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March 22, 2018
Meeting topics: 














2:37 P.M.



Mr. Chuck Porter


            MR. CHAIRMAN: Order, please.


The honourable Government House Leader.


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


            Resolution E11 - Resolved, that a sum not exceeding $4,367,099,000 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: I’m pleased to rise to introduce the estimates for the Department of Health and Wellness for the 2018-19 fiscal year.


            I appreciate the opportunity to speak about the important work being done by the department. With me are two officials I would like to acknowledge, who will help us take a closer look at the department’s budget over the coming hours. Joining me are Denise Perret, the Deputy Minister of Health and Wellness; and Kevin Elliott, the chief financial officer for the department.


            Mr. Chairman, I have served as Minister of Health and Wellness for just under a year now. When I appeared in the Chamber last Fall, I spoke about the health care priorities that the department and the government are focused on. The priorities have not changed, and our hard work is generating results. We have acted to strengthen our health care system, and we’re putting our patients’ priorities first. Because of the investments we made, we have hired more doctors, reduced the home care wait-list, and performed more orthopaedic surgeries.


            While there has been progress, Mr. Chairman, I want to acknowledge that we know there is more work to be done. We have heard loud and clear from Nova Scotians that health care remains their top priority. Access to primary health care and mental health supports, orthopaedic surgery wait-times, dialysis, and the QEII Redevelopment Project are just a few of the issues that have been keeping me busy over the past number of months. The team at the Health and Wellness Department have been busy working on initiatives like this for much longer.


            I have also been busy meeting with those who work in our health care system. One of the first things I did after assuming the Health and Wellness portfolio was travel across the province to meet with front-line health care providers - doctors, nurses, pharmacists, and many other health care professionals.


            We have listened to our health care providers and to Nova Scotians, and our budget reflects what we have heard. We’re investing to improve access to primary care, we’re investing to provide access to mental health services and supports, we’re investing in more support for those who need care at home, and we’re investing to increase the number of orthopaedic surgeries. We are investing in healthier people and communities.


            A decade and a half ago, the Department of Health and Wellness budget was about $2 billion. Since then, it has more than doubled, and this year it is now more than $4.3 billion. This year alone, the Department of Health and Wellness budget will increase by about $150 million over last year’s estimates. Make no mistake, we are making significant investments in health care in this province. We are spending about 40 per cent of the provincial budget on it.


            But health care isn’t just about money. I think most Nova Scotians expect more from us than simply to spend. Nova Scotians expect us to look at the evidence, and they want us to tailor our investments to meet the needs of Nova Scotians and their communities. In other words, they want smart, strategic spending, and that is what we have been doing.


            The first step was the amalgamation of the nine previous health authorities in 2015. For the first time, we were able to plan as a single health system. In the past, we had to track down how many Nova Scotians needed a family practice or where there might be operating room capacity to help Nova Scotians get the surgeries they require.


            We’re doing things differently now. We’re doing things in a more coordinated and collaborative way. We’re making strides in planning a single health care system. As I mentioned, we’re focused on several key areas for improvement - access to primary health care, mental health and addictions, continuing care, and wait times for orthopaedic surgeries. You can see those are areas reflected in the department’s budget and our investment priorities over the last several years.


            Our top health care priority is improving access to primary health care, including access to family physicians. Access to primary health care is top of mind for this government, for many Nova Scotians, and for colleagues on all sides of this House. Ask just about anyone, and they would tell you that doctors play a key role in the health and well-being of Nova Scotians.


            Mr. Chairman, I have spoken to doctors across the province, and I have heard their concerns and discussed their ideas. They have told us what is working and what we can do to make improvements. We have listened.


            Earlier this week, we announced $39.6 million as part of a multi-year plan to recognize the dedication of family doctors to their profession and to their patients here in Nova Scotia. Our doctors are essential to the health care system, and we value their commitment. We worked with Doctors NS to develop incentives to support our family doctors, to attract new ones, and to address the 811 Need a Family Practice wait-list.


            This year, we’re investing $19.6 million toward this multi-year plan. Family doctors will see a boost in their pay. Doctors will now earn more per office visit.


            The government is committed to increasing access to primary health care. We know there are Nova Scotians waiting for a family doctor, and we want to reduce that list. We cannot do it without help from our family physicians. Part of our plan includes an incentive to encourage doctors to take on more patients. A one-time payment of $150 will be paid to family doctors who take on patients from the Need a Family Practice list, those referred from an emergency department, or those from a practice where the doctor is retiring or moving.


            We are also working to encourage family doctors to use more technology in their practices. A pilot project will pay doctors to communicate with their patients over the phone or using e-health tools. Not only will this improve a patient’s access to care, but it will also help doctors work more efficiently and hopefully allow them to take on more patients as well.


            We’re also encouraging family doctors to confirm an up-to-date patient list. This will help us work with doctors to establish a new primary care payment model that supports collaborative practices and helps them enrol more patients.


            Doctors who use electronic medical records will also be compensated. These tools will help them improve the overall quality of care in their practices.


            I have said before, as have others, and it remains true, that our health care system must reflect how doctors want to practise. I heard this from physicians when I travelled the province several months ago, and I continue to hear it. That’s why we’re investing an additional $8 million to increase and enhance collaborative care teams across the province. When health care professionals work together, they can take on more patients. When more people have better access to care, they get healthier, and they see their quality of life improve.


[2:45 p.m.]


            Mr. Chairman, we remain focused on recruiting more doctors to our province and having a number of initiatives to help support the Nova Scotia Health Authority’s ongoing efforts to attract and retain family physicians. We are funding more family medicine residency spaces at Dalhousie Medical School because we know if people train here, they are more likely to stay and start their practices here.


            We know from experience that doctors are more likely to consider practising in a smaller community when they have experience in that community and can see first-hand what life would be like for them, their patients, their partners, and their children. The Dalhousie medical residency programs in the Annapolis Valley, Cape Breton, and southwest Nova Scotia have been successful in recruitment for that reason.


            We are 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. We only have to ask my colleague, the member for Sydney-Whitney Pier what exactly the benefits of living and working in Cape Breton can be. The additional family medicine residency positions and clerkship program are expected to begin in 2019.


            This budget also includes funding for up to 10 new doctors to come here through the new practice ready assessment program. In addition, the recently announced immigration stream will make it easier for internationally trained doctors to come to Nova Scotia to start work. In only a few weeks, it has already seen three recruits.


            Our tuition relief program will forgive up to $120,000 of a doctor’s tuition if they are willing to practise in underserved communities for five years. This was previously focused on rural communities, but we recognized that urban communities struggle to recruit family doctors too. This will bring more doctors to rural and urban communities in need. As doctors have requested, we have also provided more flexibility for doctors to determine where they want to practise in Nova Scotia.


            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 means a more traditional practice, but for many new doctors, nurses, and other health care providers, the answer to expanding access is to practise in a collaborative primary health care team. I have spoken to many students, medical residents, and others who are very enthusiastic about this model.


            By having nurses, dietitians, mental health clinicians, pharmacists, and others working as a team, they can see more patients and provide a broader range of services. For example, a nurse practitioner can diagnose and manage illnesses, order tests and interpret results, and prescribe medications. A patient with diabetes might be diagnosed by a doctor or nurse practitioner but also work with a family practice nurse and a dietitian for ongoing management of their disease. All those services can be provided together as part of a collaborative team. This means that the 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 overall health needs. We believe in this model. That’s why we have invested $8 million more this year to enhance and expand collaborative practices across the province.


            I was recently at Pleasant Street Medical Group’s offices in Dartmouth. They’re already seeing the benefits of having a family practice nurse on the team and are looking forward to welcoming a nurse practitioner. In fact, this is one of those examples where an experienced family physician of over three decades has welcomed working in a new way, as part of a collaborative team, and has been very, very happy with those results.


            We know that each collaborative team works a bit differently. Some practices have all the providers under one roof. Others are affiliated and maintain a regular connection. It isn’t a one-size-fits-all model. The many medical professionals I have spoken to say the model works well for them. It helps with their work-life balance, helps support their patients better, helps with recruitment, and allows flexibility to meet the specific needs of their communities.


            Pleasant Street Medical was one of 23 locations identified to receive new health care professionals a couple weeks ago, bringing the total number of collaborative primary health care teams across the province to 57. It is our hope that this model will help to attract new doctors to Nova Scotia


            Mr. Chairman, experience has taught us that doctors are more likely to remain in a community if they are welcomed with open arms by the residents. I 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 from them as a family doctor but also the kind of information that any of us wants to know when we consider moving to a new community. What are the job opportunities for my partner? Will my children do well in their school here? What will my commute be like - will I be able to buy a home for my family?


            Communities across the province know this best, and they have come to understand the invaluable role they can play in promoting their way of life to health care professionals. My colleague, the member for Clare-Digby knows this all too well, as he and partners within his community, along with the Nova Scotia Health Authority have been working together for a couple of years now. They are seeing the fruits of their labour, their commitments to their community and to health care professionals, pay off.


            This is also true for physicians like Dr. Simon Bonnington who moved to Nova Scotia several years ago with his family. He says Annapolis Royal wasted no time in embracing their newest residents, immediately welcoming their new doctor to the community.


            Nurse practitioner Jacqueline Green will move from Nunavut to begin work in Kentville this May. She was recruited by the Nova Scotia Health Authority, but it was the community that stepped in to seal the deal. It has been documented that the town pulled out all the stops, showing Ms. Green and her family around the community, pointing out schools, walking trails, and recreational facilities, and capping it all off with a party to introduce the family to dozens of people in the community.


            I would encourage all communities to remember that they are in the best position to promote their own way of life to doctors and other health care professionals considering setting up practice there. We’re happy to welcome Ms. Green and other nurse practitioners coming to our province.


            When Nova Scotians imagine front-line care, it’s often nurses who come to mind. It is why we refreshed our provincial Nursing Strategy in 2015, in partnership with practising nurses, unions, employers, regulators, and educators. Every year we invest nearly $4.7 million in the strategy. This investment helps employers recruit and retain nurses through orientation and support for new graduates, professional development, mentorship, and co-op student work placements. Since its launch, we have funded dozens of innovative projects proposed by nurses to improve workplaces and recruit and retain nurses here in Nova Scotia. We want to make sure we’re using the right tools to continue to recruit new nurses, and we want our more experienced nurses to stay here and advance in their careers.


            Our goal is to have the right mix of health care professionals working to their optimal scope of practice, seeing the right patients at the right times. We have made changes to allow nurse practitioners to discharge patients from hospitals and to enable registered nurses to see, treat, and release certain patients from emergency departments. Earlier this year, we amended the RN and LPN Acts to expand nurses’ scope of practice to allow them to independently administer and provide naloxone take-home kits to citizens who need them. A couple of years ago, we reviewed nursing education with our partners at Cape Breton University, Dalhousie, and St. F.X. Working together, we updated the undergraduate nursing program to better recognize learning prior to entrance, and improve clinical placements and graduate nurses at different times throughout the year.


Mr. Chairman, nursing is a challenging and, I’m told, an incredibly rewarding career. Nurses help patients recover when they are at their sickest, and they help them learn how to stay well. They are a vital part of our health care program. Not only do we value and recognize their tireless commitment, we support them.


            Take the Registered Nurses Professional Development Centre for example. This centre offers RNs a range of professional supports, including training and certification programs for specialties in areas such as family practice, critical care, and mental health and addictions. Recently, some programming has been extended to LPNs and other inter-professional colleagues. A bridging and assessment program for internationally trained nurses is also available, and most who take part are successfully getting a Nova Scotia licence. The government provides $2 million in annual funding to support this important centre and the many nurses who use its programs and services.


            We have remained focused on recruitment and retention of nurses. Our workforce of nurses is 14,000 strong. There are approximately 2,000 more nurses in the province than we had a decade ago. Despite the increase in retirements, our RN workforce has remained stable, and this year is the first time since 2013 that the number of RNs entering the workforce has exceeded the number exiting. The increased retirements over the past few years have been offset by an increased number of new graduates our local universities are educating. RNs coming here from other provinces and internationally educated nurses are choosing to make Nova Scotia their home.


            Our nurse practitioner and licensed practical nurse workforces continue to grow. LPNs are now working in many areas where they did not traditionally practise, such as emergency departments and operating rooms. Nurse practitioners are essential to the success of our collaborative primary care teams being expanded and created in communities across the province. As I said before, they can diagnose, prescribe medications, order and interpret diagnostic tests, refer and accept consultations from other health care providers including medical specialists, and perform specific procedures. Nurse practitioners play a critical role as our system evolves to give more Nova Scotians access to primary health care. We’re working with our partners to further support nurse practitioners in the future.


            Nova Scotians want and need all of our highly skilled nurses working to their full scope of practice. We have done a lot of work over the past few years around the Nursing Strategy, the nurse education review, recruitment and retention, and streamlining the health care system. We couldn’t have done any of it without the support and perspective of nurses, nurse regulators, educators, employers, and organizations like the Nova Scotia Nurses’ Union. We have made significant improvements, and we’ll continue to move forward.


            I want to talk for a minute about another key contributor to our health care system, our pharmacists. With a community pharmacy in every city, town, and village across the province, I know how many people rely on them for health advice. Our pharmacists are valued and trusted health care providers and exceptionally important members of the health care team. Over the years, pharmacists’ scope of practice has been expanded to recognize the additional supports they can provide to patients and to the health care system. Now pharmacists are able to give vaccines, prescribe medication for minor ailments and refill regular medications, review medications, provide naloxone kits and the associated training, and give valuable health information to their patients.


            I’m interested in continuing the positive working relationship with pharmacists in Nova Scotia to ensure quality care for all Nova Scotians, building on the successes I just mentioned. There are, no doubt, opportunities to work more closely with pharmacists to support patients in new ways, and I look forward to working with pharmacists and the Pharmacy Association of Nova Scotia to continue exploring those opportunities.


            I want to move on to talk about mental health and addictions for a few minutes. It’s an area that affects many Nova Scotians. Last year, we invested $281.5 million in mental health and addictions treatment, including services to those living with mental illness and payment to physicians and for associated medications. This year, we’ll invest $287 million in mental health and addiction services. That’s in addition to the new primary health care investments we have just made because we know that many Nova Scotians have their mental health and addictions care needs met in their doctor’s office.


[3:00 p.m.]


            Our priority for mental health is improved access. We will continue to increase spending in the years ahead, but we also know this is not all about money. The reality is that we have invested money in mental health, and we have noted that we have surpluses in that area. Real change takes time, but we need that money out in the communities providing the services that Nova Scotians need. That is a priority for this government and our partners this year.


            We’re committed to working with the Nova Scotia Health Authority and IWK to determine how we can more efficiently deliver services differently, building on traditional ways of delivering mental health and addictions services. We are working on a new policy direction for mental health, one that encourages integration and coordination among both our traditional mental health system and the other programs, services, and providers that play a role in improving mental health for people of all ages and with a range of care needs from prevention to urgent care.


            We need to focus more on how people want to receive these services and the role that technology can plan in increasing access to those services. The popularity of the Kids Help Phone chat service is a perfect example of this, one we funded in the Fall because the demand was great. More than $460,000 is also being provided by Labour and Advanced Education to pilot new online mental health tools to post-secondary students, where we know the needs are growing. We’re providing an additional $800,000 for the IWK to use technology to support clinicians outside of Halifax who need access to the expertise in child and adolescent mental health that may not be available in their community. There are opportunities in this area, and we’re eager to explore how we can better support both clinicians and patients using technology.


            A new policy direction requires planning with the Health Authorities, input from stakeholders, and a willingness to listen and to try new things. Mr. Chairman, I’m pleased to see a growing recognition that mental health and addictions is as important as other areas in health care. We have been working hard to take what were sometimes fragmented mental health supports and services and better coordinate them.


            The Together We Can strategy has given us a solid foundation over the last number of years around mental health and addictions care. The principles and perspective remain sound, and the good work that was done holds true today. We are building on that good work with the investments we have made and with steps we have taken. Those actions stem from consultations that have already taken place with a range of experts and stakeholders, such as the Ministerial Advisory Panel on Innovation in Mental Health and Addiction and Dr. Stan Kutcher.


            The ongoing improvement of Nova Scotia’s mental health system is a priority. We are continuing to build on the work in Together We Can, and our investments reinforce our commitment. In this budget, we have invested $2.9 million more to provide better access to mental health services, including increased funding for clients in crisis and to reduce wait times; $1.1 million will put 10 more mental health clinicians for youth and adults in communities across the province. This is in addition to the five clinician positions for Cape Breton and eight child and youth clinicians for First Nations that we funded in 2017-18 and continue to support.


            We have added $518,000 more to create community youth programs like CaperBase in the northern and western zones. Government is adding 11 more mental health clinicians for youth as part of a SchoolsPlus expansion that will see 54 clinicians in 31 SchoolsPlus hubs providing service for approximately 250 schools in Nova Scotia.


            We’re also investing $1 million more for youth health centres, which provide a range of services including health education, information and referrals, and follow-up and supports for young people in schools. There are currently youth health centres in about 70 schools across the province.


            The Nova Scotia Health Authority continues to work on a central intake service for mental health and addictions to ensure people know where to get access to mental health services that they need. This is important work, and we have invested $819,000 in this budget to continue it. This central intake process will provide one entry point into a range of options available to Nova Scotians. We expect this system to triage and connect Nova Scotians to services like individual and group therapy, specialty diagnostics and treatment, e-mental health options, and other providers.


            We need an integrated central intake process so that Nova Scotians in need of care are not on their own to sort through a range of options available through a variety of organizations. Improving mental health and addiction supports for Nova Scotians will continue to be a priority for me and for this government.


            Mr. Chairman, the misuse of opioids continues to be a challenge that is spreading across this country and claiming too many lives. Over the past year, investments in the opioid action plan and framework allowed us to reduce wait-lists for treatment and provide more specialist support. This budget includes $3 million to continue this work, bringing the overall investment to $5.7 million. Additional funding announced last week included more money for community-based harm reduction organizations in Truro, Halifax, and Sydney and more access to naloxone kits for police and correctional services.


            Nova Scotians living with mental illness and addictions don’t have to deal with this alone. We are working to increase supports so they can access the support they need to live well.


            Mr. Chairman, the province’s continuing care system provides programs and services to approximately 40,000 Nova Scotians every year in residential care facilities, in long-term care, and in home care. Our annual budget for continuing care is nearly $842 million.


            Nova Scotians have told us they want to live at home for as long as possible, and that is why we have invested heavily in home care, significantly reducing wait times for home supports and admissions to long-term care facilities. In fact, since 2015, there has been a 53 per cent overall decrease in the wait-list for long-term care. We continue to invest in what works for Nova Scotians. This year an additional $5.5 million investment will bring the total home care budget to $266 million.


            We have also expanded the Caregiver Benefit program, which will provide about 600 more caregivers $400 a month. This program recognizes the important contribution that caregivers make in supporting loved ones to stay at home and in their communities.


            We look forward to continuing to expand this program. We are looking at all aspects of continuing care, including long-term care beds, to understand how to meet the current and future needs of our aging population.


            In addition to new home care investments and Caregiver Benefit expansions, the province’s older adults will benefit from the increase to fees paid to physicians to see patients over 65, continued investment in the Seniors’ Pharmacare program and support for the province’s SHIFT strategy. Of course, we know that older adults also benefit from our investments in mental health, primary care, continuing care, and orthopaedics, as do Nova Scotians of all ages.


            Mr. Chairman, this government has invested more money every year to help Nova Scotians on the wait-list for orthopaedic surgeries, particularly hip and knee surgeries. Since 2013, 14,000 hip and knee surgeries have been completed, helping the Nova Scotians who have been waiting longest. Government has added $8.8 million this year, bringing the four-year total investment to $24.3 million. This will support the work of the Health Authorities to strengthen orthopaedic services by creating a central booking process, making better use of operating rooms across the province, and hiring more surgeons, anesthetists, nurses, and other health care professionals. It will also support prehabilitation services to improve the outcomes of these patients. For people receiving these services, the results are life-changing. We’re investing more and supporting the Provincial Orthopedic Working Group to bring that to more Nova Scotians sooner.


            Our budget reaffirms our commitment to improving access and reducing waits for health care services for primary health care, mental health, continuing care, and orthopaedic surgeries.


            Mr. Chairman, I am also proud to serve as the Minister of Gaelic Affairs in Nova Scotia. Our government recognizes the importance of Nova Scotia’s Gaels and their language, culture, and identity. Supporting Nova Scotia Gaels is a key focus of the Office of Gaelic Affairs.


            An estimated one-third of Nova Scotians have connections to the language, culture, and identity of Gaels in this province. When we introduced the Culture Action Plan one year ago, we understood the importance of sharing our stories because they help us understand who we are, where we came from, and where we want to go. That is why we made a promise to “include the language, history, and culture” of our founding cultures, including the Gaels, in teaching Primary to Grade 12. It’s why we have developed a Gaelic intensive immersion initiative and a mentorship program for intermediate-level Gaelic speakers to help facilitate access to higher level mentorship programs such as Bun is Bàrr.


            As a program, Bun is Bàrr allows the transmission of our culture and language from one generation to the next. As a culture, we stand on the shoulders of those who came before us, the elders who carry our Gaelic culture forward, benefiting in direct and tangible ways the social and economic fabric of Nova Scotian life.


            A mini documentary on Bun is Bàrr and how it is assisting in cultural transmission through language will be shown in communities during Gaelic Nova Scotia Month this year. To further assist our educators, community members, and Nova Scotians, in telling the story of the Nova Scotian Gaels through their community, language, culture, and heritage, the Office of Gaelic Affairs is currently finalizing Gaelic Nova Scotia, a Resource Guide.


            We are also strengthening the office and looking at new ways to support Gaelic language and culture. One of these will be the launch later this year of a Gaelic licence plate. Besides providing Nova Scotia Gaels and Nova Scotians who identify with Gaelic language and culture with an opportunity to celebrate their heritage, this initiative will put more money towards Gaelic programs in our province.


            I also want to recognize, acknowledge, and thank the many volunteers, organizers, ambassadors, educators, and elders in the Gaelic community who work tirelessly to tell the story of Nova Scotia Gaels and to share their culture and heritage and the Gaelic language with all Nova Scotians. We will continue to reach out to the Gaelic community to ensure their voices are heard and are reflected in government’s work, as well as help to ensure our Gaelic heritage and culture is protected and celebrated, and continues to thrive.


            As a province, we are proud to recognize Nova Scotia Gaels as an integral part of our province’s cultural fabric and the crucial contribution Gaels make to the diversity of the province, making Nova Scotia a place we can all be proud to call home. I look forward to the continued work in my role as the Minister of Gaelic Affairs.


            In closing, I’ll put my Health and Wellness hat back on as I finish up my opening remarks. As I mentioned earlier, health care spending makes up about 40 per cent of Nova Scotia’s entire provincial budget. That means for every $10 the province invests, about $4 is spent on health care. That is a significant investment but a necessary one.


            This year, the health budget will increase by more than 3.6 per cent to a total of $4.367 billion. It is my responsibility and the responsibility of my department to make sure we spend that money wisely in ways that will improve the health care system 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 are focused on our priorities and on achieving results. We continue to work closely with the Nova Scotia Health Authority and the IWK to improve the delivery of health care services across the province. We will continue to collect and share data and use it to make smart, strategic investments that support the health care Nova Scotians need.


            I would like to recognize Health Authorities and their volunteer partners, including community health boards, hospital foundations, and others for their partnership in this important area. The measures in our 2018-19 budget reflect the positive outcomes we have already achieved and will keep us on track for the future.


            Before I conclude, Mr. Chairman, I want to take a moment to thank the thousands of dedicated health care workers across Nova Scotia. These are the people who work tirelessly every day to help Nova Scotians get and stay healthy. I want them to know that they have my personal thanks and the thanks of the Government of Nova Scotia for the work they do. They are the doctors, nurses, clinical specialists, pharmacists, and many other health care professionals who are on the front lines day in and day out.


[3:15 p.m.]


            I appreciate those who have reached out to offer their thoughts on new ways to support patients in their communities. I have listened, and I will continue to listen. I will continue to meet with them and to hear their ideas and concerns as I serve the public in this role.


            We also must not forget the thousands of volunteers who are devoted to the health of Nova Scotians, fundraising, assisting clinicians, and supporting patients and their families. They do this because they are passionate about it. They do this because it matters. Mr. Chairman, I want all those volunteers to know that we recognize them and their efforts, and we appreciate it.


            With that, I will conclude my opening remarks and open the discussion, with the assistance of Ms. Perret and Mr. Elliott, to answer questions about the department’s estimates. Before I do, I also want to take a moment to recognize the work, which I am sure I will do again in closing remarks when we wrap up estimates, of the staff in the Department of Health and Wellness, those with our partners throughout the province, at the Health Authorities, and others who have provided input as we were crafting the budget.


            I would be remiss if I didn’t recognize the work and efforts of colleagues within the Department of Finance and Treasury Board as well and others throughout government for their ongoing dedication and commitment to the work they do each and every day throughout the year but in particular at this time for the work they have put in over the past number of months to prepare this budget to move forward on the priorities. I know they are as anxious as I am to move forward on implementing the many new strategic initiatives that we have identified in this budget.


            MR. CHAIRMAN: The honourable member for Cumberland North.


            MS. ELIZABETH SMITH-MCCROSSIN: Thank you to the Minister of Health and Wellness for his opening remarks. As he mentioned, health care takes up the largest piece of our provincial budget. As he well knows, as we all know, there’s a lot of frustration around this province with the current state of our health care system.


            Taxpayers are frustrated mostly with the lack of access to timely care. Health care providers - including pharmacists, nurses, doctors and other allied health care professionals - are frustrated. Every day, I am hearing from them.


            When this government took over, back in their first term, they centralized the health authorities, creating chaos throughout the entire system. In the Health Authorities Act, it clearly sets out who is accountable. I want to go through that today briefly, Mr. Chairman.


            The Minister of Health and Wellness is responsible for ensuring the Nova Scotia Health Authority board of directors is effective. The Nova Scotia Health Authority board of directors is responsible for ensuring the CEO is effective. The CEO is responsible for ensuring the leadership team is effective in making sure the health care services are adequate for the people of Nova Scotia.


            I go through this level of responsibility, Mr. Chairman, because somebody has to be accountable for the current state of our health care system. It is not acceptable to continue on to say, yes, there’s problems, and we’re working hard. There are devastating problems in our health care system. I believe somebody should be held accountable. It’s clear to everyone across this province that the CEO is not effectively managing the health care system.


            I ask the question, why has the board of directors not done their job, removed the CEO, and hired a new CEO? This CEO is paid over $340,000 a year to do her job. Why has the board of directors allowed the same CEO to stay in this position when she is clearly not able to do the job?


            In the Health Authorities Act, it clearly states that if the Nova Scotia Health Authority board of directors is not doing their job in holding the CEO accountable, then the Minister of Health and Wellness is responsible for removing the board of directors and replacing that Nova Scotia Health Authority board of directors with an administrator.


            Recently, I spoke with a physician who had had a conversation with the chairman of the Nova Scotia Health Authority board of directors, and he told her that it wasn’t their responsibility to make sure the CEO did their job. So, either that chairman of the Health Authority does not understand his role and the board’s role, or maybe he was simply trying to avoid taking responsibility. I believe if people are being paid that kind of money, they should be held responsible for doing the job they’re hired to do.


            I want to start my opening comments, before I start asking questions, with this statement: I believe the Minister of Health and Wellness should be holding the Nova Scotia Health Authority board of directors accountable for holding the CEO of the Nova Scotia Health Authority accountable. They are clearly, clearly, not fulfilling their obligations.


            When you have someone on the leadership team of the Health Authority publicly stating to a journalist that we’re building the plane while flying it and having no shame, there is a problem with that. It’s embarrassing to me. I believe the CEO should be replaced. If the Nova Scotia Health Authority board of directors is not willing to take that responsibility, then the Minister of Health and Wellness must take his responsibility and role seriously and replace the Nova Scotia Health Authority board of directors with an administrator and work to replace it with an effective board of directors.


            My first question to the Minister of Health is, what is his commitment to holding the Nova Scotia Health Authority board of directors and CEO accountable for doing their jobs?


            MR. DELOREY: Just a couple of points, I guess, in response before I answer the specific question because although there’s a specific question, there’s some more wrapped up in the commentary.


            The first thing I think is important for the members here to realize is that the fundamental premise that seems to be presented by the member opposite is that in 2015, when the Health Authority was amalgamated, and the Nova Scotia Health Authority board and executive team came together as a single entity, somehow, we had a utopian, perfect health care system. If that is the goalpost to which the member is assessing the performance of the Health Authority CEO, the board, and the department, I think you put it in a challenging place.


            The fact of the matter is, when we came in, many of the challenges in our health care system already existed. They didn’t just exist a year or two prior. They didn’t just exist because of the previous government or the one before that. Indeed, Mr. Chairman, you can go back as far as the 1960s. You can look at the legislative proceedings, the Hansard recordings of Legislative Assemblies across the country, federally and provincially, and you’ll see debates like those that we’re having now about the concerns of health care. I think this reflects not just a question of what people are doing in its entirety but also in specific areas.


            It’s always easy to point to specific areas of challenges and opportunities to invest and do more within our systems. But to assess the level of performance of individuals or collectives within that system, to suggest that everything is not perfect in our health care system, and therefore, people in that system are not doing their jobs, I think would be off-base.


            I believe the member did do an appropriate job of outlining what the governance structure is relating to accountability within the system. That’s what leads to the specific question as to my willingness and role to engage and work with the Health Authority - or Health Authorities because the Act would apply to the IWK and the Nova Scotia Health Authority.


            What I would say is that I do indeed take my responsibility seriously. If it was necessary, I would take the appropriate steps to exercise my authority within the legislative purview, the authority that is vested in me and my office. But at this point in time, we continue to work with our partners, and we continue to make very positive improvements.


            I spoke earlier about the progress we have made in orthopaedic surgeries, as an example. That’s a great example of working with our partners in the Nova Scotia Health Authority, with the front-line health care professionals - the orthopaedic surgeons and others who work in this space - to deliver those surgeries and to identify process improvements as well as necessary investments to actually achieve progress. We’re seeing those results, over 400 additional surgeries since the Fall when we announced this initiative. This is great progress. I think there are lots of examples we can point to of improvements, where these individuals and collectives are actually making progress, as we would expect them to do.


            MS. SMITH-MCCROSSIN: Well we could debate all day, but I’ll go on to my next question.


            I want to talk a bit about the recent funding for a physician program. One of the parts of it was a $150 fee for a physician who is willing to take on an orphan patient. In fact, this is not a new fee. This has been in place since 2010. If physicians were willing to take an orphan patient from in-hospital, if they took care of that patient for 12 months, then they could bill for that $150 fee.


            Can you confirm that this $150 fee has actually been in place since 2010? If you are willing to confirm that, why would you announce it now, because it has clearly not been an effective solution to the problem?


            MR. DELOREY: I don’t recall that we ever indicated that this was a new fee. The member highlighted exactly within the fee - because she’s asking about the effectiveness of that fee - why we would be touting this.


            If the member and other members who may have this question looked closely at what the original fee was, it was limited, as the member said, to in-patients who are being referred from a hospital to receiving care from a family physician in a practice. The member may look at what we announced recently along with the funding commitment and see that the flexibility and the ability and means by which to identify orphan patients is much broader now.


            We know we have a list of over 40,000 Nova Scotians on the 811 Need a Family Practice list who have self-identified as being in need of a primary care family practice. We know we have a list to make available. We also know we’ll continue to support those who are in-patients to get attached as well.


            There’s also retiring practices. This was not an incentive for people to take on retiring practices. Over the course of the last year or so, we have seen family physicians who are coming to retirement age in the media. I can think off the top of my head of at least three articles that I have seen since I have come into office. Family physicians of retirement age went to the media to have a media report highlight that they’re at retirement age, and they’re at wit’s end because they can’t find someone to take over their practice. Now there’s an incentive to support those individuals.


            It’s a clear example of how we have been listening to physicians about the challenges they have and to Nova Scotians about the challenges they have getting attached. It’s an initiative that we have invested in. Although it looks the same in the sense of it being the same dollar amount, we’re making it available to more. What’s really important to notice about this is the original one was only related to patients attached to the hospital environment being attached to a family practice. You can see we actually don’t require people to be in a hospital before we realize they need access to primary care. We have expanded to those who have self-identified and also to those who currently may have a family physician or be part of a practice. We want to use this as an incentive to ensure that if, through no fault of their own, the physician is leaving, they can be attached.


[3:30 p.m.]


            My last point on this, when one questions the value proposition here, is that I would like to remind the member and other members in the House that this, along with other incentives we announced recently, was done in collaboration with Doctors Nova Scotia. We heard support directly from them as to the effectiveness and the value of this initiative, as well as from others.


            MS. SMITH-MCCROSSIN: What I’m hearing from family physicians is quite a different response. A lot of them are very insulted because if they were able to take on patients, they would have. To be told, we’ll give you $150 - a lot of family physicians around this province are quite insulted.


            Also, if you have someone who already has a full practice and has a two-month wait-list, and they said, sure, I’ll take another 100 patients, you’re actually just making things worse for the patients that were already there. Maybe instead of having a two-month wait-list to get in, now it’s three months.


            I just question - is it just a marketing ploy? I would encourage that we need more effective solutions to retaining and attracting family physicians.


            I want to talk for a minute about the increase in the fee structure and ask the minister, has your department looked at the increased money that the province is going to attain through the federal tax changes that are impacting physicians in this province negatively?


            We all know that the province is actually going to get a tax windfall from these changes. My estimate is that the province is probably going to receive an extra $16 million in taxes. Most physicians in this province who are incorporated are going to be paying up to $20,000 minimum more in income tax starting this year, and the province is going to receive their share of that. I’m not sure if this increase in fee structure was done to try to alleviate some of this tax money. When I do the math, this increase in fee structure will not actually make that up. They’re still going to be paying out more in the tax than they will be recouping by the small increase in their fee structure.


            I ask the minister, has your department looked at the impact that the federal tax changes are going to have on family physicians, the financial impact? Was that part of your consideration for the fee increase?


            MR. DELOREY: There’s a couple of things. First, I’ll just address the opening comments of the last question, which were related to the question about the $150. The member suggested that it was perhaps insulting - I think that was the term that was used - that fund. I want to remind that member and I think also suggest that we need to look at more effective ways.


            I am a little bit concerned, and I hope the member doesn’t take this the wrong way. We have heard time and time again, particularly from the Opposition benches, about the need for us to work with and consult with our partners, often stipulating that one of those key critical ones when working with physicians was through Doctors Nova Scotia. I’ll reiterate that this and other aspects of our initiative here were done in collaboration and consultation with Doctors Nova Scotia. Much of the foundation here in the proposal comes from work done with Doctors Nova Scotia.


            Although the member may have individual physicians who don’t feel that they are in a position to take advantage of this incentive, first of all, I have heard from some physicians myself - personally, not professionally connected - who have reached out and indicated that they were pleased with this. They didn’t indicate whether they would be availing themselves of it or not, but they were pleased to see it.


            Also, we have the endorsement and support of Doctors Nova Scotia in crafting, designing, and implementing it. Again, I do defer to their expertise and influence and recognize acknowledgement of doctors from one end of the province to the other.


            Can I acknowledge that it may not be an incentive that works for all physicians? Sure. But is it an incentive that can work for some? Yes.


            The member noted that this may have unintended consequences for practices that are full and physicians that are working at a full scope of practice. That wouldn’t be the area, Mr. Chairman, where we would be looking to see this incentive maximized. What we do know is that there are many physicians in the province who are not working with a full scope and complement in their practices. This is an incentive to encourage those physicians who have the capacity to expand their practices. That’s the area where we would anticipate movement. I believe that was the intention in discussions and engagement with Doctors Nova Scotia, and where it was intended to provide value and support.


            To the member’s other question in this segment around the federal tax changes, first of all, I would be happy to take a look at the member’s calculation and feedback and maybe pick it up tomorrow, so I can see where and how the member got the calculations. The way that their tax changes work would be with the Department of Finance and Treasury Board, because any revenue changes through the tax and so on is really general revenue that comes in through the calculation changes. That would be part of the overall budgeting process that the Department of Finance and Treasury Board does when working on establishing the projections for our revenue streams. They would take into account all the best information that they have available. That comes into their calculations for us when we’re developing estimates. We look at where our cost structures and influences would be.


            As I said, the actual total package of the incentives, including the fee changes, relates to work we have been doing with Doctors Nova Scotia. It was not directly tied or related to the tax changes that were being proposed by the federal government.


            I would also like to remind the member that the tax changes that were proposed, and we spent lots of time discussing it last Fall - the federal government did receive a lot of feedback. What they were talking about in summer and Fall 2017 is a very different tax structure change than what the federal government actually brought forward in the budget that they tabled recently.


            MS. SMITH-MCCROSSIN: They did leave some parts of the federal tax changes in place. Our incorporated family physicians - or all physicians, rather, who are incorporated in this province - are dramatically impacted by those tax changes still. So, it’s definitely a factor.


            I want to ask a question around the technology stipend. The Department of Health and Wellness has long subsidized physicians in this province for electronic medical records. Again, this looks like it’s being proposed as something new, but it’s not new. It has definitely been in place since before 2006 for sure.


            One of the big needs for this is because we’re no longer able to use Nightingale as an electronic medical record provider. There has been a switch with the government bringing in TELUS. I would like to ask the Minister of Health and Wellness a question around the decision to choose TELUS as the provider. I’m wondering, what is the cost to the Department of Health and Wellness for bringing in this provider? Also in relation to that question, has TELUS provided the province any money if they were chosen as the provider? If so, what is that amount?


            MR. DELOREY: A couple of things, and perhaps, some clarifications about the EMR. I guess on the technical front, and then that clarity may help on the specific questions around the incentive program and others.


            First of all, we do have a system in place in the province. For the benefit of other members - I know the member is familiar with the health care system, but other members here may not be, so please indulge me - I’ll just explain a little bit. EMR systems, or electronic medical records, are the systems that physicians use or are available or designed for use by physician practices. If you see your family physician or someone in a family practice logging on to the computer to bring up your records or key information, that is the system they use. When we’re talking about electronic medical records, it’s that computer system.


            We did as a province have an incentive in place for many years, in early days when transitioning to personal computing, to encourage physicians to adopt the technology into their practices throughout the province. The member is certainly right in the fact that there has been an incentive for a number of years. The incentive, though, is kind of a one-time incentive to get people on to the system. I believe about 80 per cent of our family practice physicians do have an EMR system in their offices to date. It might be a little bit higher, but it’s around that 80 per cent range. Many of those physicians would have likely received that incentive.


            If you look at the incentive that we announced, while that still remains, what is also in there is the incentive for people transitioning. Again, for clarification on the technical background, the majority of those physicians who are on EMRs are on a program called Nightingale On-Demand, the software product. That particular product was recently purchased by TELUS Health, so there isn’t a government change or decision here. In the market of technology health systems, there was a change in ownership of the Nightingale On-Demand software system. As a result, the new owner, TELUS Health, has indicated that they have other products that work in the same space. They indicated, about a year ago, that they would no longer support the TELUS Health system after December 2019. They gave a warning to all of their customers of that change.


            So yes, there is a requirement, a need, for people to transition if they’re currently on Nightingale On-Demand, which as I said, is the majority of family physician practices within the province. When you look closely at the details in the announced incentives specifically around technology of the EMR systems, there’s a significant portion there for the one-time incentive to encourage early transition. We as a province do not want to find ourselves in a situation where it’s October or November 2019, and nobody has transitioned off of the system. If we find ourselves in that situation, come 2019 the software may still work, but there will be no more support.


            It’s like if you have Microsoft Office, and you buy a new computer, you’ll have support for two or three years, or your antivirus software. You get the support. When it comes to the end of life - I don’t know, perhaps a couple of colleagues may still be running Windows XP or Windows 95 on their computers. They still work perhaps, but they don’t get supported anymore.


            We certainly don’t want such critical systems in our health care system to be going without receiving support from the vendors, so we’re encouraging those practitioners that use this software to get off it with an incentive. We’re still working out the final details on it as to how we’re going to be rolling IT out with them, but we’re continuing the conversations with Doctors Nova Scotia.


            In addition, the way that this process is working - when you talk about money, again, TELUS Health bought it out. There is no change there.


            The go-forward for transitioning - there are a number, not an infinite number, but a few different vendors that do provide EMR software on the market. I think we have about three different systems that are being used in Nova Scotia right now. Really, there would be a couple of different software options that physicians could move to, but we would look at each of those vendors to have them certified with the province to know that they are providing the supports that we need, that they integrate with our other systems in the province, before a physician would be eligible for those types of incentives and supports. We want to make sure, even if there are one or two different vendors, that whatever vendor the physician chooses to use in their practice, it integrates with MyHealthNS as we work to roll out one patient, one record, that they have these integrations.


Again, we want to make the best use of our technology investments - not just the ones that we make directly as a province but also all of our partners - because that’s going to provide the best outcomes for our entire health care system.


[3:45 p.m.]


            MS. SMITH-MCCROSSIN: I have a question about your practice readiness program. I’m wondering if you would be able to share some details with us. Is it run by the Department of Health and Wellness? Is Dal med school involved? Will the College of Physicians and Surgeons be working with you? Are they willing to modify their current licensing laws so that all of these physicians that we are recruiting will not be leaving, as we are seeing right now with our current defined-licence physicians?


            MR. DELOREY: The practice ready assessment is a very important program. Again, if the member will indulge me, for the benefit of our colleagues, I’ll just remind them of what this program is. Essentially, the practice ready assessment is the program that would allow for internationally trained medical graduates to come to Nova Scotia from a jurisdiction where their licence is not already recognized. It provides them an opportunity to come here. They would be accepted under this program, which would provide the opportunity, through supervision and some training, to meet the College of Physicians and Surgeons’ criteria to become fully licensed to practise in Nova Scotia.


            You may hear in some of our discussions that there was a former program called CAP, which was run and administered by the College of Physicians and Surgeons. They ended that program a couple of years ago. That’s what has presented the opportunity to come in with the new program, which we are calling the practice ready assessment.


            I think there are a couple of questions that were posed. The practice ready assessment will be owned and managed or administered by Dalhousie medical school. Obviously, it needs the college’s endorsement, so it is being designed in collaboration with them, and the work that has been done to date. All that work has been ongoing. There has been a significant amount of work being done. We’re providing funding to Dalhousie medical school to continue to support their program to get this off and running this fiscal year. They have done an amazing amount of work to date, working with the college, to get the design. The full program isn’t rolled out yet, but they’re working hard to get it up and running as soon as possible.


            MR. CHAIRMAN: I just want to remind all ministers and members that addressing their colleagues by the term “you” is inappropriate. I’m just saying that as a reminder that “you” is not appropriate, but I will be somewhat lenient. I am not going to interrupt you every time I hear it.


            The honourable member for Cumberland North has the floor.


            MS. SMITH-MCCROSSIN: One of the things that has come up during Question Period a few times is the concern with the current number of defined-licence internationally trained physicians who are having to leave our province. I know several personally who are under a tremendous amount of stress because of the requirements of the college for them to pass these exams. They are finding it difficult to do, and there’s a lot of factors involved. One is that sometimes their initial training is done in a different language. They have come here, and most of them are working in rural parts of Nova Scotia. They don’t have access to any academic supports, even if they were provided here in the city. Almost all of them are working full-time or more than full-time hours.


            I like this Practice Readiness Assessment program. It sounds good. My question is, will the minister allow the current physicians who are in this situation, who are facing losing their licence - there’s a number of them. We lost a ton of physicians last year, and I was told last week that we have about another 60 this year that we’re going to be losing. A lot of them are in psychiatry and a lot of family medicine physicians.


            Why would the minister and department not allow these physicians to get enrolled in this Practice Readiness Assessment program? My understanding is, the goal of this program is to ensure that these doctors who are being recruited are successful in passing their exam so that they can actually stay. I know several who have had to leave in the last six months because they didn’t meet the requirements.


            Would the minister be willing to let the physicians who are currently looking at losing their licence in the next 12 months or the physicians that may have lost their licence in the last six months enroll? A lot of them want to stay. A lot of their patients are very upset. A lot of them are upset not only because they are losing their job here in Nova Scotia, but also because they’re not able to go to any other province in the country. They have lost their licence, so therefore, other provinces aren’t able to take them either.


            Basically, we have deemed these physicians, who have been working up until now, not able to practise medicine any longer. I’m just thinking that it makes sense. Would the minister consider allowing these physicians to enrol into this Practice Readiness Assessment program so that we don’t continue to lose physicians here?


            MR. DELOREY: I thank the member for raising the question and shining a light on the challenge affecting some existing internationally trained physicians, those who are known as being on defined licences within the province.


            I can advise the member that although there may be some assumptions amongst some people, perhaps in this House or perhaps across the province, that as the Minister of Health and Wellness, I have a magic solution wand, and there would be no health care challenges within my own constituency. Indeed, I can let the member and all the House know that I’m familiar in my own constituency with some physicians who have been impacted by this particular change as well.


            In the comments made by the honourable member opposite, although not explicitly, it certainly came across in my hearing of the comments, that this is a situation that I or the government has created. I want to be explicitly clear for my colleagues and you, Mr. Chairman, that indeed, the changes around the licence requirements are a decision that was made by the College of Physicians and Surgeons. That is the regulatory body that governs the qualifications of medical practitioners in the Province of Nova Scotia.


            I would be happy to hear from the member if that is a responsibility and authority that she would prefer to vest directly in me as the minister, which would give me some authority to address the concerns that she’s raising directly. In the absence of that, and I’m going to make a big assumption here, but I don’t think it’s a very big one, that that’s probably not an authority or responsibility that anyone in this House really would want, in the balance of all things. Responsibilities within the college, professionals overseeing, self-regulating, and governing their own body are the ones who are in the best place. Particularly in the health care profession, they are the ones best suited to identify what the licensure requirements would be.


            That’s just to address what seems to come across to me as a bit of a suggestion that I can somehow - I don’t want to say wave a magic wand - allow people to stay here, fix the licensing issues and concerns. There isn’t necessarily a direct line for me to do that. Again, on the balance of all of the work that gets done by the college, I don’t think the members opposite would want me to establish that level of authority and responsibility directly.


            Notwithstanding that, to come back to the broader piece, that’s exactly the challenge with our defined-licence practitioners and those changes that have been making for a challenging situation. We recognize the need for the practice ready assessment to help. It’s why the work has been done to date, again, led by Dalhousie working with our partners within the Health Authorities and the college. Of course, the college has to be a partner through this process, because at the end of the day, the college has to be satisfied that the process will achieve the standard quality controls that would be deemed equivalent and eligible for practice within the Province of Nova Scotia.


            As the question went on, the very specific question that was posed was regarding those who are currently on a defined licence working to write the Royal College exams to obtain full licensure in the Province of Nova Scotia per the requirements of the College of Physicians and Surgeons - not per anything under the Department of Health and Wellness, not because of anything that I have done or directed - whether they would be eligible to go through the practice ready assessment process. I guess, that’s one of the things. I can’t give an absolute answer there.


            In part, that’s because, as I have said at the end of the day, the college is still a critical part here in the assessment or the pre-assessment as to who would be eligible for a practice ready assessment. I wouldn’t be able to make a blanket statement that all members on a defined licence today would meet the college’s criteria to have, essentially, a temporary or practice ready licence. I can’t say absolutely that that would be the case.


            But certainly, when the practice ready assessment is rolled out, there will be an application process to be eligible. It would be reviewed, and people would then be assessed and brought through that system that way.


            MS. SMITH-MCCROSSIN: Just to clarify, what I heard was that the practice ready assessment program is for internationally trained medical graduates, and there will be training provided so that they can meet the criteria of the college’s licensing laws.


            To me, it would just make sense. In addition to sending people to the United Kingdom and other countries to bring people here to apply, why would we not do that? Obviously, it is the college that licenses, and I’m not proposing that that change. But you did say that the Health Authority, which is under your role, is working in collaboration with the college and Dalhousie med school for this program, so you are directly involved in the Practice Readiness Assessment program.


            I’m just suggesting that, in addition to recruiting abroad, you allow the physicians who are already here practising and looking at losing their licence and leaving in the next 12 months to apply to this program. Many of them would pass the licensing laws if they were provided the proper supports. It sounds like this practice ready assessment program through Dal med school is doing just that. They’re providing the training to meet the criteria of the licensing laws.


            I won’t ask another question in relation to that, but I would just encourage the minister to speak with his partners at the college and the Health Authority and Dal med school to consider that. I think it would really help with our health care system when we’re looking into human resource planning for the next couple of years.


            I would like to ask a question around the family medicine residency program and the addition of 10 seats, which is very encouraging. I think that that is great in theory. One of the challenges that we face is that, unfortunately, a lot of medical students are not choosing family medicine for their specialty. In fact, I was told, and I don’t know if this is accurate, that there’s actually four seats in family medicine in Cape Breton right now that remain unfilled.


            I do know that this is a problem across the country. It’s not just a problem here in Nova Scotia. I was told that just in this year, there’s actually 60 vacant seats in family medicine residency programs across the country. We definitely need to look at the reasons why medical students are not choosing family medicine and why they’re choosing other specialties.


            I just want to ask the minister, and I don’t expect him to have an exact answer today, but just as something to ponder, would the minister and his department consider working with Dal med school in re-examining who becomes a family doctor?


            Prior to 1991, and it might be a couple of years before that, every medical student became a general practitioner. Every medical student did their four years of medical school, and then they did a one-year rotating internship, or most did. Everyone became a general practitioner, and then they went into their specialty program.


[4:00 p.m.]


            Now medical students have to choose their specialty in second or third year medical school, and if they don’t get matched - say, if someone chooses orthopaedic surgery, if they don’t get matched, they do nothing for the next year until they reapply again to the same specialty or to another speciality, yet we have family medicine residency seats left unfilled.


            I’d love to see the department get involved with Dalhousie Medical School in trying to find solutions to making sure - maybe unmatched medical students who aren’t getting matched to their specialty could somehow be encouraged - we could be doing more to encourage medical students to choose family medicine specialty and filling those family medicine seats - so just a question around the management of that.


            MR. DELOREY: Mr. Chairman, I know the question here is specific around the residency seats in the family medicine program, but just to finish up - just a brief clarification on the previous statement. So that there’s no doubt about the question that was previously asked, about whether or not people on defined licenses could apply, I’m not aware that there would be any restrictions on applying for the practice ready assessment in the path that it’s currently on.


            What I was getting at is that I couldn’t guarantee whether or not individuals currently here on a defined licence would be eligible to proceed and meet the criteria that are defined in the practice ready assessment. To my knowledge, there would be no restrictions on who applies for it, but whether they would meet the standards needed to go through the program, I can’t say. It would be on an individual case-by-case basis. I believe the ability to apply should be there.


            I would also like to clarify about the partners there. It’s not necessarily an exhaustive list that I provided before. I want to let the member know that it also, as I said - Dalhousie is the lead, obviously, the Nova Scotia Health Authority, the Department of Health and Wellness, but again, recognition that Doctors Nova Scotia is also at the table as part of this process. We are getting feedback and hearing directly from physicians.


            I appreciate the member’s keen interest and input here, but we do have the right stakeholders at the table representing the interests of physicians. Again, to reiterate, there may be different interpretations of what aspects individuals within the province may want in an outcome, but at the table, the right groups and representatives are there. It doesn’t mean that everybody will be happy with 100 per cent of everything that comes out of that process, though.


            To the specific question around residency seats, it’s an interesting thing, the reference to the vacancy. Just to clarify and qualify, the residency process does go through multiple rounds. I believe the data to date is only after the first round of residency matching. It does go through multiple rounds, which does have an attachment thing, both for Canadians and then international applicants who would come in - just to qualify that the vacancies that are there are not vacancies that these seats will go unfilled this year, but rather they didn’t get matched in the first round. There’s a potential that there are family resident medical students who are looking for a residency program, but whose first choices in the first round were not a match, that they would go down to the next round and could be matched.


            To identify the 60 vacancies in residencies in family practice right now does not mean - and I hope members aren’t left with the impression - that there are going to be 60 vacant seats across the country, and with the vacancies in Nova Scotia that - what are we doing adding additional seats that are never going to be utilized anyway? In fact, that’s not the situation.


            I can advise the member that I recently received correspondence from the Canadian Medical Association of Nova Scotia inquiring about increasing the ratio of residency seats to the number of medical school seats. What I can advise is that the national organization was advocating for an increase in the ratio from what the current national average is. What I can advise is that, prior to the increase of the additional seats in Nova Scotia, we were very, very close to what they are advocating for. With our increase, we are actually increasing past what is being advocated for doing our part, not just for Nova Scotia, but we know that there’s that increased demand and capacity to fill those seats within Canada. We’re going to be well-received and be very attractive for prospective resident students across the country.


            As far as changing the medical school program and how that works, though, I want to make sure that everyone knows that a medical program is designed with a lot of stakeholders involved, provincially as well as nationally. Making changes is not as simple as engaging with Dalhousie and making changes in isolation. We have to adhere to and align with the medical associations, the colleges, and the educational institutions that are all working together in a national system to provide standardized services across the country.


            If we were to make changes, although we may have the legal authority to define it within the province’s purview, through Education and Early Childhood Development as well as Health and Wellness, we could open an unintended consequence, which means that if other parts of the country didn’t accept those changes, then students educated here would not have the opportunity. The reason we have a national system and the advantage of that is that when someone graduates anywhere in the country, they’re already recognized and able to be licensed here in Nova Scotia. So again, there can be some unintended consequences with what are perceived sometimes as simple solutions to very complex problems within our health care system.


            MS. SMITH-MCCROSSIN: I’d love to see Nova Scotia take some leadership in this. This is a national problem, there’s no question, but when you see a surplus of medical students not get into a certain specialty, and they literally drive a taxi cab, or get a job at the corner store, and meanwhile there are vacancies and empty seats in family medicine, there’s clearly a need for us to make some changes. I think we could be leaders in that. We could make that suggestion and take a leadership role nationally.


            I do want to ask a couple of questions around collaborative care and finances. While I am a definite supporter of collaborative practice and of all health care professionals working to their fullest scope, I am concerned about the costs of the current move toward collaborative care, with the concerns around whether proper costing has been done.


            There’s a lot of concern in the health care system and with physicians around the alternate payment structures. I think many people know that often physicians are not - the shadow-billing is below the actual salary and wages that they’re receiving. This was highlighted again this week in the financial package that was offered. There was a bonus offered to physicians on an alternate payment plan, that they actually receive a bonus if they shadow-bill 80 per cent of their wages.


            This just created further division between those fee-for-service physicians and alternate payments. The fee-for-service physicians are saying, well, if I only billed 80 per cent of what I’m getting paid, I’d actually lose that 20 per cent. I wouldn’t be given a bonus.


            I have some concerns around how financial decisions are being made. I do recall asking this question during estimates in the Fall. I wasn’t able to get an answer, and I would like to ask it again today: has the Department of Health and Wellness and/or the Nova Scotia Health Authority done a financial plan for the collaborative care model, and has a cost-benefit analysis been done between fee-for-service physicians versus alternate payment physicians? I’m not saying I’m for or against. I’m concerned, and I question, can we afford it, and are we making sure that it’s being done efficiently and being managed properly?


            I would like to ask the Minister of Health and Wellness, has the department done a financial plan, a cost-benefit analysis, and would he be willing to release this plan and financials to this House?


            MR. DELOREY: In the comments made, particularly the member acknowledging neither for nor against, just inquiring in terms of the information that’s available - as we very clearly indicated, this is a model that we recognize in terms of our path forward, something that we’re participating in as part of our move to improve primary care access across Nova Scotia.


            A couple of things: there is extensive research that has been done in this space, assessing this changing, evolving approach to providing care. Within that, I can say that there’s not unanimous consent. I will suggest - and perhaps this is why the member hedged her bets by indicating no preference for one model or another, because it is very well-known that it is not even unanimous amongst practitioners - not just the researchers who have done the research, but even practitioners on the ground.


As a case in point, hazarding a guess here, I would say that probably 30 per cent or more of the questions about health care that I receive during Question Period relate to health care in Cape Breton. When we go back a couple of months ago, when there was a public forum held in Cape Breton, there were two physicians on the panel. One of them was a more experienced fee-for-service, traditional practising physician, and the other was a younger physician who worked on the APP contract. It was an interesting dichotomy, generational as well as the compensation model being applied.


This question was discussed quite openly at the forum, and there wasn’t agreement between those two physicians. It would come as no surprise that the physician who works on a fee-for-service model was not as open to the concept of a collaborative practice that adopts more of a salary-based approach, and felt very strongly about it. The interesting thing, though, was that particular physician did not work in a collaborative environment. Now, you go over to the physician who actually works in a collaborative environment on an alternative payment plan, more of that salary-based, and they spoke extremely highly and positively about not just the work that they are able to do but the work that they are able to do in collaboration with their patients.


As an exhibit B, as I mentioned in my opening remarks, when I was at the clinic when I made the announcement about the expansion of collaborative care practices, one of the physicians who spoke publicly at that practice had been practising for about 30 to 35 years in the traditional model, I believe. This was her first experience in a collaborative practice. It had only been five weeks, and the expansion was the inclusion of the family practice nurse. They spoke extremely positively about the experience. Their ability to move patients through was being well-received by the other physicians in that practice, as well as the patients.


All of that said, you bring that forward - the member said, “Can we afford to do it?” The other thing that the member misses in this is not just the research that shows that the outcomes - the ability to strictly do a cost analysis, in terms of how much you pay for a particular physician to perform certain work. The analysis and the research that’s done in this area also take into account qualitative aspects of the research, and not simply the quantitative.


In my exposure, and the review of the research that I’ve done thus far in this discussion, is where I’ve already highlighted that there are differences of opinion on the ground, as well as differences of opinion in research that comes out. In my assessment of the research in particular, what you see is that the research methodology that goes in, and what individuals are identifying as success factors, is what influences which way one concludes as to the value of the collaborative-style approach.


To simply do a cost-benefit analysis would actually bias that research toward an outcome that was strictly dollar-focused, with an absence of, or missing the qualitative aspects of the actual outcomes - the quality of the work, and outcomes for the patients, and so on. It gets much more complex as you start delving in that way.


[4:15 p.m.]


            The last thing I would note is that some of this aspect, regardless of whether you have a preference for one or the other, is that people are being trained this way. There is a generational shift, so whether you’re standing in my seat and had a philosophical aversion to or a philosophical embrace of the collaborative practice model, the fact of the matter is that physicians and other health care professionals are being trained to work together this way.


            If you’re not at least making these an option - we’re not mandating or requiring; we are making it an option available to physicians - you would be really limiting the supply of potential physicians and other health care providers to come to Nova Scotia. I think all members of this House would agree that we want to open our arms and embrace as many primary care providers that we can get here in Nova Scotia providing primary care to our citizens.


            MS. SMITH-MCCROSSIN: The question I asked was, has a cost-benefit analysis been done and have financial projections been done using this collaborative practice model across the Province of Nova Scotia? While I would absolutely agree that qualitative is very important and that outcomes are important, we also need to be looking at if we can afford what is currently being promoted.


            Although I know we do not have time for the minister to answer another question, something that is on my mind and my colleagues’ minds, and I’m sure will be asked by other colleagues over the next few hours, is around mental health.


            I would like, at some point, to hear an answer around where this new injection of $2.9 million will be used. The minister might be able to answer in 10 seconds.


            MR. DELOREY: Sorry, not specifically on that one. With respect to the research, there is a lot of work that is under way to get the further details, as noted, around the practices.


            MR. CHAIRMAN: Order, please. Time has elapsed for the Progressive Conservative caucus for this hour. I’m sure there will be plenty of time for further questioning. We’ll turn it over the NDP caucus.


The honourable member for Cape Breton Centre.


            MS. TAMMY MARTIN: First, I would like to start off by saying, I don’t know if it’s a bad omen or what, but last time during estimates - my first time - I got coffee on my white shirt, and today I have coffee on my white shirt. I just have no idea what it is about estimates and me and spilling coffee on myself.


            Also, I would like to say thank you to the minister’s office, who have been tremendously helpful to me and my constituents. Mary in your office is a godsend. She has helped my constituents and the work of my office tremendously. Every time she answers me I say, thank you, thank you. I am constantly bugging her, but she is so quick to respond - good, bad, or ugly, and I don’t care what the answer - well, I do, but it’s an answer, and more often than not, it’s a positive one. I am so thankful for her. She has made a difference in a lot of lives in Cape Breton Centre. (Applause)


            I’m going to start off asking about primary care and where we are with family doctors, because of the announcement that was made to invest in family doctors. The last master agreement was signed in 2016. Can you confirm what the increase was in the last master agreement - that it was 0, 0, 1, and 1.5 per cent to each doctor, as per compensation?


            MR. DELOREY: If the member would indulge me for just a moment, to her opening remarks, I want to thank the member for acknowledging specifically - just for the rest of the House, Mary would be my executive assistant who works with me. She, as well as many others in the office - Tracey Preeper and employees throughout the entire Department of Health and Wellness - works very hard.


            What I really want to highlight here is not just how great those individuals are, but also what I think might have gone a little more subtly about the comment that was made by the member for Cape Breton Centre. I think what she also highlighted is what goes too often unnoticed in this Legislature and in this Chamber, which is that we debate kind of like families around the dinner table - unless my family is unique. You can have some ferocious debates, but at the end of the day, when we are working, those are sometimes philosophical debates about approach and strategies and where we believe the right approach is, but I don’t think it ever comes into question whether all of us are actually looking out for the best interest of Nova Scotians and our constituents, and that goes to show, as the member for Cape Breton Centre noted.


            It’s not limited to the Department of Health and Wellness. Everybody works together on behalf of all Nova Scotians. When a call comes in to a constituency office, regardless of the MLA, you put the call in, and the teams work hard to deliver those services. I apologize - it was a really nice remark.


            As per the question, it’s a little more complicated than would allow for a direct response. The reason is, it’s not as clear - the compensation model for physicians and the employment relationship of physicians is not the same as most other health care professionals. As we heard extensively through the summer and Fall, physicians are not employees. Now, we didn’t hear that as much because of anything that the provincial government did, but it was certainly well highlighted across the province and across the country that physicians are not employees. You can go all the way back to the 1960s when Medicare was being established and that was a heated point of debate, as to whether physicians would become employees or continue as independent practitioners - in many cases, in fact, setting up corporations to run their clinics or their practices as an incorporated business.


            For that reason, the negotiations that take place with the bargaining agent on behalf of physicians, which is Doctors Nova Scotia, result in something called a master agreement. We often refer to it in parallel to a collective agreement, but it is not a collective employment agreement. The compensation is not - when we say the rate of increase to the fees, because the vast majority of family physicians, in particular, are fee-for-service, and there’s a master agreement that dictates a number of things, including a fee schedule. For each of the fees, depending on the service being provided, there’s a rate associated with it.


            Those rates increased at the same ratio as the member described, which is consistent with the compensation increases that did take place in those collective agreements that have been agreed to thus far, as the member cited. I believe it was 0, 0, 1, 1.5, and 0.5 on the last day of that contract.


            MS. MARTIN: Yes, it’s just Mary that we deal with, but yes, the entire department for sure, as with all areas. But Mary is my go-to.


            Those increases, however they’re attached to the doctors’ schedule, are outlined as 0, 0, 1, 1.5, and then 0.5 on the last day. Where would that show in the budget?


            MR. DELOREY: The compensation that would be estimating for physicians and the total amount we would be expecting would be in the Physician Services budget. Again, to qualify, changes there are - again, as I described the rate relationship - it’s not as easy as seeing a linear direction, because they’re not salaried employees.


            In many other areas of government, you can very easily discern, for example, a 1.5 per cent increase for services. As long as the number of employees stays the same, the salaries and wages would be expected to roughly grow at that rate, but they do get more complex.


            We all know the member has extensive labour experience. I assume the member would be very familiar with having step increases based upon experience, which shows that there are increases within those collective agreements that go above and beyond even the percentage annual increases that actually increase each of those steps. Perhaps the easiest analogy would be that master agreement aligns - if each of the fees is a little bit like steps. But because they are independent, and again, the vast majority of physicians are fee for service, the more service they provide, the more growth we see in our Physician Services budget as well. The increase there could also be reflective of increased utilization forecast, not just an increase in the direct fee amount. It’s a combination of the rate and the volume that results in the total.


            For example, if the fee for an office visit has just gone up to $36 based upon the recent announcement, a physician who sees on average - say, last year - 100 patients, so they have 100 office visits throughout the whole year, it would be 100 x $36, so $3,600 that they would be receiving. That would be added in our Physician Services. But if a physician was doing 1,000, it would be $36,000. It’s a combination - 1.5 per cent would be applied to the fee, so it goes from $36 to $36.50, but again, if you’re doing more visits and thus charging that code more often, you’re going to see a higher increase than just 1.5 per cent.


MS. MARTIN: Just to be clear - because I think maybe you answered my next question, but I just want to be clear - the new rate increases are outlined, and then the 1.5 will be on top of that?


MR. DELOREY: That is correct. I believe that was noted in information that was out there, that the increase that was announced - there are two main fee codes - I’m doing this by memory - I believe is about $31.40 something. It went up to $36 with the 1.5 per cent going on top of that, effective April 1st, and then, for the additional 65 years and above, it was a $40-some increase, also with the 1.5 going on top of that, effective April 1st.


MS. MARTIN: I apologize for any repetition from other members, but to be clear - I mean, we all have questions that we’re just trying to get to the meat of, and I know there may be some repetition.


From our information, as the member for Cumberland North mentioned, the $150 incentive was nothing new, for doctors to take patients off the wait-list. But in the document outlined by the government in the budget, it says that a new Patient Attachment Incentive to pay doctors who accept new patients - from what we understand and are told by doctors, this has actually been in place since at least 2010.


Aside from that, or along with that, the negotiations to come to these new rates and fees and amounts for docs was something separate that would come just to try to enhance and improve the relations with Doctors Nova Scotia, or is that something, you know - how long has that been going on, and how did you get there? I guess that’s what we’re trying to get at.


MR. DELOREY: I guess a couple of things unpackaged there specifically about the $150, what is new in the $150. There has been an attachment fee that was around - I’m not sure exactly how long. It predates my time in office as Minister of Health and Wellness. I can’t confirm, but I’ll take the member’s word that it was around 2010.


What I can say is that that was something that was very restricted. It was eligible predominantly for attaching patients who were - the terminology they use is “orphaned” - that is, if you’re in a hospital and you do not have a family physician. It was an incentive to attach - again, they use the terminology “orphaned patients” - in a hospital to a family physician.


[4:30 p.m.]


            That’s why that was established, because they were finding growing challenges in hospitals having family practice physicians manage patients in the hospital so then patients were getting looked after or checked in on. They would get those core services that they needed if they had a specialist and so on, but to get their daily checks and then to have a physician actually do the discharge, you would need someone associated with them. In part, what transpired then is the growth of a new service called hospitalists. That would be a similar level of qualified physicians, working predominantly in a hospital setting to take on those orphaned patients while they were in a hospital setting, and they could do discharging.


            What’s happened here, and why we call a new incentive, is an incentive targeted at attaching all patients or the vast majority looking to be attached to a family physician. If you actually think about what was originally in place, it was almost predominantly a hospital-driven solution to address an issue or a challenge in a hospital setting. Although it pays dividends in the primary care setting for those who got attached through that means, it was very restricted.


            If you were a citizen, Mr. Chairman, who did not have a family physician but was also not in a hospital, and you were looking for a family practice, there would be no incentive for a family practice to take you on. What we have done now is, first, really identify the scope of the needs and where those needs are through the 811 family practice registry list that we established a little over a year ago. Now we know that over 40,000 Nova Scotians are actively looking to be attached. We have immediately made it available to anyone on that list. You don’t have to be hospitalized. You don’t even have to be sick. You just have to be looking, and you can be eligible, as a patient, to have an incentive now for those physicians out there who have capacity and an interest in expanding their practice to bring you in - so that’s why.


            I know I took a little bit of time to explain the approach and the difference there. It’s because that does actually also tie in to the second part of the question. The question was, what was really the motivation and how did this come about? The motivation is that the messages that we have heard and the commitment that we made, both through the campaign and since I have been in office, was that primary care and attaching patients to primary care practices were priorities for this government. It’s part of the ongoing discussions.


            I know in the Fall, we got - I’ll choose my words carefully, Mr. Chairman - verbally speaking, we got beat up by the Opposition on occasion in the Fall around certain information being disclosed about the relationship between physicians, particularly through the Doctors Nova Scotia organization and government. I believe if you go back to Hansard, you’ll note that I have made references then, as I restate now, that just because individuals have disagreements on certain aspects does not mean that dialogue is not continuing, that the relationship and the ability to work together does not exist. Indeed, that’s why I had indicated that we continue to work with them. That is really the culmination of working with and engaging and keeping an open dialogue with Doctors Nova Scotia.


            They came forward. There’s no secret. They developed an extensive review based on some of their consultations, I believe around June or July. They came up with a report in the Fall called Healing Nova Scotia: Recommendations for a Thriving Physician Workforce. They refer to it often. It had a number of recommendations, and we worked through them.


            You’ll note that much of the outcome was focused on attaching patients, though it was really about providing more care and retention and recruitment of physicians. Those were the motivations, Mr. Chairman, that went behind this initiative because it does align with our commitment.


            It does not change our commitment to collaborative care practices. It does not change our commitment to other health care providers that are partners in these collaborative care teams. It does recognize that, in many instances, to have the full scope of primary care access, we do rely on family physicians. They are, like our nurses and like our other health care professionals, a critical component of these collaborative practices, so we wanted to ensure that we shore up that space. That will then give us a strong foundation to continue the work that we’re doing around collaborative practices, which provides more opportunities for all of our health care providers and, most importantly, provides more access to primary care for all Nova Scotians.


            MS. MARTIN: While we may agree to disagree, we do agree that we are all here for the betterment of Nova Scotians. At the end of the day, what happens in here happens in here, and we’re working together to try to improve the lives of people in Nova Scotia. That doesn’t take away from the fact that there is an active, ongoing lawsuit with Doctors Nova Scotia.


            You did come together, then, and follow the suggestions from their report in the Fall - is that when the initial consultation began? Or was this something that came as a result of the ongoing lawsuit?


            MR. DELOREY: First of all, I guess, the clearest answer is that this is independent from the lawsuit. This isn’t part of negotiations. That case that was brought forward continues to be before the courts. We’re really not in a position to speak about a case that is before the courts, but it is public knowledge.


            Again, that is a particular dispute about a couple of provisions within the master agreement, about the interpretation. When two parties disagree about the interpretation, the process generally is to turn to the courts to have clarity provided. That’s why I said back in the Fall when this question was asked about those provisions and the intent - actually, I believe the filing took place in early December, or late November - that we disagreed on our positions at that time, and that’s the course of action to get clarity.


            As far as engagement with Doctors Nova Scotia, I began meeting and engaging with the president very early after being appointed. I believe I was appointed, Mr. Chairman, somewhere in mid-June 2017. I think I had my first phone conversation with the president of Doctors Nova Scotia by early July. It was a phone conversation, but that started it. We had meetings in my office on a number of occasions. Doctors Nova Scotia invited myself and others to their offices when they were releasing the Healing Nova Scotia report, so we met there. We have had other meetings in my office on a number of occasions, all leading up - it really all comes together. There was a lot of work done and commitments made, and this is a culmination of continuing that working relationship.


            MS. MARTIN: Briefly, would you agree or concur that these negotiations and increases have been a long time coming?


            MR. DELOREY: I think our position had been very clear, with respect to the work we were doing, that we were committed to primary care services and expanding access. That has been an ongoing commitment.


            The actual commitment around this particular package that was released recently - that level of discussion would have only come up in the new year. It wasn’t like I came in and said, I’m going to come with financial supports to address it. It was really an issue of engaging and discussing and coming to an understanding of where and what the challenges were and the opportunities to work together to advance opportunities.


            I’ll just use for an example the 2016 master agreement - for the first time ever in Nova Scotia, we provided the opportunity for physicians to bill the province for what is referred to as non-face-to-face engagements with patients. That was an initiative initially targeting phone consultations but with the potential to expand to other digital or e-platforms. That was only rolled out in 2016, and I came in about six months later, in 2017.


            We’re really only just hearing the feedback and engaging. It takes some time when you do these agreements, especially something new in the agreement like the non-face-to- face engagements. The entire system has been designed around face-to-face engagement, and the whole billing structure of health care delivery, particularly in the primary care space, has been predicated on that since before Medicare. Many of us living today would see that change to non-face-to-face engagement as just making sense, like we can do our banking, and we can do all these other things. In the health care system, this is actually quite new to be engaging and delving into - not the technology but in terms of the billing structure and the public health care system.


            Dipping our toes there and designing the process and the criteria around billing and the administrative side, we did hear - and the Healing Nova Scotia report from Doctors Nova Scotia talks about this a bit too - that the administrative burdens associated with that fee were preventing or limiting the uptake amongst physicians. We took that, we engaged in dialoguing and discussions, and we asked how we could improve it. Maybe it was tweaking the system. What we came to, as you can see, was a change that basically addresses both concerns.


            For government, the reason we support and like the concept of non-face-to-face and telephone or e-health options is for efficiency. A physician can renew a prescription over a phone or follow up on some test results and say, we have the test results - all clear. It is more efficient for the physician. It’s more convenient for patients. I’m a representative of a rural riding. I myself have to travel about 30 minutes just to get into town to see a physician or a hospital, and that’s from my house to do that. If I have the option of a physician giving me a call or sending me a message through a secure platform like MyHealthNS to let me know that I have an all-clear on a test result, that’s great for me. I don’t need to get daycare for my kids, I don’t need to spend the gas to go in, and so on. It’s much more convenient. I love that option personally, and I think many Nova Scotians will as well.


            It will be great for physicians, as well. If they can knock a few of these consults off, it opens more opportunity in their office for face-to-face consults as well.


            That’s what government’s objective and goal on behalf of Nova Scotians was. From physicians, we heard the challenge. I don’t think they disagree. They share that objective as well, I believe. But the model that was identified and agreed to in the master agreement didn’t facilitate achieving that outcome, so it was changed in the fee structure now with this agreement. It reduces the administrative burden, which should improve the uptake, but again, the proof will be in the pudding.


            We believe that with our work with Doctors Nova Scotia this is better than the approach we took in the master agreement back in 2016.


            MS. MARTIN: To be clear, the money was already allocated in the master agreement? It just wasn’t being used to its fullest potential, so to speak?


            MR. DELOREY: There would be money allocated, anticipated, budgeted - that’s what a budget is - for a certain amount of uptake of the non-face-to-face fee code. That would be one portion of all the physician services budget. But in this model, to encourage a lot more uptake, there is an increase to the amount that we would have previously budgeted. We didn’t see a lot of uptake last year, so we obviously would have budgeted accordingly, based upon what we expected. Uptake wasn’t high, so we wouldn’t have been budgeting as much in that fee code area.


            The new model is a flat payment that would be, I believe, up to $12,000 available to provide this non-face-to-face engagement, along with some other criteria. We believe we’ll get a lot more uptake, and the money is set aside for that.


            MS. MARTIN: When we talk about the current doctor shortage, I heard the member talk about the current shortages. Specifically, the honourable member mentioned Cape Breton. I would like to draw your attention to a couple of specific instances, actually. I know we cannot speak about personal issues, but I actually have just gotten off the phone with a graduate from the international school of medicine, the Caribbean school of medicine who is a resident of Glace Bay and worked for the Cape Breton District Health Authority for years as a registered nurse. They then went away and got their MD, passed all the exams.


[4:45 p.m.]


            They can’t go any further now because they’re waiting for the residency. They paid $2,500 to apply for the first one and weren’t picked. It’s no exaggeration to say that health care in Cape Breton is desperate, and we are desperate for doctors. This is why I have to bring attention to this. He has applied for the second round of picks. That was $1,350.


            Now he’s in Brampton nursing because to go back to the NSHA in Cape Breton and nurse, he would look like a failure. He feels like a failure because he has passed everything, he has done everything he can, and he cannot get a residency.


            I have also heard about two couples - one has gone to Yarmouth, and another one has gone to Maine. In those situations, they wanted to be 50 per cent family practice and 50 per cent OB or 50 per cent family practice and 50 per cent emergency room, but the NSHA is dictating what they need and where they need it.


            It really boggles my mind to think that we have people who are invested in their community - I believe that when you were born and raised in a community, you want to stay in that community. You have family in that community. You go to the local church. You go to the local bank. You go to the local grocery store. You’re not going to leave. Why are we not hiring and reinvesting in those who want to stay?


            It makes absolutely no sense to me why we have these people who are coming from rural Nova Scotia, and now one is nursing in Ontario, and another couple is in Bangor, Maine. Lucky enough for Yarmouth, one couple went to Yarmouth, so they’re still in Nova Scotia. But more often than not, they leave.


            Health care is not improving, I would hope we can all agree - maybe not. Health care is in a desperate situation in Cape Breton. Why can’t we employ these people who want to stay on the island?


            MR. DELOREY: I’ll just summarize at the front end what I recall of the two distinct questions. One is around international medical graduates and getting attached to residency seats. The other is about hiring practices within the Nova Scotia Health Authority. They’re somewhat related but also distinct, so I’ll treat them as two separate items if you’ll indulge me, Mr. Chairman.


            With respect to international medical graduates and residency placements, and actually if I step back even further to just residency placements in general, there is an extensive awareness of the competitiveness to achieve a residency placement not just within Nova Scotia but across the country. In fact, I remember shortly after coming into office, there was a horrible incident out of Ontario where a young man actually took his own life because I believe it was his second or third year going without. He had completed all of the medical studies and just couldn’t get a placement in the area of specialty where he was looking for a residency seat. It was so competitive that he wasn’t getting matched.


            I think the member used a reference to one of the individuals involved in a situation like this indicating they left Nova Scotia, left Cape Breton, because they felt like a failure. I believe in the example that I’m referring to in the news reports, indeed, that was in line with what the family’s indications were for this young man. It’s absolutely devastating. But that relates to the competitiveness around accessing residency seats.


            There’s a couple of things to know about residency seats. People say, why don’t you just do A, B, or C? If people want it, why don’t you just set one up? The other thing they say is, we have so many Nova Scotians. Why aren’t there enough seats for every Nova Scotian to get a residency seat? So, there’s a couple of things, just to clarify factual information.


            Number one is, we have more residency seats than we have medical seats in Nova Scotia, as would be the case with most, if not all, medical schools across the country. There are more residency positions than there are medical seats funded through programs. I’m doing this from memory, so don’t hold it as absolute fact. I believe the national ratio is about 1.06 or 1.1 residency seats - actually, they don’t use decimals. They do 106 per 100, 106 residency seats for 100 medical students. That’s all inclusive. That would be for international students who might be coming in, as well as the students here. It’s a way to ensure that if you’re training students - but in Nova Scotia, we’re actually much higher than that already. That’s even before the additional residency seats that we’re going to be adding into the program.


            I believe I mentioned earlier today that I received a letter from the Canadian Medical Association or some other such national organization representing physicians, which they likely sent out to all provinces, encouraging and advocating to increase that ratio. I believe it’s 120 residency seats per 100 seats for medical students.


            In Nova Scotia, we are just shy of that. We don’t have 100 medical seats, so it’s a ratio that you would do on a calculation to normalize. Based on the ratio of residency seats, we’re over 115 currently, I believe. With the additional 10, keeping in mind we have less than 100 medical seats in Nova Scotia, that actually brings us well over the 120 being advocated. We’re actually very close to the rate that is being advocated by a national organization.


            We are one of the only provinces, possibly the only one, expanding our residency program. Other jurisdictions have recently been cutting those seats, which has only compounded that challenge. Nova Scotia, as a leader recognizing and trying to make opportunities, is there. We are doing what we can to make those opportunities available, but it does make it more complicated.


            To the specific essence of what the member is asking, Mr. Chairman, which is about a member of our community - I know the member is a fierce advocate for residents of Cape Breton, particularly industrial Cape Breton. But I have colleagues like the member for Guysborough-Eastern Shore-Tracadie, who is an equally strong advocate for people in his community, as are all members in the Chamber. I use my colleague the member from Guysborough as one example. We have had literally the same conversation. There’s a young man - I believe it’s a young man - from his community, and the community really wants him to be able to get the residency back here.


            But it gets more complicated because we are part of a national program. The medical training programs, the residency programs, are all part of a national system. All medical students apply to the national program. Each medical school has seats, and they are funded by the school through the provinces. They go into a national distribution of seats that are available. When medical students who are ready to embark upon their residency are applying, they’re applying through a national program, and that’s where they try to make the attachments.


            As part of that, it ensures that we have the same level of training and programming, which is a good thing. The outcome means that if Nova Scotia is looking for a resident, if they’re coming out of B.C., Ontario, Saskatchewan, Manitoba, or anywhere else in the country, they are meeting the same standards that are required here in Nova Scotia. It means that there are more opportunities for these physicians to get established. There are benefits to this national program. One of the offsetting features, though, is that you can’t guarantee that a Nova Scotia student is going to get a residency placement in Nova Scotia. There are trade-offs here. Again, we want to be open and accessible to get many medically trained physicians to Nova Scotia.


            If we were to change our approach and say, we’re going to go on our own and fund for our residency seats, we would be limited to those seats for new physicians. There would be no guarantee that our medical licence and those students who are graduating would be recognized elsewhere. Nor would there be any more guarantee that our college would recognize other schools as you start to deviate the training programs. You introduce a lot of other challenges that could have unintended consequences.


            I think I said earlier today, Mr. Chairman, that sometimes what seems like simple solutions are not so simple to complex problems because we need to avoid unintended consequences. I believe that really ties true not just around this question around residency seats but to many aspects of our health care system.


            It is why members of this Legislature and others across the country continue to have this conversation for decades. I am sure that the members, if they were to go back to the Hansard in this Legislature or in others across the country, they would see that very similar conversations have been had by members throughout the country for many years.


            We continue to work, though, and strive to improve - continuous improvement working to make things better. That’s why we’re expanding our residency program. We’re trying to encourage them to get there.


            The second part of the question I won’t take as long to respond to. That is the question on the hiring practice. This was a bit of a conversation we had, Mr. Chairman, back in the Fall for the 2017-18 estimates debate, as well as Question Period debates throughout Fall 2017, this notion of physicians being able to choose where they practise or not. Really, our primary focus there has been, again, on primary care and allowing them to choose. But when we’re looking at other vacancies like specialties and so on, it gets a little more complicated. Specialties that there isn’t the equipment and services available for, we can’t necessarily guarantee those types of matches.


            If someone wants to work in a specialty and as a family practice, it gets a little more complicated. For family practices, family physicians, the model should be working. If there are physicians who believe that they’re being denied the opportunity to work as a family physician in the area where they wish to practise, then feel free to let my office know. We can have some conversations with the Health Authority.


            We have been very, very clear with the Health Authority. We have been very, very clear with Nova Scotians, and with Doctors Nova Scotia. I’ll say it again, we have a need throughout the province for family practices, so there should be no restrictions on where family physicians want to practise. Again, if they don’t want to just practise as a family physician, it might get a little more complicated, based upon specialized needs of communities within the province. If there’s no need for the specialty, you can’t kind of back-door through primary care if the need is elsewhere. We want to encourage those specialists to get where we have absolute needs, rather than distributing the work unnecessarily, if that makes sense.


            MS. MARTIN: Thank you for that answer. That clears up some questions I had, for sure.


            In an article in The Chronicle Herald on January 6th, it was quoted that we’ll need 997 doctors to replace retiring doctors and 182 to meet the increase in demand for care. We need 506 family doctors, 459 to replace those retiring, and 131 to meet the increase in demand for care.


            Do the minister and this government feel that, even with the increase in residency seats, we are doing everything we can to fill this need, to meet it? This is an astronomical number. We need 997 doctors to replace doctors who are retiring. What I’m hearing from many family physicians - my own doctor who is retired had a practice of 3,000 patients. The doctor who took over for her has about 1,000. The new doctors are not doing practices like the old doctors.


[5:00 p.m.]


            Does this government believe that the program you’re talking about is enough to fill this need? The member opposite talked about the election platform - the election platform in 2013 talked about a doctor for every Nova Scotian - and I thanked the member opposite for coming to the CBC event that was held in Sydney to hear the concerns and the questions of the residents. When the question was asked, do people think or feel that they want a doctor, that every Nova Scotian deserves a doctor, or do they want access to primary care? Their answer was clear: they want a family doctor.


I understand what you’re saying about collaborative care. I’ve talked to many physicians who don’t believe in collaborative care, as you alluded to at the panel that day, one is completely for and one is completely against. Some physicians feel that collaborative care only adds to their workload, because of what the NP can’t do when the patient goes south.


So, with these numbers - with almost 1,000 doctors we need in the province to replace those who are leaving, regardless of whatever practice they decide to have - how is it that this government is going to fill that need?


MR. DELOREY: Again, referencing what I think I’ve referenced a couple of times today, that forum in Sydney about a month or so ago - the member made reference to one of the questions that was asked about people’s desire to have access to a family physician. We do continue to share that objective, and collaborative care practices are not incongruent with having access to a family care provider, or a family physician. In fact, they are complementary, and can be complementary. I think it’s like a prism: when people sometimes have disputes or disagreements about something, it’s sometimes that people can be looking at the same situation from a different perspective and therein, oftentimes, lies the source of the disagreement.


Using the member’s own example that she’s heard, about why some physicians don’t feel comfortable with collaborative practices - no disrespect the member intended towards nurse practitioners, I truly don’t believe - but the scenario was, if the nurse practitioner, although they can do many things, what happens, I believe her words were, if things go south, it goes beyond the scope of practice for that nurse practitioner.


That is why, as part of the practice team, there would be a family physician doctor available. What I want to do is take that scenario a little bit further, and while a physician may look at that one scenario and say, means more work for me, if our nurse practitioner is taking on more patients, then they can’t do some things. It’s true, a nurse practitioner’s scope of practice is not as wide or comprehensive as a family physician’s. However, a physician that uses only a scenario that says, when a nurse practitioner can’t do a thing, I have to do it, therefore this collaborative practice means more work for me - that is one perspective, but it is very narrow.


Let us widen that scenario out just a little bit. How many less complicated visits may come into that practice that do not require the full scope of the physician, that could be managed by a family practice nurse or a nurse practitioner, well within their scope of practice? How much of that burden, and how many office visits could be taken off the plate of that family physician? That is the relationship, as you are taking those things, and ensuring that the right service provider, health care provider, working as close to their full scope of practice as possible, to ensure that the most care can be provided to the most citizens, in a timely and efficient manner.


That’s the way these teams collaborate and work together. Does it mean that a physician would no longer see things, or provide services that a nurse practitioner in the clinic can do? Not at all. What it means is that if a service exceeds the scope of practice of one of the clinicians or practitioners in a collaborative care team, they work as a team to ensure that someone within that team that has the proper scope of practice sees that person.


Again, I don’t see it as being incongruent that support of growing access to non- physician health care providers, as part of collaborative teams, in any way contradicts the desire to ensure that Nova Scotians have access to a family physician. They would have access to that physician as part of a team. It doesn’t mean they would see a physician every time they go in for care, because they don’t need to see a physician every time they go in for care. I hope that helps address where we see differing opinions, but that is really, ultimately, the objective there.


            I would like to just make one other quick note on the same theme, and back to that Cape Breton forum that was in Sydney. The member made reference to that one question that was asked of the audience about people wanting access to the physician. There was another question that, I think, is important for the members of the Legislature to be aware of, there was a question asked not by the panelists, but by one of the people in the audience. When they went up for the question and they asked everyone in the room who has a family physician, the member will realize the vast majority of people in that large auditorium had a family physician. There were very few people who raised their hand to indicate they don’t have access to a family physician.


I know there were some questions raised by members of the PC caucus questioning the legitimacy of the op-ed submission by the honourable member, my colleague, the member for Sydney-Whitney Pier, that he wrote in a local paper, indicating that the demand for family physicians, based upon our information off the 811 list, is less than 100 people in Sydney. I think that is consistent with what we saw when people raised their hands in response to that forum. I want to encourage the member for Cape Breton Centre to keep an open mind - and it’s not denying, there are still - and the need for those Cape Bretoners and those in the Sydney region and her constituents and others across the province, whether it’s 1 or 100 or 1,000 in a community, for those individuals still looking for that care or for that access, it’s still a challenge, and for them it is.


To continue to trumpet that an individual’s experience is reflective of the entire province is also doing a bit of a disservice to the people within our system. It is creating a situation of fear. Not denying there are challenges, not denying the fact that if you are one of those people in need, it is very challenging at times, especially if you actually have care that is required. Again, when we go out with information, we provide information, we aren’t denying certain realities, but I hope people will accept that there are other realities and other experiences out there - positive ones and positive things happening in the care being provided. We are making progress. That’s really the essence that I wanted to use of that example - we are making progress, I hope the member sees it in her community as well.


MS. MARTIN: Absolutely, those who are receiving care are receiving the best care possible. I will just agree to disagree again because I believe - and I know, I don’t believe, I know - a lot of people in Nova Scotia without a family doctor are not on the 811 list. My daughter being one of them, for an example. So, I don’t think that’s a true reflection, I don’t think that’s a real number - this 40,000 or whatever - that you’re talking about.


“According to projections, by 2017, 140,000 patients are to be served at collaborative clinics by a total of 44.9 FTE family doctors plus 80 FTE nurse practitioners; 1,750 patients are supposed to be shared between a family doctor and a nurse practitioner working together.” Are these projections accurate?


MR. DELOREY: Actually, those projections as well as - I believe in the last question, the member cited from an article in The Chronicle Herald some other numbers about projections of needs for family physicians. Actually, if the member could table those, I could take a look at them, maybe get back, I’m sure we’re good. I suspect probably, without too much room for error, that we will likely be continuing this discussion tomorrow so perhaps if the member could table the data she’s referring to, I could take a look at it and perhaps more accurately identify the actual legitimacy of it.


MS. MARTIN: Now you threw me right off.


I guess then I’ll jump to, why do you think we have a retention problem in Nova Scotia? It does seem that we are losing doctors, and I will read you something that I was sent by a doctor in Nova Scotia: We’ve lost several physicians from emergency, and continue to lose more. We may not be able to staff other emergency rooms in Cape Breton as we have to pull the resources from those in order to staff the Cape Breton Regional Hospital.


            What does the minister see as the issue? I know we have our opinions. From what I hear from the doctors, I know in Cape Breton, as well as the rest of Nova Scotia, there are serious issues that these doctors are facing, challenges, and just in one day, I heard that six doctors are leaving from the Cape Breton area, from emergency rooms. So, what is the issue? What are we failing? What is the government failing on in order to keep these doctors in Nova Scotia?


            MR. DELOREY: I believe, as I had indicated in a previous response around the residency program and residency seats, sometimes considered simple solutions to complex problems, and so on. When we’re talking about recruitment and retention - I believe the question was limited to retention specifically - if you look at the actual data on the national scale, it’s often cited by members of the Opposition that CIHI is really the pre-eminent source of physicians, we do know that over the course of the last five or six years - I forget - that the CIHI report indicates we actually saw growth in physicians in Nova Scotia, with the exception of the most recent year in the report, which saw a reduction of about five or six physicians.


            Relative to the growth that took place collectively in the years preceding, Nova Scotia, both family physicians and specialists, actually does hold its own, and we punch above our weight as a province. We often speak in the Chamber about challenges with having access to family physicians or specialists, or other health care providers, nurses and others. I’ve said it before and it’s the truth that exists, that these challenges of having an adequate number of practitioners to meet the needs and expectations of the population is a challenge faced from one end of the country to the other. It is not unique to Nova Scotia to see these challenges that exist.


            As with any profession, there will always be turnover. There will be combinations of attrition, where people retire, or choose to leave a particular practice. Although I am far from retirement age, if you’re just looking at data, I’m on my third career, very distinct careers that I’ve had in my time in work since graduating - and I’ll take the opportunity to highlight - from St. Francis Xavier University. In that period of time, I actually had three distinct careers: I worked in the IT sector; obviously in academia, where I was teaching at St. Francis Xavier University in the Faculty of Business; and now the political career that I’ve embarked upon. So, again, through no fault of the IT sector, through no fault of the academic sector, not even through any fault of the employers in those situations, I made a personal choice to pursue something different at each of those junctures in my life. That is one variable that is at play when individuals choose to leave a location.


            If it is a situation of retention within the province, sometimes it’s not the physician who has an issue or a concern, sometimes it is their partner, who may not have fully established themselves in the community, found employment, and that is a challenge not just with physicians.


[5:15 p.m.]


When I worked in academia, when I worked at St. Francis Xavier University, we would rely on recruits, faculty members, to come from other parts of the country and sometimes internationally. There would be churn and turnover and attrition challenges as well for those families. Sometimes the professors themselves were quite happy with the experience, even their families, but if their partner couldn’t get established, couldn’t find work, that was often a contributing factor. Again, to see churn or turnover and assume it is an issue with the health care system automatically - there are many variables.


One of the others, when you’re talking about people leaving, again this is a scenario. We’ve seen it in other professions. We had demographers talk about it for decades. We are seeing a point in our time with a baby boomer cohort. You’ve seen it for decades, from when baby boomers were children, how they’ve had an impact on society, because of the sheer size of that cohort, as the largest cohort going through their lifespan. It just happens that this cohort is at the point in their lifespan, as a generation, that they are reaching retirement age. It is something that is impacting many different professions.


            One of the things I think about, particularly in medicine and the health care sector, is that we see family physicians have a tendency, or physicians generally, have a tendency to work longer than people in many other careers, so we are seeing physicians who are well into their 60s, some into their 70s, still practising. Nobody in society is expecting these individuals to continue practising forever. Indeed, I think we’re seeing again that as a contributing factor.


            To the member’s question, why is there a retention-in-a-particular-position challenge? It’s multi-faceted, the answer to the question. The specific answer would be specific to each individual who is choosing to leave a particular location, and why they choose to go, whether it is for retirement, whether it’s because of other family members, or they just choose to look for another environment to work in. I hope that answers the questions that were posed by the member.


            MR. CHAIRMAN: The honourable member for Cape Breton Centre with 10 seconds.


            MS. MARTIN: I would ask the honourable minister if he could table documentation or information to support those findings, or provide them, about the . . .


            MR. CHAIRMAN: Order, please. Time for the NDP caucus has expired for this hour. I will now recognize the PC caucus.


The honourable member for Cole Harbour-Eastern Passage.


            MS. BARBARA ADAMS: Thank you, Mr. Chairman. I would like to start off by both acknowledging and congratulating the Minister of Health and Wellness for a number of things. The first is that from the first sitting of the Legislature to this time, his knowledge and the confidence in which he is speaking to these issues, it’s obvious that he has been travelling around the province, and he has been speaking to a lot of people, and he has been listening very carefully because the words I’m hearing echoed from you, I have been hearing for a long time.


            To your point that this is your third career, and given how young you are, I applaud you for that. There are also quite a number of things in the budget that, when I saw them, I was very happy with. I’m not going to talk about them. I will acknowledge them because they are some things where we’re going - why don’t we just? - and so they’re there and I want to acknowledge that up front.


            The other thing we don’t really talk about, and I just want to start off by saying it, is that from when I graduated 40 years ago my own profession had been there for only about 60 years. I was 12 when I started, just so that you know. One of the things we never mention, because it’s probably not popular saying it out loud, is that health care, when I graduated, was not a business. There were no private anything. There were no private physiotherapy companies, there were no pharmacists selling anything but drugs in their drug stores. They didn’t have Walmarts that were selling everything under the sun. So, the competitiveness of health care now has escalated costs astronomically.


            My father used to run MSI for years. He just had to argue with the doctors about what they wanted to be paid, and the dentists, and that was it. He didn’t have to worry about all the other allied health professionals, and he didn’t have to worry about private business owners, and shareholders, and all the marketing costs. I know how much it cost for the company I worked for to market the business, and it almost doubles the cost of the health care just to tell people we exist.


            It has become a business, and when we look at all the allied health professionals, and the doctors, and the nurses - the private side of the sector - they are now competing with each other. Although we have the patient’s best interest at heart, they all want to make money. These private businesses want to do that, and so the colleges and the associations and the schools aren’t just trying to figure out how to best treat a patient, they’re trying to figure out how to best market their own professions.


All of those costs are now reflected in a budget, which is sad because the money that we’re generating isn’t necessarily going to the health professionals, it’s going to that guy who lives in some country, not even necessarily here, who happens to own it, and I just want to acknowledge that we’re having to deal with a very different health care system than we did 10 or 20 years ago.


            We’re also dealing with a different generation. I’ve got four sons and I can tell you, they don’t work anywhere near as hard as I do, or my mother did - I’m not pointing out any of the Pages in the House, you guys are the exception to the rule - but it’s like previous members have said, the doctors of today are not willing to do house calls, they’re not willing to work into the late evenings, and perhaps they shouldn’t, because we’re worried about mental health, we’re worried about families surviving, we want families to be together, and we don’t necessarily want a doctor who’s willing to work 70 hours a week.


            I also want to acknowledge that we’ve changed, in terms of the technology and the connectedness of which we have Internet and cellphones, and the minister himself referred to wanting to promote technology. I’m just going to start off my questions with that promotion, that we are a very different society than we were 10 or 20 years ago, and we’ve had to adapt to all those changes.


My first question to the minister is, in terms of technology, you mentioned the use of phones and having physicians call, which is brilliant, I love it, because you alluded to a doctor earlier - she used to be my family doctor, she’d call me at 10:00 p.m. to tell me a test result was normal, and I appreciated that. I’m wondering if you have considered using telemedicine, whereby the doctor and the patient can have technology in the home, where the physician can see that patient, maybe even use the technology for blood pressure, blood sugar, those sorts of things. I’m just wondering how far you’re willing to go in terms of technology.


            MR. DELOREY: If you’ll indulge me for one second, as I did with the member for Cape Breton Centre, your opening remarks made reference to something, again, I just want to draw attention to, because it’s not something we hear often on the floor. I want to thank you for your acknowledgement off the top about the work and the effort, not just for myself, but there are many, many people behind the work, and the listening, the engaging, and the proposed solutions that come forward. Although I understand you won’t necessarily be drawing attention and highlighting those positive aspects here during our time at estimates, or probably not in Question Period either, what I do acknowledge, through your general comments, you’ve acknowledged the hard work of the many people who work and provide advice and recommendations to come forward.


I just want to say again, to put it on the record for Nova Scotians - not just who may be watching but who may read the transcripts in the future - that despite what people assume, what we read about in the paper, that the debate that takes place on the floor of this Legislature, and the notion of politics, and even partisan politics, we do work together, we do try to advance things. I do recognize and acknowledge that it is the job of the Opposition, not necessarily specifically to oppose, but to take effort to challenge - I’ll use challenge instead, Mr. Chairman - the position. That’s why we’re here debating our estimates today on behalf of Nova Scotians.


Obviously, I believe, my colleagues believe, that the decisions we’ve made in policies and the resources that we allocate, are in the best interest of Nova Scotians. It is for the good of our democracy that the Opposition Parties challenge us through these estimate debates to maintain and instill that confidence amongst the members, and indeed, on behalf of all Nova Scotians, that that is the case. I apologize for taking that time, but I thought it was worth noting for the record.


I know you have a specific question around technology, but you did talk about a couple of other items that I’ll just touch on. You talk a little bit about how time and things have evolved, and then the budget and the impacts of private.


            One thing about that is I think many of the examples used around the private services, many of those are private. Those pressures aren’t necessarily provincial health care pressures. They would be pressures seen either borne by individuals or insurance programs, which may be reflected out in society. For the benefit of members in the House who may not be as familiar with health care, and the evolution of health care, and the provincial requirements and responsibilities about the Canada Health Act, there are actually, when you think about the scope of services that are actually legally obliged to be provided - I think many Nova Scotians and Canadians would be surprised to see how small the scope of services that are protected by the Canada Health Act are.


I’m simplifying here, but the general consensus: it is the care that you receive in hospital and it is the care that you receive by family practices. Essentially that’s the scope, so when you talk about why in years gone by, in the decades gone by, that you didn’t have the physiotherapist piece, even the Pharmacare piece - all those aspects were not necessarily part of the insured services.


            Keep in mind, it’s only been within our lifetime - actually, I guess, it predates me, but for many of the members here, lifetime - that family practices, historically, until the late 1960s, were the same, those private entities. Really, it is a modern system, a modern public health care system that we have. It is natural to see the evolution. I think it’s something that is exciting, and it is something I hear when I go around, at the prospects of engaging more with practitioners. The member used the term “allied health care professionals.” That’s more succinct than when I try to list off a number of them, but it’s also more encompassing, because you don’t want to leave someone out when you reference.


            To that point, it’s why, when we talk about collaborative practices, I’ve mentioned the work we’re trying to do, we’re engaged in with pharmacists for example, not necessarily explicitly required through the Canada Health Act, but we do recognize that the services and the scope of practice that pharmacists provide can actually alleviate some of the pressures that we have in our primary health care system. They have that capacity. I look forward in continuing to meet with and work with those pharmacists and others to see where we can move.


Recently we had a big announcement for family physicians around incentives to try to encourage the attachment of patients, because that is a major part of the challenge we have. The impact of that trickled throughout our health care system, so it’s an important part of that. But so, too, is engaging and connecting nurse practitioners and nurses. I’m using this because it’s supportive of our collaborative care approach, but it also ties into that second piece that the member brought up.


Just an example of when the hours worked or house calls were touched on, and the services provided - when I was in Dartmouth, the clinic that I mentioned in my opening remarks this evening, the physician working for about 35 years, the family practice nurse had only been at that practice for about five weeks, they’ve completely changed, they’ve become more collaborative. They have a family practice nurse, and a nurse practitioner is coming shortly. That family practice nurse has been doing house calls on behalf of the physician so that they’re able to provide care in the community as part of the overall comprehensive care provided by that practice, and they target it particularly towards their elderly clients who may not be able to make it in easily.


The way they described it working was, if it happens that when the nurse is there they do an assessment, and the situation requires a physician’s engagement, then they can either, depending on the workload, or what’s going on that day, do the house call with the physician. But the physician doing house calls may not always need to be there, so they can use the appropriate provider, getting the care to as many people as possible. They are loving it.


The family practice nurse indicated they’d been working for the last 15 years as a nurse in the correctional facility, a very different type of work environment, a very challenging one, but one that they very much were proud of. But they said for their entire career, this is the type of practising of nursing that they wanted to do: in a collaborative environment, having that ability, and being seen not as someone inferior but as a team member.


[5:30 p.m.]


In many respects, when we talk about teams, we talk about being equals. I think when you engage - it’s certainly something I’ve been learning - there are, in some corners but not all, perceptions within some health care sectors that one type of provider is superior or inferior to another. There are individuals that I’ve bumped into and spoken to in multiple professions that allude to such perceptions existing, but not amongst everyone; it is a shifting perspective.


People are recognizing throughout all the professions, throughout all the allied and physicians alike, that we are stronger working together. To that end, the house calls and the hours - although, in a different environment physicians may have been able to work in a certain way, they also now rely on technology and other things. They are in some ways tied a little bit more to their practice location because they’ve invested in all these things. The house calls sometimes may be a little bit more difficult for the way they practise, but that means expanding the scope and leveraging other types of health care professionals to do that service and, only when necessary, to tap into those advanced scopes of practice.


Just to alleviate that notion, which goes into the specific question around technology that I was asked, is that it is evolving. I concede or acknowledge the member’s overall theme, which is health care is changing. It is evolving - not just the practice but also the needs and the expectations of citizens.


In my opening comments in response, I hope our highlight is not just if the needs and the expectations and the practices are changing, but if we as a province are changing as well. We are embracing the changes. We are changing with it, but it is a point of transition. That’s where much of the challenge is that we have today, because it is a point of transition. You will hear many loud voices who are either uncomfortable with change, who do not believe that the change is necessary, that old ways are the only ways, but I’ve spoken earlier, I won’t reiterate but, again, I think there’s a lot to do with perspectives in there, and we are taking an approach which acknowledges multiple perspectives. We are embracing the perspective and the approach of collaborative care teams as a future role in the health care of this province, to improve primary care access.


We also acknowledge that that is not a system for everybody. That is why we continue to support other physicians and traditional practitioners, because we know at a point of transition, you cannot force everybody to adapt immediately and indeed, the system need is in a point of transition. We will transition; those who want to change, we will be there to support them. Really, we will be able to do that, develop more, and as time progresses, the system will evolve to come to an appropriate equilibrium, I truly believe, and we are there working towards those ends.


To the specifics of the technology that could be available in-home for non-face-to- face engagement, at present, our focus is to get the technology out there and deployed and accessible to the patients. The platform that we’re using is something that we launched - actually, my predecessor, the current Minister of Communities, Culture and Heritage rolled out when he was Minister of Health and Wellness - in the Fall of 2016, MyHealthNS, which is a platform available to citizens, patients, to log in and be able to access their medical records information.


The first phase rolled out in the Fall of 2016. The information, the predominant information, is to allow lab results and information to flow through to be available to the patients. When we talk about where test results would go to - well, the citizen, the patient, would have access to their results. However, the way the system is designed and implemented, it’s actually tied to physicians, to primary care providers. In order for a patient to get access to MyHealthNS, the care provider, the physician, needs to sign up and say, yes, I want to send these results, this information about the patient to them through this platform, and then it works.


I know my family physician has signed up, and so I was able to log in. I have access to it. Knock on wood, I’m a pretty healthy guy. I have no data in there, because it’s adding data. It’s not all the data in your records today, but it would be as you have tests and things, that data would flow into the portal. I don’t have it. There is a lot of other functionality in that portal, MyHealthNS, that could be tapped into to provide other supports, which physicians who adopt are welcome to engage, and use it to fit their practice in many regards. However, we want to get it rolled out, and that’s our first step. If we don’t have the lens in, it’s hard to go to that level that the member has touched on, which is putting technology in the homes, let’s say for blood pressure monitoring.


In fact, I talked about my previous career as an academic, even though it was in business and management, one of the areas of interest was around health care at that time. I actually attended a national conference around management, and one of the streams in that conference was around health care technology management. I still remember attending it. The World Health Organization report had come out, some studies around the use of this technology, and making use of a variety of health care professionals to support the in-home technology, particularly for patients with chronic illnesses.


            Do I recognize and acknowledge potential for future in that space? Yes. Are we there today, to be able to just flip a switch and deploy? No. We have many other foundational pieces, even around technology.


An earlier question today in estimates talked about the EMR systems and physicians. We know that there has to be a major transition between now and December 2019, in that technology with physicians; we’re working with them. We’ve spoken before about One Person One Record which is our hospital system, and tying all our content together to support having access for patients and all health care providers - all the health care information on individual patients when they need it, where they need it.


We need to get those really significant and important technology foundations in place first, then again, as we continue to move - so do I see potential? I do. Do I think it’s going to happen today or tomorrow? Probably not. I don’t want to direct or dilute our attention to the very important foundational pieces we need to get in place first, even with respect to compensating the physicians and the ability for them to use the phone and the MyHealthNS system for communication.


Again, these are early days for us. It seems strange with Facebook being around for so long, but what we’re seeing in the news today about social media, and those changes, are unintended consequences that people didn’t anticipate necessarily at the front end, when you’re looking at, for example, some of the discussions about the privacy implications of Facebook, and some disclosure issues. Big impacts and a lot of discussions going on around that right now. So, again, we all know how sensitive the health care information as we evolve into our evolving technology space, we need to be sensitive of those needs and concerns as well.


MS. ADAMS: Mr. Chairman, I’m only going to have time for one more question, so I’ll get right to it.


The announcements for the collaborative health centres were made last week, and Cole Harbour-Eastern Passage was not on there. Can you explain to my constituents why it wasn’t?


MR. DELOREY: For the record, I believe this question is on the record from the Fall as well, so clearly, the member has been advocating and working for her constituents to establish some work.


The process by which the collaborative practices were identified, the NSHA obviously working with practitioners that are out there to identify opportunities, those opportunities need to have a number of things - the people, obviously, to provide services, the space, and so on - all aligned.


 When they identified the ones that were available at that time, this is the list that just happened to be prioritized and rolled out. I believe much of it was expanding existing clinics and practices, where there’s still need in those communities, and so there was expansion because the capacity was there, and the ability to build. I believe there were six or seven new ones that were added to that list, so those were rolling out. It wasn’t intended in any way as a slight to your constituents in Cole Harbour-Eastern Passage, to the member’s constituents - it’s part of the process.


There’s a lot of demand across the province for access to collaborative care practices and collaborative care teams. Indeed, the Nova Scotia Health Authority had put out what’s known as an expression of interest. They basically reached out to ask people in the health care system, who’s interested?


They had over 100 submissions for that expression of interest, and I believe that represented over 400 physicians that have an interest. When you consider that we have about 1,200 family physicians right now, that’s a third of all family physicians expressing an interest to get involved in collaborative practices, so there is a lot of interest, but not at any of those locations, that didn’t go through this time. Again, we are still committed, and we’re going to continue moving forward, and we will get them out to those communities that we can.


            MS. ADAMS: Thank you for that answer. I will let my constituents know. I will point out, though, that you can’t have an expression of interest from my constituency because we don’t have a single family doctor. Thank you.


            MR. DELOREY: Just quickly to that point, I don’t believe the expression of interest was limited or restricted to just family physicians. Just to that last point, I hope the members would know that it would be open to others to come forward. It was also not restricted to health professionals to expand or establish the practice where they currently are located. If they were so inclined to establish a practice elsewhere, there would be nothing, I don’t think, in that expression of interest to have restricted professionals who may have had an interest in establishing in Cole Harbour-Eastern Passage, to establish themselves there, if there had been an interest by health care providers.


            MR. CHAIRMAN: The honourable member for Pictou West.


            MS. KARLA MACFARLANE: I’m going to take a few moments here just to first thank the Minister of Health and Wellness. I know that it is a real tough portfolio and I know that there’s a lot of difficult days, I’m sure more difficult days than good days.


            I know in Pictou West there are a lot of difficult days, because we just seem to have a rotation of doctors coming in and then leaving, coming in and then leaving. It’s very concerning, of course, but I’m going to get right to the questions around the Sutherland Harris Memorial Hospital.


            My first question is with regard to dialysis units. We were told in the summer that there would be a review with regard to dialysis units. In the Sutherland Harris Memorial Hospital in Pictou, we have four chairs and were told that there is a great need to expand.


            I understand there was going to be a review within the province. I’m wondering where the review stands and when we may receive that review, and what determines, through the Department of Health and Wellness, the increase for chairs in certain areas in the province?


            MR. DELOREY: A couple of things about dialysis - I know we’ve had several conversations during Question Period throughout the Fall, and again during this session of the House earlier in the month, but what I can say, and we know that even in the budget that we announced today, is that there is a significant amount of money in the 2018-19 budget to go towards dialysis expansions within the province. I believe it is just over $10 million - it’s actually $10.187 million allocated towards dialysis expansion in the province. These would be under capital expense, because at this time, the expansion is capital. Once they are up and running, it will become an operating cost for the province, through the Health Authority.


            The locations that are part of the $10 million include Kentville, about $5.7 million for construction; Digby, about $4.1 million for construction; and then there is money allocated to Halifax Infirmary, Dartmouth General, and Glace Bay for the design work, as they are not yet at the construction phase. That would be something we would expect to move forward after the design is complete, and the estimates for the total work would be updated once we have more information about the design.


[5:45 p.m.]


            We are working to expand. There has been a review that was done to identify opportunities to expand dialysis, that criteria the member had asked about, one of the guiding principles there is about the need and also the distance for those who are in need within areas, and trying to minimize the travel distance requirements for those patients is a really significant part of that review that was conducted.


            We know these sites have been announced previously. When you look at the number of - the terminology here, when we’re talking dialysis, on a technical note, is chairs as opposed to beds, so when I reference chairs, those will be the specific opportunities for treatment. I believe when you add up, for just those that have been announced, when they are implemented, it’s about a 30 per cent increase in dialysis chairs across the province. We do recognize the needs of the people of Nova Scotia who receive dialysis. We’re making significant investments to improve access. We need to get these out the door and implemented, and then we can do more reassessment.


            The other thing, a final, quick note that I’d like the member and other members to know about dialysis, is that there are options. It doesn’t apply to everybody, but I would certainly encourage people if they have constituents who are feeling challenged with travel distance and so on for receiving dialysis, we know how much that can impact. There are options for home dialysis as well. It is not something that works for everybody, but for those for whom home dialysis is an option, it provides far more freedom because much of the home dialysis - as I understand it - these systems can be set up to be run overnight. Not only does it remove the travel distance for those who may have to travel to receive dialysis, but also, it’s not that eight hours or more sitting in the chair during the middle of the day. You’re actually sleeping in your bed, receiving the dialysis, so what it does for your quality of life - again, not everyone is, based on their condition and circumstances, necessarily able to make use of that technology, but it is an option.


I think it’s important for Nova Scotians to know that not every person who needs dialysis will need to receive that dialysis in a hospital setting. But recognizing there are many Nova Scotians who do, and that travel distance is a challenge, we have already committed to expanding our number of chairs by about 30 per cent, and that work is ongoing.


            MS. MACFARLANE: I want to thank the minister for his answers. I do appreciate and realize that home dialysis is an option, and it’s fabulous for those who can do it. It’s wonderful that we can accommodate them that way. I’m wondering, though, what is out there for people in my constituency of Pictou West who have to drive two, three hours for dialysis? Is there any assistance out there to help them financially? I may as well join that question with - just a yes or no to this one as well - my understanding is that dialysis units have to be under the umbrella of a hospital where there has to be an emergency unit. Can you confirm if a dialysis unit has to be in a hospital setting with an emergency unit?


            MR. DELOREY: Two questions, I believe, were included there, just to make sure I’ve got it right. The first one was about financial supports for people who may have to travel an hour or more, and the second one is about whether or not a location that provides a dialysis unit must also have an emergency department access - those would be the two questions.


            To the first question, we do have some programs for Nova Scotians who have to travel predominantly out of province for a certain distance for services. This is broadly, nothing specific for dialysis. However, the member opposite may recall, one of her colleagues in the Fall raised a question - not about dialysis, but about the notion of supports for Nova Scotians who may have to travel for specialized services. I believe the support services that were raised in that question - it was the quiet member opposite, I believe, who raised it.


            In seriousness, I do know the member opposite was very concerned and I hope he appreciates, Mr. Chairman, that I do take to heart, when the questions are raised and ideas are brought forward. I believe it is for MS patients specifically that the member raised the question about receiving some travel supports, and I believe that was the segment.


            What I can tell the member is I had committed to looking at options. I don’t have a solution directly, work is ongoing. I do know there are some initiatives with some of our partners. I know that not too far away from the member in Pictou West, in Antigonish, that the VON in Antigonish provided, and has for a period of time, a program to support people who needed assistance. They had a volunteer service to help with people commuting to medical appointments, whether they are specialists or general, so that might be an option for people within Pictou West, if there is a VON service there.


            What I think is really interesting, and this is why I pick up on the question from last Fall, was because the VON in Antigonish having some challenges with recruiting the volunteers to provide the service actually partnered last year, so this year they are still just coming to the end of their year, I believe, with the local transit organization where they directed funds to the transit organization to pre-purchase credits for their clients.


            It’s a scenario that’s not necessarily free, but it is a scenario where they work with their clients to find out how much they can afford to pay for travel, and the travel is actually provided through the Antigonish Community Transit system. It’s an amazing model. It’s fairly new, they are just in the first year of trying it out, piloting it. Personally, I think there may be some potential in that model.


            I think it’s important for members to realize that wouldn’t be possible in Antigonish - or anywhere else in the province, but specifically in Antigonish, where it’s the first that I am aware of this taking place - if it was not for the investments that this government has put in towards community transit systems. The first time when we came in, in 2013, we had a commitment to invest in community transit systems and not just the large public transit systems.


            We didn’t have transit in Antigonish until those programs were rolled out. They continue to support the work of the Antigonish Community Transit organization. If that organization was not in place, they would not be there to partner with the VON. So, opportunities do exist. It’s an area where it’s not just health care providing solutions, but I believe, it is run through Municipal Affairs that support it. We are, as a government, finding solutions. I think there’s maybe some potential there for other communities as well.


            Sorry, before I sit down, Mr. Chairman, to the second question, the dialysis units, it’s certainly desirable to have an emergency room, but it is not an absolute requirement to have them in place. I believe we do in Sutherland Harris Memorial Hospital - I believe they are co-located with the emergency, but it’s not necessary.


            MS. MACFARLANE: I thank the minister for those answers and clarification around my two questions.


            Yesterday, through the budget, we learned that the Patient Attachment Incentive Trust, I think, is over $6 million, and I understand there is a $150 incentive for doctors to receive if they take someone off the waiting list, which is wonderful, but I heard from a doctor yesterday that this is not new, so I’d like clarification.


            I know that it was presented yesterday as a new incentive, but I understand it already actually exists, so it’s not new. My other question is, is there a cap for doctors on how many patients they can take?


            MR. DELOREY: Mr. Chairman, the two questions are whether it’s a new fund program or not, and whether or not there is a cap.


There’s not a cap to the number that you would be able to take, but of course, in practical terms, the expectation is for physicians to be able to provide the care to their patients. I believe that’s the desire of practitioners as well. When you think about it, what we do - one wouldn’t expect a physician or a practice that is at or over capacity to be looking to leverage this particular incentive. The reason I say that is because in my experience, and in my conversations with physicians across the province, they really believe in and strive to provide the best care they can to patients - they’re not out just necessarily looking to receive the compensation. This isn’t about just the compensation.


If there’s concern that physicians would just try to take advantage, take names off the list just for the sake of the bonus, and then not worry about those patients, we also have a safety mechanism built in there as well - a control mechanism - because people do have to provide the service for one year. It means that the patient has to be maintained within that practice for the year. It’s not a matter of just submitting, oh, we’ll take the name and then we’ll bump it off the list, either. They have to provide sustained service to the patients that they do get compensated for through this program.


            I’m answering the member’s questions in reverse. To the actual first question about whether or not this is a new incentive, it is new in the sense that - both are correct. There was an incentive that pre-exists my time in office. That is $150 for attaching patients. However, that program or that fee - incentive - was fairly restricted. For example, it was predominantly about attaching - and the terminology used would be an orphaned patient, a patient in a hospital setting that does not have a family physician. It was really driven, as I understand it, historically from a hospital perspective, that needing a family physician to discharge and provide care in the hospital if they didn’t have a family physician there was no one there - and then, other physicians were being asked to cover and discharge patients that didn’t belong to their practice.


That’s where I think the origin, as I understand it, of this fee came from. It was really designed to provide an incentive for family practices to take on people who were being identified when they showed up at a hospital on an in-patient basis, or through emergency rooms, to be referred and then attached.


            What we have here is a far broader recognition, because if you look at the principle behind that model, individuals had to be at a more acute stage of care. If they were receiving care in a hospital, the level of acuity of their needs was higher in that moment. What the program now is aligned to is that is continued to still be eligible.


If someone is in a hospital and they get referred, either through an emergency room or what have you, to a family practice, they get taken on for the year, they get the incentive paid out. But we also have the 40,000-plus Nova Scotians who registered with 811. They may not be sick at all and they are eligible. We are being more proactive in attaching those patients to a family physician. That is what the incentive is, that’s what’s new. We’re basically saying any patient who needs attachment is eligible to be attached. It was a much, much more restricted program originally.


The newness that I talked about, if you’re being referred from the 811 list - in addition, we’re even being so proactive, we have this program adopted not just to deal with the existing names on the 811 list, but it also applies to incentivize patients who may be at risk of being without a family practice.


[6:00 p.m.]


For example, the scenario that I refer to would be, again, I believe I’ve read on at least three occasions since I’ve been Minister of Health and Wellness, where experienced physicians have been reported in the media to indicate that they are reaching a point in their career where they would like to retire and they can’t find anyone to take over their practice, their frustration, and acknowledging that they will, at some point, have to leave their practice. Well, again, the model that was there before would not be eligible to incent a new physician or some other practice to take some or all those patients.


The model with 811 would say get on 811 to be eligible. In fact, that retiring physician, if someone in the community knew that the physician was retiring, if they took those patients, they would also be eligible for the $150. We are being proactive, not to just get people off the 811 list so we can get healthy people attached, but also to get people attached before they ever make it to the 811 list by encouraging and supporting physicians who may be retiring to get individuals willing to take on their practice lists, as well. Does that make sense?


            MS. MACFARLANE: Thank you for your answers, minister. I’m not totally clear on all that information, but I will follow up with my source and perhaps get a bit more information so we will be able to chat further about it.


            Yesterday was good news - or two days ago, when the budget came out, regarding the increased funding for knee and hip replacement. I forget the number, but I know it appeared to be a healthy number. I’m just wondering if you can (Interruption) There we go - so that was a great number.


My question is, how much of that amount of money is being allocated to the Aberdeen Hospital in New Glasgow where the orthopaedic department there is fabulous and could do a lot more operations with a little bit more money?


            MR. DELOREY: A couple of things about the announcement. I appreciate the member for acknowledging the importance and significance of the commitment to seeing more orthopaedic, particularly around knees and hips, done within the province.


            What I want to advise the member is that not all the increase comes from expansion or hiring. We’ve indicated that in the Fall, when we announced this new program in conjunction with lead orthopaedic surgeons as representative of the NSHA, that it was a multi-year commitment.


            I believe what we have in store for this year is the hiring of eight key individuals; some orthopaedic surgeons and some anesthesiologists to support continued expansion, but much of the work which was done in last fiscal year, 2017-18, was actually not dependent upon investment in the infrastructure of the operating rooms or hiring of the surgeons and anesthesiologists, but more about how we restructure and realign processes so that we make better use of our ORs.


            We announced that we were going to be doing orthopaedic surgeries on Saturdays, for example, and perhaps later in the day. This was a model that was designed along with physicians, orthopaedic surgeons, and others to support with the NSHA that they brought forward with the request, required some funding, and in this fiscal year required additional hires for staff, surgeons, and specialists, so that work was all being done.


            I don’t have with me a specific list of where the expanded orthopaedic surgeons and the anesthesiologists are expected to be allocated, but I will endeavour to find out from - and as the member mentioned in our previous response, or in this question, that we’re going to continue this conversation in the coming days, so I will endeavour to have that information the next time we speak.


            MS. MACFARLANE: I look forward to that because the Aberdeen Hospital, that is one department that actually does very fabulous there. I think if they had more - my understanding is that they have more hours that they could actually be doing operations, they just don’t have the knees or the hips, so it’s more or less getting the product to ensure they can actually put in those extra hours on Saturdays and whenever. We want to make sure that department continues. I look forward to that future conversation.


            My question is, what is the long-term plan for the detox centre in Pictou?


            MR. DELOREY: I think in terms of response I might touch a little bit at the higher level in terms of care in mental health and addictions and, as a starting point, just to understand the work that’s delivered by the Health Authority on behalf of the people of Nova Scotia when it comes to mental health and addictions. One thing that’s really important to note - and I’ll let the member and all members know that it’s something I was introduced to when I toured the province. I went to a number of different hospitals and I made sure that at each of the locations I went to that I did want to go to the mental health and addictions wing, that I wanted to meet with the staff in each of the facilities that had them, to talk and engage, because there was work already under way with some significant changes around mental health and addictions.


            Most obvious was the amalgamation of mental health and addictions as one team. Previously they had been operating as two separate units, but with the nature of the clinical work that gets done to provide supports, and as we know there’s often comorbidities between - that is, the coexistence of addictions and mental health issues. One may cause the other but they are often related, so the nature of the supports, rather than directing people to mental health and saying, oh, you want to talk about your addiction, we’re going to send you over to addictions. Bringing the two teams together, getting the clinicians working together, a lot of common skill sets, was the other thing that was taking place there. That was one of the reasons I wanted to know how that transition was going.


            One of the things they educated me on, though, was how evidence and the evolving nature from evidence and research around mental health addictions around community care versus traditional detox model - when we’re talking about detox the research and the evidence that is coming through is that in some cases detox is not necessarily in the best clinical interest of the patient and that is like a closed-off detox environment because what they’ve indicated and advised me of is that going into a detox centre and being closed off and having no access to whatever the substance may be, allows time for the substance to clear from an individual’s system. What it does not allow is for the individual to truly come to terms with those aspects and the ability to cope in the community.


            What they found with research is that the recurrence rate for people with substance issue, through detox treatment programs, is that the rate of recurrence is high, certainly higher than when they worked with clinicians in a community-based environment so that they are coming off the substances and getting the supports they need in the community because then they are dealing with not just the substance within their physical system, but they are dealing with the substance and the social environment and circumstances at the same time, so long-term benefits and actually achieving results is care in the community as the primary objective.


            As far as the specific status to the member’s specific question about the detox centre, I don’t have an answer specifically to that at this time, as far as that specific site. I will endeavour to - and again, not just that one location, but other locations, are part of a review because we are looking at this evolving way of practice and care - so detox, not just in Pictou West but, indeed, across the province, to make sure that as a system providing mental health and addictions services - here we are talking specifically about detox - we want to make sure we have the right care model to provide the best outcomes.


            The role of detox is being reviewed within the system and I don’t believe any final decisions have been made, but I use that information to say that there is a lot of evidence that has resulted in - and this is information provided to me by clinicians directly on the front line, this was not a briefing note or some information that was passed up to me. I was on the front line in those mental health and addictions talking to front-line workers and they spoke passionately about how treatments and best practices are evolving.


            If I can be indulged for one moment - I won’t wait until the next time we speak, I will answer the member’s previous question. Those ortho investments we anticipate being made, not just in New Glasgow at the Aberdeen, but I will confirm that there will be investments there, we do see opportunity to provide more support in the orthopaedics, but also Kentville, Sydney, and within HRM.


            MS. MACFARLANE: I did ask what the long-term plan for the Pictou detox was, and the reason I ask that is because I’ve been fortunate enough to be able to stand in my place here for the last four to five years and ask the same question, and am told that the Pictou detox is part of a review. That’s a pretty long review - four or five years, and I can appreciate that it’s a very complex and complicated department, mental heath and addictions, but I would say that four or five years of review is pretty long.


            Basically, the people in Pictou and the employees at the detox in Pictou are just fearful that the rumours could be true - that perhaps there are intentions to close that down. I will follow up with that at a future date.


            My last question is about our Veterans Unit at the Sutherland Harris Memorial Hospital. As we all know, we take very good care of our World War II veterans. This is a unit that has 20 beds, but currently we have a few empty beds. We all know, sadly, that our Second World War vets are passing on and we are fighting a different war now.


            The men and women going to fight for us now are coming back with PTSD and a lot of different issues because it’s a different type of war that they are actually fighting, but we still have to look after those veterans. Unfortunately, when they come back and they need assistance, they don’t meet the criteria to be given one of those beds.


            I understand it is a federal issue; the funding comes federally, but what I want to know is what this province, what is the minister’s department doing for the veterans of Nova Scotia and why are we allowing a number of - three beds right now, I think, at the Pictou unit - there are Korean War veterans out there whom I understand are applying and not being accepted, so I just want to know, what initiatives are you taking to ensure that our veterans are going to be looked after through your department?


            MR. DELOREY: I thank the member for this important question. I think, indeed, the role and the important work and the sacrifices made by the veterans of Canada and in Nova Scotia - we all owe a debt of gratitude, as Nova Scotians and as Canadians.


            The member made reference to the fact that when we are talking about veteran beds, those beds are allocated and funded through the federal Department of Veterans Affairs. That is the source, and in terms of them being available or not available, that goes through that organization.


[6:15 p.m.]


I’m not attempting to use that as an excuse in terms of services to veterans within Nova Scotia; in fact, I can confirm that Nova Scotia is one of, or possibly the only province in the country that actually has a committee dedicated to veterans’ affairs, a member of our Legislature. We do have a Veterans Affairs Committee, and I can advise the member that I recently received a piece of correspondence from the chairman of that committee, in my capacity as Minister of Health and Wellness, asking me - or I believe there was actually correspondence sent to me and the federal Minister of Veterans Affairs, encouraging us and supporting us in our efforts to work with a veterans’ committee, a community-based veterans group led by Roland Lawless. They have some proposals in for providing care and some ideas around enhancing services for vets within Nova Scotia.


I have met with that group, I’ve reviewed their proposal, and we’re looking at shoring up the cost estimates that they had. They acknowledged that there might be some additional work. Obviously, we would have data that they wouldn’t to help better understand the proposal. So, that work is ongoing within the department.


            We’re also looking at other areas and ways and means to support veterans throughout the province, not just restricting ourselves by getting into this jurisdictional - you know, veterans’ affairs and vets fall under the purview of the federal government - if there are opportunities for us in our health care system to help Nova Scotians, and they happen to be veterans, to work through their health care issues. As the member noted in the preamble, much of that is mental health-related. There are many with post-traumatic stress disorder and other conditions, that may be chronic pain conditions, or others, that we can work with them. So, there is work ongoing.


I have already met with the federal Minister of Veterans Affairs, and we’re committed to continuing the conversation to find out what, and how, we can move forward to improve access to health care for veterans in Nova Scotia. We want to be a leader in this area - that doesn’t directly, necessarily apply to the beds at Veterans Memorial, but collectively, we’re here and we’re committed to the care for vets in Nova Scotia.


            MR. CHAIRMAN: Honourable member, you have three seconds.


            Order, please. Time has expired for the PC caucus. I will now recognize the NDP caucus - you have about 19 minutes.


The honourable member for Cape Breton Centre.


            MS. TAMMY MARTIN: If we could pick up where we left off, I was going to start to get into tracking the reasons why doctors would be leaving the province, and I believe we talked in this House that there have been significant doctors that have left this province.


            I would hope that the Department of Health and Wellness, and the minister would ensure that exit interviews are done with these doctors, because in order to enhance and improve the care that we’re providing to Nova Scotians, I think it’s very important to talk to doctors as to why they are leaving. Whether it be, as the minister alluded to, maybe changing careers, or moving because of family, or whatever the case may be, but I think that’s very, very important data that we should have.


            If they have that information I’d like to request that the minister would table it, as well as the numbers, per year, of doctors who have left since 2013, with the reasons why, assuming that you would have that information from any exit interviews performed.


            MR. DELOREY: Actually, I really appreciate the member’s question, because when we concluded the member did ask me about tabling some information, I was a little confused, because in my response I didn’t have any information, I didn’t think. I was talking in generalities as to why individuals may choose to leave, around retention; I didn’t have any specific examples.


            I appreciate the clarity with the member, I believe, just for her purposes, what she was asking was around exit interviews, which would provide specific answers in tabling that. What I can advise the members of course, the NSHA and the government, and the IWK, and ourselves, do work when there are opportunities to conduct exit interviews, however, and for government proper would be through the Public Service Commission often. But physicians are a challenge, because as we discussed earlier this evening, physicians are not employees.


There isn’t a means or a mechanism to mandate and require physicians to complete these types of interviews. So, knowing that, and knowing where the approximate numbers would be, to the question of would I be willing to table the information, that is something that I would have to look into and it would depend on what the specific data is.


            The reason I mention that is often, if numbers of data are not substantive enough, then individuals could be personally identified, and there may be some privacy issues, or concerns with tabling, because even though the member has asked to have the number of physicians, and then the list of reasons from certain areas, the challenge would be that sometimes the data would be so small with the reasons, it would be easy, particularly for people in the community to identify exactly which physician and why.


Anytime exit interviews are done, it is about providing the information to the employer, or the organization that is funding them, to better understand why, and to get honest and direct information, often to ensure it’s being done in confidence, and the individuals who are participating are expecting it to be done in confidence as well.


            For that reason, I can’t commit to tabling the information, but I’ll certainly look to gather some of that information detail, and see to what degree of generality I might be able to apply and, again, as we’ve noted earlier, we’re going to be continuing this conversation for a few days. I’ll see what I can get, and if at a future point, I may be able to speak to, in high general terms, but not necessarily attaching to numbers and locations. When I have that information, if I decide that it’s able to be done without jeopardizing privacy, I think we’ll bring it up on another day down the road as we do these Estimates Debates.


            MS. MARTIN: Of course, we understand any confidentiality issues, but primarily we are looking to see if there is a pattern, or something that’s very substantive that would stand out. As well as the numbers, because we are curious to see how many are coming in and how many are going out, and what the net effect is, because as I have said several times, the numbers that are waiting for doctors are significant for this province.


            According to a recent survey conducted by researchers at Acadia, 50 per cent of doctors reported experiencing symptoms of burnout. Researchers characterized the state of the physician workforce in Nova Scotia as fragile, compared to a 2008 national sample by the Canadian Medical Association.


I’d like to ask the minister, what is being addressed specifically in this province to address the physician burnout issue?


MR. DELOREY: As the member would know, we are working diligently to improve recruitment to bring in more family physicians, to spread the workload and the demands across the province, in communities from one end of the province to the other.


Members on all sides of this House, as MLAs in our constituency offices, work with our constituents to help guide them through the process. I believe the member mentioned, for example, one of the most important pieces of information for patients looking to get access is to get them to register with 811. I think the member mentioned her own daughter wasn’t. I encourage the member to let her daughter know that she can call 811, she can go online and do it as well, to just get registered, because it is working, and people are coming off the list. It’s very convenient and many physicians like the fact that they have this access point.


Historically, the way the process worked - and this may play into new physicians coming in so they don’t get burnt-out, setting up a practice or expanding - historically what would happen is someone would hear there’s a new physician in town, and then everybody who is looking for one would just call. What we hear is that the phone lines at the office would be overburdened so they couldn’t even call to schedule appointments with existing patients. They were constantly blocked with inbound calls to just get established.


            The way it’s working now, with this new 811 list, is actually not just good for government and our partners to know what level of demand exists and where that demand is located, but it’s also good for the practitioners because we’re able to take the list and provide it to them so they don’t have to go out and do advertising to let people know; it can be quietly done. They can work as they continue to provide care and build up their practice over time. They’re able to do that based on the names and they continue to reach out as they have capacity, as they’re getting comfortable, and they can take on more. They’re seeing new patients and they’re building over time and continue to take the names off that list.


            In many ways, short of the number of names registered on the list, there are many, many good things this 811, Need a Family Practice list, does provide to the province, both for the patients, for government, and for practitioners.


            With respect to the burnout question, those are the types of things. We know we need to get - in conversations and messages, whether it’s correspondence or other means, I hear from physicians that some of the burnout relates to physicians and practitioners that at that point they’re looking to retire. I think one of the contributing factors is not just the number of patients they have but this pressure they feel to provide care to everybody. I read in the newspaper from time to time physicians who are expressing that concern. It’s not just the pressures of providing the service and the care to their patients but this pressure that builds to their capacity that they know there are others out there that have need. They want to be able to provide that care, and I think that’s a contributing factor.


            What are we doing to address it? As I said, one of the big parts is us working hard to expand primary care access and we’re doing that through a number of means: increasing recruitment opportunities; expanding our residency programs; and we’ve launched a new program for international recruits to streamline the immigration process. We announced it only a few weeks ago and we have three people committed to come here who are already eligible with full licences, although they are coming here from other countries. We don’t have the challenge to find licences. They can hit the ground running because they are fully credentialed even though they’re coming from other jurisdictions.


            We’re continuing to follow up with recruitment in the U.K., a number of follow-up meetings. There is a lot of interest, especially with this new information we have. We had that first trip over to the U.K. in the Fall and now we’re going back just a few months later to follow up with people who have expressed interest to say not only can you come to Nova Scotia to practise, but we want to streamline that process for you. We want to, and we’ve worked with the federal government. We’ve got a new stream so the paperwork and the process for them to immigrate and get established here, you and your family, is actually going to be easier. We’re doing these things to help build the capacity in our primary care system and that will help relieve some of the burden and the pressures.


In addition to that, there’s the work that we do with collaborative care practices. We know that when working as a team you’re able to spread that pressure out and the workload out amongst other primary care providers. From what we hear from practitioners who work in this environment and from research, that is a helpful thing, even if you’re working collaboratively as a team to share those challenges amongst each other. That’s one of those contributing factors for collaborative practices which will also help take pressures off by expanding primary care access.


In addition to that, we continue to work with Doctors Nova Scotia. We know they highlighted that, as the member mentioned, in the research, the Healing Nova Scotia report referenced that, as they did their survey - the work that we’re doing and our engagement and continued conversations and collaboration with Doctors Nova Scotia. Again, no quick fix to situations like this but we’re working diligently with our partners to improve the situation for everybody in our health care system. But it’s one day, one step at a time.


[6:30 p.m.]


MS. MARTIN: You talk a lot about recruitment and travelling to the U.K. and streamlining processes and making it easier to come to Nova Scotia, when you’re fully credentialed, in order to practise medicine.


Were you briefed on this resource plan when you became the minister, and has there been an update to the physician resource plan since you’ve become minister?


            MR. DELOREY: To the question that the member asked about the physician resource plan - yes, as a new minister we are briefed and we are provided with copious amounts of information about our departments. We learn about a variety of items, and I can confirm for the member that physician resource planning and the work - in fact, we have a physician resource team within the Department of Health and Wellness, and they came up to brief on the work that they do and how the plan actually guides that work - was done very early back in June and July 2017, when I first came in.


            The other thing I certainly recognized from that was the physician resource plan that we’ve been working on, the last time, very comprehensive, but it was done in January 2012 - I believe that’s when it was completed - so it is a number of years dated. But there have been updates. There were updates done to that plan in 2014, and again in 2016. There was a very comprehensive plan done in 2012, and we’ve taken the same modelling approach that was used. When you’re doing a comprehensive one, you’re identifying the methodology that you go about to apply, so the same methodology. It didn’t take as much work, because you already had the design of the methodology that was applied to update that plan in 2014 and 2016.


            The work for the 2018 update is in progress now. As you may notice it was done in 2012, updated in 2014 and 2016. We work on these plans on a two-year basis even though it’s an outward look, but we continuously update. That update for 2018 isn’t out yet, but it is in progress, and I look forward to receiving those updates, as I’m sure all Nova Scotians are, because it will feed into, or impact our planning.


Regardless of what comes out in that plan, we do know that Nova Scotians need access to more physicians, we know we need primary care providers, we know that we need specialists, particularly psychiatrists, and we know we need anesthesiologists and many other specialists throughout the province.


            I don’t necessarily need the resource plan to know that we have needs throughout this province. We’re going to continue our recruitment efforts, we’re not waiting and relying on this resource plan specifically, but it is an important plan so that we can identify and know the degree to which the demands and expected demands for future work is required. We do know that we have a need now that is going to carry on into the future, so we’re working to recruit as many physicians as we can.


            MS. MARTIN: While the government is continuing to recruit physicians, I know in my constituency office, and I’m sure in many of everybody else’s in this House they hear concerns and questions, if not daily, at least weekly about issues that are going on in their communities and hospitals, and with issues around doctor recruitment and retention, doctor burnout, and emergency room closures. I see now one specific issue to my constituency: I am aware that doctors are available to work in specific emergency rooms, but the NSHA is not allowing that to happen. They’re telling them no, we’re going to leave the emergency room closed on a specific day, we don’t need you. I don’t know, it doesn’t even make sense to say that out loud. Who makes those decisions?


            MR. DELOREY: A couple of things here. We know that emergency room closures, in most frequent instances, are based upon staffing, but that staffing is not always driven by physician availability. Sometimes it’s around nurses. Indeed, the acuity of the staffing challenges, we know in Nova Scotia that some particular communities are affected more than others at some hospitals, particularly community-based hospitals - not so much at our regional hospitals that tend to have the staffing complements in place to continue to operate. I can tell the House that just recently across the border in New Brunswick, in Moncton, they actually closed the Moncton Hospital down in the emergency room because of a lack of nursing staff available.


            To the member’s question about why, even though a physician may be available, there’s one scenario where sometimes it may be other staff that are needed for the operation of an emergency room. That may result in the closure, or the inability to open up. The other thing to note about emergency rooms and emergency room closures is that we know that scheduled hours of emergency rooms, because we do know over time there are efforts to be more consistent. We knew that there were chronic challenges, we know that 96.4 per cent of the time emergency room hours were open for the scheduled operations that were anticipated.


The other thing I’d like to note is about the question of who makes the decisions. The NSHA runs the operations, so they do every effort to make sure they have the staff in place, but when they realize that it can’t be done they would notify the communities that the service is not available.


MADAM CHAIRMAN: Order, please. The time allotted for consideration of Supply today has elapsed.


The honourable Government House Leader.


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


MADAM CHAIRMAN: The motion is carried.

The committee will now rise and report its business to the House.


[The committee adjourned at 6:37 p.m.]