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April 14, 2000
House Committees
Meeting topics: 
Supply -- Fri., April 14, 2000

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10:50 A.M.


Mr. Wayne Gaudet

MR. CHAIRMAN: Good morning. The Committee on Supply will now be called to order. We will be debating the estimates of the Department of Health, Resolution E12.

Resolution E12 - Resolved, that a sum not exceeding $1,686,140 be granted to the Lieutenant Governor to defray expenses in respect of the Department of Health, pursuant to the Estimate.

MR. CHAIRMAN: I will now invite the Minister of Health to introduce his staff to the members of the committee and invite him to make some opening comments if he so wishes.

The honourable Minister of Health.

HON. JAMES MUIR: Mr. Chairman, I am pleased to introduce to members of the House, Barb Hall who is the Executive Director of Health Services in our department and Byron Rafuse who is the Chief Financial Officer. They will be with me during this debate on the estimates to provide some technical back-up for me if I should need it, which I will.

Mr. Chairman, I would like to make a few introductory comments. In many ways what I am going to say will be a summary of the message that we gave during the events leading up to last summer's election, and we have continued to pass this message on since we have been in government. I notice that somebody took the time to put a title on my comments and they are entitled: Working to Achieve a Responsive, Sustainable and Secure Health Care System. I believe in our budget and our estimates, we have begun on the road we said we were going to embark.


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Demands on Nova Scotia's health care system are increasing rapidly. It was interesting to see this on the front page of this morning's Halifax Chronicle Herald, that the Nova Scotia cancer toll is the worst in the country, not something we are particularly proud of. That is the case, but it also said that one reason for this is that Nova Scotians happen to live a little bit longer than a good many other folks in the country, and it says that age may be the biggest factor in these rates as opposed to some other things.

Our population is ageing, drug costs are rising, patient volumes and patient expectations are increasing, and expensive new technology has been introduced. As all members of this House know, Nova Scotia has a major capital deficit in its health care system. Despite popular opinion that there have been cuts to health care services in the past few years, this simply is not the case. Indeed, the health care costs in Nova Scotia have increased more than 37 per cent over the last three years. This increase, Mr. Chairman, amounted to about $112 million. If we compare the three-year period, the estimates from 1996-1997 to 1999-2000, we find that in the hospital sector the percentage increase in estimates is about 28 per cent.

Other programs, which I won't get into right now but did include Y2K costs, had gone up about 146 per cent. At the same time, revenue has increased about 18 per cent. Mental health costs have increased more than 20 per cent; emergency health services costs have gone up about 107 per cent; the long-term care estimates have gone up 42 per cent; public health estimates have gone up more than 26 per cent; detox estimates are up over 19 per cent; home care estimates are just about 52 per cent; MSI payments estimates have gone up about 32 per cent; and the Pharmacare costs, the cost to the Department of Health, I should say, have increased about 112 per cent.

Mr. Chairman, all in all, the costs of the health care system have escalated at an unsustainable rate. If we divide these particular estimate figures by three, we are going to get more than a 12 per cent annual increase in health estimates.

We have argued that these increases are not sustainable, and I think every Nova Scotian realizes that they aren't. Indeed if health care spending continued at the trend set over the last three years, there would be nothing left for anything else. There would be nothing left for one teaspoon of hot asphalt on the roads of Pictou County or Kings County or down toward Parrsboro on the Parrsboro shore where Bill Langille comes from, and the folks up there are justifiably upset because there is not enough money for roads. We all know that.

There wouldn't be any money for roads, or housing, or community services or anything else if health care spending continued, basically, at the rate it has over the last three years. We would have no health care and the health care system itself would really not be able to survive because we are spending money we cannot afford to spend. I should point out that the federal Minister of Health in his dealings with the provincial and territorial health leaders and with the provincial and territorial First Ministers said that a health care system whose

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growth or whose expenditures are continuing to increase at twice the rate of the growth in the GDP, is not sustainable. That is where we are, Mr. Chairman. Some of the decisions we have made about budgets for health care are based on the fact that we have a system right now that we cannot sustain. If we don't make some adjustments on how we do it, there won't be any health system, probably in 10 years, for ourselves or our children or our grandchildren.

When we got into the Medicare business quite a number of years ago, Mr. Chairman, the federal government was entered as a 50 per cent partner. The federal government contribution right now is about a 12.5 per cent partner. That is a decrease of about 75 per cent from the original agreement. As the federal government contribution, percentage-wise, has decreased, then the provincial contribution has increased, and it has increased dramatically. As I said, at about $112 million over the last three years. We cannot afford to continue on that path. We have to find a better way to do it. We continue to lobby our federal colleagues to help us out, but, I want to tell you, what we are interested in from the federal government is money to support initiatives that are going to make our system stable and sustainable. We have, despite the infusion of all this money over the last three years into our health care system, discovered that just pumping money into it without fundamentally altering the way we do business is not going to cure it. All we are doing is putting more money into something and the results, probably from a cost-effective point of view, are not there.

I want to tell you that last year, Mr. Chairman, the federal government contributed somewhere around $107 million to our health care costs. This year on an annualized basis, that federal government's contribution to health, and my colleague in Education and my colleague in Community Services is $19 million on an annualized basis. That is a decrease. If you take about $20 million from $107 million, you get $87 million, and if you add $1 million to that, you are getting $86 million. So the annualized decrease this year from the federal government to health dollars is $86 million. We don't have $86 million to pick that up. We have to do things differently so we can provide core health services for our citizens now and in the future.

Once debt services costs are taken out of the Nova Scotia budget, Mr. Chairman, health care consumes about 42 per cent of the program spending and because there have been some additions to the Health Department because of government restructuring, that percentage is probably going to increase.

[11:00 a.m.]

Thus, Mr. Chairman, to try and protect our health care system and to develop one that will be there in the future when people need it - one that will deliver the core services Nova Scotians need - fundamental changes were needed and tough decisions had to be made to ensure appropriate services are available when and where they are needed for today and for tomorrow. We have embarked upon some structural things. Certainly Bill No. 34, which is going to alter the administration of the health system, is one thing. Another thing that we had

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to do is to tackle the dollar aspect of it, it is one thing to have administrative changes, but if we continue to spend, we just were not going to be able to do it.

Just to refresh for the members of this House, this past fiscal year the provincial deficit, I think the Finance Minister indicated, is about $800 million. That meant that last year, Mr. Chairman, every minute of every hour of every day of the whole year, this province expended about $1,400 more than it took in. If you look at it, every minute, about $1,400 was added to the provincial debt because if it is a deficit and we don't have the money to pay for it, then it goes onto debt.

I see my colleague over there, the member for Lunenburg West, is nodding his head in agreement. He knows that the debt now is up around $11 billion and some of you, there were some mathematicians in the House yesterday, not very good ones, and some outside too, but I want to tell you if we have a debt of $11 billion, to service that debt is a lot of money and that is money we don't have to put into our health care system, to put in our community services system, to put in our transportation system. We have got to stop it, Mr. Chairman. We have to stop the bleeding.

Health is a 42 per cent player in the program spending in this province and health has to participate. We have to come up with a system where we can deliver services that are needed. Nova Scotians can be assured that when they have health care needs, they are going to be taken care of, but we have to do that within the framework of building a system that is stable and sustainable. It has to be one that we can afford. As a consequence, we have prepared estimates that reflect that. We have prepared estimates to reflect the health care needs of Nova Scotia, now and in the future, and also to reflect the current, unfortunate, financial situation that this province is in.

Thus, Mr. Chairman, the estimates for the Department of Health indicate that my department will spend $84 million less this year than it did last year. This sounds like a big chunk and indeed it is, the amount that we are not going to spend this year. If you were to take several of the other departments, you would find in some of the departments, their budgets would not be that much, but I tell you if we didn't, there would not be any money in the budgets of those departments.

A lot of the savings will not affect, can be achieved - I was going to use the word affecting twice but I thought it would not work too well with a school teacher, Rodney, behind me here - but, anyway, a lot of savings can be achieved without affecting our core services and that was what we were into. For example - and I hope the members of the Opposition are paying careful attention to this - of that $84 million, $40 million of that was gained simply because of the Y2K expenses that were budgeted last year. That accounts for just about 50 per cent of it, Mr. Chairman, the Y2K. So when we are talking about a reduction of $84 million, we have to look at that in context and we will say, well, we take away $40 million from $84 million, we are down to $44 million.

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We think that $10.5 million can be saved through eliminating duplication of corporate and clinical administration provincially and through the greater cooperation and integration in the new capital health district. We project $12 million in savings by reducing or delaying minor or non-critical capital projects. I am pleased at the same time as I say that, Mr. Chairman, that we have been able to include roughly around $29 million for capital projects in the budget next year. That will service areas in Cumberland County, out at the Sackville-Cobequid area, down in Yarmouth, and also across the water over there in Dartmouth and we will be making some announcement in that regard before too long.

In our department, across the street, we are projecting a saving of $3 million. Changes in funding allocation based on actual blood use has resulted in a reduction in funding to the Canadian Blood Services of about $4.3 million. We believe there is a $2 million saving in prioritizing and rationalizing the allocation of research grants. The new Health Research Foundation will evaluate and prioritize all current commitments and future applications for research funding.

What we discovered, Mr. Chairman, rightly or wrongly - I am not saying that it did not contribute to the overall benefit of the province - but in addition to the upfront money that was allocated to researchers at Dalhousie and the other areas, there was a lot of end running around things that we discovered. Actually I should not say it, I participated in one of them, too, but we hope once we get all these consolidated, then there is a savings to be effected and we think it is going to make the whole thing work a little bit better.

We are projecting an increase to $4 million in revenue by increasing the levy per vehicle charged to insurers to help recover the increasing health care costs associated with people injured in car accidents when they are not at fault. Basically what it means, if you were injured in a car accident and you came to the hospital, the insurance company, assuming the insurance company would pay a fee for service, but what we are trying to do now is to make the insurers pay the full price of that service and that is where that increase is going to come from. I should point out that the province has been sort of playing with this minor increase since 1992, but this year we expect that it would generate a rather substantial portion, about $4 million, by doing that.

We believe that about $5 million can be saved, or revenue can be generated for the health care institutions by standardizing rates for non-insured medical services and for increasing fees for non-medical services such as preferred accommodation in hospitals. We did talk a little bit about that yesterday. Also when people opt for better medical service, and I am not talking about a two-tiered system and I perhaps should not have used that word, but the classic example is that if a person breaks their arm, they go to a hospital and they get a plaster cast. I am told by our people that plaster casts cost about $2, but if a person wants a fibreglass cast, and a lot of people are opting for those, they cost about $25.

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So the standard fare basically that the hospital is going to offer is the plaster cast unless there is some medical reason for putting the lighter on. If a person wishes to have the fibreglass cast, it is not going to affect them medically, then they pay $23, or whatever fee it would be, that would be the type of thing. Similarly, these accommodation arrangements with the hotel costs, we believe non-clinical aspects of it, people have options there and it is a charge by choice. If you don't want it, you don't pay for it. If you don't want to pay for it, don't choose it. We also believe that there is going to be about $2 million in savings through improving provincial drug use and evaluation of drug programs in facilities.

To protect the sustainability of programs that meet the greatest needs, we have suggested some changes. Among them, the long-term care budget. As I said, it has increased roughly by about 42 per cent over the last three years. It has been increased to $149 million this year to maintain services to seniors while the single entry program is introduced. The single entry - and we have talked about that and I think the honourable members are familiar with it - in places where it has been successfully implemented, we actually found a reduction in the need for long-term-care beds. So we have increased the home care budget and the long-term-care budget on a transition basis.

Home care costs, Mr. Chairman, have gone up by about 24 per cent over the last three years. This year, funding to provide nursing services to seniors with the most acute needs have been protected and no fee is going to be charged for chronic- or acute-care nursing services. In addition, $1 million is being added to provide respite services to support families in their care for loved ones. These services include in-home respite care, adult day programs, and respite care beds in long-term-care facilities. Home support services such as light housekeeping, personal care, meal management, home oxygen, chronic and acute care, and some palliative care services are continuing.

However, to protect the essential services, effective May 1, 2000, the co-pay for the light housekeeping services is going to go up from $6.00 to $8.00 an hour and a series of co-pay maximums will be established based on a person's ability to pay, but I want to emphasize, Mr. Chairman, that there is no increase or there is still no fee for the chronic and acute home care services.

The Seniors' Pharmacare Program. The program cost-share last year was 79 per cent by government and 21 per cent by seniors. The premium and the co-pay had not changed since 1995. I mention that it had not changed since 1995, yet the Pharmacare costs to the Department of Health in the past three years has gone up around 112 per cent. So in determining how the co-pay premium was going to be distributed to generate money, which really is necessary, Mr. Chairman, so that we have a Pharmacare system, at one time that Pharmacare system, when it started out, it was 50/50 too and now here we are as a province pleased that we were able to protect that and the province is now contributing about 80 per cent, but we have got to keep it around that.

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The premium will not increase this year; however we hope, by this time next year, working with seniors to establish the formula, that annual increases or decreases are automatic and we will not have to go through this process annually to determine that. Somebody, yesterday - I guess it was the member for Dartmouth East - raised a question about what protection is there for seniors and drug costs, and clearly the maximum on co-pay does provide protection. Pharmacare, despite the upward adjustment in the co-pay this year, is a generous program. It is just about as generous as any in the country and the government continues to pay the majority of the costs.

Other Insured Programs. The province will be moving to the secondary insurer for the following programs, the Children's Oral Health Dental Program, which is regular check-ups and fluoride for children under 10 - I believe under 10 years, I have to check that - cleft palate dental program, primary routine vision care and the prosthetics program. Now what that means, Mr. Chairman, is that people will still have that service and they will have it free of charge but, for example, if you were a member of this Legislative Assembly - and I know there are members in this House who have young children - they have a dental program and under that dental program the dental care for their children is picked up by the insurance company. Under the program that existed in the province, the province was picking up those costs and the insurance company, or we were, whoever it was, was getting a free ride in this thing, and what it is simply saying is if your insurance covers it, then the insurance should pay for it. If you are not insured, then it still goes.

We believe, Mr. Chairman, that is going to generate about another $2 million in savings. On January 1, 1991, the surgical removal of impacted teeth ceased to be an insured service, but was not strictly enforced; that means generally wisdom teeth. Effective July 1, 2000, these criteria will be enforced. The province, of course, will continue to pay in the cases where the removal of these impacted teeth is surgically necessary, or medically necessary, as it would be a surgical procedure.

The $900,000 budgeted for health promotion and disease prevention focusing on community-based initiatives for child and youth wellness, substance abuse in youth, and screening for cervical and breast cancer, we think is a very positive step. Again, I go back to the comments that were made by the Cancer Care Nova Scotia people this morning, in particular with reference to some of these things, and they were talking about the screening programs for breast and cervical cancer of women over 50. In addition, $2 million has been budgeted to address the needs of children with special needs, including children with autism.

Looking at the acute-care system which would include the IWK-Grace, the QE II, the Nova Scotia Hospital, the Cape Breton Health Care Complex, and the regional health boards, I want to tell you, Mr. Chairman, that we have been in contact with these facilities and organizations since last November, to describe the type of budget that we were going to have and the financial restrictions we were going to find, our financial condition of this province, so there should have been no surprises and, indeed, I don't really think there were.

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It is interesting, Bill No. 34, of course is going to address some of these things, but we estimate that about $16 million can be saved by eliminating duplication of corporate and clinical administration provincially, and through the new capital health district coupled with increased revenues. There is going to be no direct impact on core programs unless approved by the Department of Health first and supported by the clinical services footprint. What the clinical services footprint is, is that we have basically a study or a task force or a group that is consulting with health care providers around the province to determine what services should be offered where.

Turning to Emergency Health Services, I am pleased to say that fees now paid by patients for inter-hospital transfers have been eliminated. Secondly, there has been a standardization of the rate for ambulance transport across the province. The changes to the fee services are good. What it means is that there used to be two rates for ambulances. Under 100 kilometres there was a charge of $60. If you lived more than 100 kilometres, $80. If you lived someplace else, it could be $500 or $600. As a matter of fact, a bill came to my attention the other day for a person who actually lived in another part of the province, the charge was $435 and that was basically about 100 kilometres. Under this new policy, that charge would be $85, if they went from one hospital to another hospital there would be no charge. This is a good news story and I do hope that our Opposition (Interruption) well, he is acknowledging it and that is very good, I am pleased.

MR. CHAIRMAN: Order, please. The honourable minister has the floor.

MR. MUIR: We are also taking some steps to rationalize our fleet of ambulances, and the contractor is managing the province's ambulance services and working to ensure the ambulances on the road are properly utilized. Everybody knows and certainly the members in the Liberal Party, when the change was made with the Emergency Health Services to incorporate the delivery of ambulances under one roof, the usage, they were trying to make their decisions on hard data. What happens is under the proposal, the number of hours ambulances are staffed will more accurately reflect the needs of the community. Some staff hours will be reduced as a result. It is not anticipated that this will impact emergency response times. It is also not expected to impact non-emergency calls, but will be monitored and adjusted accordingly. There will be no job losses because of the reduced hours because paramedics will be needed elsewhere in the system due to the recent collective agreement which can definitely reduce the number of hours that paramedics are allowed to work.

The cost of ambulance transports for out of province and out of country patients increases significantly. The new user-fee structure represents 20 per cent of the cost of all ambulance services, compared to 10 per cent during the last several years. This now moves us up to the national average. The fees for our ambulance services, although they have been adjusted upwards, remains lower than the average cost of an ambulance transport in P.E.I., New Brunswick, Quebec, Manitoba, Saskatchewan and Alberta. Again, user fees for

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ambulance transport have not increased since 1992 despite the fact there has been about 150 per cent increase in that particular service.

We are confident that by working together with the health care sector we can achieve a responsible, sustainable and secure health care system for today and tomorrow. Our budget estimates reflect that belief. Thank you.

MR. CHAIRMAN: The honourable member for Dartmouth East.

DR. JAMES SMITH: Mr. Chairman, I came here prepared with statistics and to be very assertive in my questioning this morning, but after all this Dr. Feelgood talk we have just had, I really am speechless. There is hardly anything left to say. The minister just stopped short of saying that Pharmacare would be making a profit in a couple of years - the way they're going. Anybody with the nerve to talk about increasing the co-pay from $200 to $350, and projecting a couple of years out you are looking at a total premium of $1,100, if the utilization of the drugs and the cost of the medications are taken in. He did stop short of saying that Pharmacare will be making a profit next year, but I think he held back.

I want to thank the minister for his opening comments and we will go over it the next week or so and look at the budget and see where we go from there. It is an important budget, it is 42 per cent of revenues, as he has mentioned. I am pleased the minister has arrived in the Department of Health and found out that all the cuts he had been talking about in the House of Assembly, when he was in Opposition, really hadn't been taking place and he was converted somewhere on the road between here and Truro.

The Pharmacare co-pay, and all these metro seniors who need ambulances that are less than 100 kilometres, that increase really isn't very much and they can really afford that anyway. It is not only the cost of the home support services - and I knew that something was going on, because you can tell. Your constituency office, like my medical office used to be, is a sort of micro of what is going on. You start getting complaints, so you know something is going on, and there are two areas where that has been increasing. Even though the calls haven't been great, and I don't want to mislead the committee on that, but more people are getting knocked out of the social assistance system and it is difficult to get in. I am talking about single mothers with one or two children, I am not talking about someone this government says doesn't want to work and all that sort of thing, that Mike Harris type attitude, that if you do give them some money, you put a chain around their ankle that can transmit the signal so that you can follow them around and make sure they are not abusing the system; it is not that sort of thing I am talking about. I am talking about young children and infants.

Also, on the home support services, people who were ill at home and were receiving services and have gone into hospital and come home and find that the services are cut. The person must have been in hospital because they were ill, their disability didn't miraculously go

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away. So that is part of the other. The user fees we are talking about and we will be talking about over the next week is one issue. The entry into the system, the criteria used, the interpretation of policy and if you notice the minister kept coming back to this, whether it is liability issue, with car accidents following that and the revenue projection, he kept coming back to this issue.

A stricter enforcement of this, a stricter enforcement of that. Impacted wisdom teeth - I have never had the privilege to have mine out, I guess I still have them back there somewhere - but this hasn't been enforced, so now we are going to really bite down hard on wisdom teeth. That is the message today.

I haven't heard much about the improvement on the continuum of care, I guess that is what we were looking for in this budget. This government, in its wisdom, the minister and his department now feel the acute care system can be cut by $70 million out of the budget. Where is that transition into health care for long-term care and the home care services and the primary care?

There is one area I want to make a few general comments on before I get into specifics. I have been a bit encouraged by some of the issues relative to child health. If you look at Community Services and Health together, I think there are some areas there. I believe that it is probably predicated on the hope and the wish and the planning that the federal government is going to come forward. So, I imagine the minister has cut some sort of a deal with the feds that he is not talking about too much yet, but that we are going to see some improvements. I hope we will.

I think what is happening is that he has cut the deal, that if you can get Harris toned down a bit and Ralph Klein off his high horse then maybe we will find a little more money for Nova Scotia, if you want early intervention. I am really glad to see that somebody's been at work there, some of the staff have been at work, converting and making this minister and some of his colleagues, at least a few of them aware that children are important and the health of children is important. We know that after awhile class size doesn't matter, but at least the early intervention that we speak of, and Paul Steinhauer and Dr. Fraser Mustard, that type of message they have been delivering across the country has caught fire here a bit, and I am looking forward to that. We will see how these programs are funded. I believe we are looking at federal initiatives here. I mentioned primary care, as well. I think very quickly we should move on from the pilot projects and move into an expanded mode for primary care, because I think the evidence is in.

[11:30 a.m.]

The issue, though, of primary care projects did disappoint me in that I don't believe we are looking comprehensively at alternate funding within the salaried positions of physicians. If we don't do that, I think it is going to be very difficult to move into a

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comprehensive, coordinated and integrated primary care system. That is delivery of the services in the community, by physicians, social workers, physiotherapists, particularly nurse practitioners and those other groups. So that continuum of care that we have just quickly gone through, there has to be a balance within that. I must say that this government has not shown a preference for all of those various components, it has cut them all across the board.

We speak in terms of what Dr. Feelgood said about long-term care increasing and this sort of thing. On one hand, we learn from his report and the Facilities Review Committee that long-term care is 99 per cent filled, which really means overflowing, and that sort of thing, and yet, we don't see any provision for expansion of that, so it must be in home care. We look through there, and there is no expansion really. We are not really keeping up with any expansion in that particular area. Maybe we can come back to that later on.

The feds and the provinces have a disagreement as to how much they are putting in, but it is low and in all fairness that would be a complaint of any minister. There is a disagreement that it is not 12.5 per cent, but it is how you count the dollars. Certainly, there has been a decrease over the last few years and I think this was some of the problem we had as a government. But, this government did put an extra amount of money in last year in the $208 million. It was very convenient to blame the new government for that. So this was a very convenient way for the government to do that and then blame us for that.

However, that is becoming history now. The Premier was going to save the health care system, fix it, after we had broken it. Although the minister this morning - that's why I was glad when he said there had been no cuts, that it was not true that there had been all those cuts - I was pleased to hear that. But, whatever we had done to it - and we will come to the health authorities and the regional health boards later - he was going to fix it for $46 million and he was going to save that out of administration. Lo and behold, if we look through the budgets here, I really don't see much decrease in administration. I haven't been able to find where that $46 million is coming from. So, instead of that $46 million cut out of administration, they dump $208 million in and blame the previous government and away they go. So, Dr. Feelgood can come in here this morning and everything is fine again. Governments tend to do that anyway, but if it hadn't been so serious, I guess I could have laughed about it, really. It was so insincere and so hypocritical.

The minister did make some comments in reference, I think, to the other side of the harbour, and I don't know if he was talking about the Nova Scotia Hospital or the Dartmouth General Hospital, but I would just make a plea, and this may not be the time for it, but in my general comments I would just caution this government and this minister that if you fool around with the Dartmouth General Hospital and change the role of that hospital, you are playing with something very dangerous, very unwise. I think that hospital has been one of the best hospitals in Canada for its size. It is the only community hospital we have in the metro community. We have over a third of the population of Nova Scotia here, right in this area. We have tertiary care hospitals.

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This hospital, I believe, has been rated as one of the better community hospitals in Canada. Its role has been very difficult in the metro community, as I mentioned before the introduction, where it is fitting into a system with tertiary care, and the emergency department particularly was at least the second busiest in metro. The services it provided, particularly with cardiac and other services, were excellent. Maybe I am jumping the gun here. Maybe the other side of the harbour can be explained more because there are probably some plans for the Nova Scotia Hospital as well. Some of this will be addressed under Bill No. 34, what will happen to some of the staff and what protection they might have if the roles of either of these institutions change.

I am in no position to warn the minister thou shalt not, because he and his government will be the final arbitrator of that, but they will also take the blame for that. If they are going to play around with the changing of the role of the Dartmouth General Hospital, I am serving notice today that this is something that this member will not be taking lightly, and I think the people of Dartmouth will not be taking lightly.

AN HON. MEMBER: Hear! Hear!

DR. SMITH: The member for Dartmouth North is saying, hear, hear.

I think there have to be some changes in (Interruption) You should do what your government committed, you are so happy to talk about it. I'm sorry, I shouldn't be talking to the minister. Mr. Chairman, he is so happy to announce what he thought was a good news item on the ambulance fees until it was pointed out to him that the people in metro will, in fact, be paying more, and most of the services are in metro. This is where the population is, but anyway, I think the pencils are kind of sharp on that one.

The commitments that have been made to the Dartmouth General should be fulfilled and fulfilled now. How this institution will fit within the capital structure, it is an awful large structure. We see the movement toward nine health authorities throughout the province, and yet the metro capital one is so large, with the QE II now involved. I wish the minister and the department good luck on this one, because that is going to be a formidable task. That even concerns me more with this type of structure, and this is why I bring my concerns about the Dartmouth General Hospital here this morning, of how it fits in that larger group.

The Dartmouth General Hospital has been outside the university for definite reasons. I think that was a philosophy they developed earlier on, and I think we have to respect that, because there are criteria when you join the university setting, what the function of your hospital will be and how the appointments are made. I think it is time that there are some changes. They need support in the administrative area with the medical staff. I was working on that. We had a commitment from a retired cardiologist that he would become an administrator and oversee the coronary intensive care unit, but he lost both of his parents at separate intervals just a few months apart and was not able to do that, but I think that sort of

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initiative should be there. The minister will say, well, this is up to the capital region, but it is really up to the minister and I am sure he would not pass on his responsibilities on that.

I think they do need strengthening in some of the administrative areas. I think the administration of the hospital must be strong. It always has been strong over the years, but an on-site manager is not quite adequate in my opinion and I think that is an initiative that we had left to the central region. Probably their needs have not been addressed within the central region structure and I am saying this, quite frankly, I would say to the minister now that within this capital structure I think an eye has to be kept on the Dartmouth General that it isn't swallowed up and the great ground lost that has been made since, I think, 1979. It is a great example of a community hospital and perhaps we will come back to those types of hospitals later on. I mentioned the revenue and the insurance liabilities and all those other issues and we will see what those cost.

I liked the comment he makes about the hotel costs, referring to the extra charges in semi and private care. I think if you are going to do a hotel cost, you are going to have to make sure that the services are there. I think people will pay for those services, but they are not going to pay for dirty rooms and food that is not served warm and all those sorts of things. So I think if you are going to increase there, you had better be prepared to ensure that the service is provided.

The issue of across-the-board cuts in acute care and all the other areas and then saying there are not going to be any changes, so we are going to take $30 million out of the QE II budget, but you cannot fire any nurses, you cannot lay off any people. All the restructuring that is going on - unnecessary restructuring in my opinion within the health care system - moving from four regional health boards to nine health authorities, all of that is fine to do within the system because other than the four year plan, which is the restructuring of government, the $88 million I guess that is down for that, will health have a call on that or not, or is the restructuring going to be different? That will be my first question specifically to the minister. With the idea that there will be increased costs with restructuring within the health care system, moving from four regional health boards to nine health authorities, where do we find that money for that restructuring? Is that in that four year plan that rolls out from $88 million to $122 million over the next few years?

I will ask maybe a second question. With the belief that there will be loss of jobs within the acute care system because you just cannot slash that kind of money out of the QE II, you have to have nursing positions vacated and other staff lost, where will the money for severance come from? Is that within the Health budget or is it somewhere outside?

MR. MUIR: Mr. Chairman, I believe the first question, the member for Dartmouth East was asking about the costs of restructuring. There is some money allocated in this year's budget for restructuring costs, but if you will look at it, you are not going to find the word restructuring there; it would be in other things. For example, the clinical services footprint,

[Page 14]

which is part of that, the cost of that thing, the cost of the single-entry program is part of the restructuring. As you know, all of the authorities that currently exist have administrative budgets and part of that budget line would be used for this transition, too.

Mr. Chairman, we are pretty confident that we can do this and end up with a system that is going to better serve the needs of Nova Scotians without great masses of transitional money and we are going to have to do it because you can see from the financial position of this province, we don't have - the reason we are making these adjustments is to try to come up with a health care structure that will protect the health care interests of Nova Scotia and at the same time be one that provides for stability across the province, sustainability in the future, and this has to be done within the means of the province.

DR. SMITH: Just so I get this right, the minister is saying that they are going to take around $30 million out of the QE II acute care budget. There would be, obviously, loss of jobs there. Will the severance packages for those people, nurses, support services, whatever, that will go from that institution, where will the money come from for the severance? Is that within the hospital budget that you are providing or is that some other plan that government has?

MR. MUIR: Mr. Chairman, I don't know the exact number of lay-offs that the member has spoken of, but if there are quite a number of lay-offs, and there, obviously, probably will be some, the dollars for those will be coming from a source outside the Department of Health.

DR. SMITH: So we can tell the people at the QE II that they will be getting more money from the Department of Health to deal with that. Maybe the minister can confirm that when he answers. I think that is very important. We are talking about millions of dollars here and we are talking about jobs. We are talking about a cut of $31 million at the QE II; 70 per cent of the cost in salaries amounts to 525 staff at a salary of $40,000. Some of those support staff may not be at that, but while the minister just wants to be sure about where the severance money is coming from for these staff, how can the institutions, such as the QE II, go through those types of extensive cuts without impacting on the quality of service and the quality of patient care? Does the minister have a plan for that? What is the plan for that?

MR. MUIR: Mr. Chairman, I would like to clarify something I said earlier. I misunderstood. I thought the honourable member was talking about incentive plans to retire and if that should ever come, that money would come from outside the Department of Health, but if there are severance packages, as a matter of contracts and things like this, then that would be picked up the institutional budget. I apologize for that, I had misunderstood what he had said.

[Page 15]

The other part of the question was where is this going to come from. I want to give you just some indication, Mr. Chairman, that about 60 per cent of the provincial health budgets for the RHBs and the NDOs goes into what we would call direct patient care services. We know that some of the things that are counted in direct patient care services would involve I suspect things that we might term as middle management and things like this in these institutions, but when we reorganized, particularly in the capital health district because that is really the major thing, we believe, and I guess this is the feeling of the people in the health care field with whom we met when we developed this proposal, that there are significant savings to be achieved by consolidation, the elimination of duplication of services, a whole variety of these things. I think they will become more apparent as the groups get together and seriously begin to talk.

[12:00 p.m.]

DR. SMITH: Mr. Chairman, I agree there is duplication, there is a lack of co-ordination of care between regional hospitals and community hospitals and the main tertiary care, and I would like to come to that later with the information technology proposal and where one might find more of that in the budget. It is obvious there needs to be improvement in the database and also in record collection and distribution of records and an exchange of records, and the duplication that does take place because of the lack of that system working well.

More specifically, I would like to ask the minister, the new nurses promised by the Premier, where do we find this in the budget?

MR. MUIR: There has been $3 million allocated this year for new nursing positions and that is distributed through the acute care budgets.

DR. SMITH: Maybe this is where it was hard to identify because of the cuts, but the cuts would have been deeper if there hadn't been the $3 million in there for the nurses. So that will cover a few, not too many. (Interruptions) That's history. Maybe before these estimates are over I can go through the Health Investment Fund for the benefit for those who haven't read it yet, which does address information technology very comprehensively, by the way.

We could talk about salary increases and all the other things, and I think I know what the answers will be here, but maybe more specifically, what is the minister's understanding of the definition of support staff? We talk about doctors and nurses and physiotherapists and various professionals, but when the term "support staff" is used, what does that mean to the minister?

According to national MIS guidelines - and I have a whole list of things here which I could read for you - they define things of an administrative nature, patient care services, things such as people registration, laundry, housekeeping, patient food services, all of these

[Page 16]

things. There is a whole list of them and I would be happy to provide them to him if he wishes to see them.

DR. SMITH: Before we leave an institution like the QE II, because I think this is one of the obvious ones with the $30 million cut to the budget and obviously the hospital has to look at the salaries, I don't think it is good enough to say we will save on administration and support staff. When you look at cuts of that magnitude, you are looking at the lay-offs of nurses and the closing of beds. Does the minister have a projection of how many beds he would see closed at the QE II? I know that there will be some transition changes, I know in theory that will work to some extent, but you can only do that so long. How many beds and how many nurses will people in Nova Scotia expect to see at the QE II in the next year or so?

MR. MUIR: There were two questions, I believe. One had to do with the number of beds that will be closed at the QE II. It would be our hope that there would be no beds closed at the QE II as a result of this. We believe there are savings that can be achieved. On the other hand, if we are able to make some rapid progress in terms of long-term care, there are a certain number of patients in the QE II who are occupying beds that could be served someplace else and I would not be adverse to seeing those closed.

Secondly, you had asked about the number of nurses who would be laid off and I think we have made it pretty clear that one of the fundamental principles in establishing this budget and our plan for health is that front-line health care workers will be protected above all else.

DR. SMITH: Just so I understand the minister, he is going to take $31 million out of the QE II budget, there will be no closure of beds, and the nursing component will stay the same.

The minister's own study said that 25 per cent of acute care beds are occupied by people who are best served in another location; either long-term care or home care, I assume. He is talking of those beds being closed and they could be better served elsewhere. I am having a little trouble with the continuum of care, again, because where will those people be served? By your own study, and you seem to agree, one-quarter of the people in acute care beds could be best served somewhere else. There is no increase, really, or minimal increase, it is not keeping up with inflation, long-term care and home care. Where will these people go? We can't treat them like we have the mentally ill, and put them on the street. You can't take a hospital bed and wheel it out in the corridor. I saw one guy when I was interning try to do that, but he couldn't get it out the main door of the VG, but he had a pretty good cut at it; but, you can't do that. Where are those people going to go, or is it going to be just less people in the system? Where in the budget does the dollar flow through and follow the patient through the continuum of care when you take those 25 per cent out of the acute care hospitals?

[Page 17]

MR. MUIR: The honourable member is using a figure for the QE II, which I think is misleading and I know it is not intentional, but the actual reduction for the QE II, once you eliminate Y2K funding from last year's $17 million I think you were using $30 million - probably it is more accurate to use $17 million as opposed to $30 million. Secondly, if I said that the people who are being cared for in sort of a long-term-care fashion at the QE II would receive better service somewhere else, that is not what I intended to say; my point was that they could receive services. I do believe that they are being well cared for in the setting that they are in now, and I don't want to give anybody the impression that they are not.

I also said, Mr. Chairman, that if things move as we would like to see them and we can find some more revenues somewhere, then we would like to move our long-term-care plans along much more rapidly. We don't have the dollars to do that right now, but we are confident the implementation of the single entry access, which the honourable member has spoken favourably of and supports, in other jurisdictions where it has been used, it has reduced the demand on long-term-care beds.

DR. SMITH: So, just to be clear. The minister is saying that the Y2K cost for one year at the QEII was $30 million. I really find that hard to believe, I just cannot believe it is at that figure. I don't know which I am arguing on here - maybe I am going against my own argument - but I really don't believe the costs are $30 million within one year.

MR. MUIR: I would like to clarify that as we continue our dialogue, Mr. Chairman. I believe the honourable member for Dartmouth East did refer to a $30 million reduction in budget and I guess if you are looking estimate to estimate that is correct. I want to tell you that last year the QE II had $6 million, a little bit better than $6 million in Y2K costs. Y2K is gone and over, so if you take it out, it reduces it.

The other thing in that budget that the honourable member will perhaps remember, there was the high-end drug program that was done through the QE II to a total of about $7.2 million. That budget item has now been transferred into the Department of Health and therefore if you take away the Y2K costs and the high-end drug program which they are no longer responsible for, then it reduces that $30 million by $13-plus million, so it is about a $17 million difference.

DR. SMITH: Mr. Chairman, I thank the member for that and I am sorry if I added to the confusion, but I needed clarification on that. I had noticed some extra medication costs, I had gone through the Community Services budget as well and I don't want to get them mixed up, but I noticed there were a couple of areas where provincial programs were brought back to the department, but we will come to those later on.

[Page 18]

Just moving into the information technology system, can the minister give the committee some perspective of what this system will look like and then I will maybe get into specific questions later. What does he see, what is the plan for the new health information technology system throughout Nova Scotia?

MR. MUIR: Mr. Chairman, what we are looking at is an integrated financial system, an integrated patient record system. There are groups working on that project right now. Our commitment to that this year is $4 million.

DR. SMITH: Do you have a projection of other years, maybe even just one year out? I think it is pretty important when this is started that it is completed.

MR. MUIR: The three year project projection was $4 million this year, $16 million next year and $10 million in year three.

DR. SMITH: Great. That looks somewhere close I would say, so I compliment the minister for that. We will be looking forward to that because I think that is an integral part of the funding formula and monitoring that and all those other initiatives. We will be watching that budget.

Looking at the IWK-Grace and the $10 million - I think I am correct in that figure - how can the minister explain the absorption of that $10 million at the IWK-Grace in their budget when they were in fact projecting probably that much more in their budget? I think their wish list was more, about the same amount as has been cut back, so it is a double-double I guess, if you will. Were there areas there of duplication or what did the minister discover when he came to the department that would lead him to believe that children and women's health could be cut $10 million?

MR. MUIR: I think, Mr. Chairman, unfortunately, and I don't say this in any sort of a critical way of the good people who provide such a valuable service through the IWK-Grace, but the honourable member for Dartmouth East did use the word "wish list", and I think there were some items in their budget which, I am not saying they are not needed and that type of thing, but probably not high priority, they said they would like to have and therefore put it in their budget.

The actual reduction in the IWK budget is roughly about $4.6 million, not the $12 or $13 million. I think the honourable member knows that. The IWK-Grace will be integrated into the capital district, at least as a partner in the preparation of that single business plan. We believe that they will avail themselves of the shared services and that there will be certainly - not only for the QE II and the Dartmouth General and the Nova Scotia Hospital but the IWK-Grace as well, as they participate in this - administrative savings for them as well.

[Page 19]

DR. SMITH: The IWK-Grace Health Care Centre, the budget from forecast to estimates was approximately $10 million. When I said wish list I didn't really include any of their wish list in that. I would suppose that their budget - I am not privy to their budget - would have been probably another $10 million or $13 million beyond what they got last year. That is what I would have thought. That is where I meant the wish list might be there, and I don't mean that as padding, there are services to children particularly, throughout this province, that the provincial programs do not meet and that they were filling that void and proposed to fill that void. It may be that I have read this wrong but it looks like a $10 million reduction below last year's budget. Can the minister clarify that?

MR. MUIR: I will try to clarify that and, again, I should have stated this probably in my introductory remarks, but the IWK-Grace had incorporated in last year's budget $5.6 million of Y2K costs, so that accounts for the difference. As I said, if you take $4.4 million and add it to $5.6 million, you will get the $10 million the honourable member is speaking of.

DR. SMITH: So we look at the type of cut, whichever way you cut it - and the Y2K is a figure that keeps cropping in here - but even if you take a $10 million hit on a budget, 70 per cent in salaries amounts to 175 staff; or even one-half that amount. Is that what the minister foresees involving the staff cuts and what other changes does he see within the IWK-Grace budget that they could absorb that cut? Even if it is not the full $10 million, as one reading the budget here would believe, this is an institution that has been a leader throughout Atlantic Canada in various services to children and youth, particularly. Without these particular services, mental health programs; emergency health; cancer care; all of those specialized services - that hospital has gone from 200 or almost 300 beds, I think, at one time, maybe less than 100 now, but the children who are there, and I still think of it largely as a children's hospital, need to be there and with such high costs and intensive care, the amount of time that is spent on small infants, newborns and neonatal care and all of that - does the minister really believe that after a hospital that has gone through that much change and paring and cutting from year to year, that they are able to sustain, without any loss of staff and without any closure of any of those beds, that type of a cut?

MR. MUIR: Mr. Chairman, in the capital district, it is estimated there is roughly $200 million being expended here in services which we would not call core services. You could say these would be the support services. I believe that the IWK-Grace, as part of the information and sort of the planning exchange exercise that they went through, along with the others here in the capital region, that there were roughly around $35 million of those services they probably participate in. What we have asked of the others is that the IWK protect its core services. The honourable member knows more about those core services than I do and, I guess, unlike him, I tend to think of it still as being very much centred on children, although they do a wonderful job on the obstetrical side and all that, as they did combine with the Grace. We are asking them to protect their core services and to actually look at how some of these other services could be shared with others and to effect savings.

[Page 20]

DR. SMITH: Mr. Chairman, I guess that is one of the reasons I wanted to highlight support services and I guess support services means different things to different people. When you see them being cut in different areas, they may well mean support services that really impact on hospital admissions in way of a drug program or the absence of a drug program for children. If that family doesn't have access to medication, then they well could become a resident within that institution at thousands of dollars of high cost beds. I won't get into that at this juncture. You start talking about support services that can be pushed aside and done away with, what we know is the determinant of health, I think, that really is a very short-sighted initiative, particularly when we are dealing with families and children who are so vulnerable and so impacted on low socio-economic issues or situations that impact on their health.

We have really looked at several areas, we had the Goldbloom report, we had the chairman, Dr. Richard Goldbloom, and the co-chair, Mrs. Scaravelli, come forward with a fairly good report. All was not perfect with the regional health boards, but they felt to move beyond that would be disruptive. What are the main determinants the minister and his department and this government would not accept in that report, and build on that, but chose to ratchet the system again, that had just gone through changes earlier on? What are the main determinants that made the minister decide they would move into nine regional health authorities?

MR. MUIR: As the honourable knows, in reference to what we are referring to as the Goldbloom report, there are a number of recommendations that came from that report that this government has supported, has indeed incorporated in its planning, as we move forward to try to develop a system which is going to be more responsible and more responsive. The honourable member is also aware that the determination to move to the nine district health authorities, or whatever their names would have been at that particular time, this was part of our election platform. I guess it is sometimes difficult for people to understand that when political Parties make promises - I can tell you this, with all sincerity, Mr. Chairman, that the support for this new plan in breaking up those existing regional health boards and the report that I, as the minister responsible now and this government, and I have talked to my colleagues, has really been substantial. I have not really had people, except some people, many of them sitting over there, say to me that you are doing the wrong thing.

The fact is that the existing structure was criticized for not being responsive to the needs of the communities. The decisions were being made outside the communities, and people in Nova Scotia kind of had input into the communities, their own help, and that was taken away. Now, granted, there would be some people there who supported it, and I guess if I was working on that board as part of that structure, I would be supporting it too. That stands to reason. I can tell you with all sincerity, since we made that decision, I believe it was last October, I have not received one call or one letter about it.

[Page 21]

DR. SMITH: It is just an amazing world we live in, it is just amazing. Mr. Minister, I wonder, have you read the accreditation of the western region and the patient survey? It is interesting, Mr. Minister, because I did get a lot of complaints about the lack of communication back and forth. People saw everything happening in the health care system, many people saw everything blamed on the regional health boards. That was sort of interesting. I know you people were chatting up all these people. You did that in Opposition, and friends of the Premier had his ear, obviously, so you came forward with this. I just really question if there are people out there who really feel it is necessary to go back to that system of nine boards centred around a hospital-oriented system. But we will get back into that when we debate Bill No. 34.

The bill right now is just riddled with problems, and that is the message the government is giving to people who are working within the health care system and any protection they have of moving people within that system. Who owns those assets when you break it up within those regions when you move to authorities? What are the rights of the workers? I mean, that bill is going to have a rough ride though this House. I know you have a majority government and I envy you that, because there were lots of things we would have done had we had a majority government, but that was not to be, and I am not here crying over spilt milk.

I just can't believe, looking at the body language of the minister, that he is really fully convinced that they are doing the right thing. I don't think they are doing the right thing. Changes could have been made within that structure. The irony of it is, you have created a capital region that is really like a big elephant and the rest are much smaller. You have eight other units. That part of it just boggles my mind.

I think the minister answered the question right. I think it was an election promise, and I truly believe that. I know our job is to be critical in Opposition, but you try to be constructive once in a while, too. But that was an election promise for the Premier and his friends. I know there are a fair number of doctors in town who are disenchanted with all that, because sure, they lost control. The Premier says, now we are going to give it back to you guys again, and I say guys, because most of them are guys, they have been around for a few more years, anyway. I know you have to be gender correct, but most of them, I find, are guys. It's only lately that over 50 per cent of the medical class are female. So the younger people are still enthusiastic and they are open to change. But some of the people are very upset that they lost the power within those communities.

However, there will be lots of opportunity on Bill No. 34. Bill No. 34 is a disgrace, that a new government in a majority position, would bring in a bill like that. You could drive a tractor through it. You could get caterpillar diesels up here and you could drive any of that stuff through it and you are going to hear about that. You have already made compromises. To bring in a bill in that position and have to make all those changes, is poorly thought out. If you haven't got the transition from the regional health boards authorities better thought out

[Page 22]

than that bill reflects, then good luck. Hold onto your hats, we are in for a rough ride. Thank you. I will be back another day.

MR. CHAIRMAN: The honourable member for Dartmouth-Cole Harbour.

MR. DARRELL DEXTER: Mr. Chairman, certainly I have looked somewhat forward to this opportunity to discuss with the Minister of Health, his estimates because I think there is much that needs to be explored in this budget. I want to say that I suppose there is much in here that I found regrettable. There was much that I found - and I think people are finding - quite offensive, but probably nothing was more offensive than the Pharmacare premium increases or rather the co-pay increases and what that is going to mean to seniors in this province. That is particularly the case, because the Minister of Health, who I have now had the privilege of knowing for about two years, sat next to me in Opposition. I had an opportunity to speak with him on many occasions about things like this and I had the opportunity to sit and listen as he sat in Opposition to his very able critique of the then Liberal Government and what they did while they were running the show and the Health Department at that time.

I know, Mr. Chairman, that the Minister of Health ran in 1998 on a platform that said they were going to eliminate Pharmacare fees for seniors. I remember that campaign very well because I remember going into the seniors' residences in my constituency and having people come to me and say, well you know, Dr. Hamm has told us that they are going to eliminate the Pharmacare fees, and this is profoundly important to us. Myself, having to be in a position to say, well I don't believe that the province is in a position to be able to eliminate Pharmacare fees in one fell swoop. Then I would set out what it was that we had said on Pharmacare fees and what our approach was going to be which, frankly, was a much more reasonable approach than the position the Progressive Conservatives were taking during that campaign. But, nonetheless, it was the position they took. It was the promise, the commitment, they had made to senior citizens in this province, and then to see this budget come down and not only not make some attempt to deal with the Pharmacare costs for seniors, but to increase it. It just boggled my mind.

Did they pass their conscience in the hallway as they were on their way into the Cabinet offices? Is that what happened? I don't know. I do know that they made a commitment in 1998 to people in this province, and upon further reflection, they decided they didn't need to fulfil that commitment. I think it is just not only a reprehensible thing to do to people, I think they will see it for what it is, which sadly, is a betrayal of the trust of those people who decided, maybe for that reason, maybe for others, to cast their vote and to support the Progressive Conservative Party in the election of July 1999.

I have to say that I come to these estimates with that background. I think I am justified in feeling that the minister has something to answer for, having made that commitment and having broken it. Mr. Chairman, I am going to table this. It is the editorial

[Page 23]

from the Truro Daily News, I believe it is from April 13th, just a few days ago. I want to read through parts of it because it is important. It says some things which I think the Minister of Health should take note of. It says:

There is a golden rule for politicians to follow. Don't enact legislation or pass measures that might negatively affect senior citizens or children. It is pretty basic stuff. There are two age groups in our society which should never be trifled with. They are the ones who most need and deserve whatever support and help the rest of society can offer. Nothing should be too good for our kids. They should be given every opportunity to learn and develop to the best of their ability. Our seniors should be given every comfort possible as a reward for their years of toil and vision to make this province and country what it is today, one of the best places on earth to live. For the rest of us, we should be able to roll with the punches in this budget.

It goes on to say things about the rest of the budget. Then it says:

"Seniors were promised by the minister of health in a public forum in Truro Monday that pharmacare costs wouldn't increase. He said increases in the health budget wouldn't match the increase in costs. A day later, the budget revealed that seniors will pay a larger portion of prescription drugs to a maximum of $350 per year - on top of the $215 annual premium for the provincial drug program. The health department budget was cut by 2.9 per cent. Just what happened here in the span of a day?"

Mr. Chairman, that is my first question to the minister.

MR. MUIR: Mr. Chairman, I can well understand why the honourable member raised that, because if I had seen it sitting in his chair, I would have, too. Unfortunately, it is one of these things that we as politicians get hit with every once in a while, and it is people who are writing don't understand. Actually, there may be a correction on that today in the newspaper if they will do it.

The question that I was asked, Mr. Chairman, is will there be an increase in Pharmacare costs? I think the actual way it was said, will you assure us that there will be no increase in Pharmacare costs, to which I responded, there will be no increase in the premium this year. If you were to take a look at the article that was written about that meeting which appeared the day before in the paper, clearly the reporter who was present understood because when I went out with him, I said, look, don't put that in the headlines, but you must understand that I am talking about the premium and not talking about co-pay and that reporter fully understood that. Unfortunately, somebody else wrote the editorial who did not know the difference and thus it was reported that way and, hopefully, they will correct it today.

[Page 24]

[12:30 p.m.]

MR. DEXTER: Mr. Chairman, I thank the Minister of Health for his answer, but what it does is it just begs the question which is, you know, I mean clearly the individual who was asking the question may have framed it and did frame it in terms of whether or not there was going to be an increase in costs. To say to them that there is going to be no increase in the cost of the premium and to know, when you are giving that answer, that there is going to be an increase in the co-pay and, therefore, the increase to the senior citizens is going to be profound, is really to give a half answer. I would say to the minister that it is not a fair position to take, to say that there was going to be no increase in the premiums. That is a half answer. It obviously did not respond to the question and I understand why it is that the editorial turned up the way it did. If I had been sitting in that audience and had heard that response, I would have drawn the same conclusion.

Mr. Chairman, I am going to table this as well. I have here drawn from a website, I believe from the Quebec Government's home page, a summary of a study that has to do with what happened in the Province of Quebec when they increased the co-pay and the premium costs for their drug plan for seniors. This is the kind of information that I would hope the minister would have in his possession when he is making decisions about doing things like increasing the co-pays.

I am going to refer to sections of it, Mr. Chairman, because I want to share this information with the minister and with his staff and, indeed, with all of the members opposite and inasmuch as this information gets reported, I would like to share it with the people of the province because I think it is important that we understand what it is we are doing when we make these kinds of decisions. By the way, this is a report prepared by 16 researchers. They were physicians and pharmacists mainly from McGill University, but also from the Department of Public Health, from Montreal Centre, the Université de Montreal, and McMaster University, and they had been given the mandate to evaluate the impact of the premiums on the drug plan. What this says is that the results are clear. The drug plan had an effect on the utilization of medications and on the health of the beneficiaries.

I am going to try to get to the most important parts because I think the minister should have an opportunity to read the entire thing and, indeed, of course, the report is much more extensive than this. This is just a summary. It says, in the more detailed analysis of the first 10 months of the plan, the researchers discovered that the new drug plan increased the number of serious adverse events, including hospitalizations, institutionalizations and deaths in the population. We estimate that the introduction of the drug plan resulted in 1,946 additional adverse events due to reductions in essential drug use in the first 10 months. The researchers also noted an increase in the number of visits to physicians in the order of 16,000, in the number of visits to emergency departments in the order of 13,000, among people who reduced their utilization of essential medications.

[Page 25]

Again, it appeared that income security recipients were the most affected by the new drug plan, particularly those with mental illness. According to the study, these people were particularly fragile because their health state is very sensitive to changes in their use of medication. In this case, Mr. Chairman, they went from a $2.00 per prescription pay to a 25 per cent co-insurance premium, certainly perhaps in some cases a dramatic change over what it had been and perhaps even more dramatic than this one. However, overall, the cost of the co-pay and the premium in this one, which is I believe is indexed to income and is $200, is actually less than what would be paid by seniors in this province.

So if we know, if independently verifiable research says that the result of co-pays on these kinds of insurance programs are going to increase the number of hospitalizations, the use of emergency rooms and, regrettably, deaths in the population, then this is something that I would hope the Department of Health considered before they made the decision to go ahead with the co-pay. What I am going to ask the minister is, was he aware of this study, was he aware of the effects of the increase in co-pay and, if so, what part did it play in the decision to increase the Pharmacare co-pay?

MR. MUIR: Mr. Chairman, it is an interesting point raised by the member for Dartmouth-Cole Harbour. Quebec is Quebec and Nova Scotia is Nova Scotia. I did not read that study, but I will do that. I would raise the question, what would the researchers say if there was no Pharmacare Program? This is sort of one of the areas that we were finding ourselves in in Nova Scotia in light of our financial situation. I think it is fair to remember, and I had said this in my opening remarks, that at one time the Pharmacare Program here was 50 per cent for the seniors and 50 per cent for the province. Right now the Pharmacare Program is about 80 per cent for the province and 20 per cent for the seniors' population.

The other thing in comparing it with Quebec, Mr. Chairman, the honourable member only told part of the story when he was talking about $200. As you know, in Nova Scotia we have a sliding scale, and if you are a GIS recipient, then the most you can pay is $350, if your income is less than $24,000, it is about $450 and now, whatever your income, the maximum would be $250 plus $315, $565.

In Quebec, for those who are non-GIS, the maximum co-pay is $750 a year. It is considerably more and if you were part of a GIS, it is $500 a year. You can see that that is considerably more than it is in Nova Scotia. So it is difficult, Mr. Chairman, from a research point of view to make the comparison because they would not have factored in there and I think it is important because clearly the point from the honourable member is costs. He is talking about the increase in costs. Believe me, I am not saying that there was not some element, unfortunately what you are saying, there is some element. We have to realize that maybe a bit of that is true but, however, if we are interested in the greater good and protecting that program, you cannot make a direct comparison as the honourable member is trying to do because if you were looking at it from a research methodological point of view, it would not stand up to scrutiny.

[Page 26]

MR. DEXTER: I am not sure what the minister is saying. He says Quebec is Quebec and Nova Scotia is Nova Scotia, and that is all true, but people are people and they respond in the same way, whether they live in Montreal or if they live in Halifax. If you increase the cost of the prescription medication that they require in order to enrich their lives, in some cases, to have lives, then you have to understand that when you increase the burden on those people there are going to be some direct results that are quantifiable, that are not lost on officials within your department. It is true, and I did say in my remarks, that there are differences in the program and I said the premiums in the Quebec case are tied to income. I don't know the details of how they index them, but I know they exist.

What they found in this study was that the increase in the use of health care services by income security recipients who reduced their use of mental illness medication did not offset the savings realized by the government, even for this population that was particularly vulnerable. According to health economist, Eric Latimer - the investigator in charge of that particular part of the study - an estimated $4.5 million was attributed to the additional cost of hospitalizations, medical visits and emergency room visits.

So, what I am trying to get across to the minister, and to all of us here whether you are a member of the government or whether you are a member of the loyal Opposition - and I would remind the minister that is our job. You can oppose and still be loyal. That is the great thing about the parliamentary system - my job is to see to it that the system you put in place, inasmuch as I can affect it, is the best possible outcome for the people of my riding and for the people of the province. That is why I am here to help. What I am trying to tell you is that if what you are doing ultimately is going to cost you more than you are going to save by instituting the co-pay system, why bother to go ahead with it? That is the simple result of what it is that you are doing.

If I am wrong, then I ask this question, can you supply me with the data on which you based your decision to go ahead with the co-pay? If you can tell me drug utilizations are not going to go down, if you can tell me this is not going to affect the number of seniors and the kind of medication they are going to be able to afford, just show me the data you have that supports that. For example, one of the positive things in this report from your perspective would be that there was a beneficial effect for elderly persons who were regular consumers of medication considered less essential. That is true, but it didn't offset the problems that came about as a result of those who needed essential medication. I attended, not more than I guess a week ago - sometimes you lose track of time in here because it all seems to be compressed - I listened to the minister stand in the Red Room and talk about the data that had come forward to the Department of Health the first time with the facilities review. He said that for the first time we have quantifiable data on which to base decisions and he talked about evidence-based decision making.

[Page 27]

Evidence-based decision making is more than just a slogan; it is more than just jargon; and it is more than just a convenient phrase that you can use at a press conference. If you are truly committed to evidence-based decision making, then where is the data that supports the decision that you made? That is my question, Mr. Chairman.

MR. MUIR: Mr. Chairman, I am pleased that the honourable member has raised that point, and it was raised to a certain degree too by the member for Dartmouth East. We made this point - and I am pleased we have his support - that decisions affecting health care should be made in evidence, and too many decisions about health care in this province have been made for other reasons. That does not mean that they were not good decisions, because you can make good decisions for good reasons; you can make good decisions for bad reasons; you can make bad decisions based on good reasons; and you can make bad decisions based on bad reasoning. Obviously, what we are trying to do is to match the good and the good. That is what we are about, and I think that member supports us.

You are referencing the literature on some of the drug utilization. The other portion of that is I guess if we look at the overall determinants of health, and we know among other things that this study, as you have described it, looked at one factor. I believe that is what you said. According to the Canada Health Study released last fall, which perhaps the honourable member has taken a look at the results of health in Canada, these indicators, there were a large number of factors that influenced the health of people. Clearly you put it right on there. The lower-income people seem to have greater health problems than those in higher levels, but it is not just drug utilization, Mr. Chairman, it is education and housing and all kinds of things. We honestly believe for things such as the honourable member was talking about, educational initiatives and the move to community health boards, getting away from regional health boards, and having a lot of decision making and health plans put into the communities will help address these things.

I am really convinced - I don't have any hard evidence on this thing - drugs are not really the solution to a good many health problems; education is and lifestyle is. If we can do things about education which would help lifestyle, then it is a lot more beneficial than simply making the access to drugs free.

I would, Mr. Chairman, love to have been able to stand up for the Minister of Finance and say that we are going to implement a universal Pharmacare Program here in Nova Scotia and there will be no charge, but the fact is the cost of our pharmaceuticals in Canada last year, for the first time - and this was borne out again yesterday - was greater than the cost of physician services. There are all kinds of high-priced technology, advanced drugs. One of the things that happens when we are talking about drugs, and it's kind of a thing, I suppose it wasn't until after I got into this position I fully understood it, that there is a federal agency that sort of rates drugs, verifies them. The honourable member is aware of that, he is nodding his head. All that agency does is says whether it is safe or not. It doesn't say whether it is

[Page 28]

cost-effective. It just means, you take it and, by and large, it is not going to hurt you. That is all it says. It really does not adjudge the efficacy, if you wish to use the word, of the drug.

We get into a lot of the talk about drugs and what drugs, and we also have a formulary review here in Nova Scotia like they do in other provinces. This is made up, not of Ministers of Health, although there perhaps would be some who would be qualified to be on it, but persons who are expert in the fields of pharmaceuticals and indeed research, such as the honourable member was talking about. They make recommendations about which drugs are to be included in a provincial formula and which ones should not be included.

I think last year in this province the number of drugs that was added was something like 83 and the number that was subtracted was in the mid-teens. Where is Derrick - if I can get somebody to nod his head on that thing - but my memory would be that. So there are drugs coming all the time to try to provide a Pharmacare system and some protection for seniors. As I say, every other province and territory does this. I think I shared this with the honourable member, that I believe the most expensive Seniors' Pharmacare Program in the country comes from Saskatchewan where Mr. Romanow is the Premier.

It is not a political thing what I am trying to point out. I guess my message is that he understands that this is something that is in effect right across Canada and he knows as well that if it was financially possible at this particular time for any government in Canada to do away with Pharmacare costs, not only for seniors but for any of its citizens, that would be done.

MR. DEXTER: Mr. Chairman, I understand what the minister is saying, but those are what we would refer to as rabbit tracks. I mean it is way off the topic. The choice was not between no program and this program. The choice was between doing what it was that you said you were going to do in 1998, when you were running for government, and the commitments that you made to seniors. It was maintaining the system as it was, something in between those, you know, there are any number of variations. It is not just simply that you choose to do no program or this one. I think that that really unfairly tries to place a false set of circumstances before people. When you choose to pay the deputy minister $180,000, when you choose to have an associate deputy minister, when you choose to beef up the administration budget, whatever it is that you choose to do, that choice results in a corresponding choice that you have to make in programs like Pharmacare and that is where you find yourself today.

I guess that is why I am having difficulty with it. To get back to the question, Mr. Chairman, that I asked earlier, what I wanted to know was whether or not you knew? The minister said there might be some of this to that, it might be that utilizations will go down, and it might be that hospitalizations will increase, or at least that is what he seemed to be indicating and what I would like to know is, what data the department reviewed in determining what impact moving the co-pay to 33 per cent was going to have? Do they know

[Page 29]

how much that is going to increase emergency room use? Have they calculated, as gruesome as this may sound, how many more deaths there will be as a result of the decision? Have they calculated what the increased number of institutionalizations will be? Have you looked at that data?

MR. MUIR: Mr. Chairman, I would like to go back to a point that the honourable member has raised twice. He was talking about the premium for Pharmacare. Indeed, in the period leading up to the 1998 election that was in the blue book. However, after that particular election, in consultation with seniors, the decision was - and I want to stress this, in consultation with seniors - that the premium should be retained and less co-pay. It was a balance put out. So if he wants to know why he effectively did not understand it for a person who has read that blue book so carefully, I am surprised that he could not remember that distinction. I know that your colleague, the member for Dartmouth North, could have pointed that out and probably would have corrected you, had he heard you say that.

Secondly, and the question that you have raised, that is a good question and I will have to get the answer on it for you. My speculation is that there has not been a widespread study on that done in Nova Scotia, but I will check with the people who are in that section and try and provide you with that information.

MR. DEXTER: I wonder, given some of what I consider to be rather dramatic results of the study that was done with respect to the increases in the Quebec plan, whether or not the minister does not feel that if the information does not exist, that he should try and find out what effects the institution of co-pay is going to have on the seniors in the province?

MR. MUIR: I guess the straight fact, Mr. Chairman, is that utilization continues to increase, if putting in co-pays and a premium, what it has really meant is that for a lot of people who would not have had access to drugs, they are now available to them. I don't know if the honourable member is advocating going back to a system where there is no Pharmacare Program, and I don't really think that that is what he is talking about, although some of the statements that he has made would tend to make me think that, he is clearly not promoting the sustainable one, but the information that he has presented, as we move to a more infra-base and base system, we get patterns of usage and whatnot.

I tend to think, as I said earlier, Mr. Chairman, education about drug use, better and healthier lifestyles, cutting down, and we have to start early to do this. I was reading, for example, today in The Chronicle-Herald, an interesting statement. It talks about cancer mortality here in Nova Scotia and by the way, I guess, somebody said to me, will you look at this. Well, people have said to me, if you live long enough, you are going to get cancer. That is it. It may not kill you, but you are going to get it. So if we want to live to be 150, as some of us do, you can be sure that we are going to be probably afflicted with something by that time.

[Page 30]

What I am trying to say - and I have been trying to point this out - is about smoking. Unfortunately, I think the highest percentage of smokers would also fall into the highest category of drug users or prescription drug users. I think you would find - you are not a smoker, are you? You would find, I think, that there would be a correlation between smoking and prescription drug usage in later years, that smokers overall, their health is not as good as people who don't smoke.

What it said here is, studies show that if young people don't smoke by the time they are 20 years old, they are not likely to take it up later on in life. I guess one of the questions when we are talking about this and you are talking about evidence-based decision making, these are studies, and we are acting on these things. Clearly the honourable member knows what a detrimental effect smoking has on the health of people, is would we be better off to concentrate more of our efforts on lifestyle anti-smoking crusade, which indeed we are going to roll out an anti-smoking campaign before too long, and if you are forced - as he knows in politics sometimes you are forced to make choices - which choice would he make?

[1:00 p.m.]

MR. DEXTER: You know, Mr. Chairman, I find this fascinating. I first want to say that I want to take the minister up on his commitment to table for this committee the information and data on which he is basing, he said he would go back to the department and find out what information they had and he would table it for us. I would be very pleased to receive it, and if I misunderstood, I would like the minister to correct me.

I will say again, I realized you were speaking with your staff. What you said is that you would go back to the department and you would look for what information you had on the effects that this was going to have on the seniors' population and you would table whatever data it is you had in relation to the effect of co-pays on seniors. You are nodding.

MR. MUIR: I think the other thing, too, is this whole thing and the line of questioning the honourable member is taking is pretty detailed, but you also got into the question, do you increase premium or do you save premium, more premium and less co-pay? Probably not a simple answer to what he said, but I think I answered this question for him on the floor of the House, that when we finally decided on what the co-pay would be versus percentage, versus limit and so on, we presented some options to a representative group of seniors, and we took their advice to determine the final form of that plan.

MR. DEXTER: Again, I appreciate what the Minister of Health has to say. I was actually trying to get from him or restate exactly what it was. At one point in time - and perhaps we have to go back and review the transcript to see this - I asked him if he would table the data on which the decisions were made to establish the level of co-pay and what effect that was going to have on the health of seniors. I understood what the minister said was that he would go back to the department, find out what information was available, and he

[Page 31]

would table it. I was simply asking him if my understanding was correct. He is nodding. Okay. Thank you very much for that commitment.

Now, I would like to take the minister up on what the roll-out of that question was, because the first thing he did was he made the jump from seniors, then he went into the determinants of health, and then he picked up the piece of paper containing the story from The Chronicle-Herald, and he talked about tobacco cessation and tobacco control. Well, this is all very interesting to me, Mr. Chairman, because the reality is that this year the Government of Nova Scotia will collect $80 million from tobacco taxes - $80 million - and do you know how much they are going to spend on tobacco control? Any idea? They are going to spend $293,000.

As you know, and I certainly recall, the tobacco taxes went up six cents. I remember standing out there in the foyer with the Minister of Health and reading the press release that was put out by the Department of Health. Clearly I felt that because they were putting the taxes up - and they said this isn't a tax grab, this is about having tobacco cessation programs - they were going to invest more money in tobacco cessation programs. Are they doing that? Absolutely not. In fact the budget this year is going to be $91,000 less than it was last year.

To stand up and say we have to start early with these people and teach them proper lifestyles, there are a lot of determinants before they get to be senior citizens, well that is all well and true, but you have to put your money where your mouth is. You can't just simply stand up and say, oh well, you know there are a lot of things that go into these studies that we have to consider, and tobacco is one of them. That is not enough; that is not good enough; and that is not a justification. You have to actually put the money into the program.

I want to give you a couple of illustrations. The $293,000 is 0.375 per cent of the actual amount of the tax collected. I know the Chair has on numerous occasions drawn the attention of the House to the fact that we don't spend motor fuel taxes on roads, and in fact he said that was a commitment of this government, and perhaps we will get to that in another estimate, but the reality is not only do they not do that, but they don't spend the money they get out of tobacco taxes on things like cessation programs. They don't.

Imagine that, Mr. Chairman. For every $1,000 that is collected, they spend 4 cents on tobacco cessation programs. Now I know this tax goes into the General Consolidated Revenue, and some of it is spent on cancer care programs and on other things, all of which is commendable, and the reality is if you are going to do what you seem to be saying that you wanted to accomplish, which is to affect the determinants of health, then the way in which you do that, as you said, is through education.

How do you do that? You spend money on smoking cessation programs. I am not trying to be pedantic about this, I am just trying to tell you that I like to hear what it is you are saying but then, because I also agree with evidence-based decision making, I look for the

[Page 32]

evidence to support the assertions you make. It is not there; in fact, not only is it not there, the opposite is there. You are not investing more in smoking cessation programs, you are investing less. Isn't that true?

MR. MUIR: I guess the quick answer for the honourable member is you have to put everything in perspective. I say that looking at one of the things we have done. We have reorganized our own department to set up a particular section that is going to deal with lifestyles. We are currently working on a tobacco cessation project with the other two Maritime Provinces which will be rolled-out before too long. There is a working group on health promotion and disease prevention preparing a report which will focus on nutrition, physical activity, and on early detection of health problems and intervention. We have a $900,000 platform issue for this very thing, and that will be done.

I will say to the honourable member that the numbers you were looking for in tobacco control, a lot of those things are for the individuals to go around and see if someone is selling to minors. There are other elements of health education. So you have to, in all fairness, Mr. Chairman, look at the whole picture rather than just precisely that thing, if that helps you a little bit.

MR. DEXTER: I am prepared to look at all the other programs. Perhaps you can tell me where this increase is? Health Promotion is down by $150,000. Addiction Services is down by $50,000. Just tell me where it is. Where are the increases in the budget that are going to support these programs? If they are there, great, but I just don't see them.

MR. MUIR: Mr. Chairman, I am really surprised at this because if you look at Page 13.9, you will see Public Health Programs. The estimates for that have gone from roughly $350,000 up to about $1,250,000.

MR. DEXTER: Well, will the minister tell us today that the programs that he announced, or which he said were going to be rolled out, the campaign measures to discourage smoking in the province and new initiatives to help smokers who want to quit and strategies to curb smoking among pregnant women and people at risk such as those with respiratory diseases, can he tell me whether or not those program costs are rolled into that line item?

MR. MUIR: Mr. Chairman, I would refer the honourable member to Page 13.4, and if he looks at the lines there, Tobacco Control and Health Promotion, we are going to come up to about $1.35 million there. Also, the Tobacco Control initiative that is going to roll out among the three provinces, and I think the honourable member understands why it is very advisable to work with at least the other two provinces on this. So there are dollars in there for that type of thing.

[Page 33]

I think, as well, Mr. Chairman, as we move and we are moving, we have legislated community health boards and community health plans, that in addition to the initiatives that are coming from our department, there would be initiatives in the individual regions and will be in the individual district health authorities. The honourable member probably hasn't had the opportunity that I have had to go around and visit the regions of the province and find out some of the great initiatives that have been undertaken in terms of a healthy lifestyle, education, anti-smoking programs, by the community health boards themselves.

MR. DEXTER: I am astounded. I am not just here for the good of my health, Mr. Chairman, and I am not here just to engage in sophistry with the Minister of Health. I asked him about a certain specific smoking cessation program. He referred me to Page 13.9 and the increase in the amount of public health services programs. I asked him a very simple question. Is the amount allocated for these programs in that line item? I was prepared to accept a simple yes. Instead what he does, he gets on his feet and he refers me back to the exact items that I had just referred him to, each of which went into decline.

It is very unfortunate, I mean, that is true, I have been in the unfortunate position of having to explain this budget to the minister now for almost three days. Perhaps I will have to continue with that because it is clear that he doesn't understand it. There is another initiative that you could undertake other than closing hospital beds or increasing Pharmacare programs.

There is another thing that you could do, you could go after big tobacco. You could sue big tobacco for the cost they are imposing on this province, just like what is being done in British Columbia, just like what is being done in other provinces; they are continuing with that, just like what is being done in the United States. There were big awards made to people in the United States within the last few weeks. You could do that. Will you undertake to at least look at that and to see what is going on in other jurisdictions?

MR. MUIR: I can tell the honourable member we are actively monitoring that B.C. case. Unfortunately, it was about three weeks ago - well, the province didn't come out the winner in that thing. Now, he has just indicated it is going to the Supreme Court or something like that.

MR. DEXTER: That is my understanding.

MR. MUIR: Yes, okay. We continue to monitor that and, obviously, we would be most interested and anxious that, if the courts found, in Canada, the tobacco companies were liable for that, we would be up to the plate pretty quick.

MR. DEXTER: Mr. Chairman, it is still regrettable that of all the tax that is being collected, for every $1,000 of tax they collect through tobacco taxes, they spend four cents. That is the ultimate truth about the commitment of the government.

[Page 34]

I want to talk a little bit about something else actually. The minister mentioned earlier, and I have not had a chance to hear from him the detail on this, but he talked about an insurance surcharge on companies when people are involved in motor vehicle accidents. I am afraid I don't know exactly how that works. I want to share a little bit with the minister about the insurance policies and the way that those work when people are injured. I would like at this point for him to explain to me, if he can, exactly how that revenue generating program is going to work.

MR. MUIR: What it basically is, right now on the average, or up until this year, there has been an $18 per premium; it is sort of like an unsatisfied judgement fund, and that money was put into the province. That premium has been increased from $18 to $25.

MR. DEXTER: I wonder if he can tell me if that is simply on every policy that is issued or does it result from actual attendances at hospital by individuals, or is it just industry-wide on every motor vehicle policy that is issued there is a, I think he said an $18 surcharge? Is that what I am to understand?

MR. MUIR: It is on every policy, Mr. Chairman, and the charge in the past was $18. It had not been adjusted since about 1992 for CPI. What happened, basically, is that the province was losing money on this thing, and as an insurance company our policy is now trying to obtain cost recovery where we can regain it, and there are some other initiatives that are parallel to that, but that certainly is one. Probably the honourable member for Dartmouth-Cole Harbour was like me, he didn't know he was paying that $18 on his auto insurance policy, and we have increased that to try and get back some cost recovery.

MR. DEXTER: Mr. Chairman, I wonder if the minister has considered this, the insurance companies, when they issue their policies, the way they determine the premium that is to be paid by the policyholders is that they look at their costs. If you increase the cost to the insurance company, what they do is they turn around and they pass it back to the consumer. So I was wondering, does the minister understand that essentially this is just another fee that the government is charging right back to the public?

MR. MUIR: Mr. Chairman, there was fair discussion about this, when the decision was made to go with this during the budget preparation process, and I am just trying to remember the details of it, but obviously, I suppose there will be some passed back, but I think the general opinion by our people was that it might be shared at that point. The situation is that if third party liability comes up, then we are going to ask people to absorb the full costs and coupled with that, for example, which I suppose that will be a question anyway, but - no, I will let him find it.

MR. DEXTER: I suppose the other part of that is if you increase the cost of the policy, you also increase the payment of the health services tax that is paid on the policy. So you not only get the increase in the premium, but you also get the tax increase on top of that.

[Page 35]

So your consumer not only pays an increased insurance cost, they also pay an increased tax cost. I mean there is only one consumer out there, again, they get to absorb it.

I am just going to pass along some other information to the minister and perhaps he can share it with his Cabinet colleagues. Mr. Minister, the standard insurance policy in this province includes in it something called, Section B, which has $25,000 in it for the payment of non-insured medical services. For example, if you want to go to a private physiotherapy clinic, you can get that covered under your insurance policy. The problem is, it has been set at $25,000 for many years, more years than I can remember, and in this case, people who are chronically injured, exhaust the $25,000 limit in very short order. Really, Section B of that standard auto policy has to be revisited. The weekly indemnities have to be increased because when they aren't, what happens is the families fall into, in many cases, social assistance and on to other income security measures. There is just not enough in there to cover their actual costs.

It would be, I suspect, in the best interests of the government to actually amend the legislation to see to it. It has already been done in New Brunswick. Your staff may know, I don't know if this is something that has come up with them or not. It has already been increased in New Brunswick, and I am sure the Insurance Bureau of Canada and the Insurance Institute in Nova Scotia have information that they would be more than willing to share with you on that issue. It is one that directly relates to people who are injured as a result of motor vehicle accidents and who, therefore, have an impact on the health system of the province.

You mentioned earlier about dentistry, that insurance coverage will now cover children's costs. What I would like to know, Mr. Chairman, is whether or not he has done any calculation on what impact that is going to have on insurance premiums?

MR. MUIR: In the course of arriving at that decision, Mr. Chairman, there were discussions with the insurance industry, and those discussions continue.

MR. DEXTER: Well, I assume - I guess I shouldn't assume - I will ask, did they indicate to you what the increase in the premium would be in order to cover those costs.

MR. MUIR: I expect, Mr. Chairman, there would probably be some increase, but it is not yet determined. I think the thing the honourable member has to keep in mind is that for years, people have been paying for this protection, yet the province has been picking it up and paying it instead of the insurance company.

MR. CHAIRMAN: Thank you, and that is time.

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The honourable member for Dartmouth East.

DR. JAMES SMITH: Mr. Chairman, just to clear up a couple of points as we left off earlier. I am just wondering, in the budget, information technology, is the $4 million the minister spoke of for this year, other than the $1 million or so that is in there under some of the earlier ones, under Chief Information Officer. Where is the other $3 million or the $4 million that he mentioned was separate? Where is that located in the budget?

MR. MUIR: Mr. Chairman, $2 million is included in the Department of Health under Other Programs, and the Department of Finance has $2 million which will contribute to that as well, for the total of $4 million.

DR. SMITH: Thank you, Mr. Minister, that is why I couldn't find it, I guess. Just looking at certain areas around the province in the Cape Breton area, specifically at this juncture, looking at the Cape Breton Health Care Complex and their restrictions on their budget, looking at the numbers of potential job losses there and changes, I am wondering, are there any more plans in the area? The Health Facilities Review Committee was announced and the example used there was the New Waterford Hospital and the changing role of hospitals. Are there other facilities in that area that are being slated for a change of role, moving to long-term care? I keep coming back to that continuum of care and looking as to where, if long-term care is 99 per cent occupied, so that is really 110 per cent in some instances, where would this long-term care go? Is it part of the plan of the department to move in the change of designation or the changing role of hospitals? If so, particularly in the Cape Breton area, in that area, a string of four or five hospitals around the perimeter of the health complex, is there any designated change of roles for those hospitals?

MR. MUIR: Mr. Chairman, at this particular time, there are no plans to do that. Notwithstanding that, or as a qualifier, I understand the clinical services footprint is now being developed, and we will await the results of that, I can't predict the future.

DR. SMITH: Just an update perhaps, Mr. Chairman, on the nurses bursary program, and the status of that at this juncture. I know it was slow getting under way and people weren't even able to get information on it. The status at this juncture of that program and when the first people would be entering in that program?

MR. MUIR: My understanding is, Mr. Chairman, that program is up and running. The applications are available. Now whether there has been actually money distributed already, I don't know. The program is operational.

DR. SMITH: Mr. Chairman, looking at the nursing profession in general, I know the minister has been quoting quite large numbers that we on this side of the House, or at least in this particular section of this side of the House, don't believe are realistic, certainly as new positions. Can the minister today be specific, that he has more information at his disposal as

[Page 37]

to how many new nursing positions have been created specifically since they took over as government in August last year, not counting the change from casual to full-time positions? Could the minister be specific as to those numbers?

MR. MUIR: Mr. Chairman, the best information I have is in my other briefing book. I apologize. It was out of the Question Period book as opposed to the Estimates book. I can tell you that there are more nurses working in Nova Scotia at this present time according to figures released by the Registered Nurses Association in Nova Scotia in December, than there have been for some years. There are more RNs employed in hospitals. There are more employed in nursing homes. So we reckon about 152 conversions from casual to permanent positions and I think it is a matter of taking the difference in numbers and doing the subtraction.

[1:30 p.m.]

DR. SMITH: Two things, Mr. Chairman. I wonder if the minister could give us an idea of how many nursing positions, or in light of what he has just said, are included with the cuts in the acute care sector? Will there be less nursing positions then or will the hospitals be ordered by the Department of Health, in spite of these cuts, to absorb the cuts and not lay off nurses? As of today, what is the optimum number or what is the goal for the department for this year? Will the hospitals be allowed - I notice you mentioned earlier about core services not being changed without an okay from the department - anyway, I will leave that question for now. The numbers of nurses, does the minister see less nurses or more nurses? What is the goal? Will there be a movement away from the original commitment of nurses now that he has found out he may not need so many that he is going to cut acute care costs?

MR. MUIR: I think probably this government has made a greater commitment to nurses than any other in recent history and our commitment to the nursing profession remains the same. We have increased the number of spaces in nursing schools, we continue to work with the profession to try and find a solution. I don't stand up here with any great degree of joy to say that yes, we could use more nurses in the system. Clearly, we had a little difficulty down in Yarmouth, and that is an issue, but we have not only increased the training seats, the bursaries to which the honourable member alluded, but also our primary health initiatives, if we can keep some people out of the acute care facilities and perhaps some different roles for nurses, including nurse practitioners. We maintain our commitment to nurses and I guess what he is saying is, I don't know if he is trying to fearmonger which he was very good at accusing the Opposition, including the person who now occupies the chair, the last year he was talking about this, but the objective of our reorganization is to continue to deliver health services and productive front line care providers. We don't expect nurses are going to be laid off.

DR. SMITH: Has there been any order given to the acute care hospitals that they are not to lay off nurses at this juncture? What is the status there? There is a message that they are to cut their services, there is no increase in services basically, except in a few minor areas.

[Page 38]

Has there been a direction to the acute care hospitals that they are to maintain the status quo and is the minister saying that there are enough nurses now? There will be no promise of any more nurses coming into the system?

MR. MUIR: The number of nurses that are available across the province varies from region to region. In terms of whether they have enough nurses or whether they don't, I think there are two aspects to this. One is the hospital side of the equation; clearly there is a shortage of nurses for a good many of our hospitals. We hear stories of people having to work more overtime than they wish, now I realize that a lot of the overtime is probably because people don't mind working it because they get paid for it - casuals. On the other hand, as you said, in Yarmouth, they reached a point where they felt it was better to close some beds and give the staff a bit of a break.

The absolute number of nurses. It appears that there is certainly room for nurses in the province, I guess I would say that. As the member knows, there were a couple of reports last year that suggested that, but as we move with this clinical services footprint and we move the facilities review and all of these things, we are going to have better data to make an absolute statement. He is asking me how many nurses there should be in this province. All I really could make is a general statement that there would be a sufficient number so that every facility had the appropriate number of nurses to deliver the services in the way that they wished. We will continue to do our work, through the nurses bursary program, through increasing the seats, but again I want to emphasize that we are working in the profession to try and address these needs.

DR. SMITH: What I was trying to get at, the profession is saying there is a need for so many hundred more. What does the government feel, and the minister wants to skate around that and I can appreciate that because he may not want to come right out at this juncture, but when you have had time, as you mentioned, dealing with your budget, to know what the impact will be. Perhaps there will be a movement from acute care into home care, but then again, we look at that budget and we can't see how that is going to pay, unless the nurses will work for free. The minister did mention about people wanting to get the overtime and I think that is true in some cases, rarely perhaps, but I will tell you the stories I hear, that is not really what it is. For every person who may say they want to get extra money from overtime, you will hear five or six or ten stories of nurses who have worked a double shift and they want the next day off with their family and they get a call.

I think the movement to casual is positive, so I guess we don't have a determination or one that will not be shared today with that, but the spaces that were announced under our government that the minister has mentioned, he can take some credit for keeping that program going, at least that wasn't cancelled.

[Page 39]

Is the government actively assisting in recruiting nurses at this juncture? Or are you leaving this to the various institutions and facilities and if so, what are those recruitment initiatives? I am thinking of advertising in journals, newspapers and can the minister be specific as to what the recruitment program for nurses looks like or are you anticipating with your cuts there will be lay-offs so the numbers will balance out and there won't be a need for recruiting new nurses?

MR. MUIR: I can't give specifics for the individual institutions who are doing their own recruiting, of course we have our nurse policy advisor who is working with the institutions. I can tell you that I see ads for nurses in local newspapers, I know that some of the individual institutions have posted them on the net, I know that other institutions through the community health boards have written to people from the communities and said, look, if you want a job in our facility or if you want to come back and work and you are a registered or a practical nurse, then there would be an opportunity for you to come back home.

There have been a number of initiatives that way, I can say that our nurse policy advisor continues to work with them. Don't forget, we also have the long-term care sector where they use nurses and similarly in home care. It is not just in the hospitals and as you pointed out, the overtime is not important and I wasn't trying to imply that. I was only saying that some people are willing to do that, but you are right, I recognized Yarmouth because people got to the point where they didn't want to do it anymore, they needed some time off and that was done.

I can say as well, Mr. Chairman, that the department attended a job fair for nurses, participated in one of those and we have also developed a provincial website to advertise for nurses.

DR. SMITH: As long as you aren't like community services and take it off that web site when they were advertising for social workers, now it is child protection, I guess they are interchangeable. I think the law dictates they should be the same, but anyway we won't get into that because the web spaces tend to disappear sometimes.

With the Home Care Program, on Page 13.8 of the Supplement and the issue of provincial programs under Home Care, could the minister explain more about what that is. We have the Central, Eastern, Northern and Western Regions and then we have Provincial Programs. There has been an increase there, with the others having a decrease, all of them are decreased. Can the minister explain that, what that does involve and why that would be?

MR. MUIR: Mr. Chairman, as the honourable member just mentioned, a number of the seniors' programs, including the Seniors' Secretariat, came over from the Department of Community Services. They reflect the increase there of about $8.2 million, which includes $1 million for respite services, which was a platform issue, and then the cost primarily of bringing home community services into the Department of Health.

[Page 40]

DR. SMITH: In those areas there, under those regions, the Central, Northern and Western Regions as we know them, and the restrictions within those budgets, those decreases, will there be more nurses or less? We know the nurse is the backbone of the health care system but in the Home Care Program, they are crucial. So we are going to have the people who should not be occupying acute care, moving out somewhere into long term, that was the purpose of my question about renovating new facilities in Cape Breton and other areas, like the New Waterford Consolidated Hospital. So how about home care? Do we find any increase there for nursing services?

We talk about the need for respite care, rehabilitative nursing care delivered in the home. Within these budgets, in these particular areas, and I know the transition may or may not take place to the nine authorities but at least this is the category now of funding within the regions. We talk about moving health care into the community and closer to the people. Can the minister guarantee there will be more nurses in home care to deliver that service, with the reduction in all of the budgets, except the provincial program? He said most of this is what has been transferred from Community Services.

MR. MUIR: Mr. Chairman, the honourable member has asked about home care nurses and it is our intent to protect core services. We think actually there is going to have to be a fair bit of administrative efficiencies to pick up some of the decreases that the honourable member has referred to.

DR. SMITH: I am sorry, I apologize, someone spoke to me at the time and I didn't get that other comment. I was asking about any more nurses in health care and I didn't quite get the answer. I wonder if the minister would be kind enough to repeat it for me. I heard about efficiencies or something like that but I (Interruption) yes, and core services.

MR. MUIR: I guess if I go back, I believe the honourable member had asked, is the number of nurses in home care going to be reduced? (Interruption) Increased? Hopefully they could be increased but as we move into this continuum of care and get a lot of this care out into the communities as part of really a primary health care system, Mr. Chairman, if we get this thing working right - and it is not going to be a one-year shot to get it working right - the long-term care, the home care, and all of those things will be part of the district health authorities and this seamless and integrated service system will be in there. It is not going to happen just like that, overnight, unfortunately.

However, I can say, Mr. Chairman, that we are going to try a model of that before too long, in the Cape Breton area, to see if we can achieve that in and around the Cape Breton Health Care Complex. So we think, like other segments of the health care system, once we start to integrate services and there are some administrative savings, if we can implement these savings then obviously they would be implemented to protect the front line workers.

[Page 41]

DR. SMITH: I would like to compliment the minister. I think that was a gallant attempt. I don't know what he said but maybe somebody else did. We don't get the Hansard right away. I listened to it, he is going to integrate, so he must be going to take a whole bunch of houses out there in the community and put them closer together. But there are some areas perhaps that could be better coordinated. I know that some of the health care workers come from different agencies, to the same house even sometimes, so there is some integration there, but I am still not clear about cutting money out of acute care, cutting down the beds in the acute care services. You can talk about what you want to but when you take money out of acute care you are talking about nurses' salaries, basically, and support services' salaries.

You are not going to increase your long-term care or you might change the role of the hospitals but they don't know what those are yet. The New Waterford Consolidated Hospital, we had started, and they finished that and I thank the minister for doing that. Then home care, we are going to integrate and have a seamless continuum of care but we are not going to have more nurses, so the only thing I can do is put the people closer together again in their own communities, and maybe you could have them all together and lined up in a community hall somewhere and that way you could save nurses. I don't see how you can cut the budgets and do that. So unless the minister wants to explain further, I didn't quite understand.

Now you talk about nurse practitioners and their changing role in the primary care area, that is certainly a team approach. I would point out to you, the goal of that program is to offer services that are not being offered now, like physiotherapy, nurse practitioners, those things. It is awfully hard to do that at the time you are slashing budgets. So maybe I should just leave it and say that maybe it is the answer I expected.

I am just interested in the whole philosophy of all of this. I understand the continuum of care and the seamlessness and the movement of patients through the system, or the residents, and how the dollar should flow through, and that is the funding formula, whether the person is in the Kentville hospital and moves to the QE II Health Sciences Centre and then moves to the Nova Scotia Rehabilitation Centre that the funding formula should reflect how that money flows. That part I understand, but somebody has to see these people and somebody has to look them in the eye, or somebody has to call on them, and you just can't have a continuum of care and cut the services.

You can talk about the bloated administration in health care if you want to, and the Premier said in his election promises to Nova Scotians on television every night, or several times a day, that he was going to take $46 million out of administration and pump it into health care and save it. But sooner or later there has to be somebody who goes looking at those people and attends them. I don't know if the minister, again, I will have one more attempt, are there going to be extra nurses in the Home Care Program in Nova Scotia?

[Page 42]

MR. MUIR: Mr. Chairman, there is a lot more to home care than just the nursing service; there is a whole variety of services that are delivered by personal care workers or practical nurses or registered nurses and all of these things. The fact is, as the honourable member well knows, that most of the nursing services provided in home care are contractual arrangements with VON. One of the things that we will continue to do is to provide these services through the contract. The cost per unit of service is a little higher than we would hope, and we are endeavouring to lower that cost of unit service, and I really don't understand the honourable member's point about taking nurses out of home care. I am not sure exactly what his point is.

DR. SMITH: My point simply is, Mr. Chairman, if you don't increase the budgets or you decrease the budgets, and you are paying basically salaries for the budgets because you don't have facilities to maintain home care essentially, except administrative, then why wouldn't you be either decreasing nurses or not increasing them? I agree with nursing care often given by an LPN and the role of the homemaker, but that is what we are seeing cut back now. I mentioned earlier about the person who had a homemaker, went into the hospital, came home and had her services cut off and was unable to get them reinstated. Other people have had that experience. When you look at the budget, you can see why that would be.

Maybe it is very simple and maybe I am missing the point here, but when I look at home care and I see it cut back, what are you going to cut back in there? You don't have facilities; you can't blame it on the workers laying around; you can't blame it on administration, particularly, unless you have started off - and, at one time there was a social assessment being done along with a nursing assessment and I think that has been more streamlined and integrated - you are talking about setting up acute care nursing and I agree, they all don't have to be RNs. But what you are talking about is moving these acute care beds, these one-quarter of the people who are in the hospital who could be better treated somewhere else. Well, that is true, but some of them are there also because the acuity of care would be much heavier than moving out.

We know that there is some picking and choosing sometimes as to who gets into which nursing home. But I know that your friend, Brian MacLeod, is going to take care of that because he has that committee, and I don't want to say anything about Brian because I insulted him, obviously, about being a Tory bagman, but we are in good hands with determining where our long-term care is going to go now because as you mentioned, I had also appointed him to committees that he represented certain organizations, but we are in good hands on that one, so . . .

AN HON. MEMBER: Don't get too hasty.

DR. SMITH: Somebody said, don't get too hasty. Seriously, the level of care is going to more acute, both in the long-term care and in the home care when you tighten the screws on the acute care and that is what is happening. We were accused of closing beds and cutting

[Page 43]

back nursing staff without home care. I think that was a valid criticism; I accepted that. That was done earlier in our mandate and we still do remain high, relative to the numbers of beds per population in Nova Scotia. So maybe there is room within that system to do something. If you are going to do it, say it. Don't use weasel words, don't cut them. Don't cut the hospitals, tell them you are not to let go any nurses; you are not allowed to cut any beds because we don't want this hassle. Dr. Butler's polls out there will go ballistic. I mean they are probably going to go ballistic on Pharmacare now anyway. I am sure polling on Pharmacare this weekend would be very interesting.

Once here, I mentioned something, the only time I was ever misquoted out of Hansard and it was the headline in The Chronicle-Herald the next day. I remember that. Of course that person is now one of the spin doctors for the Tory Party, so I hope he can read Hansard better than he could in those days. Anyway, we won't get into that. I am sort of digressing and letting the minister off the hook here because I wanted to focus on that. I think the thing is you have a majority government. If you are going to do something in health care and you are going to cut back on the nursing staff and the hospital beds, well, tell the people, because out there now they are scared. They were here yesterday, the people, and a person I recognized waved at me from the gallery. I looked and she was trembling like a leaf, or like a bird, some would say. She was really upset. She was so upset the media went to speak to her, and I give her credit, she didn't want to speak to them but that was her job.

This is what people are going through in Nova Scotia right now. I think you have to be honest with them. You can talk about core services. Other people can read this budget. It is not terribly complicated, and if you follow through, follow the money, follow the patient, it is sort of like a plug line. I really don't see where that is going to be unless you are going to make some dramatic changes and move those one-quarter people that you say, and your report says, are occupying beds that they shouldn't be occupying. You can argue that and you have some statistics on your side to do that, but if you are going to do it, you have to do it. You have to take the hit and you are going to have to take the political fallout for that. Maybe we will leave that and I hope that we have made our point there, and I am sure you will be hearing from others besides myself.

One area that the previous government did make some changes on, and I think very dramatic changes and very positive were in the areas of emergency health services. I want to just look at Page 13.5 - just to help the people who are with you - Emergency Health Services. I am just hoping there is not too much afoot here. I think at first blush, when you look at the budget and you see reductions, reductions, reductions in that service, the alarm bells just sort of go off. I would hope that is one, we will certainly serve notice on this side of the building that this is a service that we would not like to see dismantled. Maybe you have statistics on your side when it comes to acute care and acute care hospitals, but certainly in emergency services, I think the side to be on there is on the side of the program.

[Page 44]

So we see Administration reduced there, so that is keeping the Premier's promise. The Ground Ambulance Support is down, Technical Operations are up slightly and the Medical Quality Control, but Provincial Programs are substantively reduced by $1.2 million. Communications and Dispatch are down and Emergency Response is pulled, total. I would have a question on that, where that went, or why that would be, and where Recoveries are reported there; they are not reported underneath there. He mentioned the liabilities issue this morning, earlier, and increased vigilance in Recoveries, where the government may be due some money.

I am wondering, generally, what the plan might be for emergency health services. This is probably the best service in Canada as a jurisdiction being covered. There is no question it was costly and remains so, but pre-hospital care is pretty important. You go back to that continuum of care, when we talk of primary care, it is even pre-primary I guess.

[2:00 p.m.]

So we are looking at no increase, certainly some decrease overall. So are there any plans with the Emergency Health Services and where we are going?

MR. MUIR: Mr. Chairman, in summary, as members of this House know, we have a very sophisticated ground ambulance transport service here in the province. The honourable member for Dartmouth East indicated it is probably as good as any in the country. It is a very good one and it is supplemented - not only the ground service, we also have an air transport service which provides not only to Nova Scotia, but also to New Brunswick and Prince Edward Island as well. I guess the short answer is that our intent is to maintain the quality of the ground ambulance service that we have, as well as the air transport service.

MR. CHAIRMAN: The honourable Leader of the Liberal Party.

MR. RUSSELL MACLELLAN: Mr. Chairman, it has been stated this afternoon that instead of the $46 million the government said they were going to find in administration to apply to other areas of health of care to improve the health care system they in fact have spent an additional $208 million. Does the minister agree with that? If he doesn't, what figure was spent over and above what was spent by the previous government, and where did it go?

MR. MUIR: Mr. Chairman, I welcome the honourable member to this discussion. As he knows, last year when we came into office, which was about halfway through the budget year, the budget we presented was primarily not ours. We were locked into decisions that had been made by he and his colleagues. If he said it was $200 million, then it probably was $200 million. The $46 million figure, and that has been tossed around and tossed around, and I don't know where that $46 million figure - the honourable member for Dartmouth North nods his head about $46 million, too, but is that written down or something?

[Page 45]

MR. MACLELLAN: Mr. Chairman, the minister told me in the House the other day, in acute care now in Nova Scotia, 25 per cent to 30 per cent of the beds are occupied by patients who really shouldn't be in acute care. Is that correct?

MR. MUIR: Mr. Chairman, on the average, that was correct. I believe in the report, which I don't have in front of me, it was from 18 per cent to 30 per cent, depending on where you were. The highest area was up in the far eastern part of the province. This is a substantial number, but some of them, if you were looking at it as a 100 per cent answer, that is not so. Some of those folks there may have been included in the count, and it wouldn't be, I suppose, enough to really sway it from the point of view that he is taking, but there are some people whose condition is so severe it is a chronic thing, and they can't be accommodated in other facilities, so they are in the hospital.

MR. MACLELLAN: I think the minister would admit that is not an ideal situation, and that is not even a preferable situation. If you have somebody in acute care who could be in long-term care for instance, not only are they in beds that go over $1,000 a day, they could be put in beds that are one-tenth that cost and receive just as good care. For that person who is in acute care in that bed, he or she is in that bed perhaps for months. Now in acute care, the way patients come in, even with cardiovascular surgery, they are only there for a few nights and then they are gone. So, that one person in that acute care bed that doesn't need to be there, if that person was moved to a long-term care facility, that bed could account for perhaps 30 or 40 patients. The difference is marked.

When you say 25 per cent to 30 per cent or 18 per cent to 30 per cent, whatever the minister is using, in total, how many in Nova Scotia would be in that position, that is, people in acute care beds who don't need to be there and could be in long-term care beds?

MR. MUIR: Roughly around 750.

MR. MACLELLAN: The minister also knows that conversely, there are people in long-term care who perhaps could be in home care. What percentage would he say of people in long-term care could be in home care, by using his own definition? I don't know what that definition would be, so I realize the difficulty in that. What would the total number be?

MR. MUIR: We have introduced an instrument that is going to help us figure that out, Mr. Chairman. Indeed, it is in one of the nursing homes in Glace Bay as one of the pilot sites for this. It is called RUGS II, Resident Assessment Instrument. It assesses persons to determine what level of care. I don't know the answer to your first question. One of the things that complicates it is that, for example, if you have a residential care facility and you are a person who might feel uncomfortable living at home, and keep in mind that some of these people have been residents in them for a long time, and it was really like, in some ways, they operate like an apartment hotel. I will give you an example. Perhaps Melville Lodge, which is a high test one, but people go there and I think they can get two meals a day

[Page 46]

downstairs. I don't think that is a residential care facility, I don't know under which licence they operate. Maybe it is a residential care facility, but there are probably no public-pay people in there. If you get private-pay people, people who are paying privately as opposed to people who are paying public, it is difficult sometimes to isolate that. It is a good question.

MR. MACLELLAN: It is a good question. The Minister of Transportation doesn't believe that. The reason I am asking that question is that I, too, like the member for Dartmouth East, feel that the single-entry system is a very good idea and will work very well. My only concern is that the government is using the single-entry system as a means for not dealing with where we are going in long-term care and home care. I don't say we are going to have all of the answers, but if you have 750 who can be moved from acute care to long-term care, and an undetermined figure who could move from long-term care to home care, then I think it would be safe to say there is a need for more long-term care financing and yet in the budget, correct me if I am wrong, there is only $1.1 million in additional funding in this budget over the last budget, is that correct?

MR. MUIR: Yes, that is correct.

MR. MACLELLAN: There is only an increase of $1.7 million in home care in this budget over the last budget, is that correct?

MR. MUIR: That is correct.

MR. MACLELLAN: Well, we have seen in the estimates that the reduction in the funding for acute care is $72 million. The minister said, and I think with some justification, a good percentage of that is the Y2K allotment. That was a one-time expenditure, but it is still a considerable sum of money that would be left. I would say $50 million, something like that?

MR. MUIR: It is $40 million.

MR. MACLELLAN: It is $40 million, even $40 million, now, that is a main reduction. Yet there is very little to go into long-term care and home care. My concern is where are these people going to go? The reductions have been stated for acute care. Mr. Smith, the CEO of the QE II, says they are going to have to shut down maybe as many as 100 beds, and that is a concern. This shutting down of 100 beds, or shutting down of any beds, does that mean just the closure of the beds per se, or taking these people who were in these beds, and putting them in long-term care or another arm of the health care system?

MR. MUIR: I am reluctant to comment on what Mr. Smith said, Mr. Chairman, because I really only had second-hand information, although I did hear a radio clip yesterday morning. My suspicion, and I think it is important to say, at least in the clip that I heard, that Mr. Smith said absolutely no decisions had been made. That was, obviously, the quick reaction before the institutions pulled up to the table to try and work out some of these things

[Page 47]

from a collective point of view. I would expect he was talking about closing beds that were not occupied on a long-term basis.

MR. MACLELLAN: Well, there are very few of those in acute care and I think that Mr. Smith and Mr. Nurse at the IWK-Grace know, they can pretty well tell, they are familiar enough with their own budgets to know that if they lose a certain amount of money, where those cuts have to come from, and I am concerned by that. The minister, or somebody has said that the long-term care facilities are about 99 per cent occupied. If people are moved out of acute care they have nowhere to go. This is going to cause a very serious problem, an alarming problem. There is no money to build facilities, as I can see, in the budget. I just want to know what the government sees as happening here and where they see themselves going?

MR. MUIR: Mr. Chairman, I respect what the honourable member is saying and he is correct in some ways, but it would not be a wise thing, it was indicated in the facilities review report, until we get this single entry access up and running, to make major capital expenditures in long-term care.

To get a system that can accommodate appropriately, one that works, and he and the member for Dartmouth East have both recognized and I expect the member for Dartmouth-Cole Harbour will stand up and indicate that that is a very positive thing, too. Once we get some of these things in place in this RUGS II, Resident Assessment Instrument, then we would be prepared. The honourable member has been around long enough in government circles to know that - as I say, we want to make good decisions for good reasons and, as I said earlier, too many times decisions are not really evidence based and I would sooner move a little bit slower and do it right. That is not in any way to say that we may have to end up putting a massive capital investment in long-term care beds, although I would be reluctant to do it until we knew what . . .

MR. MACLELLAN: I join with the minister in suggesting that we want to make good decisions, and I would suggest to him that if we don't have the long-term care facilities, then we cannot move people from acute care beds into those long-term care facilities because the beds are not there. At the same time, we cannot realize the savings of moving these people out of acute care into long-term care, which is cheaper and just as efficient. So I don't see how the government is going to realize savings in that direction this year without causing a major upheaval and a major problem in health care in Nova Scotia. I just want to get the minister's ideas on that and see if he can tell me, based on what I have said, where he thinks the government is going?

MR. MUIR: We are moving to try and set up a system that is going to be sustainable and responsive. We need innovation not only in the long-term care sector, we need it in all sectors of government and, not to mention, we certainly need innovation in health care and that is recognized by most people. I think one of the things, in terms of capital, just to give you an example, and I am always reluctant to do this because somebody is going to say, well

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you just said you were going to do it, now go ahead and do it, so I want to make it abundantly clear, there are hospital facilities in this province that have space that is unused. You know where some of those are and I know where some of those places are. So, if push came to shove, and to deal with an immediate need, we had to maybe make alternative use of those facilities or to turn a facility into one which provided more than one level or one type of care, there are some options. Again, let me state that we have not gotten into that business, except up in New Waterford and it has worked pretty well up there.

MR. MACLELLAN: Please, Mr. Chairman, don't misunderstand me, I am not trying to box the minister into a corner. All I am trying to do is to get an idea of where we are going in health care and try to anticipate and visualize how we are going to deal with this problem. If there are cuts to hospitals that result in closures of beds, where are these people going to go, that is all. I just want to touch on the issue regarding the nurses for one minute and that relates to, just to follow up what my colleague, the member for Dartmouth East, has said, where he talked about nurses and nurse reductions, that if there are cuts in acute care, would that result in nurses being cut and, if not, why would the nurses be kept if the number of beds was reduced?

MR. MUIR: Would you please repeat the question, I apologize.

MR. MACLELLAN: I just wanted to say that if there is a reduction and if the cuts to these acute care facilities do result in the closure of hospital beds, as a lot of people have speculated, a lot of knowledgeable people, whether you agree with them or not, but it is still the speculation and still the opinion of many people, would that not result in the reduction in the number of nurses in that acute care facility? Would not the number of beds relate to the number of nurses you need and, if not, how would the nurses be used if the number of beds was reduced?

MR. MUIR: That is a very difficult question to answer. First of all, I said our intent in this whole thing is to protect core services and clinical services. That is number one. We don't expect that beds will be closed. Notwithstanding the other part of this is, and then you are getting into speculation here, that we do know that there is, obviously, a shortage of nurses in the system. There will be no real change in the clinical delivery service unless it was approved by the Department of Health. That is part of the agreement at the present time. We don't need less nurses in the system at the present time, we need more, so it is not an issue, I don't think.

MR. MACLELLAN: Just a couple of points that I want to pick up on what the minister has said. I know that he thinks that no cuts in acute care beds are anticipated but, quite frankly, they could happen. Even though the minister says that we don't need fewer nurses in the system, you need more, when the pressures are put on these facilities they are going to cut where they think cuts are going to have the most effective result.

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I just want to say to the minister that what he says in that and what he feels is going to happen is not necessarily what is going to happen and I think he knows that. Once these cuts start taking shape, this planning, and where the cuts are actually going to be manifested, is going to be a concern to the CEOs of the hospitals, to the district health authorities and whoever. I think that the minister has to give us an assurance that regardless of what happens, no matter if the cuts do result in fewer beds, that the number of nurses will not be reduced. I think it is fair to ask the minister for that commitment.

MR. MUIR: I am not trying to avoid the question, Mr. Chairman, it is a difficult question to answer because we don't anticipate any bed closures. From the information we have at present, we need nurses. Now if he is taking about the overall complement of nurses, then it is a very easy question to answer. If he is saying in terms of a particular facility, that it had for one reason or another, a service discontinued as a result of a clinical footprint or whatever it happened to be, if those people would be kept there and not have anything to do, the answer obviously is no.

Then there is the redeployment. Your colleague has talked about changes in home care, which is a real thing, and we have the shortage of nurses, either RNs or practical nurses, in the long-term care facilities. If they are going to hit the unemployment lines it would be by choice, I guess, as opposed to something else.

MR. CHAIRMAN: The honourable member has approximately 10 seconds.

MR. MACLELLAN: So conceivably, there could be the reduction of nurses in hospitals where the number of beds are reduced.

MR. CHAIRMAN: There are approximately 25 minutes left.

The honourable member for Dartmouth-Cole Harbour.

MR. DARRELL DEXTER: Mr. Chairman, when I left off we were talking about insurance premiums on the dental care program. I asked you whether or not you had calculated what the increase in insurance premiums was going to be as a result of that decision.

I guess one of the concerns I have - and I think that you go about generating what benefit this is going to be to the province - in other words, how much less is the program going to cost or how much more revenue is going to be generated or whatever calculation you go through? I am just wondering, did you take into account the fact that as the employer to one of these programs, that you would also have to contribute to any increase in the premium under the employer's portion, if that is the way the particular plan is structured?

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MR. MUIR: I believe the honourable member is referring to the child's dental program, is what we were talking about, I believe, when he left. Yes, we do recognize that again people have been paying that for a long time and never availing themselves of it. It was sort of like the decision made by the previous government, which was a good one, to make the province the payer of last resort in prescription drugs for seniors. In other words, if people had a plan that covered people in any other province, that plan had to cover people here in Nova Scotia.

MR. DEXTER: That is an interesting response. My recollection of that was it threw things into absolute chaos and turmoil and we received lots and lots of calls about people who didn't know which plan they fell under, who was going to pay for it. Certainly I heard from people who worked for insurers who said, we have no idea what this is going to mean, in terms of increased premiums; we are going to restrict benefits; we are not going to offer the same coverages. It had very profound effects. When you make these kinds of decisions, you have to understand that you have to be prepared to live with the consequences. Quite frankly, they can be quite severe on the employees. It actually reduces the amounts of benefits available to the families.

I started last time with an editorial from the Truro Daily News. I offered you an opportunity at that time, Mr. Minister, to respond, which you did. I have not seen the retraction in the Truro Daily News yet but who knows, with a little luck maybe that will happen.

I want to refer now, if I can, and I will table a copy of this after I get a chance to use it first, from the Kentville Advertiser. It is under an article called Facilities Review Hogwash M.D. What it says is, the health action coalition of Kings is terming the provincial government's newly released Health Facilities Review absolute hogwash. Then it goes on to say that - it quotes hack spokesman - Dr. Michael O'Reilly suggested on Thursday that of all of the recent comments by the minister on the state of the province's health care, this is the one that really gets my blood pressure up. It is absolutely irritating to hear some of the comments. First he suggested that the professionals were not doing it right, now the facilities are not doing it right. Where, he wondered, is the onus on the department which seems to be scurrying from its responsibilities. O'Reilly takes exception to the suggestion that hospitals could be making better use of alternate care facilities. Even if we accept that one in four patients could be managed better elsewhere, he stressed, I ask where? We have inadequate hospice care, inadequate home care, inadequate long-term care. The policies of the Department of Health haven't left anywhere standing for people to be taken for care other than a hospital. If this is health care reform, it is about time for all of us to get on a bus and get out of here.

Then he goes on to say, I am approaching the veracity of their statements with a grain of salt. All they did was show up here for a day, talk to the chief of staff. Even in our region we encompass 10 health care facilities. Two weeks is a hell of a quick look; you take more

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time picking out a car. Then he goes on to say, O'Reilly admitted, however, that there was at least one positive aspect of the review that was heartening to him. He said, after going through the same thing with the Liberals, now at least we can recognize hogwash when we hear it. It didn't make sense before and it doesn't make sense now.

Mr. Minister, I think what the doctor is doing is putting his finger on a very important point, which is that if you don't increase the number of long-term care beds and you tell the hospitals that you are not going to invest any more money, where do you expect people to go?

MR. MUIR: I was wondering, Mr. Chairman, if those comments came from Dr. O'Reilly or from the PR firm that they hired?

[2:30 p.m.]

MR. CHAIRMAN: I will ask the honourable member to table that document, please.

MR. DEXTER: I will. Just for the record, they are credited to Dr. O'Reilly, and I guess I have to take from that that the minister has no response. Is that what I am to take from this?

MR. MUIR: Well, you know I met Dr. O'Reilly on a number of occasions. He is very critical. I actually met with him a couple of times. He has some very strong feelings and obviously he is concerned as a medical practitioner. Unfortunately, about the only thing I can say about Dr. O'Reilly in terms of his immediate thing is put more money in it and it will fix it. Dr. O'Reilly was part of the system, you will have to remember, for some time. I believe he was the chief or the director, or whatever it was, at the Western Regional Health Board, when I first met him. So clearly, as I have been told, I think probably he had some input into what is going on now.

I don't want to get into public debate with Dr. O'Reilly; he is a good physician, he works hard, he serves his patients very well. They do have an active lobby in Kings County, though, and they have hired a public relations firm to put their positions forth. Perhaps you remember the little discussion we had with the emergency room physicians down there and he was among that group. We have tried to work that out with the people in the Valley and I am confident we will. They have a good facility down there and the people work hard and good care is delivered there.

MR. DEXTER: I want to follow up on this because one of the things that the Minister of Health told the people of Nova Scotia during the election of July 1999, was the following - he, along with his friends over there on the government bench - said that the John Hamm Government would be "Providing generous tax incentives to family care givers who stay at

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home to care for a family member who would otherwise be classified as a candidate for a long-term care facility." Is that in this budget?

MR. MUIR: I am proud to say that that is something this government is moving towards, that tax credit will continue to be worked on. It is not present at this particular time, but I am really pleased because that is a very real thing and it is something that this government intends to do. We are not able to do it this year, we will continue to work on it, but we have put in an additional $1 million for respite care.

MR. DEXTER: Mr. Chairman, I am glad to receive that undertaking from the minister. I am certain that at this time next year, when we are going over the estimates of the Department of Health, I will be able to refer him to the transcript or, in the alternative, he will be able to refer me to the transcript and to the appropriate line item in the budget that will account for this (Interruption) or to the Finance Minister, as he points out.

Mr. Chairman, I am going to table a letter, one for the table and one also for the Minister of Health. Sometimes in exploring the estimates here, one of the best ways to look at the budgets of the department is to take a look at a real-life situation and the way in which the life of a particular individual is affected by the decisions of the government. I have here a letter that I received from a Ms. Charlene Ward. I can table this and one copy for the minister. I am going to read it so that it is on the record and so that perhaps I can get some undertaking from the minister. It says:

"Dear Sir

I am writing in anger, disgust and desperation. My eighty year old mother has Macular Degeneration. I understand that the treatment for this disease is Photo Dynamic Therapy and the equipment and the specialists required to perform the treatment are available in Halifax, but due to government cut-backs the service is not being performed at the present time. When it does become available it will be used on an experimental basis and only on a selected few patients.

My mother needs help now! Since the diagnosis of her Macular Degeneration in January, she is already blind in one eye and is rapidly losing sight in the other. Each week she is able to discern a noticeable difference in the vision of her remaining eye. Macular Degeneration can rob a person of their sight in an extremely rapid time. If you have the ability to empathize at all, put yourself in this position and imagine the dire consequences to your life and its quality by waiting. This disease will not wait. The vision cannot be restored but the loss can be halted. The treatment must be immediate.

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My mother has never abused the medical system, running to the doctor for every cold or itch. Now even though she is an extremely healthy eighty and could use this particular treatment, it is unavailable to her because of government cut-backs and red tape. She was such a happy, completely independent and vital person up to this point in time, singing in the church choir, bowling, driving, swimming, doing charitable work, attending concerts and chauffeuring other less fortunate friends around to keep them in circulation. Now she is unable to drive, unable to read a newspaper, unable to read the music to sing in the choir, cannot see the bowling pins, can no longer see to sign her own name or to help others and is trying desperately to remain independent but finding it more and more difficult with each passing day."

I think this is the kind of illustration of the particular effect that these kinds of cutbacks have on people. I would like to ask the minister, and I realize that I have just presented this to him, but I would like to ask him if he can tell us or if his staff can tell us whether or not it is the fact that this program is not available, or has been cut back and, if it has been, when it will be re-instituted and what recourse exists to Mrs. Ward and her mother.

MR. MUIR: Mr. Chairman, quite frankly this is the first time I have seen this, and I think the honourable member realizes that. As a matter of fact, I note that it is dated April 12th; today is April 14th. It probably has not been received in our department or, if it has been, it certainly has not been looked at. Mrs. Ward, did she write to us or did she just write to you?

MR. DEXTER: No, in fact, Mr. Minister, that is why I brought it with me today. She wrote to me, as the Health Critic. I presented it today, not to embarrass you or your department, but simply to bring to your attention that these kinds of situations exist out there, and ask you if this particular program had been cut. I would certainly be greatly pleased if you would take it upon yourself to look into this particular situation, and assist if you can. I guess in this forum what we are really doing is looking at the broader question of whether or not the program itself in fact has been cut or if the service is not available.

MR. MUIR: Certainly we would be pleased to provide that information. As you say, I don't know anything about the program; I don't know anything about Mrs. Ward or her mother.

MR. CHAIRMAN: We have approximately 10 minutes remaining.

MR. DEXTER: Mr. Chairman, in effect I would not ask the minister to get involved and to interfere in the care of a particular individual on an individual case; I was asking as an illustration of a broad-based program. Anyway, that being said, I wonder if the minister would be able to tell us whether or not the budget for the Valley Regional Hospital has been

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maintained, if it will be the same as it was last year or whether or not there is going to be an increase or a decrease?

MR. MUIR: We don't develop the individual facility budgets for the region, Mr. Chairman. It is done, as this one, as part of the regional health boards.

MR. DEXTER: Mr. Chairman, I am assuming at this point - and the minister can certainly correct me if I am wrong - that there must have been business plans that have been filed with the minister for the upcoming year. If he has received those plans, have they been approved and, if they haven't been approved, will he table them so we know what the business plans are? Then we will be able to assess, at a future time when the decision is made, whether or not the government is going to meet the needs of the various institutions.

MR. MUIR: Mr. Chairman, again I will repeat the statement I made, that the allocation is by region and it is by program rather than institution.

MR. DEXTER: Mr. Chairman, can you tell me whether or not the programs that are going to be offered at the Valley Regional Hospital are going to be funded to the same level they were in the past year or whether there will be an increase or a reduction?

MR. MUIR: Mr. Chairman, the business plan for the Western Regional Health Board is currently under development, based on the figures we have provided to it.

MR. DEXTER: I would like to follow up on that question, to ask this question. Were you presented with business plans and, if you were, did you then send them back in order to comply with your budget?

MR. CHAIRMAN: Would you like to have the question asked again?

MR. MUIR: Yes.

MR. DEXTER: I have no problem restating the question. My question was whether or not you had received business plans from the western region and whether or not they had gone through the process and not been approved and sent back to comply with the budget, or you simply haven't received plans from them at all to date?

MR. MUIR: We have had, Mr. Chairman, preliminary discussions. They have not submitted a formal plan and they have been at the table with us about that. They are going back now to construct a more formal one. We asked them in the course of their planning to try and find more administrative efficiencies.

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MR. DEXTER: Well, I guess the question is, if they can't find additional administrative efficiencies, are you willing to admit that there will be losses to the jobs of health care providers?

MR. MUIR: Mr. Chairman, as the honourable member knows, as all members know, we are beginning the transition to district health authorities. He is concentrating, I think, for the purpose of his questions on the Valley Regional Hospital, so maybe the public relations firm did get hold of him or something like that. Clearly and seriously, as moving toward the district health authorities, we do believe there are some things, the western region is probably no different that the other regions, there was no difference, and we believe there are some efficiencies that can be gained by taking a more serious look at how they are doing business.

MR. DEXTER: Mr. Chairman, how much time do I have left?

MR. CHAIRMAN: The honourable member has approximately three minutes.

MR. DEXTER: I will continue this discussion with respect to the Western Regional Board perhaps at the next opportunity but, before the day is up, I would like to follow up on something that we discussed earlier, and table if we can a news release from the Ministry of Health and the Ministry of the Attorney General in British Columbia with respect to the tobacco legal action. I would like to just quote from it briefly. This is for the information of the minister.

"'The court ruling upheld most of the essential principles underlining the act,' said Petter. 'The court confirmed that the province has the right to sue for the recovery of health care costs. We will now make legislative changes to deal with the one aspect the court found to be beyond the jurisdiction of the province.'"

So the province, in fact, is going to continue to take on big tobacco and look at recovering those costs to the health care system. I guess, perhaps if the minister has the opportunity to review this, he could tell us whether or not he will look seriously at undertaking an action to recover the costs.

The other question I would ask, if I have the time, is whether or not he knows what the smoking-related costs are to the system in the province?

MR. MUIR: Mr. Chairman, an estimate of that type is available. I don't have it with me, but we will endeavour to get it for you. I have seen it in a presentation earlier this year, and I didn't bring it with me.

MR. DEXTER: The other part of my question, Mr. Chairman, was whether or not he will undertake to try to recover those costs from big tobacco?

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MR. MUIR: Mr. Chairman, I am prepared to discuss that point with my colleague the Minister of Justice who, obviously, will be pursuing it on the province's behalf. As I said earlier, we are monitoring and have continued to monitor what happened in British Columbia. The last information I had, I don't know the date of that statement, but obviously it updates me, and I appreciate that from the honourable member.

MR. DEXTER: Mr. Chairman, I would ask again - I am down to the short snappers - I wonder could the minister tell us, with relation to addiction services, whether or not the reduction in addiction services will result in the lay-offs of any employees in that program?

MR. MUIR: Mr. Chairman, the reduction for administrative services was the basic reduction we asked each section of the department to find.

MR. CHAIRMAN: Order, please. The time allotted for debate in the Committee on Supply has now expired. The committee will now rise and report progress and meet again on a future day.

The committee stands adjourned.

[2:50 p.m. The committee rose.]