brunswick will be in session - they're in session now, I believe. I wonder if the minister could be a little bit more specific on a timeline. Would we see additional funds transferred to the province this year if the ministers in Atlantic Canada can get together and put a proposal out there?

 

            MR. GLAVINE: The monies have not been allocated as of today. They are waiting for proposals from across the country. It was talked about in terms of not just money to provide necessarily just home care providers, as important as they are. They wanted to see some of the innovative programs that are starting to roll out in terms of home care, especially monitoring of people in the home. We will have our proposal to go in to the federal government, and that money should be in this fiscal year.

 

            MR. DAVID WILSON: I'd love to keep going on this because I think we'll have more questions, and I look forward to it. I hope, even if there's not an agreement around Atlantic Canada, that Nova Scotia puts forward some kind of request for those funds. We'll look forward to it, and I'll continue to make sure that I put the pressure on the government to keep Nova Scotians informed, especially seniors in Nova Scotia and those who depend so much on home care.

 

            I would agree with the minister's comment. I said it often myself that people want to stay in their homes as long as possible. People don't want to give up where their families grew up and where they put down roots. But some of my criticism over the last little while on long-term care still needs to be top of mind also because, ultimately, you can only stay in your home so long.

 

            I know there was significant investment over the last seven or eight years in home care. I'm glad to see that it's still a priority, but we can't forget that there still is a requirement, and there still is a wait-list for long-term care in this province. I know the minister has indicated that there has been a drop in the number on the wait-list, which is fine. Changing that criteria and maybe taking some of those people off the list who haven't decided yet that long-term care is for them is fine. But there's still well over 1,400 or 1,500 people - 1,490 or around there. For the most part these are seniors in our province - some of whom are in transitional units, some are sitting at home or under the care of loved ones - who are accessing home care. But ultimately, unfortunately, they're getting sicker, and their needs are higher, and they do need placements.

 

            In the last 10 minutes or so, I'm going to do some line items in the budget. I'll be referring to the Estimates and Supplementary Detail, Page 13.2, the second page in the budget. I know my colleague from the Progressive Conservatives talked a little bit about the Chief Medical Officer of Health, so I think I'll leave that for now unless I think of some more questions for tomorrow.

 

            Under Service Delivery and Supports, Physician Services, there has been a reduction this year of about $635,000 from estimate to estimate. I'm just wondering if the minister could tell us a little bit about what that line item entails, Physician Services, and why a drop of about $635,000 in this year's budget.

 

            MR. GLAVINE: That represents a transfer for physician recruitment that went to the NSHA as part of the total physician services budget. We anticipate much the same amount of millions going out for physician services this year. We still have, of course, the master agreement to work with and live with once that is brought to a completion this year.

 

            MR. DAVID WILSON: I mentioned this in one of the other estimates. It's a bit challenging this year going through the budget because of such a large number of departments and groups moving from one department to another. I don't know if we need to get Coles Notes to do a Budget for Dummies for this budget. But it's difficult, so I appreciate it. Many of my line-item questions, there might be a good answer. That movement of services can be frustrating. These are not my first Budget Estimates, but it has been frustrating this year.

 

            Under Physician Services last year, what was estimated and what was the end result of the forecast was about $6.7 million, what I'll say, underspent. What was estimated was $809 million, and it was about $802 million that was spent. Is there any real specific reason why? I know there's going to be an influx for that amount, but $6.7 million is significant, I think, in physician services. Is there any specific reason why that line item was underspent?

 

            MR. GLAVINE: As we know, $800 million of physician services - I know $6 million is still a very significant sum of money. Most of it really can be around that utilization area where collaborative practices versus fee-for-service saved dollars. Also some dollars allocated for advancing collaborative practice were not utilized. There are some positions that are generally in the AFP category that were not needed or not subscribed to in this particular year. The Canadian Medical Protective Association, CMPA, increased rates and utilization; that was an increase, but then that was offset by some of the other funding plans that needed less money to be executed this year. Really in essence, utilization was probably our biggest factor that impacted.

 

            MR. DAVID WILSON: The minister mentioned the master agreement. Of course, that's going to drive, I think into the future, potentially, that line item - good or bad, up or down, whatever you want to say about it. I had the same kind of criticism in Labour around the overall budget, with the projected surplus being there even when negotiations haven't finished with the public sector workers, and there's no real wage pattern to base that on. I think there's a lot of hopefulness that if it doesn't go well then Bill No. 148 will be enacted.

 

            So under this, can the minister give us a kind of timeline on how the master agreement is going, that negotiation? Is there a timeline he can give to us and to the House on when the government may see some kind of agreement going to the membership and maybe a settlement on it?

 

            MR. GLAVINE: It's an area that I felt I needed to stay away from, and I've done that over the past year. We've been into the negotiations now for over a year. They are probably some of the most complex negotiations that have gone on. When you start with an area like payment for non-face-to-face care, a very complex area, how do you work on a formula to deal with that? That's just one area to demonstrate how complex these negotiations are.

 

            I'm very optimistic that we are getting close to an agreement. Other than to say we're close, as I said, I've continued to meet with Doctors Nova Scotia during the period of negotiations. There are always many topics beyond the actual contract that impact the work of doctors and the work of doctors for Nova Scotians, but I know we're close, and we hope it stays on that positive path that the last month or so has been bringing.

 

            MR. DAVID WILSON: I'm wondering if the minister would commit to some kind of a timeline. Would he maybe see that agreement being finalized within the year? Or does he anticipate it may take us into the next budget year? I know it's going well, but like I say, it has been going on for well over a year, so I'm wondering if the minister has a rough end date in mind. I won't hold him to it, but I wonder if he has one. (Interruption) It's on record.

 

            MR. GLAVINE: The department and our government laid out the fiscal picture of the province. We're really looking at a $17 million surplus at the moment, which is a very thin surplus.

 

            We know we have to compensate doctors fairly. We see now in Ontario, after two cuts to doctors' fees, that they're reaching a boiling point. They're trying to get back to negotiations. I believe their negotiations are over two years now in duration. I certainly think 2016 will bring us to a conclusion.

 

            MR. DAVID WILSON: I know it's not all about money; there's much more to it than just the fee that they charge. It's the work that they do in their offices and being recognized, so I understand that there are challenges there. But like I say, it's more than just the money they charge for the visit; it's about ensuring that the fee structure is there and that the codes they have reflect the work that's being done, especially over the last number of years with the transformation of how services are provided and the collaboration that physicians find themselves working in now.

 

            I know I'm out of time, so I'll pass it off to the Progressive Conservative Party. I'll have some more questions tomorrow.

 

            MR. CHAIRMAN: Just before we move to the Progressive Conservative Party, I'd like to check with the minister if he would like a short break now. We've got about another hour and 35 minutes to go.

 

            MR. GLAVINE: We're good, Mr. Chairman.

 

            MR. CHAIRMAN: We'll now then proceed with the Progressive Conservative Party for one hour of questions.

 

            The honourable Leader of the Official Opposition.

 

            HON. JAMIE BAILLIE: I do want to say welcome to the minister and to the officials who are here with him. This is part of our great democratic process, so we get to examine the health budget in some detail. I know, for those of you who work at the department, whether you're here on the floor or maybe overhead, that it's a late night, and I do appreciate that you're here.

 

            If I could just take a moment, as the MLA for Cumberland South, to recognize the work of employees of the department and of the various partners in health care of the department and the health authority in my constituency. I see them all the time in my travels around and how dedicated they are. Whether they're part of the emergency health service, EHS, our paramedics; whether they're in our nursing homes, whether they're government or private homes; the registered nurses, the continuing care assistants, the nurse practitioners, the LPNs who make up continuing care - they do great work, and I just want to recognize them. There are so many. Of course, I wouldn't try to name them all in Cumberland South, but they know who they are. Whether they're at the Manor in Advocate, Bayview, the Parrsboro care centre, All Saints in Springhill, or many other places, they are dedicated employees, and I just want to recognize them before we start.

 

            Of course, we are going to ask some questions, and some of them are harder than others. But I think we all recognize that the work that's done by our health professionals across the spectrum of services from neonatal to palliative is very important, and they do that work with great dedication.

 

            I would like to start with some issues that are important to my own constituents in Cumberland South. I would like to turn the minister's attention to All Saints Hospital in Springhill. There used to be a blood lab there. It's an important service to the people of Springhill and area. They are still doing collections, and I believe that the bloodwork is then sent to the regional hospital for processing. Could the minister just confirm for us what bloodwork continues to be done at All Saints Hospital to this day?

 

            MR. GLAVINE: This is an area not exclusive to All Saints. A number of our smaller community hospitals are in a period of change in terms of service delivery, in terms of blood collection, and all of those routine values that are able to be provided as a doctor checks off his list of 10 or 15 requirements to give him a better picture of the health of the patient maybe for an annual checkup, maybe something that is suspect.

 

            What we do know about the service there is that patients aren't seeing anything different. We now have some of those samples that are sent out. Some are able to be managed by point-of-care testing. The technology has changed dramatically. It's going to change even further, probably in a relatively short period of time.

 

            Just as an add-on to the question asked, I'm pleased that in the last number of months, we have added two hematopathologists to our complement here in the province, which means that now there are very few blood tests that will have to go out of the province for a full evaluation. That puts us in a much better place than we were six months ago.

 

            MR. BAILLIE: I do want to pursue that just a little bit because the question was what has changed in the provision of blood services there at All Saints. It's great that there are new hires across the province, but I can tell the minister that the people in Springhill have certainly seen a change. Maybe the minister can enlighten us as to why it's a good change or not a good change for people who could go to All Saints Hospital in Springhill, give blood there, have the bloodwork done there, and get results the same day or by phone call or even, because it's a small town, have it shared with the local pharmacist when appropriate, and walk out with their prescription all in a day. That's what people are used to, that it would be a high level of care, the high level of care that people expect. Now that's not the case. I would like to just direct the minister specifically to the blood services at All Saints and inform us of what's going on there today.

 

            MR. GLAVINE: What has taken place at All Saints has taken place in a number of other hospitals as well. The blood collection is done, it's taken there, and it's often sent to the regional hospital for the full blood analysis. I would have to check on the personnel situation there to see if there was some inability to hire in some parts of the province. Replacing the aging work staff also propelled change. But we know that more and more point of care right at the bedside is giving us the same level of care during the transition. There may be a little bit of delay in terms of the results coming back, but most that are of a suspicious nature are certainly dealt with. If All Saints, and I've been there, comes back to me, I would say that patients should not be experiencing any difference in the results that they always expected. They'll get the same results even though the practice there may be different than what they traditionally had.

 

            MR. BAILLIE: I want to thank the minister for that answer. A few moments ago, he alluded to further changes coming. I want to just make sure I'm clear on that. Are there further changes coming to the blood collection work that's done at All Saints, and if so, what are those changes?

 

            MR. GLAVINE: I don't have an up-to-the-moment or just-in-time answer for that. But I would see that a community hospital like All Saints probably has reached the point now where the changes that have taken place will be in effect for the future based on what I know the health authority is putting in place across the province.

 

            MR. BAILLIE: I will take that to mean there are no further changes planned at this time. I'm just going to confirm that. Okay, that sounds good. That will be helpful to the people of Springhill.

 

            I would like to move on to the emergency care at All Saints. It's a CEC, as the minister knows; I know he has been there. I want to ask the minister to talk to us a little bit about the hours that the CEC is open and closed in Springhill. I know we had the accountability report, which reported on hours of closure. There's an alarmingly high amount of closed hours continuing at the CEC in Springhill. Can the minister tell us why that is and what is being done to bring the number of closed hours down?

 

            MR. GLAVINE: We know that Springhill All Saints is one of the hospitals that moved from an emergency department that could not staff the emergency 24/7/365. Also, the service provided at our CECs really begs that whole question around the word "emergency," which probably was a word that was trying to provide some assurance to patients that their emergency department was not completely disappearing. We don't have emergency room physicians in those sites; they are GPs who provide general patient care, in some cases just daytime hours, with an advanced care paramedic, or I think in the case of All Saints, a primary care paramedic and a nurse. We have some different models and variations. That seems to work very well; however, very underutilized as a report by consultant Mary Jane Hampton did point out.

 

            Sometimes the daytime is somewhat of a conundrum. There are doctors in their offices who do not take part in the rotation that is designed for that particular CEC. There is, within the community, access to primary care physicians, and from 8:00 p.m. until 8:00 a.m., we do have the availability of a nurse and primary care. They're not able to provide, for example, the level of care in an emergency to the extent of calling 911 and having EHS. EHS would in fact be the call to make and not a visit to a CEC overnight. They don't have the same scope of practice as our emergency providers would have and the training to deliver.

 

            It's an area that I know will be in my next meeting with Janet Knox, taking a look at why this conundrum of having physicians in the community but not participating in that regular cycle to cover the CEC in the daytime is in fact one of the current challenges. Is there a proper fix for that? That's something the health authority will need to address.

 

            They look after the day-to-day operations. We have the funding in place, without question, to provide that service. But it is up to the health authority to monitor and make sure that there are as few interruptions in service as possible.

 

            MR. BAILLIE: When the CEC in Springhill was created as a solution to the ER problem, it was sold to the people of Springhill as a service that would be available around the clock - not always with a physician on the premises, that was clear - but that it would be staffed by an RN and an ACP, an advanced care paramedic. A PCP, as the minister pointed out, is what's there now. That person absolutely is doing all they're allowed to do as a primary care paramedic, but the difference between the two is that there are certain procedures, sometimes intensive emergency procedures, that are only allowed to be done by an advanced care paramedic.

 

            Yes, the definition of "emergency" can be debated, I suppose. But my point is that the people of Springhill expected when they were told they would have an ACP and an RN, that that's what would be the case. Can the minister tell us, has the department given up on having an ACP for Springhill? If so, what is the plan for those extra procedures that only an ACP can do?

 

            MR. GLAVINE: As I said, I believe at the moment when I was there - it is over a year now since I've been to the hospital there - Ron MacCormick, the site manager, spoke in terms of the number of doctors they had in the community. In his view, we're adequate. We always say we can use more.

 

            The department at this time and the health authority are committed to the model. We got strong recommendations for future direction, but we have not moved to implement that report, because there was a commitment of having service at the hospital. It's one that is experiencing those kinds of problems. Do we need to look at it in terms of maybe having a nurse practitioner available who could address some of those common complaints? One may not be able to get into a doctor's office in the daytime, especially during flu season. The high temp of a baby or an elder who has a minor fall, any of these areas do need attention through the day. If the model that was put in place, which was certainly directed to be a solution, if it is not providing the level of care, then what I can tell the member is that I will have the health authority investigate the service of primary care at the hospital because it is mainly primary care not emergency care that is now delivered at All Saints.

 

            MR. BAILLIE: I believe I heard the minister say we're committed to the model at some point in that answer. That's something that Springhillers are going to want to know right now. I'm not sure if he was talking generally about the CEC model or specifically about the CEC that's in place in Springhill. When the minister has been to town and pointed out that it's the view of the department that it's an underutilized emergency room and it's involved in primary care and not emergency care, it does cause people to wonder whether there's a commitment to maintain that CEC in Springhill. The minister said they're committed to the model. I just want to confirm that the government is committed to keeping the CEC emergency model in Springhill for the foreseeable future.

 

            MR. GLAVINE: The commitment to the model and how we look at human resourcing that model is really one of the challenges there and in a couple of other sites. Some committed to just having a 12-hour daytime service, and in a few of those communities where that model has been implemented, that has gone very well. If we look at the 8:00 a.m. to 8:00 p.m., it provides, I suppose, some level of comfort and knowledge that there is somebody to address a health need.

 

            We're now finding 811 to be one of the areas that people are calling on more and more to get first information. Generally the nurse at the end of the line, hearing the symptomatic picture, says either get it checked out the next day, or I think you should go to where there's a full ER service.

 

            We know that in our regional hospitals, there's 24/7/365 emergency service. The member raises a good point: if the model is not being resourced and staffed currently, then looking at it and working with the community if there are cases in the daytime that are not being addressed, that is certainly a deficit for the community of Springhill and area. We do need to have it resolved.

 

            MR. BAILLIE: My point is that the CEC is there. There are doctors in the hospital and in the community - the minister has acknowledge that. It may not be staffed to the extent that the people were promised in that it has primary care paramedics instead of advanced care paramedics, and there is a big difference. I just want to be clear: the answer to that is not to question whether that emergency room service should be there or not; it is to find a way to reach the standard that the people of Springhill were told would be there.

 

            I've asked the minister if there are any changes coming, and I think we need a very clear answer for the people of Springhill. In the upcoming year, are any changes planned for the All Saints CEC?

 

            MR. GLAVINE: To give a definitive answer to that would be difficult at the moment because one of the great exercises that are long overdue in our province especially based on the dramatic changes in the past 25 years or so in the delivery of health care is currently going on. That is a health services review as to what service should be provided in communities across Nova Scotia. We know that, for example, the hospital where the chairman resides used to be a full-fledged little community hospital, where you could deliver a baby and have other procedures taking place. Once Valley Regional was built, the redundancy then was very apparent.

 

            This is why doing this clinical services review to have the right services, the right amount of services, in the right place for all of our citizens is currently going on. We saw that when we announced the VG replacement and took a look at areas where we have capacity in the system like we have at Dartmouth General, like we have at Hants Community Hospital. We're putting services where we have capacity.

 

            The clinical services review will clearly outline in parts of the province where there is substantially less population, a very different population than there was during the baby boom era to provide more long-term care, continuing care, geriatric services. This is where the clinical services review should help us determine. All Saints and what services need to be in Springhill and in that community are part of that evaluation process.

 

            At the moment, the CEC plays a role. Is it as good as it should be? No; because when there are closures, that's problematic. We all know that when a service is to be provided, the hours of service are known to the community. If there are closures announced, that is not a reliable service. I believe, in that context, keeping the CEC, keeping a level of services for Springhill, is part of that evaluation process.

 

            It's difficult at the moment to be absolutely definitive. We know that there's a place for the CEC, but we need to have it staffed as well.

 

            MR. BAILLIE: I really don't know why it's such a hard question, are there any changes planned or not in Springhill? It would have been very welcome in Springhill if the minister had said, no, there are no changes planned, but we're doing a clinical services review for the whole province, and I can't project what that will be in the future, but for now there are no changes planned. I think for people who want to know if they have to go to the emergency room, the CEC, whether at 2:00 a.m. or 2:00 p.m., that it's there for the foreseeable future. That is part of our emergency system.

 

            I also want to ask the same question in a way about the Parrsboro CEC, which was the first one in the province. It was announced under a previous government. That CEC is in an even more remote area of Cumberland County than Springhill. In fact, Springhill is not in a remote area. It's a pretty big town; it's close to the highway. But when the minister says you should call an ambulance if you're not confident the CEC will be there, that's not an option in Parrsboro, where the distance to the nearest emergency service or the regional hospital is too great - or even to call 811. These are not really options for people. They deserve better than that.

 

            There is a CEC in Parrsboro. As I said it was the first one. It has also spiked in the number of hours closed, in the accountability report. I'd like to ask the minister, can he tell us, what is the plan to bring the closures under control at the Parrsboro CEC?

 

            MR. GLAVINE: I know the member for that area speaks to the reality that Parrsboro is in fact one of those special cases where having an advanced care paramedic is critical to that area because geography plays a key role. If somebody is in an emergency, having a trauma, how can they be best cared for in a facility that is part of that community's life for some time? There certainly is a full commitment to Parrsboro. We know that attracting physicians, nurses, and sometimes even having paramedics travel long distances to cover has become more and more a very unfortunate reality in some of our more distant areas of the province. It's one that I've heard about from a number of communities. Every now and then, we are able to recruit and improve the complement of clinical staff to an area. But certainly for Parrsboro to be open and have advanced care paramedicine is very critical to that area.

 

            MR. BAILLIE: I'm glad the minister was able to make such a clear statement about the commitment to the Parrsboro CEC. I just want to follow up, though, on the problem they're having in the short term there. It is a doctor issue, as the minister may or may not know, but I'm sure his officials do. Parrsboro is a place with not a large number of doctors, so if even one goes on leave - and in this case that's actually what's happening in Parrsboro; we have a maternity leave - it puts a strain not only on the primary care for the area but also for the CEC itself.

 

            The thing about maternity leaves, of course, is you get months and months of notice that they're about to happen. In the maximum case, you'd have almost nine months' notice, depending on how quickly the employer is informed of these things. Certainly in the case of Parrsboro, there was a lot of notice, yet when the day came when that particular doctor went on maternity leave, that caused a strain on the CEC services in Parrsboro. Why is the department not planning ahead for these known absences and putting in place a plan to keep the CEC operating, whether it's a locum or some other backup plan, when we know in advance that these things are going to occur?

 

            MR. GLAVINE: I know that just in the past week, the deputy had a meeting with staff at the department and with the NSHA. Drawing up a stronger recruitment plan, especially for those short-term circumstances as well as securing doctors for the longer term in an area, is now something that we're able to do in terms of a much more robust provincial plan. Recruitment overall in the province is very, very good this year; however, we do have specific areas of high need.

 

            What kind of model do we adopt to be able to have that kind of flexibility to get a care provider? My own view, and I'm really expressing a personal view here versus the office, if you wish, of the minister, but I absolutely believe that greater utilization of nurse practitioners must become a bigger reality in our province. Looking at nurse practitioner locums that can fill a very big percentage of care, I believe the time has come for us not just to look at this but to work with the NSNU and nurse practitioners to look at how that can be executed in our province.

 

            We know there are communities where, even with economic incentives now, we are unable to recruit for some communities in our province. This is true right across Canada. We can look at every province and every territory at the moment, and we can point to areas.

           

We are lucky - at the moment, CMA with 2016 statistics have said that we're at 90.3 per cent of residents with doctors. The average in Canada at the moment is 85 per cent. Recruiting to small town rural areas is a huge challenge, but I know that for that 7 per cent who don't have a doctor - because 3 per cent never look for a doctor unless it is an emergency; they don't even look to have a family doctor. We know that having a primary care provider - and we are hearing more in my community now; there's a number of people when I ask, who's your doctor, say, my doctor is a nurse practitioner. We're hearing that, and we'll hear more of that.

 

            I believe providing primary care to our small rural communities is going to look different in the coming years than what we have traditionally known and again as their scope of practice advances. My very strong personal view, having lived 45 years with a very capable nurse and knowing the kind of areas of health care she provides in our community now as a retired nurse, I know changing the model is difficult, but I believe it may be one of our solutions with a combination of nurse practitioners and advanced care paramedics. I believe that's absolutely what we have to look at.

 

            MR. BAILLIE: I suspect there will be many people in Parrsboro and in other places that would welcome greater use of nurse practitioners. We're expressing personal views, and I think there's absolutely an expanded role for nurse practitioners. I've heard from the Nurses' Union that they'd like to see more RNs and more nurse practitioners doing more things that used to be done by doctors, and I'm sure that's all true. But until that day comes, we can't leave the community without. That's the problem in Parrsboro.

 

            This is not a case where we're saying please go and recruit more doctors forever. This is a case where there was a known maternity leave coming up that occurred, and then the community went without. That might meet the budgetary needs of the Department of Health and Wellness, but it does not meet the service needs of the community.

 

            My question was, what do we do to fill these temporary leaves when they occur? I just can't accept that, "someday in the future there will be nurse practitioners." This is an example where we go without today while we wait for some future solution that may come someday.

 

            I don't mean that to be pushy; I just mean we have a very real need now with a very real vacancy. To tell us that there might be a plan in the future for everybody doesn't address Parrsboro's needs today. There is a vacancy. It's the result of a maternity leave. It's backing up the CEC. It's causing problems with primary care.

 

            Is there a process for filling short-term physician needs? I do not accept that there was never anything like that in the old DHA system, and it's only now that we have one Nova Scotia Health Authority that we can do these things. There was health human resources before last year for these kinds of things. What's in place today that Parrsboro can draw on to fill this short-term need?

 

            MR. GLAVINE: This is what I alluded to just last week when the deputy minister met with Dr. Lynne Harrigan, who is now the lead for the province, vice-president of medical services. That whole area of recruitment is under her direction, and the provincial health authority is looking, in conjunction with Doctors Nova Scotia, at how we can identify much earlier - I know there was an allusion to nine months that there's going to be a vacancy. Again, that's an area where we haven't had those kinds of requirements of informing what was probably the old district or now the zone about, "I'm winding down my practice with a retirement," or "I'm scaling back to about 50 per cent of my patient load." We haven't had long periods of identification.

 

            One of the other areas that has become a bit of a deficiency for us is the physician resource plan, which very often identified X-number of physicians for a community. We now know that physicians are practising differently in terms of the amount of hours they work.

 

            We're also going to move to a time when 50 per cent of our physicians will be women. I look at med school today: 52 per cent of the students at Dal are women, and they're going to take time out for childbearing years. They're going to take time out for child raising and family time.

 

            So we're in the midst of a significant transition of providing our communities with the right number of primary care physicians and nurses and paramedics. I know the current moment is problematic for the people of Parrsboro. What I will tell the member is that I will speak with Dr. Harrigan tomorrow to see if there is a short-term plan developing for Parrsboro. We also have a couple of other communities that have some of the same challenges.

 

            MR. BAILLIE: I'm glad we got to the end of that answer because it was getting to be a little frustratingly general, but we got there. The minister will check with Dr. Harrigan on this topic for Parrsboro. That's great because it is hard to imagine that prior to this year, no one ever thought to be ready for a maternity leave among our doctors or any other kind of leave. I'm sure that that can't be the case.

 

            There used to be doctor locums for exactly this kind of thing. I'll just wrap up this part of my questioning by asking the minister, are doctor locums now off the table for filling short-term needs in communities like Parrsboro?

 

            MR. GLAVINE: Doctor locums are still part of the process for sometimes short-term or sometimes a little longer. If a physician is sick and has a longer recovery period, locums, indeed, are provided.

 

            MR. BAILLIE: I can only then strongly encourage the minister, in his discussions with the authority, to look at a doctor locum for the remaining maternity leave in Parrsboro. It would go a long way to relieving the primary care and CEC needs of that community.

 

            I know last week in this House, we asked about a doctor shortage in Pictou, at Sutherland Harris. A locum would go a long way to relieving the pressure on 2,500 people who now are without a doctor because of a retirement at that clinic, which is now closed after-hours. They were all directed to go there when their doctor retired, and now the clinic is closed because of a lack of doctors.

 

            Even then, the minister talks about longer term transitions, but in the immediate sense, doctor locums would go a long way to relieving pressure on the system and making sure people get the care they need until this new plan, whatever it's going to be in those cases, is in place. I just encourage the minister to take a look, for those specific situations, at doctor locums.

 

            I do want to move on to long-term care and ask the minister about long-term care in the Cumberland South area. I have a specific question. There is a Level 1 care facility in Advocate Harbour; it's known as the Advocate Manor. There are eight vacancies there - eight beds available. Yet the wait-list for long-term care, or advanced care perhaps, as the minister knows, is up to two years long. Why can't we use those eight beds for residents in the area to get the long-term care they need?

 

            MR. GLAVINE: Just to return to the locum question for a moment, Kevin had time to look up the reality of $2.4 million available for locums, but getting them in the right places at the right time is certainly a more challenging factor for us.

 

            In terms of Level 1, there are times when there may be within the geography of a particular area using the 100-kilometre radius for the movement of people into nursing homes and I would actually have to inquire as to why there would be eight. I know those are requiring higher levels of care. There would be few beds across the province that wouldn't have a significant need. But in a Level 1 facility, you have to have a person who is mobile. They're able to get themselves out of the facility. They're able to go to a dining hall, and so forth. Why that area would have eight beds, I will have to check and get back to the member with that information.

 

            MR. BAILLIE: I do take the minister at his word on that; he'll look into it and get back to us with the information. It may well be that we should look at the cost of upgrading the service and the facilities there to take Level 2 patients. There is a high need in the area. Advocate's a fairly remote part of the province. People have the desire, when they go into long-term care, to be relatively close to their families and their home areas, and that's a reasonable desire that people have. Or perhaps the department has a policy just not looking at Level 1 beds anymore. I don't know. I ask the minister, is that a new policy: that we're not looking at making Level 1 admissions, that it's all home care now?

 

            MR. GLAVINE: We certainly have full support for Level 1. There will always be those who have a good degree of mobility and a very small number of health care and nursing needs but don't have family members and do need some observation 24/7 and are patients who do require meds and so forth to be provided. There is a place for Level 1. That being said, we're providing more and more care in the home, and there are in fact, we would say, a very significant number of Level 1 patients at home. They are able to look after a good number of their needs, but perhaps they're not able to look after all of the personal care, all of the upkeep needs of their home.

 

            In many ways, our CCAs are providing a combination of care of the home and care of the person and would certainly fit the category of Level 1. But for now, there is no plan to reduce the Level 1 beds. It could be an area of the province where, again, those patients who could be in Level 1 have made a statement about staying at home.

 

            Each area of the province is different. I know in the area where I live, there's a very large Level 1 home with 100 per cent occupancy and a wait-list. It may have something to do with the availability within that 100-kilometre radius.

 

            MR. BAILLIE: I know the minister said he would look into it, so I'll wait for the results of that effort before we go any further, in fairness.

 

            I just want to turn for a moment to the composition of the board of directors of the new Nova Scotia Health Authority. There is a belief or feeling in Cumberland County that there would be a Cumberland area representative on the board. The minister may have made such a declaration; I wish him to say so and clear that up, whether he has or hasn't, with the people of Cumberland County. If so, when will we see a Cumberland representative on the board of directors?

 

            MR. GLAVINE: Some weeks ago now, but not that long ago, I met with board chairman Steven Parker to discuss a number of issues. There is one pending vacancy as well on the board - two, I should say - one-year terms that are up that will be replaced. Along with giving some indication of people interested in those two positions, I made it very clear to Mr. Parker that we need to see a member from the northern part of the province, and I know that he was investigating that, as he wants to have a full complement of the board for its second year of operation.

 

            MR. BAILLIE: Well, I'm not going to debate geography and what's northern and what's Cumberland and what's not. The minister knows, because we've raised it before, of the commitment to have a member from Cumberland County on the board. We'll see if that's what happens.

 

            Mr. Chairman, I'm actually disappointed I have so little time left in my hour because the next topic I want to move on to, and I know that we're staffed here for it, is Pharmacare. I suspect we're just going to get started, and we'll have to return to it another time. To get going anyway, I would like to turn the minister's attention to the Seniors' Pharmacare Program. He may be familiar with the program and the controversy in the last few months.

 

            The Budget Estimates for the Department of Health and Wellness contain some interesting things. I just want to start by looking at the estimates for the cost of the Seniors' Pharmacare Program, which are found on Page 13.9 of the Estimates Book. This is the total cost; this is before collecting any premiums, I might add, from seniors themselves. The minister will see that the total cost of the program was estimated for the year just ended to be $166 million. The estimate for this upcoming year is $169 million, which is a 1.8 per cent increase. I guess I'll start just by asking the question straight up. Can the minister account for that 1.8 per cent increase, the reason for it - I know it's not a lot - in the cost of the Seniors' Pharmacare Program?

 

            MR. GLAVINE: One of the strongest realities that we have in our province is the percentage of Nova Scotians who are seniors. We have a significant number who are not in our program. They're able to get the benefit of a military or an RCMP insurance program that's a little stronger than our provincial program. But the one thing we do know is that utilization continues to go up each year.

 

            There is an additional $4.125 million that will go into the program this year. That will be based on utilization for new drugs that will be added to the formulary this year. We don't know what the uptake of those will be; it's a general estimation as to what the utilization would be.

 

            The volume of patients is obviously a big factor with 1,000 or a little bit over 1,000 a month who are eligible. Unfortunately, we don't get 100 per cent of people joining the program, even of those who do not have another insurance program. They take some chance and move into their senior years without the benefit of a program. That's why, this year, we moved to bring in another 12,000 who would pay no premium and another 29,000 who would have a reduced premium. We all know that someone can go from one very low-cost medication at 65 to be on a very high-cost oral cancer drug at 66 or 67.

 

            MR. BAILLIE: If I could just get to the bottom line, I believe the minister said it's a combination of increased utilization and some new drugs that are going to be covered. That's great, but what's very interesting about that, is that's an increase of 1.8 per cent, a little over $3 million, on $166 million. If you look at the forecast in the Estimates Book, the forecast cost was $168 million, and it's going up to $169 million. That's only $638,000 in additional cost for the program, a 0.3 per cent increase over the forecast for the year that just ended.

 

            The reason I want to ask the minister about this is, when the Department of Seniors consulted with the Group of IX, consulted with seniors, about their proposed change to the program, seniors were told that the costs were escalating and the program was becoming unsustainable, that they expected the cost would go up by 5.4 per cent specifically, and that was why seniors, in many cases, had to pay more. I know every senior in that program is going to want to know, why were their representatives told the cost went up 5.4 per cent when in fact it's going up by a very small amount?

 

            MR. GLAVINE: Maybe the member doesn't have this breakdown in front of him, but when we look at the rebates of over $5 million and generic drugs at over $5 million, that will lead to about a 6.61 per cent increase in the cost of the program.

 

            MR. BAILLIE: I just want to be clear: in the budget, both for this year and last year, were rebates and the cost of generics - are they included in this estimate number, and were they included in this estimate number the year before?

 

            MR. GLAVINE: Yes, they were included. Obviously, if we hadn't had some of the savings, the cost of this program would have escalated dramatically.

 

            MR. BAILLIE: Wasn't that known at the time that the minister had his consultation with the Group of IX and told them that the cost compared to last year would go up by 5 per cent and not the 1 per cent that we see in the budget today?

 

            MR. GLAVINE: One of the areas that I'm sure the member is very familiar with, when we look at the age group of our seniors who were impacted by tainted blood. As we added Harvoni alone to try to get as many of our seniors covered by that this year, that was one of those areas that have certainly added to the cost of Pharmacare. We knew that it would escalate not just this year but over the next number of years, and in fact we are not able to put all of the drugs into the formulary that we would desire to put in. So in looking ahead, we know that over the next five years, there will be a significant escalation of drug costs for the seniors program.

 

            MR. BAILLIE: Every bit of that was known at the time that the government consulted with seniors. The rebates were known. The cost of generics was known. The need for blood drugs was known. We're only talking a few months ago. Yet seniors and the Group of IX were told that costs would go up by 5 per cent. They're not going up by 5 per cent; they're going up by 0.3 per cent on a forecast-to-estimate basis and 1.8 per cent on an estimate-to-estimate basis. Clearly the government is trying to justify a big increase in seniors premiums when they're not themselves facing a big increase in Pharmacare costs.

 

            Just to show that, I have with me the chart that was produced by the minister's Department of Health and Wellness at the time entitled Seniors Pharmacare Program Remodel, five-year projections. This was given out to seniors and then to all Nova Scotians at the time of the controversy. If the minister wants a copy, I'll provide it to him, but I hope he's familiar with it. It shows a 5 per cent increase in this year - not some vague future year, in this year. In fact, it says the increase is 5.4 per cent, and that's what they were going to ask for from seniors, or what seniors were led to believe they would be asked for; in some cases they were asked for much, much more than that in a premium increase.

 

            I haven't even gotten to the premium side of this equation yet. I'm only looking at the cost side. There are equally odd questions on the premium side, but I don't want to let this go.

 

            Why did the department put out a chart that said the cost of Pharmacare in this year would go up by 5.4 per cent when it's going up by peanuts?

 

            MR. GLAVINE: What I can tell the member opposite is that one of the areas that we do not know prior to making that plan that has to get out to seniors early - usually notification in January because the change takes place on April 1^st - we don't know the amount of rebates that will be there from year to year.

 

            We've made a decision that just four drugs will be added this year. There are always more that are being asked to put on the formulary. Every health minister will go through this agonizing ask each year, what else can we afford to put on the formulary? In looking ahead, that's one of those areas that is now coming at us very fast because we're nearing the end of the benefits that we derived from generics. So a new reality is on us, and we will see the need for government, or government and those who join the program, to participate to a higher degree in future funding of this very important program.

 

            MR. BAILLIE: I know the government stopped the changes for this year. We're still waiting to see when the consultations are going to start again. I don't know how seniors can have any confidence in the upcoming consultations when, in the round before, they were told that they had to pay more because the cost of the program was going up by at least 5.4 per cent in the coming year . . .

 

            MR. CHAIRMAN: Order, please. The one hour allotted to the Progressive Conservative caucus has expired. We'll now move back to the New Democratic Party caucus with approximately 34 minutes remaining.

 

            The honourable member for Sackville-Cobequid.

 

            HON. DAVID WILSON: I want to continue on. I kind of said there would be more questions tomorrow, and I forgot I have about 34 minutes left.

 

            When I left off in my last round of questioning, I asked about physician services and a bit of money that was underspent last year. I'm talking about Page 13.2 in the Estimates and Supplementary Detail. If you go estimate to estimate, it's pretty much a flat line item, maybe a little bit of a reduction. Is the minister confident that without the master agreement in place now, that flat line item - or a slight reduction; I'm trying to think of it, it might even be a $0.5 million reduction - will meet the needs of the services physicians are providing now? How can you see a reduction when, like I say, the big question not answered yet is, what does the master agreement look like? Is the minister confident that it will meet the needs in the upcoming year if the master agreement does take us closer to the end of the year? Why is there about a $0.5 million reduction in this year's budget?

 

            MR. GLAVINE: I would say we are confident that the amount it is lower by is money that with the transition out to the NSHA around recruitment in terms of actually providing services to Nova Scotians. Again, it's an area where we saw some utilization changes as opposed to perhaps not seeing any great dramatic change in the number of patients seen but those being seen now in the collaborative practice model. In some of those areas where, in a community, there would be four doctors, we now have three that are under contract and a nurse practitioner or a family practice nurse as part of that model. That certainly is changing the cost to the department and to government to provide the same level of service, one of the areas that probably has been most challenging in terms of the master agreement.

 

            As I said, I decided to not be apprised of the process as I still have to work with Doctors Nova Scotia on a regular basis as issues come along. That commitment to staying within the fiscal envelope of the province was put forward as one of the tenets of negotiations, and the commitment to stay on course is certainly strong to the conclusion of negotiations.

 

            MR. DAVID WILSON: Would any of those savings be the result of the recent policy change for the central region with respect to issuing new accreditation or licences? I brought this to the minister's attention during Question Period. In my area, a number of practices have closed. There's a pending retirement coming up, and they haven't been able to fill that position. We've had physicians - one was very vocal in the media the other day, Dr. Saad who has a practice in Beaver Bank. He receives calls every day, 10 or 15 calls, from patients asking if they're going to take new patients. He requested an additional physician so he could expand his family practice, but it was denied by the health authority. Would that savings be reflective of that policy change of the central region not to permit any more family physician accreditations or licences to be issued on a go-forward basis? I believe it was maybe October or November when the board made that change.

 

            MR. GLAVINE: I'm just reviewing some of the areas in terms of dollars put into the budget to work on recruitment. That's what I'll address first, and then specifically Dr. Saad and other clinicians in the metro area.

 

            In terms of tuition relief, there's almost $1 million in that area; family medicine bursary, $500,000; and debt assistance, $200,000. We have the programs in place to support doctors coming to the province generally. Recruitment has been strong in metro. Many of our new doctors are not available until June or July. Some wait until September and actually take a vacation and start their practice in September.

 

            As we work to change the model of delivery of primary care around the collaborative practice, this is a new model, especially doctors who have been practising for a considerable period of time will find it different and challenging perhaps to make that kind of adjustment. We know that in the long run, over time, this is the type of practice that new doctors want to be part of . . .

 

            MR. CHAIRMAN: Order, please. I would ask all members to keep the chatter down a little bit as we go into the final stretch.

 

            The honourable Minister of Health and Wellness has the floor.

 

            MR. GLAVINE: We know that this is the model now of doctors coming out of our 17 med schools across the country. They're not going to just sign up and necessarily work in a traditional clinic that may have three or four or five doctors but is not that collaborative model of practice that they want to be a part of. Some doctors who currently own a clinic and do the hiring themselves have had some degree of success. But I'm a firm believer, and the department sees provincial recruitment as a viable, sustainable long-term way in which we're going to get the right complement of primary care clinicians across our province.

 

            I know for doctors who have recruited positions themselves, it works in some instances, but I think starting to line up positions well in advance in the new model of delivery is important to the new doctors who are coming into the province and coming from our own med school. I think this will work very well for us in the long term. In cases like Dr. Saad's, I know it's a change. It's a challenge that we will have to work through.

 

            Dr. Harrigan and the team at the Nova Scotia Health Authority met with the owners of walk-in clinics. I know it caused quite a stir that walk-in clinics may not be part of the future, but it was very well established that they would remain part of the future, but they will transition into collaborative models of care. They can be open into the evening to serve patients who have late requirements in the day. There's that change that is going on, and I think it will move as quickly as possible.

 

            MR. DAVID WILSON: It's great that the government is looking forward to this new kind of model in the province. But that doesn't mean you can forget about providing the services now. That's the challenge, and I mentioned this before when I was standing up on another piece of legislation and in Question Period, an issue that rural Nova Scotia has been dealing with for years. It has been very quiet in the central region.

 

            In my community, I don't think I've ever received a call up to this year about not being able to gain access to a family physician, and I've been here for almost 13 years. I receive many, many calls now and many, many emails from people in and around my area concerned that they do not have a family doctor.

 

            To say that this new model is going to be here is great. I said in the past that I support that. We supported that in government around Collaborative Emergency Centres, around collaborative clinics, ensuring that the scope of practice for health care providers is best and they're utilized to the best of their ability so that we meet the needs of Nova Scotians.

 

            But we can't forget about the family practices that are out there. The family practice my family goes to has about seven physicians, I believe, and a nurse practitioner. What I'm hearing is this focus on this new model, but that's not going to eliminate what has been going on and the good work that family practices have been contributing to providing care in Nova Scotia.

 

            I remember when I was minister that there was pressure at that time to limit the amount of licences that are accredited in Halifax, in the central region. The reason behind that was that if there was a new physician coming into the province wanting to get licensed, then you would be able to say, okay, we have opportunities, but not in Halifax; it's in more remote and rural communities. I'd like to ask the minister, is that what has driven the change in the policy for the central region? Is it to try to get new doctors coming in who want to get a licence in Nova Scotia to go to the underserviced areas, which I know have been underserved for many years, and it has been a challenge to find doctors? Is that really what's driving it? I know that was the argument when I was minister. They brought that to me. Is that what's going on with the new health authority? Is that the hope: we'll be able to find some doctors to go to those more rural communities?

 

            MR. GLAVINE: What I want to emphatically convey to the member and to all Nova Scotians, especially the residents that we're talking about at the moment here in HRM, is that we are not using a limitation of licences to restrict access to practice here in metro. At the current time, we have more physicians in the central zone per 100,000 of population than anywhere else in the province, well above the national average. We know that in some geographic locations we can certainly use another physician, but overall, we're in a very, very good place. We'll have to see how recruitment follows through this year. I have been told that since the start of this year, altogether full- and part-time physicians - I believe around 50 have been recruited. We'll see how they will be distributed in clinics and practices across the province.

 

            There's no question that the commitment of the health authority is to move to different models of providing care, and change and transition is always very difficult. I will ask specifically about the area that the member has raised today to see how that clinic will be staffed in the future.

 

            MR. DAVID WILSON: The government and the health authority are trying to fix one problem, but they're creating another one and limiting the ability of family practices to expand right now, at a time when there's nowhere else for these patients to go. I understand that the government wants to curb the walk-in clinics, that they want to make them into more of a collaborative model, which is fine. But I've mentioned a number of families over the last week or so - the Watsons, the Eales, a number of them - who don't have a family physician. Where are they going? They're going to walk-in clinics. Many of them have complicated health issues. A walk-in clinic does not meet that need.

 

            Now, a number of years ago, the walk-in clinics - yes, there's a lot of them. I have two or three of them in my community. But they're well-used because people can't get into a family physician. I've said this in the past: my family has used a walk-in clinic because we can't get into our family practice clinic because they're busy.

 

            Until that model is up and running, why would the minister continue to allow - there was Dr. Saad. There was another physician clinic in Bedford that was in the media more recently that has also been denied the ability to recruit another physician. These physicians want to help the government address the need that's out there. They'll take on the responsibility of trying to find a physician, and I think the government at this point should be saying let's go; let's do that.

 

            There's a void right now, especially in Halifax, and it really started with the big practice in Clayton Park that closed down a couple of years ago. I indicated that I know a family that has been looking for two and a half years now for a doctor in Halifax, and they've been going to walk-in clinics. How can the minister continue to support that policy of the health authority in the central zone when I'm telling the minister right now that there are people without a doctor? When I go back to them and say, I asked the minister about it, and the minister continues to quote the stats that we have, everybody knows that. But that gives no comfort to the Watsons, who are sitting home now with no doctor. They're in Halifax; they're in Sackville. You would never think that would happen.

 

            I've got to tell you, when the minister continues to quote the per capita, that's great; that's fine. But that's on paper. That's not reality for so many Nova Scotians. I don't understand why the minister doesn't understand that.

 

            I've already indicated that I support the idea of this new model, of this collaborative approach to health care, especially primary care. It's so important to work as a team, to make sure that the new doctors who are coming in work in an environment that is receptive and that supports daily living. What I mean by that is the ability for a physician to have a life outside of just practising medicine.

 

            That was one of the main things we heard when we were in government and we opened the Collaborative Emergency Centre in Parrsboro. The physicians up there worked their butts off, almost 24/7, to the point where they had a huge thriving private family clinic, they did hours at the hospital, and they did the emergency room. So when this new model of care came about to help them with not having to work seven days a week, they received it with open arms. I remember one comment from a physician who felt guilty because they had to take some time off because they worked day and night, four days straight, in the emergency and was criticized because they went to their grandson's hockey game I believe at the time. I think physicians are more than willing to adapt and change and embrace new models of delivery. I do believe that.

 

            But until we have them up and running, how can we have what's going on right now? There's a need in my area; as I said there's a pending retirement. I hope by June or July that government and the physician - they're trying hard to find someone to take that practice over. But there's a number of practices that have closed down over the last year due to illness, unfortunately, and the death of a physician. There's a huge need. I don't know what I tell the families that I talk to about what they do. When they have complex illnesses or when they have chronic disease, it's very difficult to go to a walk-in clinic.

 

            I don't know if the minister understands the need to change that policy so that physicians like Dr. Saad and others who know that there's a need - as I indicated in a member's statement this morning, I had a family that has been given four days' notice that their physician had to close down because of an illness. They called clinics from Clayton Park right through to Fall River, and not one family practice will take them in.

 

            I'm wondering, can there be a commitment by the minister to go back and revisit that policy and lift the ban so that these practices that can address the issues right now by attracting and recruiting a physician would be approved and stop the road blocks that are put in place? In the past, physicians would be accredited through the College of Physicians and Surgeons. Now they also need to be accredited through the health authority. So physicians are very frustrated by the lack of information, the lack of correspondence, the lack of telling them if they're approved or not. It's a couple of months now that some of them have been asking for approval without any correspondence from the health authority.

 

            I'm wondering if the minister would commit to going back and changing that policy until he can stand in his place and show Nova Scotians this new collaborative-model clinic that will be up and running so that I can tell the people who are calling my office, here we go; you can go to this clinic. You can get great care. It's open, and it's ready to go. What the minister has been talking about over the last number of weeks is something that's in the future. The need is right now. So I'm wondering if the minister will go back and look at changing this policy until this new model is up and running so that people in the central zone can find a family doctor. It's a huge concern for so many.

 

            MR. GLAVINE: I thank the member opposite and former health minister for raising a very important question here in estimates. I'm looking through the estimates briefing book for an answer on this one.

 

            But in all seriousness, I know the health authority has now taken this on in recent weeks, to look at where those who have been recruited will want to work. There's one element that sometimes we do forget as we look at getting doctors in the right places and getting enough doctors, and that is, they remain very much individual business people. It's not as easy as simply saying, look, we need a doctor in the Bedford clinic; that's where you're going to go.

 

            Doctors have told us that they'd love to work with older doctors as mentors, but they want this to be a full collegial practice that they're going to engage in; that the model of care that they're trained for is the collaborative model. They want to be able to have a nurse practitioner or a family practice nurse as part of the delivery model of care so that they are seeing the patients who need to be seen by a doctor. Others, who have a chronic disease being managed can be seen by another provider.

 

            As the member rightly says, we are in a transition period. What kind of support can be given to these traditional clinics in the short term is something that the health authority will obviously need to come to some measure of support so that patients aren't without a primary care provider. That's really what we need to put the emphasis on.

 

            I will be meeting with the health authority shortly to get a picture of how recruitment has gone this year and where some of those assignments will be heading. It's not as clear and as straight as saying there is a need for a physician at a clinic in Sackville, and automatically somebody is going to inform the health authority, I'm prepared to go there. We need to make sure that we have a strong team that is recruiting right across the country and in fact beyond. That's the kind of coordination that we will need to make sure that we have the right number of doctors in the right places for the future.

 

            In the short term, we are experiencing some challenges, but I will try to find out exactly what is planned for each of the clinics that have raised the issue that they are in need of further physician help in the coming year.

 

            MR. DAVID WILSON: I'm just wondering if there is a commitment by the government to continue to support what the minister said, traditional clinics in the province. I know the minister often talks about these collaborative clinics and maybe working with the walk-in clinics to convert them or change them or morph them into a more collaborative clinic. Is there still a commitment by the government to support the traditional clinics that we've had for - well, the start of time, I believe - in the province when it comes to health services or delivery of primary care? Is the government still committed to those traditional clinics? Does he see a mixed model of services into the future? Or are we talking about getting away from the traditional clinics that we have and ultimately just seeing collaborative clinics in the province in the future?

 

            MR. GLAVINE: I think the best way to start off is to take a look at the flashpoint that developed this year when there was talk about the change that would be needed in our walk-in clinics. The health authority met with the owners of these clinics on how they had especially provided valuable after-hours care. I think one doctor alone owns seven clinics. We have to keep in mind there's a certain business model here. They met with him and said look, this is going to take place over about a 10-year period, but the goal is to have a primary care provider.

 

            I will soon be going into a clinic in my hometown where it will be different. For 35 years, I have had the same family doctor. I will soon be going into a clinic where I may see the family practice nurse, where I may see the nurse practitioner. That's what is changing and developing. That's difficult for all of us to perhaps get a full appreciation of, a full understanding of.

 

            When we did a survey of every student at the med school, even those who are going to go into specialty areas want to be part of a team. They want to practise in that full new model of practice. So there will be challenging circumstances that will come along.

 

            But the guiding principle of working towards everybody having a primary care provider being that right provider at the right time is the commitment of the health authority. I absolutely believe that it is a model of care whose time has come, and I believe it can deliver stronger care for all Nova Scotians. But there is pain in that short term. We have to see how some of what we call traditional clinics will be supported through this change. Again, that's perhaps what I will have more commentary on as our time in estimates goes along.

 

            MR. DAVID WILSON: I know the minister mentioned that the health authority met with the walk-in clinics, some of the owners. I don't know if the minister met himself, or the deputy. I'm wondering if the government, the minister, or the health authority has met with the College of Family Physicians, who oversee many of these physicians who work in the traditional clinics. Is that on the radar, that there should be a broader discussion or consultation done to mitigate the growing pains or the challenges which we have right now? I think it would go a long way.

 

            I'm wondering if the minister is aware of any meetings with the Nova Scotia College of Family Physicians. If not, will he look into that, and will he ensure that they are part of the discussion also? They're frustrated. As I've seen in the media recently, it's their members who have been going to the media saying the correspondence, the information is not flowing quickly enough. They're the ones on the front line. They're the ones getting multiple calls a day from patients who don't have a family doctor.

 

            I'm wondering if the minister, in the last minute or so, can indicate, has that consultation happened? If not, will he ensure it does happen so that we can hopefully address some of the immediate issues that we see like some of the shortages of physicians in and around the area that I represent?

 

            MR. CHAIRMAN: Order, please. Could I have one moment of silence to listen to the final words of the honourable Minister of Health and Wellness?

 

            MR. GLAVINE: This is an important theme that has been raised this evening by both Opposition Parties. I know that we get calls at the department from right across Nova Scotia, obviously, when any area of health care is not at the level of people's expectations. One group that we have met with is Doctors Nova Scotia to take a look at family practice and how it is moving forward and how we will meet the current needs and requirements that are being brought forward through the media and through calls to the department . . .

 

            MR. CHAIRMAN: Order, please. The time has elapsed.

 

            The honourable Deputy Government House Leader.

 

            MR. TERRY FARRELL: Mr. Chairman, I move that the committee do now rise and report progress and beg leave to sit again.

 

            MR. CHAIRMAN: The motion is carried.

 

            [The committee adjourned at 9:22 p.m.]