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28 septembre 2017
Comités pléniers
Sujet(s) à aborder: 
CW on Supply (Health & Wellness) - Legislative Chamber (2162)











3:09 P.M.



Mr. Chuck Porter


            MR. CHAIRMAN: Order, please. The Committee of the Whole on Supply will now come to order.


            The honourable Government House Leader.


            HON. GEOFF MACLELLAN: Mr. Chairman, would you please call Resolution E11.


            Resolution E11 - Resolved, that a sum not exceeding $4,214,153,000 be granted to the Lieutenant Governor to defray expenses in respect of the Department of Health and Wellness, pursuant to the Estimate.


            MR. CHAIRMAN: The honourable Minister of Health and Wellness.


            HON. RANDY DELOREY: It's my privilege to introduce the estimates for the Department of Health and Wellness for the 2017-18 fiscal year.


            With me are two officials from the department who will help us examine the department's budget in more detail. Joining me are Ms. Denise Perret, the Deputy Minister of Health and Wellness, and Mr. Kevin Elliott, the Chief Financial Officer for the department.


            It has been my privilege to serve as Minister of Health and Wellness since June 15th of this year. With this privilege comes a responsibility that I take very seriously. It is a responsibility that each member of the team at Health and Wellness, the NSHA, the IWK, and the other health care partners also take seriously and exercise each day they show up to work.


            Over the last year, we've heard loud and clear from Nova Scotians that health care is their top concern. We have heard that access to primary health care, mental health support, orthopaedic surgery wait times, dialysis, access to take-home cancer therapies, and the QEII redevelopment project are just a few of the areas Nova Scotians have as top of mind.


            I've travelled across the province in the last several weeks. I've met with front-line health care providers in 19 different communities, I've toured 12 hospitals from Sydney to Yarmouth, along with primary health care practices. I've talked to new and experienced doctors, medical students and residents, to nurses, nursing students, to paramedics, pharmacists, and many others in our health care system.


            There are challenges, of course, and I've heard about those. But I've also heard a great deal of optimism about the foundation we are building. We are investing in healthier and stronger communities, with the support for an aging population in this budget. To do this requires innovation. There are providers out there finding new and better ways to deliver the care for their patients' needs. At primary health care practices, in pharmacies and mental health, and among our paramedics.


            Our front-line health care providers have excellent ideas. They're determined to find new and better ways to support their patients, the people of Nova Scotia. I have greatly enjoyed these conversations and I will continue to listen to the front-line health care workers Nova Scotians rely on.


            Mr. Chairman, 15 years ago, the Department of Health and Wellness budget was $1.98 billion. Since then, it has more than doubled to just over $4.2 billion. This year alone, the budget of the Department of Health and Wellness will increase by 1.98 per cent, or about $82 million over the previous fiscal year.


            Make no mistake. We are investing heavily into health care in this province. Health care is identified as the top priority of Nova Scotians and this priority is reflected in our budget. We are spending 44 per cent of the provincial budget on health care. We've dedicated a great deal of time and effort to it. But I believe most Nova Scotians expect more from us than to simply spend money on health care. They expect us to look at the needs of communities across the province. They want us to look at the evidence and they want us to tailor our investments to meet the true health care needs in their communities. In other words, they want smart, strategic spending. And that's what we've been doing.


The first step we've taken was the amalgamation of nine previous district health authorities in 2015. Our first goal was to consolidate administrative spending and focus on front-line health care. What it also allowed us to do is begin to plan as a single health care system, for the very first time in our province's history.


In the previous district health authority structure, we had no way to track how many Nova Scotians needed a family practice, or where there might be operating room capacity to help Nova Scotians get the surgery they need. We were doing things nine different ways a great deal of the time. We had no way to streamline procurement or other administrative functions. The system wasn't set up to look at the health needs of communities and to tailor primary health care and other services to meet those needs.


In fact, in many ways, it pitted communities against each other, each fighting for investment, equipment, and physician or health care provider recruitment. Two years later, we are making strides in planning as a single health care system. We are focused on several key areas for improvement. They include access to primary health care, mental health and addictions, wait times for orthopaedic surgery, and continuing care. You can see those areas reflected in the department's budget and indeed in our investment over the last several years.


[3:15 p.m.]


            Access to primary health care is top of mind for this government, for many Nova Scotians, and for colleagues on all sides of this Legislature. Just this morning the Canadian Institute for Health Information has released its latest report on physicians across the country. I'd like to take a moment to share some of that data with my colleagues. Over the last five years the Canadian population has increased by 4.5 per cent while physician population grew by about 11.9 per cent. In Nova Scotia, our population increased by 0.17 per cent but the number of physicians increased by 3.8 per cent. That's 22 times our population growth.


            We continue to lead the country in the number of physicians per 100,000 population. We have 258 doctors per 100,000 people compared to 230 in the rest of the country on average. That is a statistically significant variance reflective of our commitment to ensure we have physicians to provide services to Nova Scotians. It is also worth noting that our ratio of physicians per 100,000 population has increased since the last CIHI report. Given that we have more doctors per population than the rest of the country, I can understand Nova Scotians wondering why the continued stories of Nova Scotians lacking access to a physician.


            There are a number of potential reasons for that. We do know that today the way physicians practise has changed. Today's family doctors may not choose to practise the same way as physicians of yesterday. That, of course, is their choice. But one thing that hasn't changed is physicians' commitment to provide the best care they can to Nova Scotians. Nova Scotia has the highest percentage of physicians paid through alternative payment arrangements - 48 per cent of our doctors are paid through alternative arrangements compared to 52 per cent who bill through fee for service.


            I also want to recognize that our population is aging and we do have a higher burden of illness in some areas of the province so it is important to recognize the role that plays in physician practices as well. It means they may need to spend more time with some patients, the alternative payment model allows for a physician to spend that time with their patients to provide care for the entire patient and not simply focus on a single health issue or concern. That may mean fewer visits needed to that doctor's office.


            We want to support doctors, nurses, and other health care professionals to work in the way they believe will offer the best care for Nova Scotians. For some, that is a more traditional practice but for many new doctors and other health care providers, the answer to expanding access is to practise in a collaborative primary health care team. I've spoken to many students, medical residents, and others who are very enthusiastic about this model. By having nurses, dietitians, mental health clinicians, and others working as a team, they are able to provide services to more patients.


            A nurse practitioner, for example, can diagnose and manage illnesses, order and interpret tests, and prescribe medication. So a patient with diabetes might be diagnosed by a doctor or a nurse practitioner but also work with a family practice nurse and a dietitian for ongoing management of their disease. This means that family doctors can see the patients who need the skills only a physician can provide while the patient gets care from a team focused on their total set of health care needs. We believe in this model, that's why we've invested $9.6 million this fiscal year to expand collaborative practices across the province.


            As I toured the province, Mr. Chairman, I visited several successful collaborative teams in Woodlawn, Lunenburg, Digby, Annapolis Royal, and Westville. Each one of these practices worked just a little bit differently, some practices have all the providers under one roof while others are affiliated and work together and talk to each other regularly. What's interesting to note is that it's not a "one size fits all" model.


The medical residents, nurses, and new physicians I have spoken to - and many more experienced physicians as well - say that this model works well for them. It helps with their work/life balance, it helps support their patients better, and it helps with recruitment. But we've also heard from some family doctors who prefer to practise in a more traditional way, working alone or perhaps co-located with another physician to provide care to their patients. They are free to practise that way in Nova Scotia too.


            The Nova Scotia Health Authority is responsible for recruiting family physicians across the province and we're supporting those efforts through several new measures introduced in this year's budget. We're investing $2.4 million to create 10 more family residency spaces and a new practice-ready assessment program for international doctors who want to set up a family practice here in Nova Scotia. That means 56 more family doctors per year available in the province.


            We know from experience that doctors are more likely to consider practising in a smaller community when they have experience working in that community and can see for themselves what life would be like there for themselves, for their partner, and their children. The Dalhousie Medical Residency Program in Annapolis, Cape Breton, and southwest Nova Scotia have been successful in recruitment for that very reason. So we're expanding on residency and creating a new clerkship program for medical students starting in Cape Breton. This will allow students to get a feel for what practising in Cape Breton would be like and the kind of lifestyle it can offer.


            Experience has taught us that doctors are more likely to remain in a community when they are welcomed with open arms by its people. I've heard from many medical students and new doctors that what makes the difference is how the community presents itself. They want to know not only what will be expected of them as a family physician but the kind of information any of us would want to know when considering moving to a new community: what are the job opportunities for their partner, how will my children perform in the school in this community, what will my commute be like, will I be able to afford to buy a family home? Communities across the province know this information best and they have come to understand the invaluable role they play in promoting their way of life to health care professionals.


Recently, business people in Cape Breton contributed to a new video to promote Cape Breton lifestyle to doctors considering a practice there. I would encourage all members of this House to watch it if they haven't already. It's available online at We will continue to improve the tools at our disposal to train and recruit more physicians to meet the needs of Nova Scotians but we all have a role to play. I'd encourage all communities to remember they are in the best position to promote their own way of life to doctors and other health care professionals considering practising in those communities.


            As I mentioned earlier, physicians have a choice to practise in Nova Scotia where they wish to practise, to see and care for patients in the way they feel is best. The department and the Health Authority regularly meet with Doctors Nova Scotia and with individual physicians to hear about their concerns. In the end, we all have a common goal - for Nova Scotians to have access to the health care they need.


            Mental health and addictions impact many Nova Scotians. Last year we invested $274 million in mental health and addictions treatments. That includes services to those living with mental illness, payments to physicians, and medications. This year we will invest $281.5 million towards mental health and addictions and we will increase that spending in each of the next four years with a focus on youth mental health. We will expand access to front-line mental health services across the province, our funding will put more than 70 more mental health specialists in communities across the province, and at the recommendation of internationally recognized adolescent mental health expert Dr. Stan Kutcher, we will also expand the successful Caper-based program to provide more support in industrial Cape Breton as well as other communities.


            Later this year we will offer a central intake service for mental health and addictions to ensure people know where to get access to the mental health services and addiction services they may need. We're also expanding access to crisis services across the province. I was honoured to visit the addictions unit at Soldiers' Memorial Hospital in Middleton and the South Shore Drug Dependency Program in Lunenburg. I know that the staff there and at mental health and addictions programs throughout the province work tirelessly to help the people who are struggling with some very significant challenges.


            One of those challenges can be the misuse of opioids, a challenge that is spreading across the country and claiming many lives. We knew that Nova Scotia's not immune to these challenges and we had to act quickly to address this growing challenge and that's what we have been doing. Last March, we were able to commit more than $1 million to fund community-based harm-reduction organizations in Truro, Halifax, and Sydney and to make Naloxone kits available across the province. These Naloxone kits are on their way to community pharmacies and will be available to Nova Scotians free of charge.


            Naloxone is also available in ambulances and emergency rooms, and when necessary, to people being discharged from correctional facilities. These actions, and Naloxone, save lives. In July, we released our provincial opioid framework, which set out our plans to address this complex health and social issue from many angles. Following up on that framework, this year we will expand treatment for opioid use disorder. We will meet the current demand for this important treatment but also create new capacity to help an additional 250 people beyond the current wait-list. This is an area of priority for all of us.


            Nova Scotians living with mental illness and addictions, they are our friends. They are our friends, our neighbours, our colleagues, and loved ones. They don't have to deal with it alone. We are working hard to increase the supports so that they can live the lives that they want.


            Since government has been in place, we've invested more money every year, to help Nova Scotians on the wait-list, for orthopaedic surgeries, particularly hip and knee surgeries. Since 2013, an additional 2,200 surgeries have been completed, helping the Nova Scotians who have been waiting longest. But the wait-list remains lengthy and we need to do more. We're committing $6.4 million this fiscal year to orthopaedic surgeries. This will allow us to complete 500 more surgeries this year. These funds also support pre-habilitation clinics that help patients prepare for a successful surgery and improve the recovery afterwards. That money means four more orthopaedic surgeons and four more anesthetists, along with nurses and other health care professionals, will be hired to support those surgeries. We will work with the NSHA to develop a stronger province-wide approach to significantly reduce wait times.


            The Continuing Care staff at the Department of Health and Wellness serves approximately 40,000 Nova Scotians every year and has an annual budget of $833 million. Through Continuing Care, we support clients in residential care facilities and long-term care and in-home care. Today, Nova Scotians want to remain active and involved in their community life as they get older. They may still be working or volunteering and they are integral to their families. Their age doesn't change that. Many people want to remain in their own homes for as long as possible, living close to the social networks they've built up over their lifetime. That number has gone up significantly. In 2003-04, we had just over 15,000 home care clients. By 2016-17 we had just under 30,000 Nova Scotians receiving home care or home nursing services.


[3:30 p.m.]


Over the last several years we've had great success in approving access to home care services that help people remain independent and stay close to family and friends. In March 2015, there were 890 people waiting for home support services. As of September 1, 2017, there were just 97 people in the province on that wait-list. I would like to make a note there is no wait-list for home nursing services at present. That is a significant success. We have invested $64.2 million more over the last four years in home care to meet that growing demand.


            That kind of reduction in the wait-list isn't just about spending more money. We have worked closely with the home support agencies who provide this care, with their staff, with clients and families to improve how those services are offered. Eventually, some Nova Scotians may need the kind of enhanced support that can only be received in a long-term care facility. In recent years, we have worked with long-term care facilities across the province to help them find ways to operate more efficiently with a focus on administrative savings in areas like procurement. But we've also heard concerns with this approach. As a result, we are increasing the food and recreational program in this budget by $3.2 million, investing in front-line services for the residents. We'll be communicating the funding increases directly to facilities once this budget is passed.


            We're currently in the planning phase for our new five-year continuing care strategy. We know the demand for home care and long-term care is expected to grow over the next 20 years as the baby boom generation ages. This strategy will continue our commitment to help support Nova Scotians to remain at home as long as they are able and to provide quality long-term care for those who need it. It will identify how we will meet the current and future needs of the population as Nova Scotians age. We'll be engaging with the sector, with families and clients, and with Nova Scotians in the coming months on the strategy.


            Mr. Chairman, to put on my other hat for a moment, I am also proud to serve as the Minister of Gaelic Affairs in Nova Scotia. Our government recognizes the importance of the Gaels, it is why we have the Office of Gaelic Affairs. Thousands of Nova Scotians have connections to the language, culture and identity of Gaels in the province. That is why the Culture Action Plan promises to include the language, history, and culture of our founding cultures including the Gaels and teaching Primary through Grade 12. It is why we are strengthening the office and looking at new ways to support Gaelic language and culture. That's why we are working on establishing the Gaelic licence plates, an initiative which will put more money towards Gaelic programs in our province.


            I also want to acknowledge and thank the many volunteers, organizers, ambassadors and educators in the Gaelic community who work tirelessly to share and promote Gaelic language and cultural identity in this province. As a province, we are proud to recognize Nova Scotia Gaels as part of the unique diversity of our province and I look forward to discussing the work of the Office of Gaelic Affairs during my time here at Estimates.


            Mr. Chairman, as I close, I'll move back to my role of the Minister of Health and Wellness. I'd like to point out that the priority areas I've spoken about are by no means all that the staff at Health and Wellness are doing. I know Nova Scotians living with an acquired brain injury and their loved ones face significant challenges. I've met with the Brain Injury Association of Nova Scotia to hear about those concerns first-hand. Work is continuing on the report that was previously provided and our response will be shared soon.


            We continue to work on the dementia strategy, working through a strong partnership with the Alzheimer Society of Nova Scotia who receive funding for this work. Thanks to them, we are able to provide more information, support and services to patients and families. We are enhancing dementia protocols as part of the 811 service, we've revised the supportive care program to improve access for caregivers of people living with dementia, and we supported the development of a series of webinars and national dementia symposiums. We continue to work with our Atlantic colleagues on a regional approach to Pharmacare programs to make sure they are stronger programs now and well into the future.


In the interim, while we work with our colleagues on that issue, we have also introduced in this budget a program to support those Nova Scotians who face significant costs of take-home cancer therapies to ensure that no single person must pay an exceptional amount for those therapies.


We continue to support wellness programs that support community needs to the Chronic Disease Innovation Fund. We have supported the Cumberland Opioid Council, personal health coaching for African Nova Scotians, access to healthier food in Cape Breton and our school systems across the province, and many other important projects. That's thanks in large part to volunteers on our community health boards who dedicated their time and attention to improving health in their communities. They partner with us in the Chronic Disease Innovation Fund grants and do some exceptional work on their own in their communities.


I could continue well past my allotted time, Mr. Chairman, but these are some examples of the continued work being done by the Department of Health and Wellness. As I mentioned earlier, health care spending makes up 44 per cent of Nova Scotia's entire provincial budget. It is my responsibility and the responsibility of the department to make sure we spend that money wisely in ways that will improve the health care Nova Scotians rely on every day.


There is much to be optimistic about. With the creation of a province-wide health care system, we are able to plan provincially. We're working closely with the Nova Scotia Health Authority and IWK to improve the way we deliver health care across this province, to collect and share data, and to use that data to make smart, strategic investments. I would like to recognize both of those organizations and their volunteer boards for the partnership in this important area.


Before I conclude, I also want to take a moment to provide my personal thanks and the thanks on behalf of the Government of Nova Scotia to the thousands of dedicated Nova Scotia health care workers who work tirelessly every day to provide Nova Scotians the care that they deserve. These are the doctors, the nurses, clinical specialists, paramedics, physiotherapists, pharmacists, and many, many other front-line health care professionals. I will continue to meet with them and to listen to their concerns and their ideas as I continue to serve the public in this role.


I would also like to recognize the thousands of volunteers who devote their time and devote their expertise to the health of Nova Scotians whether that's through fundraising, through assisting clinicians, education, and supporting patients and their families. They do this because they are passionate about it. They do it because it matters. I want all of those volunteers to know we do recognize their efforts on behalf of Nova Scotians and we are grateful for them.


With that, I will conclude my remarks and open the discussion with the assistance of Deputy Minister Perret and Mr. Elliott. I'll be pleased to answer the questions the Opposition members of the Legislature have about the department's estimates in this year's budget. Thank you.


MR. CHAIRMAN: The honourable member for Argyle-Barrington.


HON. CHRISTOPHER D'ENTREMONT: Thank you very much, Mr. Chairman. Welcome to the first Opposition hour of many hours of questioning the Department of Health and Wellness and other departments as we have time. It seems to be what happens here during Estimates, we spend a really long time on Health and Wellness - and I apologize and thank the deputy minister for being here and of course our chief financial officer for their hard work in preparing the documents, and of course I am sure the people who are behind me ready to answer any other questions that might come along that the minister might need a little bit of extra help for.


I also want to stand with you in thanking our health care professionals, whether they be doctors or nurses or paramedics or physiotherapists or clinical psychologists, and the list will go on and on of all these individuals who work so tirelessly within our health care system that truly make our system, our Canadian health care system, our Nova Scotia health care system, one of the best in the world.


I know it's kind of funny, we spend an inordinate amount of time complaining about issues within the Department of Health and Wellness but that's our job, in a way, that we need to underline the issues that are wrong, but we also have to understand all the things that are good within our health care system. We don't just spend $4.2 billion for nothing, we spend $4.2 billion to ensure that services are available for Nova Scotians. I just want to thank those individuals who work in our system, who work so tirelessly for our patients, for sure they are loved and thanked by all of us in this House of Assembly and by all Nova Scotians for the hard work they do.


            Mr. Chairman, I can say it is an honour to be a Minister of Health. I know it doesn't seem it at first because there's a lot of things you need to learn really quickly but I know the minister came from a good place in Finance and Treasury Board, came from a good training at St. F.X., that he is more than capable and willing to take on this task.


            I can also tell the minister, and I know the previous minister can probably say it as well, the best day is when somebody else gets to be the Minister of Health and Wellness. It has been a long eight years since I was able to be Minister of Health for this province. It was four years as minister that I will never forget, that I thoroughly enjoyed but I can tell you that since that time, I know too much. I can't be the critic in the way that I want to be the critic because I know some of the answers and I might provide you with a few things that I want you to take out of the briefing binder and just crunch it up and throw it out because it's the same briefing note that I would have provided to the House of Assembly eight years ago.


            The more we stand here and talk - I've got a whole bunch to talk about but I've only got a half-hour and I'm going to share the rest of it with our actual Health Critic, the member for Cumberland North. The first thing I want you to take out of your briefing book and crunch up is that fallacy, that thing that we continue to talk about, that our physician to population ratio is the highest in Canada. Yeah, sure, great - if we count every possible person with an MD or whatever designation they may have behind their name, if we count every single one of them and count it against our population then sure, we'll have a very high number. But a lot of those people are teachers, a lot of those people work only part time, a lot of those people are surgeons, some of those people are specialists, and some of those people are - you know we can go on with all the other things.


            What I want the minister to actually provide to us, if he can, is actually the number of family doctors providing service to Nova Scotians, to the population. That's the number that I want the minister to commit to me and maybe break that down by region, if that's possible, so that we have a better idea of what the problem is across this province when it comes to family medicine because that's the question that I get, as a member of this House of Assembly, is people looking for a family physician. I was wondering if the minister can provide us with that kind of information.


            MR. DELOREY: Mr. Chairman, I thank the member for the comments but also for the recognition of both the honour and the challenge that this role affords. To the question about the ratio of physicians in the province on a per capita basis effectively and the question of how many of those actually end up being family physicians, the CIHIHIH report actually was mentioned in Question Period today, I think, maybe, or I was scrummed on it anyway. It was just released earlier this morning so this is the most current data. I haven't got through it all. So at the high level, not on a regional basis, the total number of physicians is just under 2,500 - 2,457 - broken out in an almost 50/50 split between family physicians and specialists, 1,215 family physicians, 1,242 specialists.


[3:45 p.m.]


            MR. D'ENTREMONT: Okay, so if he can take that data set, as you take all that information and put it into one place, is there a way that you can take that information, maybe regionalize it and then compare it to across Canada, you know? Where do we rate in that, per population? Because, again, it's not a real number when you start to get further out from Halifax but even to Halifax or to HRM where we hear the challenges today, Mr. Chairman, of people unable to access family service, family physician services even in the metropolitan area and even the challenge of physicians to set up in this area. So, I'm just wondering if there's a way to spin that up. I mean, I'm just looking for a commitment maybe for later on where they're practising and how that works.


            MR. DELOREY: The challenges sometimes in rolling it up is the level of the data. So, when organizations are collecting the data, as in this case, they're looking for really the provincial/regional on a national basis, so I'm not sure right now if the CIHI report, again, it just came out this morning, early this morning, as to what the data is but there is some interesting data that we've become aware of in particular since we started the 811 service.


You know, I think, historically, when in Nova Scotia the question of primary care access, access to having a dedicated family physician for individuals and families came up, often, I think, perhaps, back when the member opposite was Health Minister - and he references the briefing notes may have had some statements where it was referring to the rural health care challenge and crisis in communities. Indeed, even today, and I mean today both literally today but also generally, you know, during the session, often the questions are coming from rural members of the Legislature asking about recruitment and the challenges of physicians in their communities but, really, to the extent that I've seen some regional data we see it on the 811 list, we actually recognize now something that came up more towards the election time that, indeed, even in our urban areas there are some challenges as well. So, it is important to see the regional breakdown because it can set aside some assumptions about where challenges exist, and we do need that internally as we build it up.


Right now, we've got just general data that does show that even our urban areas like in HRM do have some of those challenges and, I guess, just some information here broken down by zone. So, this would be from internal data from the Health Authority. This is a little bit older, so, again, one of the challenges with data, your numbers might not line up completely to the number because they're always snapshots at a point in time, so I want to make that qualification. In family medicine, I do have a little bit of data but it's from 2016: we have in the Western Zone, 234; in the Northern Zone, 151; in the Eastern Zone, 192; in the Central Zone, 636; and there's two family physicians that we didn't have identified which zone they were employed in. Then if you look at specialists in those same areas: Western Zone, 151; Northern Zone, 97; Eastern Zone, 151; Central Zone, 842; and one where the zone is not defined explicitly.


So, again, just to summarize those numbers for 2016, it was 1,215 family physicians and for specialists, 1,242. So, this data for 2016 would actually be presumably the data we provided to CIHI because it actually does line up exactly with those CIHI totals in the report, although it was only released today.


MR. D'ENTREMONT: I appreciate those numbers and how they're broken down. So, I want to move to the issue that, okay, now, we have physicians practising and, yes, the rural-urban divide tends to be a bit of a challenge of trying to figure out, you know, how we're going to be recruiting in some of the rural areas, but again, it is a challenge here as well. So, we bring the overarching issue of talking about primary care and primary care teams, primary care clinics, trying to have them fill maybe some of the voids where we're having that challenge.


            Maybe you can talk generally where the department envisions that these primary care clinics might be and maybe what kind of composition they might have.


            MR. DELOREY: The commitments, as you mentioned, at the high level for the where and the how, first I'll just touch briefly on a reference I made I think earlier today. One of those collaborative practice clinics, a relatively new one actually, I think they've only established themselves about four months ago here in the metro area, well in the HRM area, over in Dartmouth. In that facility, they established a group of four physicians, two nurse practitioners, and a family practice nurse that came together to work in this particular clinic.


            There had been an operation there in that facility that had retirees, I think one or two physicians who left. In the short time since they've been established, they have replaced the - they worked their internal list from the physicians who left so they contacted all those patients, replaced them and have also, as of the end of August, brought in 800 people who had previously registered on the 811 list. This is just one clinic, with the four physicians, two nurse practitioners, and one family practice nurse. It just goes to show the efficacy that they do work and they work well.


            As far as the question of what the composition or structure would be, this is where some of the challenge and the discourse in the discussions around collaborative practices has been and some of the criticisms and concerns that have been raised by front-line providers comes from. When we go back to the original establishment of the Health Authority and their efforts to do the best they can to get the optimal system operating, they did look and say collaborative care, the evidence shows - and this is what is going to make sense - and they were looking at here's what an optimal system looks like, that is in this kind of configuration with these specific practitioners is what we see as being the optimal collaborative environment.


            What we've learned since then, particularly from people on the ground that are front line, is that in a particular community, depending on the needs, depending on the individuals that come together, it's difficult to just use a template and plug it in. That's the long answer which really in the short answer is, we need to, when we engage the communities that will be getting the collaborative centres, find out where those needs are, what their main needs are and try to put together the team that will most effectively address those needs. So, whether that's the dietitian that should be in there - so the example I used didn't include a dietitian. Maybe a dietitian is needed if it's in an area that has high diabetes or demands, and needs like that should be incorporated in that practice. So that's more the short of the long answer.


            MR. D'ENTREMONT: We already know why we spend 20 hours or so just looking at these budget issues, because of the breadth of the discussion that we end up having about health issues.


            On that, the challenge that I'm seeing, I mean we can take the Weymouth example and with all respect to the member for Clare-Digby, there was one that was set up there and was working well and then we had a challenge of trying to find doctors to go in and replace there, so we have a community that all of a sudden had a really good one and then all of a sudden doesn't. We have communities - I can only take my own communities - the Pubnicos, there's a nice clinic there, I know there's a couple of clinics over in Barrington, but if you were actually trying to force them into or trying to entice them into a clinic facility as you are envisioning, it wouldn't work because you have that challenge of taking independent business owners - they are physicians but they are independent business owners, and then you're trying to get them to work together, a tremendous challenge. Because I know of a number of occasions where they've tried, and for the sake of 30 days, and it just doesn't work. Because they practise differently, their trainings are different.


You have different ages, you've been practising for 20 years, and this one has been practising for 30 years, this one's brand new. Maybe the brand-new ones, we should be able to entice them to maybe work in a primary collaborative practice. But trying to take some of the older physicians who maybe have been around for 25 years, that have a few years to give us still. They're not going to be changing their method of practice.


I think that's the challenge that the department has to try to figure out, and they can't be forcing these things either, because they'll have a total revolt at what's happening. More specifically, I want to fire in as much as I mentioned the Weymouth issue, which has been a challenge for southwest, because there's some impact to Clare, and Yarmouth, and Digby.


I want to stay on my side of the province when we talk about what's going on in Shelburne, and there has been a clinic there, which has been promised to that community since the NDP were government. In their dying days, they realized that they had to move forward on a clinic for Shelburne, and today we have a gravel parking lot, that's pretty much all we've got there right now. Just wondering where that's slated in the system and how that matches into the budget that we have before us.


MR. DELOREY: You did mention the specific facility, just to confirm, you're referring to the Roseway facility in Shelburne. So that particular project, you're right, that's been long-standing, I know there were some concerns. But even for ourselves, a mea culpa, we had committed and did a big announcement for that project. The project team went in there to do the work. What was on the table for that project was a renovation.


When we went into the facility to begin that stuff, you learn more, and so they did have to step back because they got more information and said, wait a second, maybe a reno is not the right model. Rather than doing the type of thing where, you know what? Well, we made the commitment, let's keep forging ahead and running into major cost overruns and challenges. We said, you know what? It's better to make significant changes on the front end early in a project than it is further down the road. So we stepped back, that's the reason from our government's term, that there was a bit of a delay, because we did realize after the assessment was done that it was more cost-effective to actually decommission the building, take it down and build an entirely new structure.


            That work is under way. As you noted, the facility - and I was down there a couple of weeks ago - is demolished. That part is done. The site is right next to the facility there. For this budget and the work that's - again, it is ongoing, the construction workers are onsite - $2.2 million for 2017-18 has been allocated, with an approved budget for the entire project of about $3.4 million. Again, the reason you don't see the whole amount is the project spans over multiple fiscal years.


            MR. D'ENTREMONT: I think that the added point that has been going on there - the member for Queens-Shelburne actually, will probably have more questions later on on this one. But there are a number of my constituents who travel in that direction. Because they feel if they go to Yarmouth to an emergency room or to see a physician, they're going to be there for eight or nine hours, waiting in that lineup, or if they chance that it's open, that they could be seen within four hours at the Shelburne site.


            The challenge that we've had is - because the clinic's not up and running - that we don't have the facility available, we haven't necessarily done the recruitment to put the people in there, and we continually have ER shutdowns and closures because of a lack of physician availability.


            It has been closed a lot in the last bit, especially summer, and I don't blame the doctors in a way, because they deserve to have some time off too. I don't know what the rotation is in Shelburne, but I'm sure it's like one in three, two in three, or whatever that rotation is for them. I'm just wondering, for the constituents that I represent, and for those who access Roseway, what's the next step? The building's building, how's the recruitment going, in order to make sure that that's up and running on the day the keys get turned over to the community?


[4:00 p.m.]


            MR. DELOREY: Much of the recruitment, I think they've had success but those physicians just aren't working in that facility. In fact, physicians currently are working, as I understand it, in the facility next door, and in a temporary kind of space in the hospital until this gets built. They were relocated out of the facility that was taken down a couple of years ago.


            What I was advised by a physician in the community was that right now they indicated to me when I was down there that - this isn't from a briefing note, this was the meeting - that they actually have more physicians now than they've had for decades in that community to provide those kinds of primary care services. That's the situation, those would be physicians that would be moving from temporary locations into that facility, having a better facility with a little bit of room potentially for others, depending on what the actual allocation needs are in that community for physicians.


            MR. D'ENTREMONT: Mr. Chairman, I think I'm going to move on because I only have a half-hour before I turn it over to the member for Cumberland North, our Health and Wellness Critic.


            I want to move on. Again, credit where credit is due, is the issue of oral cancer medication. I have spent many hours talking about this issue, I have asked many questions in this House of Assembly about oral cancer medication. I was glad to see it's included in this so maybe I'm going to give you an opportunity to explain how it's going to work. As I said, it's not everything that I wanted to see, it's not completely free but it's good to see that it's capped at 4 per cent of net income. Can you give us an idea of how this might be rolled out over the next 12 months?


            MR. DELOREY: Mr. Chairman, this is a program that is quite exciting, there were people that have been looking for this for quite some time. Clearly, in particular in the last 5 or 10 years, we know there have been lots of advances in cancer treatment. Along with that came new technologies, new means of treatment. Historically, and this is as much for the benefit of people who may be viewing and may not have the experiences, traditionally the only means of chemotherapy was through an intravenous which explains why it was traditionally provided in the hospital system.


            But with the advancements in technology in treatment options, other methods of delivery, whether it's oral or other means, can be taken at home to receive those treatments. With these treatments, the costs can be very expensive. I think you're talking upwards of $75,000 to $80,000 a year that somebody could be paying for a take-home product. We expect to see continued advancements where initially you may have seen an intravenous in hospital with the option of a take-home and you're seeing advancements now where perhaps the new treatment just only has the take-home availability. That's one of the reasons why it's so important to move forward and ensure the feasibility of this program and the treatment options for Nova Scotians.


            How the program is envisioned to work, you already mentioned, number one is that it is designed to be a payment of last resort. That is, we know that over 60 per cent of Nova Scotians have some form of private medical insurance so there will be some coverage through there. There are many Nova Scotians, particularly our seniors and low income who are eligible for various provincial Pharmacare programs which have historically and continue to provide coverage. We want those coverages all to come into play first and any other forms of payment to help offset the costs.


            We're looking at what would a Nova Scotian - after taking in private coverage, provincial coverage - have left over to pay out of pocket to receive these treatments? Then what we're saying, in the data that we have, we've seen where individuals pay as little as a couple of hundred dollars a year in the current system, up to, again as we said, $70,000 or $80,000.


            Our concern is the catastrophic area and so we cap the amount that would be out of pocket. That would work with the Nova Scotia Cancer Care organization to manage on the administrative side of the program so you get through the applications there. We get you into the provincial Family Pharmacare Program and get you registered for any programs that you are eligible for and then with the net remainder to work with the organization to cover the gap.


            MR. D'ENTREMONT: If I can provide any other thoughts on that one is make sure that when a patient is sitting with an oncologist that the decision is not one of paperwork, that the patient can walk down to the pharmacy and pick up their drug and move on with their life because it's going to be a tough next number of weeks and months, depending on the treatment they are receiving, that we don't over-burden our oncologists, our specialists with okay, let's see what kind of drug coverage you have here and what kind of drug coverage you have there and then as a last resort we're going to go over here. All of that time is time that that patient might not be getting their drug so that they can beat cancer. I just want to make sure that that's envisioned in the process, that the process is as least encumbered as possible.


            MR. DELOREY: I agree with the member opposite and we have taken that into consideration on two fronts. One, of course, as a government our desire is to be more efficient in processes where we can be. We've taken a lot of steps in our organizations as a government to make those improvements so health is no exception, we want to be more efficient but also recognizing - the member made reference to the role of the oncologist for filling out the paperwork and forms and of course there may be some medical requirements but we did recognize, for the patients in particular that would be going through a very traumatic point in their lives, that part of the funding estimates actually is going towards some employees who will act as navigators and to help through the application process for dealing with any paperwork that's necessary.


            MR. D'ENTREMONT: I appreciate that and I know from the reading that I've done on it, I think the Alberta model is a pretty good one and how those people can do it. I know the deputy minister might have some friends still left over in Alberta to be able to steal that idea from them, so thank you for that.


            Maybe one last thing before I share my time, revolves in and around kind of the same and different. We have the Western Nova Scotia Cancer Support Network at this point. It's a Facebook site and there's like 20,000 people who now belong to it. I want to thank Derek Lesser and Councillor Sandy Dennis. I know Derek did a lot of work in providing you with a real face of oral cancer medications but they're also working on the bigger issue, and you've met with them, about radiation oncology in Yarmouth, which is a big job. It's a big job, understand.


            This is something that's important because that's the dirty little secret of our health care system. I don't know if many people understand it until they really need to access services. Not all services are available in all parts of the province so people have to travel. For the people in southwest Nova Scotia, they need to travel here to Halifax in order to receive radiation oncology because this is where the linear accelerator is and the zappers are - I forget what they are called. But they have to come here and take on that cost to stay here. If they are lucky enough to go to The Lodge That Gives or they are supported by other programs, but quite honestly, a lot of people make a decision whether to receive that service or not, because of even just that travel.


            If you take an older patient who might not have a family to help with the travel to even get them here, that they decide that they don't want or just can't get that service. So it's not just if we found a way to travel in here, in the meantime there's still a whole bunch of costs and time that has to be spent here in Halifax while they're receiving that kind of service. I'm going to leave it on this issue, maybe you have a couple of comments because I know Dr. Bethune is working on it but it's an important thing and I know the member for Yarmouth is on this one as well. I'm more than happy to help work this one through, I know it's a long process but I'm feeling good about it. I'll let the minister comment.


            MR. DELOREY: Mr. Chairman, let the record show that I think this is the first time in history the member for Argyle-Barrington and the member for Yarmouth are on the same page in this Legislature.


            In seriousness, this is a very serious topic and the member is correct, I did have the opportunity when I was travelling the province and was in Yarmouth to meet with a number of individuals who are advocating to look at radiation services in Yarmouth. Currently the only two locations that do provide this service are in Halifax and at Cape Breton Regional. So most Nova Scotians do have a fair distance to travel to receive this service because it does only exist in two locations.


            But what was committed to earlier this year, Dr. Bethune, who really is the expert here for us in the province, has initiated the review of those services to identify what makes sense. As I made reference earlier in my opening remarks was a need to actually rely on our experts to get the evidence and I'm quite confident that he and his team will be conducting an appropriate comprehensive, evidence-based review to make some recommendations back to us. I won't prejudge where he's going to go or his team with those recommendations but I do have every confidence he'll cover all of the base points that need to be assessed, particularly from a clinical perspective to make sure the people get the best service they can in the province.


            MR. D'ENTREMONT: Thank you for that and again I'm more than happy to work with the member for Yarmouth as we have worked on a number of issues together before. But then again, I will oppose him if I need to at some point along the way too.


            With those comments, I will come back at some point to talk about dialysis in Barrington and all those other fun things that are important to my constituents. I want to thank you for the time and I'm going to share my time with the member for Cumberland North.


            MR. CHAIRMAN: The honourable member for Cumberland North with just under 26 minutes in this round to go.


            MS. ELIZABETH SMITH-MCCROSSIN: I look forward to a great discussion with our Minister of Health and Wellness. I echo our MLA D'Entremont's comments about thanking the people that work in our health care system.


            MR. CHAIRMAN: Order, please. Just a reminder for all members to address each member in this House by the constituency and not by their name.


            MS. SMITH-MCCROSSIN: I take the role of Health and Wellness Critic very seriously because I know first-hand the jobs that the workers are doing every day. People, whether in medicine or nursing or physio or pharmacy and other allied health care professionals, what draws them into health care is that they care, they care about people. That's one of the reasons that it's so challenging for them when they feel they're getting discouraged when they see that they're not able to meet all of the needs that come their way. I'm hoping that even though I'm the Health Critic, that we can work together to improve the health care system for all Nova Scotians.


            The low morale is getting worse and I'm worried the toll that it's taking on our doctors, we're really starting to see them stand up for their colleagues now and share their concerns. I'm also hearing it from our nurses and I'm particularly concerned about what's to come, especially with the contracts and the union negotiations and I'm hoping there can be some work done on that so that we don't see further decline in morale of our nurses and physicians.


            In the spirit of being a voice for these workers and for the citizens of Nova Scotia, I hope to ask questions today that will be useful for the department and the overall health care system. There are some aspects of our health care system that are working. People access care every day and are receiving good-quality care and I want to recognize that. However, there are many deficiencies and I feel they are growing daily. Health care is becoming a bit of a lottery system. You kind of feel lucky if you've got access to a family physician and I don't feel that that's fair to the people of Nova Scotia. It shouldn't matter who you know. Everyone should have equal access to care.


[4:15 p.m.]


            Every day, I think, some here in the House know I've been a registered nurse for 26 years and probably about 80 per cent of what I'm seeing as an MLA is health care-related issues and I'm thankful that I have the experience of being a nurse because that is such a large aspect of what I have coming to me. People that are desperate and don't know where to turn and I'm doing my best to help them navigate the system and be their voice here.


            So, in looking at the budget, I would ask for some help in trying to understand. In the very first part of the estimates, it has the Programs and Services and Strategic Direction and Accountability. One of the things I noticed is that almost every Actual was less than what the Estimate was. I'm curious as to why that is. I know that our department and our board are trying to be very fiscally responsible, which I applaud you for, but I'm fearful that it has come at the expense of health outcomes and our health care.


If you look at the Chief Medical Officer of Health, that department spent less than budgeted. Client Service and Contract Administration spent less than what was budgeted. Corporate Service and Assessment Management spent less than what was budgeted. Investment Decision Support spent significantly less than what was budgeted and System Strategy and Performance - and I am particularly interested in that one, Mr. Chairman, because in looking at the budget it appears that's where the accountability would fall into play and I'm particularly concerned about the lack of accountability that I'm seeing in our health care system. When I ask people that are responsible for plans or evaluations of the work they're doing, it doesn't seem to be available and, whether you're in business or in health care, evaluation of the work that you're doing is a very, very important aspect of the care of the model because then you know if what you're doing and the money you are spending is actually of benefit.


            So, I would like to ask the question specifically in that area around System Strategy and Performance administration, maybe an explanation of those five areas and what that money is used for and an explanation of why less money was spent than what was budgeted.

            MR. DELOREY: I would like to acknowledge the member for Cumberland North particularly on her role as the Critic for Health and Wellness, again, a very important file to be provided, particularly right out of the gate. So, congratulations to that member through you, Mr. Chairman, on that.


To the point of her question, I guess, you know, in some respects it's a little bit of déjà vu for me because in my first Estimates Debate when I was wearing a different hat as Minister of Environment across the way that was something that I had identified in the budget that I was responsible for. Where that variance between what was budgeted and what was actually spent in the year was to a large part based on vacancies within the organization. Any organization, clearly, you budget for the staff that you expect to have in place, as there is turnover as there is in any organization, whether that be through retirements or people choosing to pursue different paths, promotions, horizontal, vertical, it could be inside the organization or not that vacancies open up and then you have to go through the recruitment process to fill those vacancies.


            That was the challenge I had back when I was at Environment, was trying to fill vacancies that had not been filled. That fundamentally, I would say in each of those five categories - not the entire amount - other things would be efficiencies, managing around travel, advertising or initiatives like that, that are also lower. I think in each of these categories that the majority in each of them would be around vacancies.


            To provide some context, though, to say why would there be vacancies and should this be long-term, something we're concerned about on an ongoing basis, I would say no. The reason I say that is, we recognize that as you go through and you try to fill those vacancies but it's important to know that with the restructuring of the Health Authority we also went through reorganization within the Department of Health and Wellness.


            Everybody seems to talk and focus on the reorganization and the amalgamation of the health authorities but perhaps what has gotten less attention was that as part of that reorganization, we actually looked at the Department of Health and Wellness as well.


            One of the things that was identified, because again we want to go back and remember back in 2013 what our focus and our intentions were when we were going through and designing the amalgamation process, was to find administrative savings. Part of those savings were, again as people talk about the amalgamation, fewer CEOs and VPs and so on, to control the growth of costs and get that in but also the capacity to plan as a single health structure across the province.


            What is less known or has gotten less attention is the fact that back when we had the historical, the original - I won't say original because it has gone through changes over many decades - but the model that was in place back in 2013-14 with the multiple health authorities or districts, that there was work being done in the Department of Health and Wellness and the same or very similar work being done in the Health Authority. So part of the restructuring was not just simply taking the nine and restructuring and amalgamating but also realigning the nature of the work that was being done to remove and avoid some of the duplication between the Department of Health and Wellness and the authority that's in place.


            Throughout both the planning and the implementation phase of the work, identifying where those places were, what vacancies may we need not just at present but in the longer term, so as the restructuring is taking place which really kind of came to a conclusion last fiscal, around January - the end of last fiscal, we'll say, that we kind of locked in the model of the Department of Health and Wellness. So again, we recognize these vacancies are there, we're working to fill those but again, part of the reason they have been higher than they otherwise would be is part of that restructuring and just making sure that when we're reallocating those resources, because we've realigned the priority areas and the focal points within specific divisions and teams, we want to make sure that we're hitting the right ones and that's what we'll be moving forward with.


            What we're forecasting for next year, we'll be working of course to make sure we have those people in those important positions to ensure we get our work done to the best of our abilities.


            MS. SMITH-MCCROSSIN: Thank you for that explanation. Would you be able to provide a little more explanation for the vacancies? For example, was it an expected turnover or was it people leaving their job due to dissatisfaction or was it planning?


            Also in line with that, I'm just curious, who made the decisions for the restructuring? Was it at a ministerial level, like Minister of Health and Wellness or deputies? Who is responsible for making the structural changes to the department?


            MR. DELOREY: Interesting that you ask whether it was the minister or the deputy. Both of us have been here for less than a year, so all those decisions within the department were made before either of us arrived.


            Suffice to say the importance of the restructuring and the work really is part of the government's direction and move, so it really doesn't matter where the specific decision came in. Certainly at an operational level, reclassification of positions and so on, that is work that is tasked and charged at the deputy minister level, staffing and so on gets allocated and falls under the responsibility of the deputy ministers.


            The role of the minister is really the strategic, the need for amalgamation, the need to be more efficient and so on and then the deputy minister and the team work together to come up with the strategies and really the implementation side of that. They're there to execute on behalf of the direction that comes from the government. If you follow that all the way back it comes down to the budget and other direction that comes through legislation and so on, it even comes from this Legislature in many respects. You have the Health Authorities Act that gets implemented to give the direction and so a lot of those things play into the role. It's more complex than saying just an individual.


But you also made reference to the reasons why vacancies show up. There are many, there is generally an operational reality whether it's in government, in health care, in any other department in government or in any private sector organization, non-profit organization. Vacancies are a reality, it's a part of business operations. Organizations over time, you try to establish what is normal vacancy values or rates versus what is out of the ordinary. Again, part of the ratio here I would say is a bit higher than we would consider within the normal operation level but the reason for that was because of restructuring within the departments. I think the decisions being made, in some cases as the vacancy came up, okay we need to hold on a little bit longer to determine do we need to replace that particular position with the exact same position or do we need to reclassify the position to do something else in the new reality?


            I think it would be far worse in the long term for the province to rush and just refill every vacancy that came up when you're going through this stage of really establishing a foundation within our health care system that's really designed to go out into the future. I think it was really strategic, the appropriate steps to be taken to make sure they did that analysis. As I said, it has really only been since the fiscal year wrapped we can really say they locked in on what the model and the role would be. We recognize the vacancies and you can see what our estimates are on the go-forward.


            In some cases, there are some variances, we recognize there is going to be longer term change or we're saying we don't need to fill some of those vacancies. But to some degree we know that where you see the estimates for 2017-18 going back up, our intentions would be to fill those vacancies in this operational year to ensure those roles. Whether a specific role is the exact same as it was the previous fiscal year, it might be a little different in each of the departments.


            All that said, we do still have, and we will still have next year, people out on leave through sickness or choosing other roles. You want to encourage people, particularly successful people in your organization, to pursue opportunities. I mean, you want to keep them and you want to keep that great expertise, too, but at the same time, particularly in an organization as large as government, if someone sees an opportunity within the organization and they want, for career development, exposure.


For example, I was very excited when I was appointed to Health and Wellness that there's a friend of mine from down home who I worked with back in university days and I knew worked in the Department of Health and Wellness and I was quite excited at the prospect of having the opportunity to work with this individual in a professional capacity opposed to when we worked in jobs in the university days.


The day I was sworn in, I get the letter that individual actually transferred just about a week before that to another department in the government but it was a fantastic career opportunity for the individual - a loss for the Department of Health and Wellness, but not, I think you mentioned job satisfaction, not at all to do with that. The individual was very appreciative of their time in the department, it was just a phenomenal opportunity in another department that allowed them to expand their skill set. We should all be happy that the employees in our Public Service have those opportunities in the organization and we encourage them to do so even when we miss some of the good people.


[4:30 p.m.]


At the same time, some people are choosing to come in to our department for their opportunities as well and I think the deputy is one and our ADM is another, people who've come in in the last year that are great resources to have.


            MS. SMITH-MCCROSSIN: Thank you for that answer. I think in looking at the numbers and the significant decrease it causes a little bit of concern. If you've had that much turnover that you have that much savings - and the reason I say that is because in any organization when you have turnovers it can create a little bit of lack of confidence in the employees and the staff that are remaining. So, it is a little bit of a cause for concern.


The other thing is I do believe it does matter who makes the decisions and my question was who did the planning? I know you said it was done before you came into place but who was the one that made the decision of further restructuring for the Department of Health and Wellness? I do think it makes a difference and the reason I say that is I'm wondering do the people that make those decisions have the background and knowledge in health care and one of the things that I've been fairly vocal about and I know Doctors Nova Scotia have as well is the lack of clinical expertise at a high leadership level within the department and on the Nova Scotia Health Authority board of directors.


            When you look at the IWK board of directors, there's a clearly strong representation of both physicians and nurses that are providing input so that when the board makes the decisions they can give input on what the expected outcomes would be of those decisions. I think it's very important, both at a Department of Health and Wellness level and I'm assuming these levels of vacancies you're speaking of and also on the Nova Scotia Health Authority board of directors, that you have strong input of clinicians that understand the repercussions of their decisions and that's why I think it does matter who makes the decisions.


            Going back to one of the first questions, I'm wondering if you could go back to the budget on System Strategy and Performance administration and, again, I'm looking for where in the budget would represent accountability and who in the Department of Health and Wellness would be responsible for measuring outcomes. That may be related to data. Is there any IT department that's currently collecting data on outcomes of the care of Nova Scotians whether it be in-patient or primary health care?


I know there are some physicians that were part of a system called Nightingale and that was a web-based electronic medical records system that allowed the department to actually collect data on outcomes. So, approximately how many diabetics would be in the province and are they getting care that's based on national clinical guidelines? Is there continuity of care - hypertension, and other screening things like pap smears? I'm wondering, when you talk about accountability, where does that fit in the Department of Health and Wellness budget and is it increasing, decreasing, and what is currently being done to measure?


            MR. DELOREY: Thank you. I couldn't help but notice the light went on first to my left here, the desk of the former Minister of Health and Wellness. He spent a lot of time standing during these estimates before. To the question, a couple of things, you know, I appreciate the clarity or the clarification with respect to the rationale as to the location of the decision on the restructure piece, both in the Department of Health and Wellness and also in the authorities and, I guess, to that end, I would say again specific operational-level decisions about specific - particularly on the human resource side, specific positions or what have you, you know, it's generally the boards, the elected or appointed bodies that govern and oversee that provide kind of a strategic level of insight but the specific operationalizing of that takes place in the operational side, so you'd be seeing the staff, for example, using the Health Authority as the example.


            I assure you that the executives within the Health Authority very much are made up of clinical expertise, be they nurses, physicians, or what have you in their background. So to the extent if you have concerns about whether there is clinical experience and expertise in the operationalization and the implementation of broad strategies and say okay, amalgamate, what is that going to look like, really those operational level decisions get made predominantly within the staff, which are really heavily made up of the clinicians, which ties in of course to your question about accountability and your perspective there. Of course, the accountability of the staff level we see play out really comes back and the board and government then providing oversight there or accountability measures when necessary.


            To the question then about how you manage accountability and the need for data and information. I made reference to those in my opening remarks as well, the fact that our goals and our efforts are really about making evidence-based, informed decisions throughout. You need to have that data.


            You made reference to one particular source of data, there are many sources that feed in because of course a health care system, a lot of different providers providing a lot of different services, using a lot of systems to pull that data together. I think one of the very significant success areas in that data and data management in the last couple of years has actually been in the drug information system side of things, partnering with pharmacists, getting that information into the system, centralizing it because pharmacists may all use different systems. You get it in and that has been one of the reasons we've been able to identify and use that data to build the opioid framework to plan, to roll out things like the Naloxone programming to identify where particular needs are in our community. I assure you those are taking place, the data is coming in.


            When you're talking, though, about the categories there under Strategic Direction and Accountability, the category that's more within the five areas underneath that, the one that does mostly on the information systems and the data management side of the work would be the Investment Decision Support team. That is the group that is predominantly or primarily tasked with bringing the data to bear for us to inform the decisions and the path and the direction that we go forward with. So that's a team that does a lot of great work. Thank you.


            MR. CHAIRMAN: The honourable member for Cumberland North with about 48 seconds left to finish up the first hour.


            MS. SMITH-MCCROSSIN: Thank you for that information. I noticed the budget again - the actual was quite a bit less than what was budgeted, even for the Investment Decision Support administration. I'm just curious, the reasoning why that happened.


            MR. DELOREY: I'm not known for short answers. It seems to be a requirement for this role, if you think about who my predecessor was. Really the vacancies that you'll be looking at predominantly are administrative, not clinical type of positions that are there. Again, part of that restructuring, the supervisors or which way we want people reporting up through the system, which again the salary levels or compensation levels would also be higher, which is why you see again the amount of dollars that would be associated isn't necessarily - the number of people not necessarily as high as you might think, based on the dollar amount.


            MR. CHAIRMAN: The honourable member for Cape Breton Centre.


            MS. TAMMY MARTIN: Thanks so much, Mr. Chairman, and thank you so much to the Minister of Health and Wellness and his staff and department for all the hard work they do in providing us answers to these tough questions. I would be remiss if I didn't recognize the health care workers in the Province of Nova Scotia, one of which is my daughter, and I was one as well for 16 years. It is a challenging job, regardless of what position you are in.


            I'd like to refer to it as a tire. Health care is like a tire and without one of the spokes, the tire doesn't go around. In order for health care to work in the best way possible, we need to ensure that all the spokes are looked after, whether you're at the very bottom of the totem pole, or whether you're the CEO of the NSHA.


            Anyway, going forward, I have a few comments to make before I get into my questions. It is a privilege, actually, to be the Health and Wellness Critic and the Labour Critic for the NDP, because both are my passion and I've had some great discussions with doctors since I took over this role. My own family doctor has expressed concern to me, going forward with the collaborative practice model. In fact, I was in her office the day that your government made that announcement and she was very skeptical. She doesn't believe, for her practice or for those other practices in Cape Breton that she could speak to, that it would provide the necessary help that she believes the system needs. She believes that it's only a band-aid.


            Other doctors have said the same thing because, while extra nurse practitioners can provide a quick in and out for patients, if they hit a bump in the road, then they do have to go to that family doctor. So, that is just adding more pressure onto those family doctors.


I believe it was mentioned some time today, I've worked for the Health Authority for 17 years and never, in my experience, have I ever seen a group of medical doctors come out prior to an election to express their concern. That was mind-blowing for me, to think that medical doctors are getting involved, because they are so concerned and so scared of where this health care crisis is going.


Although the Premier keeps dodging that bullet, and says we're not in a health care crisis, I beg to differ. The newest number is over 105,000 or 110,000 Nova Scotians without a family doctor. More than 20 doctors have left the Province of Nova Scotia since this government took office. I believe, as does the rest of Nova Scotia believe, that this is a health care crisis and we should all be scared.


Another doctor that I had the privilege of talking to said to me that by the time the Health Authority does exit interviews, it's too late. This is part of the problem. The Health Authority is not checking in with these new doctors when they come in to practise, in month one, and month three, and month six, to ensure that the services that they need and that their requests and concerns are being looked after. They only come to them when they hear, oh, Doctor John is leaving, so they come to an exit interview.


The doctors that I know personally, and have met with and listened to their concerns, tell me it's too late then, they've already checked out, they're just waiting for their end date to go. So, I think in the Health Authority that has to be looked at.


I was part of the merger, I worked through it, I have colleagues and friends that are still working through it. It was supposed to be a merger to save money; however, I disagree, because I think we all can point to situations where there has been more money spent on new office equipment for senior management than there has been on front-line workers, and this we know for a fact.


            I know part of the issue with Doctors Nova Scotia is the disconnect between the doctors and the Health Authority. This has happened since the merger of the Health Authority. Specifically, I can speak to Cape Breton because I worked there. They don't have the power anymore to order a staple. Their concern is that they must come through Halifax for everything, when before we were quite autonomous, as I spoke to yesterday in my maiden statement. However, that is one of the major concerns with Doctors Nova Scotia and why they think that recruitment is at its worst.


            So, with that, they are just a couple of my concerns, my questions, my thoughts. In order to bring us to where we need to be, our information tells us that we should be recruiting 107 doctors a year; while the 10 new positions to Dalhousie is a wonderful addition, there is no guarantee that those 10 doctors, when they're done their studies, will stay in Nova Scotia. So, we are about 400 behind the eight-ball, in order to look after the health and welfare of the Province of Nova Scotia.


[4:45 p.m.]


In your remarks, one of the questions or one of the answers was about IT and the function of it. I hear that there's a lot of time and money wasted because the province's systems are not connected. Many years ago, when I worked in the Health Authority and Meditech was brought in - I don't know if anybody's familiar with that system, however it guaranteed the people of Nova Scotia that if you went to a hospital in Yarmouth you could get the same results, the same information as if you were at a hospital in Cape Breton. The doctors who are coming in now are saying that that is not happening; the systems do not talk to each other, which is completely wasting doctors' time.


            So, Minister Delorey . . .


            MR. CHAIRMAN: Order, please. Order. Just a reminder to the member not to address members in the House by their name but by their constituency or the ministry. Thank you.


            MS. MARTIN: Thank you, Mr. Chairman, my apologies.


So, before I get into the specific questions, I'd like for you to comment on some of your comments you've made in the last little while. When you talked about a central-based intake board for mental health during your questions before - where will that be located? Because if that is just in Halifax that is completely ineffective, so we're looking to find out where that central intake will be for mental health patients.


            MR. DELOREY: I appreciate the opening remarks and the question from the member. A couple of things, first, about the opening remarks there, just a couple of assertions that I'd like to speak to first. For example, the concerns that were brought forward about the notions of collaborative practice, I'll let the member, Mr. Chairman, through you, know that indeed I've had physicians tell me as MLA as well that they didn't think and they don't believe that collaborative practice is right, that it's not the right model.


What I can let the member know is - and this was before I was appointed Minister of Health and Wellness so this is something that took place prior to the election that, again, hearing that concern and some other concerns, I organized a meeting with physicians in my community. I don't know, there were a dozen, 20, sitting around a table to have the conversation and what was interesting, the physician who - just the one who had expressed their concern to me - that was the person I reached out to to pull together a group for a variety of conversations to hear from them, and they had a variety of things that they brought to my attention as MLA and learned it from.


What was interesting, even though the person who raised that issue with me organized the whole thing, it wasn't the topic that came up during the discussion, so I raised it because I wanted to know what the general consensus was about this, and the physicians who spoke there at that table, the consensus was this is a good model. This is actually a very good model; this is a model that does provide good, indeed potentially even better care for Nova Scotians wherever it's deployed. So, I guess the key thing to highlight and note here is that I think in any system, and in any organization, but particularly one as complex as health care you're not going to have unanimity in any given direction. I certainly don't, as the minister, expect I will have unanimous consent - certainly not in this Legislature - that I would hope to achieve, but what I've come to realize is it's not unanimous on the front lines either.


So, I just provide that as an example from my own community, that I've heard the same thing, but the consensus I've heard is consistent with the data and the recommendations and the feedback that's been coming up through the department from the NSHA and the IWK, from physicians.


            I went out, then, as the Minister of Health and Wellness and I toured the province. I had conversations with people and I saw many practices in the province and, in these collaborative practices, people are very excited. They're very much in line - and I'll even use the example that you used. It's not a direct quote but, effectively - sorry, through you, Mr. Chairman, the member effectively, I believe, said something along the lines of the concern that the physician raised was: NPs, yes, they can see a number of patients, move things forward, but if they hit a bump in the road or a hiccup, then it has to be referred; therefore, the system is ineffective or inefficient.


            I fail to see where the inefficiency is because, even in that example, if you acknowledge that a nurse practitioner is able to see many without a hiccup, all of those are patients that were seen receiving primary care service before going to see the physician. So that is all caseload supports in health care being provided to the citizens and patients in the Province of Nova Scotia. I will assure you, Mr. Chairman, and all of the members here in the Legislature, and the member opposite, that nurse practitioners have a very broad scope of practice and a capacity to do a large volume of primary care services to the people of Nova Scotia, and patients.


            While in the hiccup case or a case that may exceed the scope of practice or that area for the nurse practitioner, in that example, may mean that that individual sees the nurse practitioner and gets referred to the family physician, that may be seen as being inefficient in that example because that's two visits instead of one, but what it ignores is the overall health care being provided in that primary care system that for all of those many patients that we're seeing that only needed to see the nurse practitioner once are getting the health care more quickly.

            What it also ignores is the fact that even in a system that is solely structured with family practice physicians, everybody doesn't know everything. One of the things that I heard in my time here going around speaking to front-line health care workers, including physicians, is that acknowledgement. When you talk to physicians who are working in a collaborative environment, at least the message I've heard from them is that is one of the things they value most about the collaborative environment, the fact that they can consult freely - and what's really interesting is those consultations are not always referrals where you see a patient, you're not sure so you refer the patient but sometimes those are just consultations informally because you're working in a collaborative environment, you're having a coffee or you're at the water cooler, figuratively speaking, and you talk about the cases you have.


            What is also very interesting in these collaborative environments that I've seen is physicians telling me how much they value not just the nurse practitioner, but family practice nurses who also have a scope of practice who can do a lot of work for patients and provide a lot of value that in a couple of cases the physicians indicate it's not necessarily their area of expertise. That would be for people, particularly with chronic types of illnesses that need more work to manage, things like diabetes or what have you that a family practice nurse has a lot of scope, or the dietitian, to really help manage those clinical conditions that don't need to have a visit with the physician on an ongoing regular basis.


            The physicians have expressed how much they value that because that is time they don't have to spend. They know the patients are actually getting better service in those areas, for those services, than they would have gotten from themselves as a physician because their scope of practice and their area of expertise is different. It really depends on the cases that come forward.


            Although this conversation is really focused on collaborative practices, if you go back to the foundational tenet that I guess triggered my need to respond to those comments, or that scenario that was brought forward, is underlining that I hope the member opposite and other members do keep that in mind when they are assessing information that they receive, when they're assessing the concerns being raised by people, whether in health care or other areas, is to recognize you want to try to get out and hear from many voices, get different opinions and perspectives as to concerns being raised.


            That is not to suggest in any way, shape, or form that the concerns being raised by individuals are wrong or incorrect, but it is important to ensure that we do take the time because I assure you in the example where I was talking as the MLA, I really was raising that concern because the only person who was talking to me about it was very critical, despite the former minister, my colleague, was very adamant, he would get up here in Question Period and talk about it, and highlight how this is the information he was receiving at the time, that this is the path forward, this is what new practitioners want, but on the ground I was hearing something different.


            I have to admit in that moment I was wondering. But that is why I took the initiative to go out and expand the scope of discussion to say, okay, how is it really? To my surprise, again, it's not that the individual who raised the concerns is wrong, but it wasn't right for that person. That's why you can see, also, one of the concerns that was raised was the disconnect between the Health Authority and the government and the front-line health care workers.


Well, when I had that discussion with those front-line health care providers, the physicians, and I brought up the question of the collaborative practice and the physician was talking about it, what they also went on to say is, you know, when the Health Authority came out and said this box is what a collaborative practice is going to look like - thou shalt have a facility that looks like this, and thou shalt have these individuals with these skill sets, X number of physicians, nurse practitioners, family practitioners, this is what a collaborative practice will look like and it will look the same in every community across the province - I said, that's a non-starter; that will not work.


Also, understanding, underlining, when people raised concerns, whether it's the overall concept or the specifics of how the concept is being proposed at a particular point in time, and to the notion of whether or not the Health Authority, and government hears from or entertains input and feedback from front-line health care providers, what I was told at that time, again, even before I was in this position, before the election campaign commenced, what they said was, but what we're hearing now.


They already saw the change, and the flexibility, particularly around collaborative practices. Why do you think they heard the changes? I can only ascertain the changes that they were seeing in the flexibility of the collaborative care side, was because the Nova Scotia Health Authority had heard from the front-line professionals that they needed more flexibility, that a one-size-fits-all wasn't going to work within our health care system.


I'll revert to the comments from the previous set of questions, from the member for Cumberland North, when she was talking about how things get rolled out. Where's the authority for the decision making within the system? Is it the elected officials, your appointed officials on a board, versus the staff level? Where do these decisions, and so on, come from?


Certainly, to my knowledge, that flexibility at that point in time, when I had the meeting with the physicians in my community, there was no directive or anything coming from government. As far as I'm aware, that came from the NSHA. So, clearly, they were hearing from the front-line - it's the only conclusion I can come to, that they were hearing from front-line physicians and front-line health care professionals that, again, the one-size model doesn't fit, we need to be more flexible, and they were adopting or adapting their model for that.


I am curious about exit interviews - well I guess one thing about the exit interviews, by definition, exit interviews do take place once an individual has decided to exit an organization or a practice. That, by very definition, is what they are. So, that is when they would take place.


I think, underlining that - and the member can correct me if I'm wrong - but I think what I'm taking from the comment is, really, more broadly about the communication on an ongoing, day-to-day basis, that the desire on the front line is to have their concerns heard by, particularly, the administration, and so on as opposed to, necessarily, a formal - and I'm asking this in seriousness: whether what the member was referring to was a desire to have a formal, structured kind of engagement survey done on an ongoing basis, or if what was meant, in the reference to exit interviews that need to be done sooner, if what was meant there was a formal thing, or just the informal, physicians need to be heard and front-line health care workers need to be heard by their staff - they need to have a way to voice their concerns and so on, even if it's in an informal way. I'm just not certain where that was going.


[5:00 p.m.]


One of the examples that was used and I'm curious if this is a factual example or if it was - and I don't mean, Mr. Chairman, any disrespect with the term, any other word is escaping me - "hyperbole" in the example of not being able to order a staple, I think is the example used in the remarks. I don't know if that is a legitimate, real example that a physician really can't get the procurement of office supplies they need and they can't do it, because the reason I raise it is whether it might be hyperbole is because if it is, hyperbole just trying to make the point of a frustration being felt by front-line health care workers that their autonomy and their contribution to decision making in their specific sites, their locations where they work, if that is really the underlying message that was trying to be conveyed there as opposed to a very specific, tangible example of procurement practices and process, the response is very different.


            If it is an example to illustrate the concerns being raised from physicians and front-line health care workers about whether their voices are being heard and whether they have input in the decision-making process within their work space, that is one thing, but using hyperbole and examples I think exacerbates the problems and the concerns and doesn't provide help in moving forward to address the very legitimate concerns that get expressed from the front line.


            I guess I would just ask, and hope that the member and other members do take that in mind, particularly when bringing things forward for concern. There was recently a CBC interview on CBC Information Morning, and I don't recall the woman's name, I believe she is some kind of health care consultant in the province, and she spoke about this. She actually spoke I believe about some concerns that she saw with - I think the way she referred to it was that Nova Scotia was starting to possibly become a bit of a self-fulfilling prophecy, that is, some of the recruitment challenges and concerns that people are raising are, to some degree, potentially a result of a lot of negativity being - I think the phrase used in the interview was "airing the dirty laundry," so that with all of the attention if someone out there in the country is looking to consider coming to Nova Scotia and they google Nova Scotia health care, what they read and they would see in news coverage and so on, are the negative stories and the areas that, really, I look at as opportunities to improve our system and health care in the province.


            As the member for Argyle-Barrington in his opening remarks highlighted, there are many things in the health care system that are positive, but when only one side or one aisle of this Legislature is willing to stand up and speak and highlight those positive things and the great work that many of our front-line health care providers are providing, that story doesn't carry the day. So, it's not to ignore or deny the challenges and the opportunities, but it is important to recognize that if one continues to go so far down a particular path that they actually create a self-fulfilling outcome.


            I encourage the members if they really, truly want to see improvements in our health care system, they want to see improvements in recruitment and retention, certainly the burnout and the frustrations, it does not help when all that individuals on the front line of our health care hear from the members opposite are the negative things and they don't hear the very positive comments about all of the great work that is happening within our system and recognize that phenomenal work that our front-line health care workers are providing within the system, again, that is not at all to take away from the concerns that are raised, the legitimate concerns that are out there, but those concerns and those issues are things that are part of the continuous improvement process, part of identifying them. Yes, that's step one, and then moving forward to try to improve and address them.


            Finally, I think where the question fundamentally went to with the member was the question about - from the data they were proposing was the need to have about 100 physicians per year available for Nova Scotia. I guess I just would like to highlight that although in the budget what we've talked about is currently we find 36 new residents per year and four family medicine emergency physicians each year within our residency program that is actually about 375 residents which would span specialists and family medicine, so that's 375 across our programs recognizing that family medicine is a two-year residency program so that's 36 each year, plus the additional residents that we've noted in our budget and our commitment to move towards that.


            We have to be very careful and ensure that when we're talking about our numbers and the data we present, particularly data we present to Nova Scotians, that we are talking from the same perspective. I just wanted to highlight that fact that the numbers and the role that our residents - I believe data shows that residents that practise in Nova Scotia, although they may not have necessarily studied here in the province, if their skill set or the area of practice aligns with the needs in the province, they do have a significant proportion that do stay in the province.


We have a very good track record of retaining those who do practise the residency which is why we're quite proud, we're quite confident in both the clerkship program - I'm sure the member would be pleased to know that clerkship program which is getting designed so that medical program students, before they even get to the residency point, have the opportunity to do their studies.


            I think just under a year about 40 to 48 weeks of training the program is designed for with their third year of the study of medicine, those individuals get the opportunity to practise in the environment in the community and we're targeting that clerkship program to Cape Breton communities.


            Just one more illustration of our commitment to the enhancement and improvement, not just a short-term fix but really a commitment to ensuring that we will have, over the long term, resources in place to provide primary care services to the member's residents, her constituents, but indeed that commitment spans to all of Nova Scotia.


            MS. MARTIN: Thank you, Minister of Health and Wellness. I have to say that  people call me naive and I come here with the greatest of intent to make our communities and our province a better place, just like I did in my union work. While I appreciate your ability to give long answers, I would hope that the process, the way that we work through this is to get as much information out to be correct for both sides. I don't think anything needs to be regurgitated, with all due respect to the member; however, I would like to try to work together so that I can actually get the answers that my constituents and the people of Nova Scotia need.


            I just think it's unfair to try to waste the clock when you've said, we've said, the PCs have said we're in here regardless of stripe to try to work together. I do not see that, unfortunately, and you still didn't answer my initial question.


            MR. DELOREY: I guess I would ask the member to repeat the specific question. She had a lengthy introduction, I thought my response talked about many of the points that were made in there. With all due respect, I do think that to the point of the objective that the member raised there about these discussions, the information I was sharing in my response was indeed about getting information out to Nova Scotians and being factual, as I said.


            I asked some very specific points about things that were raised by the member in the preamble and the question, and if I didn't answer a specific part of the question that came up there, I would just ask that the member restate that part of the question; I would be happy to oblige.


            MS. MARTIN: Actually, I guess my preamble was just a few statements. I didn't expect, with all due respect, a 30-minute response.


            However, I will clarify some of your points. I am taking the concerns of my constituents forward, so when I say a "staple" maybe it's not a staple but the decision-making power has been taken away from the individual health authorities. That is the point that I'm trying to get across. As well, the front-line health care workers are not all doctors. When you talk about they have no decision-making power, it's not just with doctors it's with the spokes, with all of the spokes of the wheel that need to come into play for the health care facility to work.


            My issue about the exit interviews - there is sometimes absolutely zero contact with doctors until they hear that they're leaving, so yes, my concern is why aren't they following up to make sure that their working conditions and situations are up to snuff so that they can stay? But when I did finish, I did say to the Minister of Health and Wellness, you spoke earlier about the central-based intake initiative that this government is moving forward with - can you please explain to me, is that in Halifax and, if so, how does that affect the residents of the rest of the province?


            MR. DELOREY: For clarification, the notion and the design of the central intake system that we're working on rolling out is not explicitly about a physical locale where individuals facing mental health situations go through. It is about having that central body of expertise, a central phone line if people need help navigating through the system. It's about bringing those resources together to ensure that it's not about being passed from one clinical expert to another, but better about how the system shares the information, communicates, and works together so the system works more efficiently and effectively.


            To use your analogy of the wheel and the spokes, we have a lot of very good initiatives and programs to the mental health and addictions space throughout the province, it's about how we centrally bring that all together, so it's not about as much as a physical central location where there is literally a door to go through but rather there are multiple phone numbers to try to centralize that and ensure people get directed then to the best resource for what they need at that point in time, wherever they are in the province.


            This is about providing a service. As I've said a number of times in the House, this is about all citizens, not just about Halifax, not just about Cape Breton - all people of Nova Scotia. The importance and significance of mental health and improving how we deliver those services really, truly, and honestly is a priority for us.


            MS. MARTIN: Would the Minister of Health and Wellness provide us with the job title and the salary of the lowest paid employee in the department or that's funded by your department?


            MR. DELOREY: Mr. Chairman, I believe the salary information of public servants throughout the province does get published as part of the Public Accounts process at the end of the fiscal year, not as part of the budget process. I don't have the budget documentation here, I think it's maybe Volume 3 of the Public Accounts where I think the member would be able to track down those details. I don't believe I have it here offhand, Mr. Elliott is looking to see, but I believe that information comes out through Public Accounts rather than through the budgeting process.


            MS. MARTIN: I'll ask the Minister of Health and Wellness then, how much did the department spend on services provided by a temp agency last year, and how much is the department budgeting for temp agencies?


[5:15 p.m.]


            MR. DELOREY: I guess the way that departments and organizations - I don't think this is necessarily unique to government - budget isn't by a temp agency. We have positions that require work to be filled, full-time equivalents that we get allocated. From time to time, services that may need to be provided on a temporary basis, sometimes that is about filling in a gap or a stopgap measure while the recruitment process takes place, or sometimes it's just waiting for a position to be filled or if a position is winding down, that someone has left through attrition. So, there are a wide variety of reasons.


I don't believe that there's anywhere in the document that explicitly says this - I'm not aware and, again, Mr. Elliott is not aware that we have any line item that says this is what's budgeted for temp agencies. Temporary work, again, would be provided, but I'm not aware that there's actually a line item in the budget explicitly around temp agencies.


            MS. MARTIN: Mr. Chairman, because from what I understand there's a hiring freeze on, so I'm wondering if the Minister of Health and Wellness can provide us with those amounts - just how much has been contracted out to a temp agency and the lowest paid person in the department?


            MR. DELOREY: I just want to make sure that I did hear the question properly, so a couple of questions there. One is what the highest and lowest paid - no, just the lowest paid individual, and the dollars paid to the temp agency. We'll look to see if we have that. Again, it's not something that I have right here off the top. I will say I think we have a list of individual salaries but, again, they're by name not be title. So, again, that wouldn't be something we want to necessarily disclose here.


I could possibly look to see if the dollar amount is - if you just give me one moment, I'll just take a look to see. Okay, they're not necessarily ordered, they're ordered by division departments. So, to actually find which one, it will actually take a bit of time to do that. We can get that back to you or your caucus - sorry, Mr. Chairman, we can get that information back to the member or her caucus. We'll have to go through it in a different way; it's not something that will be done in a timely way here in paper copies.


            MS. MARTIN: Mr. Chairman, could you give us a time frame when we can expect that information?


            MR. DELOREY: As I said, as I had mentioned to the member, the information would be available to the member right now if the member went to the Public Accounts available online. Again, as I said, I believe it's Volume 3 of the Public Accounts. It's available on the Department of Finance and Treasury Board website. So, the member and the caucus could go there, go through the document, and find the information themselves. If they want us to go through the document, because it's listed alphabetically by name, it would take time to pull that off but the information is available to the member and the caucus already.


            MS. MARTIN: So, speaking of finances, Mr. Chairman, I'm wondering if the Minister of Health and Wellness can tell us - this is a two part, I guess. I'll ask it all at the same time - how much did the department spend on employee overtime last year and how much did you budget for in this year? As well, can you tell me about the nurses' overtime, how much you spent on it and how much is in the budget because, as I said, I know that nurses' overtime is atrocious?


            MR. DELOREY: Mr. Chairman, I thank the member for the question. What I was just confirming there before responding was, again, if you look closely at the budget and the budget document of the budget process here as the Department of Health and Wellness, our budget line items relate to the amount that we distribute to the NSHA. When you are delving into the specific question on the operational front line with the NSHA, that would be getting into their specifics of the budget. So, we have the amount that we provide to the NSHA for their operations but they develop their own budget separately from the Department of Health and Wellness. We provide resources, so a grant effectively, from the Department of Health and Wellness to the Nova Scotia Health Authority.


The Nova Scotia Health Authority creates a budget so if the member wanted specific answers to questions that fall on to the details of the NSHA that would be something we would have to reach out to the NSHA to get those very specific questions about what is the NSHA specifically budgeting on front-line nursing care. I think that specific question is OT - that's not something that the Department of Health and Wellness explicitly budgets for because, again, as I said in the structure, the NSHA delivers the front-line care and this is not a change because of the restructuring at all.


The same would have been true if one was asking, prior to 2015, each of the individual health authorities would have their specific budgets and one would have to go back to the specific health district at that time. In this case we have one so it's easier to go back to a single entity and I guess this is just to highlight one more advantage of having a single Health Authority rather than having to go to nine different places and amalgamate that to answer that same question on a provincial basis.


            MS. MARTIN: If the Minister of Health and Wellness - obviously the Department of Health and Wellness is the funder and from all accounts we know that the overtime for nurses is atrocious, so I would think that the department would need to know exactly how - I would want to know how you are spending my money so I would think that the Department of Health and Wellness would know how much is going for FTEs and, as well, being paid in overtime.


            I would ask that the member opposite get that information and respond to us in kind.


            MR. DELOREY: As mentioned, certainly we'll reach out and pull the data and pass it along to the member either directly or to the caucus. I know there's a process. There are times throughout the estimates where the specific question, we don't have the data, and I think it does go back to - I'm not sure - it comes here and flows back. We'll make sure that the specifics do get passed along.


            MS. MARTIN: In 2017, the Liberal platform committed to 15 additional specialist residency spaces, including five for Cape Breton. In this platform, this money is not allocated until 2018-19. It is anticipated that the commitment will cover residents who begin in July 2018. Will the spaces be available to applicants during the 2018-19 residency cycle which only begins in October 2017?


            MR. DELOREY: That's the process that takes place. Dalhousie, the residency program, gets work through the Dalhousie Medical School. One of the interesting things I discovered while I met with residents and the residents' group, as well as the representative from Dalhousie who coordinates the residency program for the facility was actually how nationally integrated the residency program is, so there is some administrative work being done. We're working with Dalhousie to get incorporated because actually there's like a - I forget the name of the program, but there's a matching system that actually takes place.


            It's one of the reasons why, Mr. Chairman, that residents in Nova Scotia, if you've met some, they don't all go to Dalhousie. It's not a situation where a residency program does not mean that the students from the facility, the university, the academic institute, that may administer or manage the residents' program, it's not a situation where a student moves into the residency program seat provided by the institution that they are attending.


            In fact, in the residency model there is a national pool of residency positions and there's actually basically a system that residents, when medical students are about to embark on the residency program submit a prioritized list of where they may want to, so they can say - if they're at Dalhousie they can say they want a residency position in Nova Scotia from Dalhousie as their top pick, and, second, to wherever they think the residency position might be. But medical students who would be entering their residency in Ontario, Alberta, or anywhere else, could also say that they would prefer a Nova Scotia residency position, if that's available.


            The system matches the characteristics, the preferences of the individual, at that time. Medical students applying for residency and the residencies that are available.


            I had to do some administration work to get that integrated and plugged in. I don't have the exact time frame on when that administrative work, to get integrated in there. But, of course, the goal is to ensure that we get them out there for next fiscal.


            MS. MARTIN: As a follow-up to comments that have been made throughout the day, and in the budget, you talk about allocating money to collaborative centres, specifically one in New Waterford.


            I've recently learned that two nurses have been displaced from New Waterford Hospital because the emergency room cannot open. So, actually, they were over core in New Waterford, so they sent off two nurses. They had one doctor who was looking to work there on Mondays, but they wouldn't take them on, which I find kind of shocking.


            However, in a response to a letter that I sent you: When I'm asking about the difference between maintaining the services that we currently have in the New Waterford Hospital versus a collaborative health centre, because to the residents of my community, they want to know - we can't staff New Waterford Hospital right now; we cannot keep it open because of the lack of physicians, the lack of trained lab techs - how can we keep New Waterford Hospital open, as well as run a community health centre?


In your response to my letter to you, you say, when I ask for a point-blank answer, and what I'm being told from the NSHA is that the New Waterford Hospital will not close. That is not the answer. Your comments are, any impacts on other health facilities in the area, including the New Waterford Hospital, will be considered during the design phase of this new centre. So, by "considered," I need you to explain to me, and to the constituents of Cape Breton Centre, what does that mean for New Waterford Hospital?


            MR. DELOREY: As the letter response states, when evaluating, and I think I did speak earlier today about the process for establishing collaborative practices. I spoke even, I think, in the response back to the member about collaborative practices, and the need to be flexible for community needs, and how to best deliver that primary care service, or services?


            The fact that the Health Authority had, based upon the information that I had, were apparently listening, and receiving that feedback, because they recognized that a cookie-cutter model for all the communities was not the best way to move forward.


            As I indicated in the response that the member cited there, what I was getting at is one has to assess the community needs, and the environment, and the impacts, when moving forward with any kind of initiative.


            What, if any, impacts may materialize, one won't know until it completes going through that assessment and engages with the community to see what those community primary care needs are, and how to best fulfill them.


            MS. MARTIN: Will the Minister of Health and Wellness give us a plain, and simple, and concise answer? We have a hospital now that we cannot keep open. We have a hospital now that is not completely staffed, that the residents of New Waterford and surrounding communities - maybe you weren't here yesterday when I cited that Devco miners paid for that hospital, to keep that hospital open, in our community. Why are we reinventing the wheel when we have New Waterford Hospital? Why is this government not investing in staffing that hospital, and maybe building a new treatment centre, or treatment facility for mental health and drug addiction? Can the minister give me a straight answer on what is going to happen to the services provided now at New Waterford Hospital?


[5:30 p.m.]


            MR. DELOREY: I thought I was quite clear and direct in my response. As I said, the objective here is to ensure - and I believe and I hope that the member opposite shares this priority. I believe all members share this priority of ensuring that we provide the best primary care services that we can to communities across this province, and that includes the community of New Waterford.


What we've committed to is providing the opportunity to develop and deliver a collaborative practice to help improve the primary care services within that New Waterford community. You know, the member says that the hospital is closed. I don't believe that's an accurate statement. The hospital still functions; the building is open. I think the emergency room side of the practice is what the member is referring to there, not the entire hospital being shut down. The building is not closed that I'm aware of; if I am mistaken I stand to be corrected - as I'm sure the member would.


Again, to summarize, our goal and objective as I believe the member would share is to ensure that we provide the best primary care services to that community that is possible. As part of the process to establish a collaborative practice in that community, it would require engagement and identify exactly what those needs are for that community and roll that out. What, if any, impact to the hospital, until we have those conversations in the community, we wouldn't be able to speculate on that at this time.


            MS. MARTIN: Mr. Chairman, can the Minister of Health and Wellness identify the vacancies currently that we have in the emergency room for nurses, family practice physicians, and nurse practitioners?


            MR. DELOREY: Just a point of clarification for the question before I answer. I'd have to go back to the member, Mr. Chairman. The question was about the current vacancies for the physicians in the emergency room. I'm just curious. Most of the questions to this point have been directed at specifically the New Waterford community. I'm wondering if the question is about that community or on a provincial scale.


            MS. MARTIN: Mr. Chairman, actually, the first couple of questions were not just specifically to New Waterford, and we're here looking for the numbers for the entire province.


            MR. DELOREY: Mr. Chairman, again, as per an earlier question put forward by the member opposite, as I've mentioned, the budget that we have and that we table as government and, thus, the information that we bring to bear here during the Estimates Debate is the provincial departmental budget. Our budget that we table brings with it an estimate of the total cost of delivering health care, those programs and services and staffings that the department is responsible for. Within the budget, a very significant portion obviously goes towards our health authorities, the IWK and the Nova Scotia Health Authority. They create their own budget out of the funding that's allocated to them. It is through their budgeting process where those details come up.


            Recognizing the earlier comments that the member made, Mr. Chairman, that of course our health care system is more inclusive than just physicians, so where the front-line employees like the nurses and other health care professionals, I wouldn't have that vacancy information.


            What I do have is that as of September 19, 2017, we have 57 family physician vacancies. We have the physician side because that is something through Physician Services the Department of Health and Wellness does play a role in. But if the member is looking for details about really the operational NSHA employees' data, that is information housed with the Health Authority and the IWK.


            MS. MARTIN: As a follow-up to that, in two parts if I may. As the funder, as the person who is paying the bills, I would hope that you would have the knowledge and the information - maybe not here but accessible - to exactly how many vacancies are in the Nova Scotia Health Authority; and to that end, as the Health and Wellness Minister, do you not believe that your responsibility to this IWK - do you not believe that you are responsible to oversee and ensure this IWK scandal is handled properly?


            MR. DELOREY: I appreciate the question. I guess in particular the question about the circumstances surrounding the IWK, Mr. Chairman, I'd certainly like to stress and highlight to the member opposite, and I have stated publicly on a number of occasions, that I believe the board at the IWK is managing and handling the situation that has come forward with that organization the way that the people of Nova Scotia would expect.


            Just to summarize, Mr. Chairman, what that entails, the board, the organization, became aware of some concerns about expenses of the CEO. The board chairman stepped in immediately and the board stepped in to take control of that situation. They ensured that the review that would be conducted would be done by an independent group. They had a third party come in - Grant Thornton - to do that assessment, reporting directly back to the board, not through the staff. Obviously when a senior member of the executive is identified as one of the parties that concerns had been raised about, that of course taking it out and having an independent group take a look at that is the appropriate course of action.


            Since that point in time that review provided additional information, identified some recommendations. It gave ideas to the scope of the problem from a fiscal perspective. They've taken steps to begin recouping the dollar amount that was identified as a concern. They've gone through and already identified an implementation plan for the 14 recommendations that they adopted, which they indicated they were going to adopt right away, but just a week or two ago they did have the implementation plan approved by the board. That work continues as more information became available throughout the process.


            They recognize, of course, the need and the appropriate steps to engage the Auditor General and pass information on to the police, Mr. Chairman. If the member opposite thinks that there is something not being done to respond to this, that Nova Scotians should expect more, I'm happy to hear what the suggestion is. But from my assessment I do believe that the appropriate steps and accountability are being taken through this particular situation. I commend the members of the IWK board and the chairman for their diligence and attention to this matter.


            MR. CHAIRMAN: The honourable member for Cape Breton Centre, with about five seconds remaining in your hour.


            MS. MARTIN: I thank the Health and Wellness Minister for his answers and I look forward to further questions and answers.


            MR. CHAIRMAN: Order, please. The time has expired for the NDP caucus. I will now recognize the PC caucus.


The honourable member for Cumberland North.


            MS. ELIZABETH SMITH-MCCROSSIN: Thank you, Mr. Chairman, I'd like to address the minister, and going back to the responsibilities of the Department of Health and Wellness. In looking at the responsibilities of the Department of Health and Wellness one is setting strategic priority, but another one that I'm focused on and I want to go back to is measuring and monitoring the health system performance.


            I'm wondering if you could share with me, what is being done right now by the Department of Health and Wellness to measure outcomes?


            MR. DELOREY: Per the earlier set of questions, we talked about where some of the work is being done, from a data collection - obviously, data is an important part of identifying and establishing - and I also noted, how there's been restructuring and realignment, to ensure that we do realign our staff, to have the right people in the position to do that type of work.


            One of the other important steps that's being taken, and is under way, is working with our two Health Authorities because, of course, much of the data that's being generated from the operational side, we need to engage in that. Really, in the consideration of the organizations, we're still relatively early in the amalgamation, the restructuring that's taking place, where the focus needs to be on maintaining and delivering the operations, this work on how we evolve to do a better job of collecting the data, the accountability measures, so we're currently working with both the NSHA and the IWK to establish accountability agreements that get to exactly that point. Again, it's being informed by information and data that we have and clinical insights as to areas that we need to focus on, and those would include some of our priority areas.


            MS. SMITH-MCCROSSIN: Thank you for the answer. Is there anyone in the Department of Health and Wellness who is measuring the effectiveness of the Nova Scotia Health Authority board of directors?


            MR. DELOREY: The work that I as the minister do with the board of directors - I actually have taken steps to ensure that I meet, on a very regular basis, probably four, maybe five times, already-scheduled meetings to meet with the chair of the board. I've met with the entire board once already, in just the couple of months that I've been in place, to ensure that they are aware of the priorities of government, certainly since I came in under a new mandate; that is, after an election. We did have a new mandate from the people of Nova Scotia, as a government. We ran on a particular platform that outlines what our priority areas are over the next coming years of our mandate.


Just for summary, those areas are, in particular, around primary care, mental health and continuing care practices, to a large extent. Particularly the primary care, obviously, but also mental health and continuing care do tie in to the board, so through those meetings, I take a very active role in ensuring that the work that they do takes place.


I'd also highlight that on the day-to-day operational side, there are engagements that take place with appropriate department staff, both within the Department of Health and Wellness and the NSHA and the IWK, for the work that gets done. Again, where direction is being delivered, or oversight - in terms of the strategic goals and directions - through the department, ensuring that at the staff level that's communicated effectively.


It is a complex process that takes place. I know the deputy and the CEOs of both the IWK and the NSHA, there are frequent engagements there as well, to make sure we're all growing in the same direction.


MS. SMITH-MCCROSSIN: Has the department of Health and Wellness asked the Health Authority Board of Directors how they're measuring the performance of their executive leadership team?


[5:45 p.m.]


MR. DELOREY: The very specific question, I haven't asked that very specific question to the chair of the board of the NSHA. But what I can advise the member is that in my meetings with the chair and the board, certainly their oversight on the operational side of - which, of course, would implicitly include the executive team - is in place. They are regularly engaged to work with the updates that are provided on the strategic planning process, and so on, to make sure that that work continues, the work on the provincial plans in each of the priority areas for the province.


            The board gets regular updates, again, through the executive team. Of course, the work gets done throughout the organization. As far as the interactions and the oversight that takes place, it is, again, through the board, and the senior leadership team executive.


            MS. SMITH-MCCROSSIN: The reason I'm asking these questions is, we spend a lot of money in the Department of Health and Wellness and the outcomes are not great, when you talk to the people of Nova Scotia. I question what measures are put in place. I know we have our budget here and I was just curious, where in the budget would we find those accountability measures?


No matter what organization you're in, we want to make sure that we're spending our money wisely and that we're getting good value for our money. I know the minister has spoken to a lot of health care workers around the provinces, as have I, and has likely heard very similar stories. There's not a lot of confidence in the leadership team, and I would question the effectiveness - and it's not meant at any particular person directly.


It's always a good thing to have measures put in place, to make sure that an effective job is being done, and if it's not, then to make changes so that those in those positions can either be replaced with someone who is more effective, and/or help them in their role, to be effective.


I do want to just comment to my colleague here - I know some of you clapped when the minister brought up the issue of attitude and criticism of our health care system, and the effects of that. I understand that. However, I don't think it's helpful to hide our head in the sand either, and pretend that everything's great when it's not. It does concern me when I hear a Minister of Health and Wellness lecture, because I had the same lecture from someone on the leadership team just a week ago. The conversation that this person and I had was going very respectfully and very professionally, until this person started lecturing me, for being critical.


When I shared with this person why I was being critical, I gave specifics, like the 14-month wait-list to get in to see a therapist - and this was by someone who accessed mental health services in an acute care crisis, through an emergency, and still waited 14 months and then was never seen.


These are real situations and I don't think it's helpful to pretend that there are not problems. We have to address them, we have to be willing to talk about them openly. When I shared with this person on the leadership team why I knew that what I was sharing with them was accurate - that when people go to an emergency department, in an acute psychosis, it will take an emergency-room doctor two hours or more to try to find an acute care bed in our province. Only the emergency-room doctor can do that. The nurses aren't allowed, because the psychiatrist can only speak to an emergency-room doctor. That's tying up our emergency rooms. It's just a big backlog and often this patient, who's in crisis, gets either left in the emergency department and/or is discharged without proper care.


There are real problems and people's lives are dependent on it. I think it's important to have a style of leadership, at the department level, and at our leadership team level, that's willing to accept that there are problems, so that we can work together to make the changes that need to occur.


            After this meeting that I had, my staff person who was with me - and she is still pretty new and naive - she just looked at me and she said, I think the people in those positions have been sitting at their desks too long. There was a real disconnect between the theory and the philosophies that they were sharing with me, versus the reality at the ground level for the people of Nova Scotia.


            That's why a lot of my questions have been focusing on accountability, measuring outcomes, who is responsible and who's holding people accountable to make sure that their jobs are done. I just wanted to offer a little bit of an explanation on that.


            My next question is with the relationship of the Department of Health and Wellness, the Nova Scotia Health Authority, and Medavie Blue Cross. I was able to identify some of the estimates that are in relation to Medavie Blue Cross, but I was wondering, could I have some clarification, disclosure on the relationships within the Department of Health and Wellness, the Nova Scotia Health Authority, and Medavie Blue Cross?


Then also to look at the contracted services that we're currently paying to Medavie Blue Cross. I know some would include paramedic, EHS services, the physicians on call for CECs, I did find those in the estimates. I'm wondering, are there any other contracted services through Medavie Blue Cross?


MR. DELOREY: Really, at a high level, or a fundamental level, Medavie Blue Cross is a very large organization. They have subsidiary components so to simplify the information at that level, the major work that gets done - and I just qualify this, there may be a small contract for some kind of service or work that I don't have off the top of my head, that might be subcontracted somewhere through the system, that again, I might not be aware of. But fundamentally, the really big contributions go towards - Medavie Blue Cross manages our insurance programs, which would be the MSI program, gets managed through Medavie Blue Cross. EMC, which is a subsidiary of Medavie Blue Cross, provides our paramedic services. Within the paramedic services, as I believe the member opposite cited, they provide a variety of services. The most well-known is, of course, the ambulance services, paramedic services through the ambulances, for emergency services throughout the province.


What was also cited were things like, in centres and some emergency work that they do, they're also doing work - expanding, to look at, with their expanded scope of practice, potentially doing some palliative type of work as well. Also, I think, another large piece is the 811/911 telephone system. I can't recall off the top of my head if that's under EMC, but it is under the Medavie umbrella largely.


Mr. Chairman, for your benefit and the benefit of the members, it was very interesting that when I first came into office, the Halifax Chamber of Commerce actually hosted some representatives from Medavie at one of their luncheons. I attended and it was actually quite good so early in my tenure as Minister of Health and Wellness. It actually highlighted something that I don't know if members are aware of, that Medavie is actually a non-profit organization. It's not a for-profit organization and, through that process, they highlighted and stressed how they actually have a program within the organization that sees them donating a significant amount of contributions back to community-based programs.


That's a situation where one can say that, through all the revenue generated in all of Medavie's operations, when they have surpluses they actually have programs where they are able to provide grants and research initiatives and partner with organizations to actually do even more than what we would be listing and what we'd be necessarily enlisting their services for - again, recognizing Medavie provides services not just in Nova Scotia but in other jurisdictions both in the U.S. and across Canada.


            MS. SMITH-MCCROSSIN: Thank you for that answer. I was just curious about the ongoing relationship with Medavie and I know that the guest speaker at the AGM was, I believe, a former board member - I think, yes - and our current chair of NSHA is a former board member of Medavie, I believe, the chair. Another one of our NSHA board members is from Medavie, so I was just interested in the relationship. Also, I was told recently that someone within the department was hired who was a relative of someone with Medavie, so I was just curious how deep the relationship with Medavie Blue Cross goes and the integrated relationships throughout. I was curious if there are other ones that I'm not aware of.


I'm also curious, has the Department of Health and Wellness done any costing of these services that are contracted and I'm wondering, would it be more cost beneficial to provide these services through employees of the Department of Health and Wellness? Has that ever been examined?


            MR. DELOREY: Mr. Chairman, a couple of things. Making references to individuals that one can point to who worked with one organization and are now involved in working in another, you know, I think both Medavie, the NSHA, the Department of Health and Wellness, or the Public Service - these are all very large organizations with thousands of people working for them. To have relationships or relatives or individuals who work with one organization, recognizing that they all work in the health care field, is - I think the member having worked in the health care field would recognize despite how many people do work in it, it is also still a small community of people.


Certainly, from my perspective, I recognize that, particularly in an Atlantic Canadian context, the probability of being able to point to individuals who have had a previous work relationship - I can use for the member's example of my first employment outside of university, my undergrad, I went to work for an IT company. It has nothing to do with health care - maybe they did in their broader corporate structure - but probably half of the people who worked there came from Medavie Blue Cross, so you could argue that I worked with many people. Through the rough days, eventually that organization ceased to exist in the community and now pretty much those people and many other people that I formerly worked with, now currently work with Medavie Blue Cross. Of course, you can identify those types of connections and relationships.


[6:00 p.m.]


That's the nature, I think, of such large employers, particularly in a small Atlantic Canadian context. I wouldn't expect to read much more into it than that. But, also, to recognize that if there's concern around the NSHA piece and these contracts, is that these major areas that I highlighted, the MSI program, the EMC or paramedics program and the 811/911, these are actually contracts or programs held through the Department of Health and Wellness and not the NSHA.


I guess if there were any governance concerns or controls there that I would make that clarification, that these are things that are housed within the - although they work very closely with the NSHA and the IWK, our two health authorities - there is no reporting or direct reporting relationship there, but certainly relationships in the delivery of services because they obviously overlap and touch upon each other in the services they provide. So that was for that piece.


            The other question part that you came up with was looking at doing services in-house versus externally. I guess many of these services are fairly historic. If you look, MSI has been around since the 1960s. If you look in a Nova Scotian context, our paramedic service, which is world-class, I've come to realize in here with counterparts or outside, that they are very impressed with the work that gets done, the innovation that's done in a Nova Scotian context with our medics, dating back to when in, I believe it was around the mid 1990s, a major restructuring took place. I don't remember the exact date but even, as we all were younger back then, I remember in Antigonish that the ambulance - I think we had two service providers - but they were both funeral homes, which I found quite interesting in retrospect, that the ambulance was managed by the funeral home.


            We were talking earlier about outcomes, you wonder how they measured their outcomes back before the mid 1990s, but there was obviously a major restructuring that took place to centralize and provide a provincial-based EHS, emergency services system with paramedics. That's who won the contract. Each time a contract comes up, comes due, obviously it goes through a review process, procurement process, to identify where we get value for money.


            I use the 911/811 system for example, actually was won by a different provider but they subcontracted the contract out to Medavie. So even some of these contracts that are in place are not based on relationships; they are actually subcontracted by a third party, which led to them carrying the work and delivering the service. I think that goes to show that when you are talking value for money, we put it out and a third party actually found that the service that was there, in that case provided by this organization, was positive.


            But again, when each of these contracts or any of the contracts come due, they do go through the appropriate review process and procurements that take place there.


            MS. SMITH-MCCROSSIN: Thank you for that explanation. One of the questions I was curious about is, is there any ongoing examination of these costs, to ensure that ongoing, we're getting the best value for our money? So again, just to ask the question, the services that we're contracting out, does the department - how often would they examine? Is it better to be contracting these services out or to be hiring and having employees within the department providing the service?


            MR. DELOREY: I thank the member for the question. As far as the review periods, as I mentioned, really comes into the life cycle of the contract and the agreements because the cost of trying to take something internal mid contract period, obviously you would expect they would be significantly more expensive. Certainly, on an ongoing basis you review the services. One of the positive things when you do have a contract, are the service-level agreements that you establish. We talked a lot earlier about accountability and tracing and tracking. I think, in particular, our EHS, our emergency system, the medic system, does have a lot of metrics in response time in deliveries, that both gets tracked very well by the third party that provides the service, and feeds that back in, and again ties into contractual obligations.


            As far as timelines, in some respects it's ongoing in terms of the efficiency or the effectiveness and the value of services being offered. In terms of a very explicit assessment of outsourcing versus bringing in-house, that would be, I would suggest, more along the lines of when a contract is coming up and you're assessing the value of the proposition or the options that come up to you as a contract is coming up for renewal or expiration. What is the approach you want to take? What are your options?


            Obviously, options then are: cease providing a service, bring it in-house, continue with the current contract, go out and look for others to provide the service. Those are the types of questions you obviously would be asking as you're coming up to consider the renewal of a service within the health system or any other organization system, when you have contracts coming up. I don't have a specific timeline - because, again, it would be tied to contract expiration dates - for that large of a question.


            MS. SMITH-MCCROSSIN: Thank you to the minister for that answer. I'll just finish up on that line, this topic, by just emphasizing the importance of the past relationships with Medavie, that some of the people who have had those past relationships have had a very significant leadership role in that organization, and just to make sure that we're always making the best decisions for the people of Nova Scotia.


I'd like to ask a couple of questions around physician services and just as a disclosure, I am married to one, I don't want anyone to think that I am asking on behalf of him. I'm also a nurse, so I like people in both professions. With that, I'd like to focus for a moment on the budget line for physician services. Again, I noticed that less was spent than what was estimated. Is that again because of unexpected vacancies?


            MR. DELOREY: I think while we've had several discussions back and forth, particularly in Question Period, about physician recruitment and vacancies, I think your own member, the Leader of the Official Opposition, even tabled a list of advertisements there. Again, just to reiterate in terms of the vacancies, those advertisements were cited somewhere in the vicinity of 100 or 150 being recruited, but as I disclosed earlier this evening, I believe the total vacancies are just over 50 - about 50-some positions. The fact we're recruiting in advance of vacancies coming up, shows the commitment to try to be proactive and fill, and ensure that we do maximize. Although vacancies would make up a portion of it, I think, the larger contributing factor to that actually has to do with a new agreement, the master agreement.


Physician relationships are a little different than other - they're not employees, so it's called a master agreement instead of a collective agreement. Through that agreement, which identifies the payment structure, there were significant changes to various programs within that agreement. That was only signed last year, partway through the fiscal year, so how transitioning from the old agreement into the new agreement does result in deferral of where and when some of those payments rolled out. It's less about who's available or the number of positions, but more about the specifics of payments through the master agreement programs that are in the system.


MS. SMITH-MCCROSSIN: Would I be fair in asking the minister, does that mean the master agreement with the physicians decreased what the physicians were being offered in remuneration? Do you think that, maybe, is one of the contributing factors to why we're losing physicians? I think it's fairly well known, they're remunerated around the 11th in all of Canada, as far as pay.


My follow-up to that, is the Department of Health and Wellness willing to look at physician fees as a way of looking for us to be competitive in attracting and filling some of those vacancies?


MR. DELOREY: It's important to clarify for the member, and indeed all members in the Legislature, just to put into context the size and the scope of the concern being brought forward here. I believe that underspend on the physician services budget was about $1.5 million, on an $808 million budget. To put that into context, that's 0.18 per cent of an underspend in an $808 million budget. That's quite close to - in any organization, let alone a $0.75 billion organization, coming in within less than 0.2 per cent of that budget is quite good. I would hope that the member, and others, would recognize that point.


Back to my earlier comment, that explains really, by our analysis, where the bulk of that was. It was really about the transitional point. It's not about what the compensation is, or under-compensating physicians through that process, but rather that transition from moving from one fee structure, because there were some areas where they made some changes. Again, it's important to note that those changes were agreed upon by physicians. This was a master agreement that was agreed when Doctors Nova Scotia took it out to the membership. It was something in the vicinity of 86 per cent or 87 per cent in favour of accepting the new master agreement. I think those are very important contexts to keep in mind with respect to this discussion.


To the specific question that was asked about if there is an opportunity within compensation to incentivize physicians, whether that is as part of a recruitment or retention piece or for providing particular services that we need, do we think that we need more effort or focus on that? Again, back to the accountability on the outcome side, I would say there may be opportunities there.


[6:15 p.m.]


I think that's one of the things, when you look at the master agreement, that is actually quite good about the program and that type of agreement. The master agreement covers a lot of things, but within that it particularly talks about fee structures and payments, which really gets overseen not just within the master agreement itself as a fixed piece, but provides that ability to work to make adjustments with the government and Doctors Nova Scotia as the bargaining agent. I think they have a committee that works together to look at some of those things from time to time, on the fee code.


            Are there opportunities possibly to work towards? Again, I think the master agreement provides some of those opportunities to work within the resources we have available. But if we're going to reprioritize in a new area, it means, perhaps, changing how much a current area is prioritized.


            MS. SMITH-MCCROSSIN: Recently Doctors Nova Scotia have come out with a couple of position papers and one in particular emphasizes their desire to work with the Department of Health and Wellness and to be included in health care planning. Is this something that the Department of Health and Wellness is willing to do, to sit down with Doctors Nova Scotia?


            I think that at this point in time it's a critical point and it could be a turning point, really, for our health care delivery services in Nova Scotia. Even though most physicians are not technically employees of the Department of Health and Wellness, there is an employer-employee type of relationship, in that the remuneration is coming from the Department of Health and Wellness. Anyone who has ever been an employee knows the importance of feeling appreciated and feeling that you can have open dialogue with the organization that is providing your funding, your salary, your wages.


            Is the Department of Health and Wellness willing to work closely and listen to the recommendations of Doctors Nova Scotia in the near future?


            MR. DELOREY: This is a request that I find interesting. I say that because the way it was phrased in the question and the preamble suggests that the department doesn't engage with Doctors Nova Scotia.


            I can really only comment on what's transpired in the last few months, but I can tell you I've had numerous meetings both face-to-face as well as phone calls with, in particular, the President of Doctors Nova Scotia, but also in broader sit-down meetings face to face with staff and others within the association, to talk about their concerns and so on. I would dare suggest, I would have to go back to my calendar to confirm, but by recollection, I would suggest that of any organization and stakeholder group, I would say Doctors Nova Scotia as far as my own calendar and engagement, is probably one of the organizations that has had the most face time and engagement of any.


            If you add to that the level of engagement and time spent out engaging with physicians and other front-line health care providers who have gone around in meetings in facilities and clinics and in other areas where health care is being provided, if you add that all up, there is no stakeholder group, really, that has had more engagement, more opportunity to provide input directly to the Department of Health and Wellness. That's on top of the work that, I note, takes place on a day-to-day basis with employees through physician services and other parts of the organization within the Department of Health and Wellness. Those communication lines are open, they do get engaged.


            Do we always land on the same page of everything? I've made comments earlier today, I would be extremely naive in this position if I thought that every time we made decisions or came up with a plan that there was going to be unanimous support. I can use one of the examples, when I was on the tour, where I was sitting at a table - did you ever see the cartoons where people go into the fight, start the fight and then everyone jumps in and then the people who started the fight kind of bounce out and you're just watching? You know the one, the cartoons that do that?


            It really felt like that at one of the meetings, because there was a topic that came up and it was really interesting. We started into the discussion, were talking about it, but the consensus around the table with those physicians was not - and they got into, I'm not going to say heated, but a detailed discussion which I was no longer part of. It was great to be there, to hear the various positions, and the pros and cons of the various aspects of the suggestions that were being put on the table. Health care is very complex, and what makes it even more challenging is the fact that it is so important, and everybody throughout the health care system cares so much about the delivery.


            I guess, specifically, we are working and do work with physicians, both directly and through Doctors Nova Scotia, to try to find solutions to some of the challenges. One I would talk about that came to bear almost immediately after my being appointed has to do with a specific position, a hospitalists' position and the way that that program exists and rolls out. There was a lot of work done before I came in, with staff levels, with physicians, which included representatives from Doctors Nova Scotia on that working group, representatives from the Health Authority, and then it eventually moves into the Department of Health and Wellness to engage in those discussions. That work's been ongoing.


We've brought it to a master table within Doctors Nova Scotia, and the government recently, to try to work forward - as we said earlier about the compensation capacity - to move forward, and get that funding moved over, so we can move forward on the proposal that, literally, came from physicians themselves, to move this forward. I'm certainly happy to work with Doctors Nova Scotia, and I hope they move, in particular on that file, to ensure we get this rolled out to the physicians, who have been asking for it.


MS. SMITH-MCCROSSIN: I appreciate all of the time you've spent since you've been in office and in this position - some of the feedback that I'm getting, and that I've read in Doctors Nova Scotia position statements, have been ongoing. Certainly, if there's been a shift in the last two months, I think that that's great to hear, and I would encourage the minister in that work.


I know in the position paper, I was surprised to see that one of the first goals was that they be included in health care planning. Most people would just assume that physicians would be at the decision-making table and be part of the planning. For example, they've repeatedly asked to be included in the leadership team.


I realize that there is a physician on the leadership team with NSHA, but there are none on the board of directors. I know that's one area where physicians would like to have some input, and I do know that there is definitely a feeling across the province that they're not being heard, so I just encourage you to continue on that path.


            Along the same lines, I'd like to ask a couple of questions of the minister around collaborative practice, and in particular nurse practitioners and family practice nurses. I'm supportive of both working with family physicians, if that is the desire.


            The first question I have with regard to collaborative practice is, with the current model of the central board, there's no actual connection with our communities any longer, since the dissolution of the nine health authorities. What can be done to change that? True primary health care is based on the needs of individual communities, and right now there's no direct link. I realize that there are community health boards, but their mandate, up to just recently, has always been health promotion, and most people on the community health boards don't have the experience and/or expertise, or desire even, to be providing that level of expertise to the central board.

Most of them joined the community health boards to be part of community wellness-type projects. My question is, what could be done to create community and allow for community input so that the central board are getting that feedback of what are the needs of particular communities around the province?


MR. DELOREY: It's a very important question, and one I would like to underscore the importance of for the members, and one that I want to highlight. Making reference to community health boards, I think, is appropriate as well, because they don't often come up in conversation and discussions in terms of the role that communities do play and can play and have a very positive impact.


            I think the underlying premise of where the question is going as to where people participate and get engaged, I think that question although more acutely felt or articulated today, I suspect it may be argued would have also been felt in communities under the old model. For example, in my community of Antigonish, which was the centre for the GASHA health district prior to the amalgamation, I would say people certainly very much felt a part of the process in the community and knowing that the decision makers were our neighbours, perhaps our family members or friends - lots of those direct relationships. I suspect that residents in Guysborough, in Richmond, and in Inverness would have felt equally removed from the decision making that was being made in Antigonish.


            I think the premise of the question is not one that is uniquely derived from the amalgamation and the Nova Scotia Health Authority. I do think that if you actually look at the underlying premise, it likely existed as well previously.


            As far as the approach and how we manage that, that is something that we worked to try to manage and address with our structuring and our planning for the Health Authority. It was when my predecessor, Minister Glavine, he spent about 18 months from when we were elected going around gathering information and feedback from communities and health care professionals, from the previous boards, but also the community health boards that existed as well. I can say I know he did that because I was at those meetings with him in Antigonish when he was having those meetings.


            I can also say that the feedback that was provided by those groups - again I can only speak in the Antigonish context - I know that I saw information that was put on the table, concerns raised with what was kind of preliminary-design processes, brought to the table from front-line professionals in the system from those community health boards, and it was reflected in the final design. If it happened in Antigonish, I have the utmost confidence that the minister and his team took feedback from other communities as they went around to design the system.


            To the point about getting localized, I know the member for Cape Breton Centre had previously been asking about the autonomy or the ability for front-line health care providers to feel their input was being received within the system. We recognized in the restructuring that, having a single central authority, that concern would exist. That's why as part of the model, it's designed to have zones to provide a regional feedback and input. Not to duplicate the entire administrative structure, but to ensure there was a senior leadership element that did exist closer to, not just the facilities and the front-line workers, but also the communities.


            That was something that was part of the design with that intention, also recognizing from early on that the community health boards could play an expanded role in that. As you noted, some recent changes with the community health boards, we do see them, with the volunteers that work on those boards, as community leaders. While they historically had as the member said, interest in health promotion and programs like that, I think the calibre of the individuals who step up to participate on these boards have a capacity and, given their interest in the health care system, the ability to do even more. I think they would respond well to that.


            As we continue this work, we'll see what works and if things aren't working as well as we hoped, we'll listen and hear and try to adjust to ensure the people do recognize their voices are being heard and reflected in the delivery of health services in the province.


            MR. CHAIRMAN: Before I recognize the honourable member for Cumberland North, I just want to remind the honourable minister and all members of the House, once again, about using members' names versus - perhaps recognizing them by their constituency or their ministerial department. This debate is rather relaxed, as it should be, through the Estimates, but I will keep some formality to it by way of the rules.


[6:30 p.m.]


            The honourable member for Cumberland North has the floor.


            MS. SMITH-MCCROSSIN: The reason I asked that previous question, I forgot to final up with it, it was with regard to collaborative practices. Some communities are interested in collaborative practices and others are not.


            It's important to define what is going to be the proper method in making that determination, and I didn't end my question properly to clarify that. I do want to just, before I ask the direct question, with collaborative practice, just with regard to the structure. I remember back to the regional health boards and what a disaster they were. Many of us who work in health care were shocked to see the Department of Health and Wellness go back to, even though they were called zones, they were still based on the same four units, and those didn't work.


            One of the things that I've asked for, and I realize this isn't directly related to the budget, but one of the things I've been asking for in my role is organizational charts. I just think that they're really important, looking at accountability. A lot of people who work in the health care system cannot tell you who's responsible for what.


            That's a real problem and I've asked people at all levels, can you share with me the organizational chart, the organizational flow, who is accountable to whom? What's happened - this is my estimation - is that there wasn't proper planning done on the front end, so now what's happening is, managers are now being band-aid-placed around the province.


            I would encourage the Department of Health and Wellness to try to look at and encourage the NSHA, and again, looking at accountability, to ensure that there is an accountability chart, and that there is a definite organizational structure so that people clearly know who they're responsible to. When you brought up the zone and the organizational structure, I just wanted to bring that up that no one, no one, at any level, so far, has been able to clearly - and I know the health care system is complex and I'm not trying to diminish that. However, if I work in the health care system, I should be able to say who I would go to.


We had a surgeon in our zone whose software equipment failed, so they continued to do scopes, but he said it was like it was in the early 1970s, and for six months, he could not find who he was supposed to talk to, to get this software fixed. Now, that was a year ago. My point is, there's a lot of work to be done, and three years out, I don't think we can keep saying we're still in the early phases. Three years out, we should know who's accountable to whom.


Back to collaborative practices. I'm just wondering, from a business model, has there been any cost-benefit analysis done on looking at care given by either a family practice nurse, a nurse practitioner, and/or a family physician? I support all three models, and I think it's excellent when people can work to their full scope of practice, and that's probably when we get the most value for our dollar.


However, I do think it would be valuable to do a cost-benefit analysis, in particular with nurse practitioners and family physicians, and you simply can't look at salary versus the fee-for-service, you need to look at things like pension, vacation time, work costs, and looking at the whole picture, staffing, administration, and make - the reason I emphasize that is if a community is saying they would prefer fee physician services, there may not actually be any cost benefit to putting nurse practitioner versus family physician, but I would encourage somebody to look closely at those numbers. That could be part of the decision-making process.


It also would be helpful in making your argument pro or con, when you're looking at family practice nurses, and there's a significant difference in cost of family practice nurses versus nurse practitioners, and when you're looking at scope of practice, there is a difference but not a huge difference. My question with regard to our estimates is, has a cost-benefit analysis been done comparative of nurse practitioners and family physicians?


            MR. DELOREY: I thank the member for the question. A couple of things - just on her preamble first, about the organizations and the org structures, again, I think that's shared amongst a lot of people. It's something I had heard. But I just want to add one piece to it.


            To your last point about being two and a half or three years into the system, one of the things I have often heard from people who raise the health care professionals - whether it be physicians, nurses, or other professionals working with the Health Authority, the NSHA - is that there have been more occasions now where I'm hearing "but that's changing." Like the example of the collaborative practice that I had mentioned, they expressed the concern with what was coming out, but now it's different. In the example that the member brought to the floor, the member acknowledged that it was a year ago when that was the situation.


            It's not to suggest that it's necessarily perfect, but again, it's worth noting that the scenario that was referenced was about seeing changes in the organizational structure, seeing managers move around. That really is reflective, I think, of the NSHA and the senior executive team hearing and learning from membership. Although they had a design and a program for the structure to roll out, when it was rolling out in practice, they were getting feedback that maybe it wasn't perfect or the right model and that changes were needed. I think what it actually demonstrates, although it may not feel that way, particularly in the moment in the first year or two of the structure being implemented, is that it is illustrative of hearing from employees.


            Again, it may not feel that way, and it may feel like the voices were lost. The restructuring and moving some things around may actually have been as a result of the input and feedback - maybe not the specific feedback of a given person in the system that you may speak to but others within the system who may have made those recommendations of those changes.


            I think it's actually reflective of the dynamic nature and their willingness to listen and to adapt and change. Again, we get competing references sometimes from people who criticize - that the NSHA and the department are far too rigid and structured and fixed in their ways. Yet in scenarios like this, what we're hearing is that it's really bad because they didn't come in very rigid and structured and jam this down our throat and hold the line on that initial design but rather did try to adjust and be flexible. It's a fine line.


            Any time you have a large organizational restructure, I think particularly an essentially $2 billion operation, or between $1 billion and $2 billion, it's complex. Nine separate organizations were doing nine separate things. I just wanted to make that point - cause for optimism in the system that things are moving forward.


            With respect to the analysis of nurse practitioners and the other health care providers, the decision and the discussion of the what and the how, there's an element of engagement. I'm certainly hearing from communities about their primary care needs and also hearing from the front-line professionals about how they want to practise.


            That flexibility and what a practice looks like - it's not to say that a nurse practitioner is necessarily the collaborative centre. I think a lot of discussion goes on because, really, if you look at collaboration in the practices that I have gone out to see, there are many different models. I think I made reference to that in my opening statements. I think there are half a dozen or so different practices that I visited. Each of them self-identified . . .


            MR. SPEAKER: Order, please. The time for the PC caucus is up. Of course, you can come back in the next round. If she wants to continue in that stream, that's fine. But I do want to make sure that the time is allotted appropriately for each caucus. We will switch to the NDP caucus.


The honourable member for Cape Breton Centre.


            MS. TAMMY MARTIN: Looking at the budget for long-term care and realizing that this government cut significant funding from the long-term care budget and replaced some of the funding for food specifically to the tune of $1.3 million, I'm wondering, how did you arrive at that number? I believe the number that you took out was around $8 million, and you put less than half of it back. Specifically around food, how did you come to that number?


            MR. DELOREY: The process for budgeting and identifying exactly what dollar figure may get put towards any particular program or service does get complex at the minutiae level. Generally speaking, in this case, the member brought up the notion of where reductions over the previous couple of years had taken place.


            Those reductions, those estimates, and the budgeting process work, from a government perspective, the goal and the efforts that were taken were to target administrative savings and initiatives such as procurement initiatives. That was our target and goal and initiative and focus of where we were getting savings. It was identified that there were some organizations making decisions that were impacting the residents within these facilities. We recognized that as a problem, one that we wanted to move forward to make improvements on.


We identified two key areas that we felt were appropriate for targeting and trying to ensure that when resources were put back into the system, they didn't get eaten up through potentially administrative allocations. We wanted to make sure that administrative efficiencies that were found in the previous years were retained in the system. We wanted to make sure that when the money went back in, it was going back in targeted. That again is targeted towards the food and recreation budgets of the organizations.


            Coming up with the actual calculation is very complex, particularly in our long-term care environment because there are many different contract types at the various facilities that are out there, the number of beds and so on, and even the rates based on different contracts. The process that you get into doing the calculation to provide the increases gets a bit more complex, but again, keeping an eye on the fact that this was about targeting to ensure that we improve the services, particularly the food services and recreation, for those long-term care residents.


            MS. MARTIN: As a follow-up to that regarding long-term care, in the budget, the estimate last year was $8.571 million. The actual that was spent was $7.990 million. Estimated in this budget is $8.373 million.


[6:45 p.m.]


            Recently, you've been in New Waterford, and I asked to meet with you to show you Maple Hill Manor, exactly what is going on there. Not only have they had over $90,000 cut in the last two years in budget cuts, but I also wrote to you and I explained to you the issues and the problems there.


            The staff and family members are fundraising to put in lifts so that seniors and workers are not harmed on the job. They're fundraising. They're going out and selling spaghetti dinners to raise money so they can put in a lift. In the budget from this government, you have cut funding to infrastructure. There are patients in Maple Hill Manor who are in a wheelchair and cannot get into their bathroom because the wheelchair does not fit.


            How can you justify cutting funding to infrastructure? When do you plan on bringing that facility, among others, up to the standards for Work Safe Nova Scotia? Currently, they are not, and I don't believe any individual working person or family member should have to raise money so that they don't get hurt on the job.


            MR. DELOREY: What I want to highlight for the members and for the member for Cape Breton Centre, who has asked the question, is that when you actually break it down into a little more detail - I don't know if this data is the budget document or not - what you have highlighted there on the infrastructure side was really a transfer of about $198,000 province-wide from continuing care to home care programming service, so from continuing care to overall delivery of programs and services to Nova Scotians. That wasn't a reduction to continuing care. It was a little bit of a shift from continuing care, again province-wide, of about $198,000 to the home care program, delivering equipment to people, helping them stay in their homes and providing services there. The money is certainly still there to provide that care and those supports to those people who need it.


            MS. MARTIN: Then does this minister agree that workers in this province need to fundraise to provide safe equipment so they will not get hurt on the job and/or have injured residents at the facilities in which they work?


            MR. DELOREY: I thank the member for the question. Of course, the question does touch on something very important, we know. The member brought the question particularly about the impact of the work environment and injury rates or the potential for injury rates. Indeed, just in the last few weeks or month, data has come out from the Workers' Compensation Board that confirms exactly the concern that was brought up by the member. It's a concern that is shared by government, but that concern is also shared by union leaders and representatives of the care providers as well.


            I also believe it's important to note that a workplace action plan committee for health care and community services has actually been established, again recognizing that this type of scenario that was brought to our attention here by the member for Cape Breton Centre does also apply over in that space, in the community services sector as well, because they have some care providers as well. So this committee is to come together to try to move forward and address exactly that concern, how we can ensure that we improve the safety and the environment in these industries, in these areas, and the services that are being provided. We know that taking a focused but also collaborative approach in moving forward, particularly in workplace safety initiatives, can work. We have seen that this can work.


            It was demonstrated in the fishing industry, which I suspect the member probably has some familiarity with in Cape Breton. I know down home we do know. We have seen in our communities, those of us members who have fishing communities, the improvements. More of our fishermen are making it home safely each year. Still there are tragic accidents from time to time and people getting injured. But when you look at the actual data, you see significant results and improvements. You're seeing that because there was a focused, targeted effort similar to this workplace action plan.


            We are taking steps. We're working with other stakeholders in the industry to make those improvements.


            MS. MARTIN: To be clear then, as a follow-up, the Health Minister doesn't believe it's the responsibility of the workers to provide and fundraise for those lifts so that they work in a safe environment and provide safe care to the residents for which they work. That was the question. Is this government committed - although it's half fundraised for now - to ensuring that they work in a safe workplace? They have already fundraised for it. You have missed the ball on that. That is the point. But going forward, they are continuing to work in an unsafe environment, and this government has done nothing to help on that. They are fundraising for lifts. But I'll move on from that.


            Recently in New Brunswick, they are talking about a pay for plasma clinic. Will the Minister of Health and Wellness guarantee the Province of Nova Scotia that we will not have to pay for blood in this province?


            MR. DELOREY: One of the things I think Nova Scotians can be very proud of, Mr. Chairman, is the fact that we as citizens collectively, I believe, are one of the few jurisdictions in the country where the volume of donations received in this province through the Canada Blood Services agency, particularly for whole blood requirements, meets those needs.


            What else exists is that the nature of products that come from our blood donations, there is a variety. When we donate blood, I know I always thought when I stop in and make my donation, that the bag of blood is just thrown in a refrigerator somewhere and when someone who is the same blood type is having surgery, they just hook it up and receive the blood. It's an amazing learning experience to discover that that's not the case. In fact, while that is one use for some of the blood products and donations, in this day and age with advancements in medical technology and treatments, a lot of treatment is being developed from other blood and plasma products from our donations.


Those products that are being provided are provided by a number of organizations. But again, from a donations perspective, at this point in time, I'm not aware of that as being a concern or a problem in a Nova Scotia context. The data that I have shows that Nova Scotia donations are very good. We have a great population. I think this goes beyond blood donations, the recognition that as Nova Scotians we look out for our neighbours and our family, and we're a very giving community, right from Cape Breton down to Yarmouth and all points in between. I'm not seeing that as an issue. In a Nova Scotia context, data is not suggesting that's something we need to be overly concerned about at this point.


            MS. MARTIN: Thank you for that reassurance, Health Minister. That's very reassuring to hear.


            I want to go back to an earlier question that I had about the budget and the vacancies with the Nova Scotia Health Authority. Realizing that the government and the Department of Health and Wellness is the payor, I can't imagine me handing over a pot full of money and not knowing exactly where it's going, what vacancies exist, what shortfalls there are, and what facilities need upgrading - specifically, staff related, building maintenance, infrastructure. I'm wondering, if the government is the overseer of the money for the Department of Health and Wellness specifically, which we're talking about now, do you need to be an insider to have this information? I'm sure as an ex-employee, I could go online and see the vacancies. As well in the report that comes out every year, I'm well aware of the nursing overtime that comes out every year. I would think if I'm paying it, I should know it. I would think that you should have that information at your fingertips.


However, the budget isn't clear, or there isn't clear information to let us know exactly where we're falling down, if these are reasons why there are backlogs in certain services, why there are such huge wait times, why there's a discrepancy in the budget from 2016-17 between what was budgeted for, what was actually spent, and then what was re-budgeted for in this budget. I would think that you should know the staffing levels that you require - whether you can fill them or not is another thing - what type of vacancies, and if it's administration, what kind of administration? I would think as the funder, I would want to know that. I think the public deserves to know that.


            MR. DELOREY: I thank the member opposite for the question that I believe was in the statement. I guess as I've stated previously, Mr. Chairman, when this question came up earlier this evening, what's before us here is the tabling of the budget of the Department of Health and Wellness. Of course, one of the line items within that budget is a grant that goes out to our health authorities to provide the operational services. The specific details that the member has requested - I have made reference earlier this evening that we would provide the information to the member.


[7:00 p.m.]


Reference to having information "at my fingertips" I believe was the phrase used - I hope the member can recognize or acknowledge that we are here discussing $4 billion worth of services. Between the department and our stakeholders - again, the health authorities that provide these services - that is a very significant amount of data. The member is asking about something that falls into one of those third parties which does get captured as part of the budgeting process within those organizations, as an organization as part of the budget process. If this was going through that process, that information is captured, is tracked, and is available.


            For the benefit of yourself, Mr. Chairman, and all members, the reality is that, again, that is a separate budgeting process. Because it is such a significant amount of money, it actually gets broken out into separate organizations. They go through the budgeting process to identify those estimates and those factors. So yes, the information is available in the system. It's part of the process. Of course, in a multi-billion-dollar operation, that information is assessed and decisions are made that influence the process.


            But those specifics, when it's not specifically the NSHA's budget that I'm here to provide the details and the analysis on, that of course is a budget document that comes out outside of or after the provincial budget. I apologize to the member if she has concerns or the expectation that I would have every detail of the NSHA's anticipated budget at my fingertips while here this week or for however long the Parties wish to continue our discussion about the Department of Health and Wellness budget for 2016-17.


            The other thing is, as the member has noted to the assertion about being an insider, I think the member opposite answered her own question when she made reference to the fact that that information was readily available and is readily available to the public. I believe she said she can find it on a web page within the Health Authority. So I guess the information is clearly available, as the member knew when asking the question.


            But again, as noted, I did make a commitment with some of those very specific NSHA questions to gather that data, bring it back, and make it available to the member. Again, I suspect that in our discussions, there will be more instances than just this over the coming hours as we continue our discussions, our debate, here, where I don't necessarily have all the information.


            We are an organization with thousands of employees who provide phenomenal services on behalf of the people of Nova Scotia, not just the front-line health care workers who we acknowledge and recognize frequently in this Legislature but also the support teams that provide the analysis and the input and collect the data. You will notice that there are only three individuals here, Mr. Chairman, on behalf of the entire organization to pull that data together. I won't be surprised if, throughout the debate, there are other times when I'll have to get back to the member.


            Throughout this evening, I think there has only been a couple of times when we have had to make that commitment to both Parties. Again, we'll continue to do our best to have the information on hand so I can deliver it right away. But in those instances where I can't, I'll certainly be getting the information to those members.


            MS. MARTIN: We have recently heard some discussion about supplies that are budgeted for years in advance and never used. Specifically, health authorities sign on to contracts to use a specific type of equipment, but they don't follow through and get all the equipment that's needed in order to make this one particular device, like a scope, work to its full capacity. Then there is a breakdown in service, the ability to clean something or to sterilize it, and then boom, surgeries are cancelled for weeks on end because you're reactive instead of being proactive.


            In my estimation, this government is paying for things in advance and then not using them. Are you aware that we are paying for equipment that we are not actually able to use and that that is causing surgeries and services to be cancelled for the residents of Nova Scotia, who are subsequently suffering health-wise?


            We don't have those procedures and policies in place for upkeep of equipment, for maintenance on equipment, to ensure that the water and the sterilizers and these things - is there something regularly in place that you can guarantee and assure the people and the residents of Nova Scotia that they have the equipment and the facilities that they need in order to have the services provided?


            MR. DELOREY: I thank the member for this important question. I want to assure the member, and indeed all Nova Scotians, that of course there are emergency processes in place for procurement if there is an emergency situation where equipment, particularly equipment that is vital to the delivery, if there's a breakdown that was unanticipated, or what have you. There is funding through the capital medical equipment, that is kind of managed to ensure that we can deliver in those emergency situations. So when that is needed, we certainly respond. I think the specific example there, the member spoke about, a bit more detail was around specific medical equipment and used an example around sterilization and things like that, which is a critical step in ensuring the safe completion and delivery of health care, particularly surgeries within our health care system.


            There are processes in place certainly, where in an event that there is a system breakdown, the sterilization or a problem that comes in, we certainly have - and I'll use an example. I believe it was one of the hospitals that I was visiting that actually used that exact example. It wasn't that the equipment broke down but that - for the lack of better terminology and I apologize for not using the proper clinical terminology - but essentially the configuration of the equipment wasn't done properly at a particular point in time, which meant there would be a short-term disruption in the sterilization of the equipment at that site.


One of the advantages of the one provincial health authority overseeing our multiple hospital sites throughout the province, they were able to actually work with another facility very quickly to ensure that the equipment was being sterilized, utilized, recognizing it was going to be a short-term impact until they got the equipment reconfigured, cleaned out. Again, it wasn't a permanent breakdown in the equipment but a misconfiguration before cleaning, that required some time to fix. They minimized the impact on patients, but again, recognizing that they put the patient safety and the safety of the services being provided at the forefront of the decisions going into those surgeries, they both put the safety of the patients and the delivery of the services being provided front and centre, but they also took the steps necessary to minimize any impact from the delays that may have materialized through the incident that took place.


            I guess that is to say that yes, there are protocols and processes in place and, indeed, I think that again the information in that scenario that I just gave that came up as part of my tour around the province, makes it very clear that even in practice that it gets deployed and minimizes impact to patients when unforeseen or unanticipated impacts occur.


            MR. CHAIRMAN: The honourable member for Cape Breton Centre with about nine seconds.


            MS. MARTIN: I guess just in response to that I guess we would have to hope then that these instances don't happen in a hospital in Yarmouth and . . .


            MR. CHAIRMAN: Order, please. Time has expired for the Committee of the Whole on Supply for today. We'll recess just for a moment or two while staff get reorganized and the House does as well.


            [7:09 p.m. The committee recessed.]


[7:10 p.m. The committee reconvened.]


            MR. CHAIRMAN: Order, please.


The honourable Government House Leader.


HON. GEOFF MACLELLAN: I move that the committee do now rise, and that the committee report progress and beg leave to sit again.


            MR. CHAIRMAN: The motion is carried.


            [The committee adjourned at 7:11 p.m.]