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April 9, 2010
House Committees
Meeting topics: 

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9:27 A.M.


Gordon Gosse

MR. CHAIRMAN: Good morning. The Committee on Supply will now be called to order, and this morning I will announce that next week the Committee on Supply in the Red Room will be moved to the Dennis Building for Thursday and Friday of next week.

The honourable member for Halifax Clayton Park.

MS. DIANA WHALEN: Thank you very much, Mr. Chairman. I look forward to this morning while we continue our estimates with the Health budget. I was remiss yesterday - I didn't welcome the staff from Health as I just got right into my questioning. I certainly would like to thank the deputy minister and others who have come today to help. It makes a big difference to have your expertise. I know that the department is so huge, as we had said yesterday. There are an awful lot of programs and so many different aspects of the department that it's a great help to the minister to have you there as well. That way the Legislature gets the best answers possible.

I'd like to just start in on the issue of the other costs that we were looking at yesterday. There's a one-line item that had "other programs", and I had asked the minister to table for the House just what the breakdown for that one figure of "other programs" would be. It has a number of items on it which I thought we could look at today, and that would be helpful to me. A number of them have no variance whatsoever, but there is a variance in the autism line and I'd like to go to that, if we could, and just see what exactly happened last year and where we're headed this year.


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The estimate said "autism EIBI," which is a behavioural - you might know exactly what that stands for.

MR. CHAIRMAN: Early Intensive Behavioural Intervention.

MS. WHALEN: Thank you very much, Mr. Chairman. We have a lot of different acronyms, and that one I hadn't heard. You've got Methadone Direction in that line as well. So there are actually a number of things rolled together in that.

Last year in 2009-10 we had an estimate of $950,000, I guess, and we didn't spend it all - we spent $800,000. Just to stick to the first number, my first question would be, why are we down at least $150,000? I'm assuming that is in thousands - $150,000 down on that.

Again, this area is very important, certainly to many families. We know that with autism, there's a growing number. I read just yesterday, Mr. Chairman, a resolution for World Autism Day. It was interesting to me that the United Nations has named only three health days like that, and autism is one of the three areas that they have identified as being a growing concern, a growing issue, and a growing number of people affected with it right around the world. Perhaps the minister could talk to us about that line, which is the fifth one down on the list of numbers. Thank you.

[9:30 a.m.]

HON. MAUREEN MACDONALD: Mr. Speaker, to the honourable member, she is correct in saying that this piece of the budget, the autism EIBI Methadone Direction 180 - children with complex care needs is also in there - is off by $150,000 in terms of what was estimated for the cost of these programs. The way I guess this works is that funding is based on claims that are submitted annually to the department, and the actuals fluctuate for some of these things. For example, I would assume that children with complex care needs could be up or it could be down or whatever. So based on claims annually, there has been a fluctuation. What was estimated wasn't fully spent.

In terms of the reduction in that program, what has happened is there has not been a reduction in funding - there's been a transfer of funds that were held centrally in the Department of Health in this program to the IWK for EIBI program implementation. So there has been a transfer of $74,000.

I want to speak to this question of EIBI for children with autism a little more broadly, in terms of policy and implementation of policy. As the member knows, children with autism under the age of five have the possibility of receiving EIBI treatment. However, not all children receive treatment. About 75 per cent of the children who have been assessed and who are candidates receive treatment, based on the funding that we have. We want to see 100 per cent of those children treated.

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Our Party made a commitment in the election that we would ensure the full treatment for those children in year three, that we would expand the program in year three of our mandate, so additional funds have not been provided in this budget. However, what we have done is, we have transferred funds that were held centrally in the department out to the IWK where, as you know, there are wait lists, in anticipation that those dollars may be better utilized closer to where the patients are and the families are. It's the kind of thing, I think, that involves taking your existing resources and working smarter with them, working differently with them and hoping to see better results as a result of just a small change that doesn't involve increasing the amount of resources that we have available.

I've had the opportunity to visit the Autism Society here in Halifax and they do fabulous work. There are many different approaches to working with children with autism. It's a syndrome and with a very broad spectrum of features. Each child has some unique characteristics, in terms of autism, perhaps with other disabilities in some cases or not. With EIBI, we have found in the research portion of the program - as you know, this was relatively a new treatment and with a research component to evaluate the effectiveness of this treatment - it has been very effective for some children in particular and overall quite effective, but not every child is a good candidate. There are other forms, there are other programs and services that are useful and are required in dealing with autism.

I'm always mindful that we need to do more with respect to children who are waiting for this treatment, but we also need to be very open-minded and understand the need for multiple forms of intervention that really put the child at the centre and work toward seeing their needs addressed.

I think as part of developing a mental health strategy, we'll certainly be looking at children and adolescents in particular. I think that one of the things - while children are very compelling - because of the importance to intervene early and the successful impact you'll have with an early intervention, I'm always mindful that children grow up. I've met some very interesting people who have adult children with autism. They are very concerned about issues around education, training, employment, community supports, housing - all of these issues as well. That, I think, requires a pulling down of the silos between government departments like the Department of Education, Community Services and Health - and really looking at a multi-faceted kind of approach to ensuring that these individuals have a good quality of life and have opportunities that give them the ability to meet their potential. This is something that is very important to me, Mr. Chairman.

MS. WHALEN: I do appreciate the minister giving us a fuller description of the program. I'm not yet sure about how much of that figure is devoted to autism. I understand now $74,000 has gone to the IWK, and I appreciate that if, in fact, there was no additional money to take more children into the program, or to actually put more dollars into it, perhaps giving this money to the IWK will serve to allow more children be served. It's possible - I

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mean they are front-line and maybe they can leverage it in some way to actually help more families.

But, I think, along with what the minister said about her concern, the thing that we should all be concerned about is that 75 per cent of the children who qualified, who have been assessed, are actually getting the service, getting the help they need. I think the minister did talk about older children but let us remember that if you're under five or six years of age, the intervention that comes with this EIBI therapy has tremendous results. It really does help families and young children to overcome a lot of the difficulties, to learn to communicate where they haven't been communicating, to learn to socialize where they had no social abilities.

So there is a lot of testimony from families saying that there have been tremendous changes in their children when they have begun the EIBI therapy and this is for the youngest children. As they get older, they can still benefit, but it is not as dramatic. The sooner we begin to give them that help, we know that we have the best chance of giving them a good outcome and a good life.

So the timing is really important and the minister didn't mention the word "lottery", but that is how the families see it and I guess, in effect, it is a lottery. Because, if you qualify your name goes into the hopper and 75 per cent will get service and 25 per cent will not. Those families, their names can go back in and they get more than one opportunity to be drawn out, but it is a travesty as families are waiting and recognizing that every month and every week that goes by their children are missing an opportunity to begin to address the issues they have. Every parent wants the best for their children and they can actually see evidence that this kind of therapy can make a tremendous difference in their child's life, that they can gain the skills that they don't have for one reason or another.

In fact, I don't know if the minister would remember, but in Opposition I did bring in a bill and it was, in fact, I think the first bill that I introduced in the House, which was calling for ABA therapy at the time, that was behaviourial therapy as well, similar but not exactly the same, and there was at a time when there was none offered in this province. The Progressive Conservative Government did introduce one after that, a small program in their budget, and it has expanded slightly, I suppose, in fits and starts over time.

What I want to know is this: Where are we at today and how much money is going toward any of the services for autism that is buried into that line along with methadone and children with complex care and can we tell whether or not it was utilized last year? I guess I'm trying to drill down to one more level of peeling the onion and see what exactly, in that figure of $955,000 that was budgeted last year for autism and then, recognizing that you made the $74,000 change to the IWK, what is left there for this year? I want to know exactly what we're devoting to this program for children with autism.

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MS. MAUREEN MACDONALD: Mr. Chairman, I can appreciate why it would be somewhat confusing to try to follow the money here because, to be honest with you, I'm finding it a bit confusing myself. This is why it is confusing - the department, in our section of the department for mental health services, has held money centrally for particular work in this area. So for example, these numbers that I am going to give you are numbers that are held in our department. However, in addition to that there's money out in the DHAs that the department provides to the DHAs and the IWK. For example, the EIBI program overall is a $4 million per year program. That will not change, that hasn't changed - it's not being increased, it's not being decreased - but there is some shifting around of resources from what the department held to the IWK. I kind of explained that a moment ago, but let me take another shot at this.

In terms of last year, what the department held for EIBI was $250,000, which really is not a huge allotment in terms of the overall $4 million. We are estimating that this year the department will hold $176,000. Now some of that money that is held in the department is used for things like staff development on autism. It is used to have regular conference calls linking the coordinators of EIBI around the province. Those kinds of activities need to be supported at the department level.

The "children with complex care needs" is also in other programs as a line item. That estimate was $300,000 last year and the forecast was $200,000, which means that it was off $100,000. The expenditures fluctuate depending on the number of complex cases in the system. Again, the estimate for this year is $300,000, so that hasn't decreased either.

[9:45 a.m.]

In terms of methadone and Direction 180, it is also in this particular budget. It is $400,000, and that remains $400,000. It was forecast at $400,000, so it sees no increase but it sees no decrease. It is holding steady.

MS. WHALEN: Mr. Chairman, I just wanted to double-check - we've got no change in the Methadone Direction 180, that's the same amount of money for next year. I don't know if it was underspent or not last year, but we know we've got as much money available. No, it was not? Good. So we used it and we've got it available again for this coming year.

On the "children with complex care", I realize there was $100,000 not used in last year's budgeted amount, but that, of course, would depend on the number of children who come forth. I hope that it doesn't mean there was anybody turned away, because the funds were there. What I'd like to know is what is in this year's budget, then, for the children with complex care? Is it the same, $300,000?

MR. CHAIRMAN: The honourable member for Halifax Clayton Park.

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MS. WHALEN: Thank you very much, Mr. Chairman, and the answer was that it stayed the same as well, so I hopped up instead of the minister getting up again, because I'll pose a different question.

So those two are the same and the only difference, then, seems to be largely coming from the difference with the EIBI. That would be the main change, and it looks like the variance for this year is about $74,000, so that does explain it.

You can appreciate why it is important to peel that back - if you've got a single figure and it has three very different programs in it, it is very hard for us to know whether one has been completely eliminated and another one has been doubled and just where we're at. So to get a relative sense of how they are changing and what are the reasons for the changes is very important to us. So, I know sometimes the accounting aspects of the budget debate may seem less interesting, but it really is important because, certainly, to go back to the autism one, I hear frequently from parents with autistic children who are asking me what is going to happen and where are we at and would you please raise it again in the House. I know that the minister is well aware of that role in Opposition, that we need to ask.

Now, I did hear you say today that there is a commitment for year three of this government's mandate, and it is good that it is committed and I hope that is something that you will be able to achieve, but it seems like a long wait. We can appreciate a commitment has been made but it is just going to be difficult to wait that period of time.

Going back to what I said earlier about the urgency, really, of every day that passes for families that can't afford this. Perhaps the minister knows the cost of providing it, but I understand if you were to get it individually, if you went to speech pathologist and to the people who are specialists in this, it literally is tens of thousands, isn't it, for a year. So, if a family were to try and pay it themselves - perhaps the minister has a figure - I would be interested in knowing what the cost is for a family to try to get that support if they don't have it through government.

MS. MAUREEN MACDONALD: Mr. Chairman, I'm not really certain what the actual cost is per family, and I think, possibly, there is some variation because some children will have higher needs than others. There are a lot of really interesting things that I'm learning about treatments and approaches. I met somebody not so long ago who had been to the U.S., to a program that trains parents, that give parents the tools to work with their children with autism. He is a parent of an autistic child and he was so excited about his experience and the opportunity that he felt was there, not only for himself and his wife and their son, but also the opportunity that this would present for other parents.

Now, again, it is not everybody's cup of tea, you know. The resources that you have to - and I'm not talking about financial resources, I'm talking about sort of the emotional resources and the physical resources that you have to be able to bring to working with a child

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with special needs - are considerable. So, he and his wife had tried a whole variety of different approaches and nothing seemed to work, but this particular approach was exactly what his family needed.

I don't know exactly - and it is interesting, I think he was looking at organizing some work shops here that would allow other parents like himself, who had access to different approaches, including EIBI, that hadn't necessarily been all that successful for them, but as I say, EIBI evaluations are very good, we know that more children would benefit from this. Unfortunately, Rome wasn't built in a day and I have to keep the focus of my department on what we are already committed to, use the small resources we have, to address some of those big outstanding issues and be very mindful of where we can transfer money closer to people, get better results in this way. I look forward to the time when I do have the resources through Every Kid Counts program, which is the program that we campaigned on in the election, which will see an expanded opportunity for services for children with autism.

The other thing I would say that I find very interesting is that we don't really have good information - statistical, sound information - that tells us precisely how many children we are dealing with and we can look forward to dealing with over the next number of years, and this I think is a very important piece of information to have. We need to know, I think, in order to plan for our programming, so that's very important. I think in closing I just want to clarify that EIBI has not been reduced, there's been no reduction, but there has been a transfer of some of the funds that we held centrally with respect to EIBI, and then in addition to that, there is already money provided to the IWK through their budget - and not just the IWK. I should make it clear that EIBI is available through all of the DHAs around the province. So in fact there is funding not reflected here in that section; it's buried in those millions of dollars that go out to the District Health Authorities for these programs.

MS. WHALEN: Thank you very much, and I think there may be more questions that I'd like to come back to on autism, but I did want to know how many families or children are currently receiving the EIBI. Have you had a number? The minister began to go to the fact that it's difficult to project how many more will come into the system and will require help, but do we know how many are receiving it now and then how many are waiting in that queue, basically, for their number to be drawn? As I say, I think that's important to families to know, and again, it may differ by region, but I'd like to just know overall.

MS. MAUREEN MACDONALD: Mr. Chairman, we will get the member that information. We certainly have that information, how many children are in the program and how many are waiting, but we don't have it with us today.

MS. WHALEN: Thank you very much, and I'm going to go to one of the other line items that have had some changes in this breakdown of other programs. So here's the supplementary details on that. There seems to be a big reduction in the line item, the last one on the list. Intergovernmental Affairs, Midwifery Regulatory Council - that may be one item

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- and Funding Methodology. What are those three things that are rolled together? I'm certainly very interested in midwifery and how we can expand that in the province. I think it would be of interest not only to the women in this House but to everybody that we had better prenatal and postnatal care, and that is something that has begun in the province since I've been a member in the last six years. Quite recently we have the new Midwifery Act, which has allowed midwives to practice here in the province. We were a little slow in adopting that, and I certainly knew people who had that available to them in Ontario 20 years ago when I was having my children. So I'd like to know what we're doing, and before we go into what we're doing with midwifery, how do the three numbers break down? I'd better stick to that. Thank you.

MS. MAUREEN MACDONALD: Thank you very much. So the three items are Intergovernmental Affairs, which is $479,500 estimated for last year, forecast for this year, and estimate for next year, so no change, $479,500; that would be resources to support the work across provinces within the country - teleconferencing, occasionally, probably some travel to federal-provincial-territorial meetings. There is a significant amount of collaboration and communication across provinces around the provision of health care.

I use H1N1 as an example. Staff in both the Department of Health, and Health Promotion and Protection would have been in communication daily - probably more than once a day - with their counterparts in other provinces and at the federal level, sharing information and gaining understanding and ideas about what was working, what wasn't working and how to adjust the H1N1 process in terms of planning and implementation.

This item here supports that work of staff in the department. There is a small departmental staff on the Intergovernmental Affairs file, who stay on top of these issues.

With respect to the midwifery, the next item, Midwifery Regulatory Council of Nova Scotia. The numbers are as follows: $135,000 estimated for 2009-10; the expenditure forecast is $206,000; and the estimate for next year is $206,000, a slight increase there. The reason for this is there is a salary for the executive director of the Midwifery Regulatory Council, it was transferred, though, from another cost centre, so it's not necessarily new money, but it's showing up here.

[10:00 a.m.]

We have three midwifery pilots in the province. We have one at the IWK Health Centre, we have one in Antigonish-Guysborough-Strait-Richmond and we have one in the South Shore. These projects are being evaluated. There is this group, it was established in 2009, the Midwifery Regulatory Council of Nova Scotia, to govern the profession of midwifery in the province. It regulates the profession of midwifery in accordance with the Midwifery Act and regulations.

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The mandate and legislative duty of the council is to serve and protect the public interests by regulating the practice of midwifery. The council registers qualified, competent midwives to provide safe, high quality care to women and their families in Nova Scotia. The council is mandated to protect the public by ensuring that all registrants engaged in clinical midwifery practice are safe, competent and ethical practitioners.

That line item supports the work of this council. As you can appreciate, I'm sure, because this is very new and it's a very small group, to expect that the licensed, registered midwives in the province could support their own regulatory body through dues, which is generally how other groups do it, is not really realistic for this group. They would require some funding.

I think the member is indicating an introduction.

MR. CHAIRMAN: The honourable member for Dartmouth East.

MR. ANDREW YOUNGER: Mr. Chairman, on an introduction. Thank you and thank you to the House for the time. In the west gallery today I would like to introduce 35 Grade 12 students from Prince Andrew High School, where I went to high school and graduated in 1992. With them is John MacDonald, who actually was one of my teachers, Sara Durnford and Ashley Ellis. If they would like to stand and receive the welcome of the House. No, really, you can stand. (Applause)

The Minister of Education here, you might want to go up and say hello. I know you've already met the Justice Minister this morning and enjoy the Health budget debate.

MR. CHAIRMAN: Thank you and we do welcome all visitors to the gallery and hopefully you enjoy the procedures as we are in the Committee of the Whole House on Supply. The honourable Minister of Health.

MS. MAUREEN MACDONALD: The last item is funding methodology in this particular item. Last year it was estimated at $1,231,000. That has disappeared. It's gone. Where has it gone? It's been transferred to the DHAs. Again, it's been - this was a line item that was used for PHSOR consultation. It was there for, I'm told, several years, it was never really used. It has now been put to good use by transferring it to the DHAs, particularly to help them with their wage pressures. That accounts for those items in that portion of the budget.

MS. WHALEN: Just before I pose a couple of questions around that, I would just like to give a little context to the students in the gallery so that they might know what we're doing today. We're on the first full day of estimates which is our opportunity as Opposition members to look at the budget and go through line by line or whatever questions we have on a particular department's budget. We begin with Health because it takes up almost half - it's

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about 45 per cent, I think - of our total budget. It is certainly the largest department and the biggest spending that we have. We have allotted at least 10 hours that we will be doing these estimate discussions.

They're much different from Question Period and a lot more productive because we actually get to have a dialogue with the Minister of Health and ask about what exactly is included in these programs. I ask for one hour of these questions and then it will revert to the Progressive Conservative bench and they'll ask for an hour and then it will come back to the Liberals. So you have an idea what we're doing, I think I'm here until 10:21 a.m.

I was not a teacher. I'm actually an accountant so I like this kind of stuff. That's good for me, I like to go through the numbers.

We're looking at this one line item, I'm going to go back to the minister. We're looking at a line item that had some strange things rolled in together. Just before I go back to midwifery, I would like to know about that funding methodology a little bit more. That's a lot of money that had been allocated to be used. I didn't understand what methodology it was that they were supposed to be looking at. There was a term you used that I didn't know, I think there are never any stupid questions, so it's good to go back and ask again if you don't understand something.

The $1.23 million had been allocated to that. If it hadn't been used and it's now going to the district health authorities and they can use it to maintain their commitments to increase people's pay, I understand that, that's probably a good redirection. But, my question to the minister would be, are we missing anything by not having used it? It was originally thought to be important enough to put in the budget, so are the people of Nova Scotia missing anything by the fact it was never used and has now been brought down to zero?

MS. MAUREEN MACDONALD: The member asks good questions. It gives me a chance to provide some clarification. The $1.2 million was allocated, initially, with the idea, understanding, intention that this would be used to develop a funding formula, a funding mechanism with the DHAs. That work is now being done in-house by staff, it will not require consultants, so that's one thing. We are getting good value for dollar from the use of our own human resources on this, number one.

Number two, that money was actually used, in a previous year, for Corpus Sanchez, which was a million-dollar report, so when they had to fund the Corpus Sanchez Report that's where the money was found. This $1.2 million has now been transferred into the budgets of the DHAs to help them deal with some of their financial pressures including staffing.

MS. WHALEN: Mr. Chairman, I'd like to go to the Midwifery section of that budget line item and have a look at that. Now that's gone up from $135,000 last year. You said we

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actually spent $206,000 and I guess the department has recognized it cost $206,000; am I right, $206,000?

MS. MAUREEN MACDONALD: Mr. Chairman, I think with guests coming into the gallery and your colleague doing an introduction and the commotion, which wasn't very much commotion, you missed that I had indicated earlier that the increase in that line item reflects a $70,000 salary for the executive director of the Midwifery Regulatory Council of Nova Scotia, which was transferred from another cost centre. It's not new money but it's appearing in this particular line for the first time.

MS. WHALEN: Mr. Chairman, that does explain it because it's just about $70,000 more, so that would explain where that has come from. Can you tell me how many people work in this regulatory council?

MS. MAUREEN MACDONALD: I don't think we have that information but we can certainly find that information. Let me say that the midwifery program, as I indicated, is really a new program; it's in its infancy in some ways. This council was constituted in 2009, so two years ago. We have three midwifery sites, one at the IWK Health Centre, one in Antigonish and one in the South Shore. The models are all different, the models aren't the same in each DHA and an evaluation is occurring, or needs to occur, to evaluate how those have gone. I had an opportunity to meet with the midwife in Antigonish, in the GASHA district health authority. I was really very interested in her and her work and I look forward to getting an evaluation.

I know that there's a good deal of interest in other parts of the province. I've certainly heard from individuals in the Annapolis Valley who are very interested in seeing the Valley move in the direction of these other DHAs, but we want to make sure that we do this in an appropriate way. I think, given that it is a new experience for us - although it's not a new experience by any stretch of the imagination, midwifery is one of the oldest professions going - I think we will wait for the evaluation. We will do a lot of consultation and have good input from midwives around the province as well as people who have an interest in maternal and child health care.

MS. WHALEN: Mr. Chairman, just in the few minutes left to me - I have only about 10 minutes, a little bit less than that, to speak to this - I did want to stay on the subject and I think during our estimates, you may hear as well from my colleague, the MLA from Bedford-Birch Cove, because she has had some constituents who very much wanted to have the service of a midwife and, because of the very small number that we have licensed and put into these pilot projects, it wasn't possible. This was really an issue of great concern to that family. They wanted it, they felt they would have had it in other provinces and they were not happy that it was not available to them here. I know she may have more to say about that, I see she is in the gallery right at the moment, so perhaps she is listening on this subject.

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I wanted to ask you about whether or not midwives in this province can practice independently. Can they set up their own practice? That would be an option for those who are happy to pay the extra because they want that pre and post-natal care. I think it is important that we allow them to practice now that we've got an Act in place. The only ones I've heard of, I think, are the seven who are allocated to these three - the IWK and the two DHAs. I'd like to know why we have so few in the province and whether or not they can practice on their own.

MS. MAUREEN MACDONALD: The member raises a very good and interesting question. The way the midwifery programs are set up is through each DHA. We provide funding from the department to the DHA so they can hire and pay and ensure the work of midwives.

Now this question of whether someone can practice privately as a midwife has always been a conundrum to me, in a way. As I understand it, there is no prohibition to prevent any person who is qualified - and that becomes a big question mark, what does that mean - from offering their services as a midwife. I'm kind of talking off the top of my head here, but as far as I know, the only prohibition is the Criminal Code. If you are practising and you are negligent in some way, then you stand to feel the force of either criminal charges or, I suppose, there also could be litigation of certain kinds, the same way people would sue any of us for doing bodily harm, the tort law or whatever area of the law that falls into.

[10:15 a.m.]

For midwives, it's a very difficult thing. A qualified midwife has to be able to get an income for their services. So even if you're qualified and you hang your shingle out, the cost, really, for families in our system, in our world, is kind of prohibitive to get those kinds of services, which is why we're trying to incorporate and build midwifery into our public health care system. I mean, that's what's happening - midwifery is being added as a professional group into our public health care system. We are doing that in a systematic way by starting with pilots in the three DHAs. They're very different when you talk about getting numbers of people. It's been very difficult in GASHA, for example, to be able to do home births and there are different issues within how midwifery is delivered.

In Antigonish I was surprised, to be honest, when I met the midwife. She is just lovely and so fascinating to hear her talk about her work. I was very surprised to learn that not only do women have her services as a midwife, but they also continue to have obstetrics and they see the obstetrician. That kind of startled me, I suppose, in a way, because I've always understood midwifery to be a way to not have to necessarily have obstetrics involved and allow those highly trained specialists to deal with higher risk pregnancies, more difficult pregnancies and have midwives do the more regular kinds of things.

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When we look at this, we'll look at a whole variety of approaches. The regulations, as I understand them, require that two midwives have to be employed and available in order to have home births occur as part of the model. So, in some areas it hasn't been possible to recruit the number of midwives we need to be able to deliver that aspect of the service. People get excellent care, they're being seen by the midwife before and after and she's involved during the delivery, but in terms of the location, it's not a home birth because we can't meet, in those areas, the regulatory requirement of having a certain number available. That has nothing to do with money or decisions from the department saying you can't do this - it has everything to do with supply.

We're kind of in that situation, not having had midwifery as part of the public system in Nova Scotia, we didn't have the supply. We have to kind of build up the people who are here to provide those services. As I said, we'll do an evaluation of the three sites and we'll have better information as we go forward with our planning for any expansion.

MS. WHALEN: Mr. Chairman, through you to the minister, I had just a couple of questions. Can you tell me the exact amount of time I have left?

MR. CHAIRMAN: You have approximately one minute and 15 seconds.

MS. WHALEN: So a minute left. I don't know that we'll get another question answered but I would like to come back to this again in the next hour that I'll have. I'd like to know when the evaluation of this program is going to be done. When we did have the family in Bedford that had been very insistent and very upset that it wasn't available to them, we did realize, when I did some research on it, that it's in its infancy, as you say. It is just starting, we haven't really got much information.

It's a bit soon to be criticizing because we know you're getting your feet under you, in terms of this program, but as people are having babies today, they want this service. That's what we're hearing loud and clear; they want that kind of option available to them. It's attractive. It has been available in other provinces for a long time. As I said, I have friends of mine who had midwives and it would have been in the late 1980's and early 1990's in Ontario, so it was available to them then.

I think there's a big demand, and often I know our medical system is pushed by public demand, but again, going back to what the minister likes to say often about the right professional and the right setting at the right time, as the minister just mentioned, it's actually cheaper in the long run and you get better care in the sense of prenatal and during the birth and postnatal care than you would from an obstetrician who will come in for the birth and then you may have a little bit of post-birth care from perhaps public health, but it's not the same as having somebody who knows you and your family and actually can help advise you. They become very close during that period of time and they give great advice and great support. I think it's really important that we look at that.

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I don't know if the minister has read the book The Birth House, which is a Nova Scotian book. Ami McKay is the author and she lives in the Valley and wrote about midwifery in the early part of the 20th Century and how it was really displaced by medicine; I guess by modern medicine. It has its place and people have found it again. When I come back to it, I would like to ask about the plans for the future in terms of evaluating.

MR. CHAIRMAN: Order, please. The member's time has expired for the Committee on Supply.

MS. WHALEN: No more speeches.

MR. CHAIRMAN: The honourable member for Hants West.

MR. CHUCK PORTER: Thank you, Mr. Chairman. That was the longest minute and 15 seconds I've had in a long time, but that's okay. I know that honourable member enjoys the Question Period time and could probably fill in quite easily, I think, for hours on end on this topic and others and that's great.

I appreciate having a few minutes to ask the minister a couple of questions around health. We'll start with one of the comments made, I think, in the Budget Speech with regard to Cobequid, I believe, being hours extended. Can you go into some further detail on that? It is either 24 hours or two more hours a day, what exactly is that, minister?

MS. MAUREEN MACDONALD: Mr. Chairman, I welcome the honourable member to the discussion about the Health budget. The Cobequid Community Health Centre, as the member would know, is in some ways a very unique health care service in the province. It's a wonderful community health centre, providing many services to a growing area and an already substantially populated area.

During the election, our Party made a commitment of $2.25 million in this fiscal year to work to keep emergency rooms open and reduce health care waits. It was our view that the Cobequid Community Health Centre would need to be a part of that proposal, including adding capacity for three additional assessment beds there. That centre currently operates from 7:00 a.m. until 10:00 p.m., so 15 hours a day, seven days a week. We're in the process now of planning for an expansion of hours and services in that centre to complete our campaign commitment to the people of that community and as the details of that plan are available, we'll certainly be making them available to the members of this Chamber as well as the public.

MR. PORTER: Thank you, Mr. Chairman, and thank you, minister, for that answer. I'm quite familiar, yes, with Cobequid Community Health Centre. I had the pleasure of working as a paramedic out of Sackville and Bedford for a number of years and Cobequid Community Health Centre was a facility that we would be involved with on a daily basis and

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right through until closing. I can tell you there were many nights at closing where we were unloading patients, unfortunately, and taking them into town as there were no further beds and the facility was not open adequate hours. The fight had been on there for many years to try to extend the hours and possibly much talk about going 24 hours.

Obviously, from what you have just said, it doesn't sound like the plan is to go 24 hours, there is an assessment being done, but it doesn't look like it will be 24 hours. That's unfortunate as the issues in the HRM and the hospitals here in Halifax, the QE II, continue to grow. There are long waits. The paramedics, ambulances and stretchers are tied up for hours on end. It doesn't appear to be relieving the issue at all, it will only continue to grow that issue between Halifax and Dartmouth. There will still be an hour where closure will take place and patients will still need to be transferred for further care regardless of the time of day or the situation and the severity but, again, you're right, that is a wonderful facility out there, a new facility they've moved to, and offer great services. It's unfortunate that we're not able to see that go for the 24-hour period, even at a reduced level perhaps. More of a clinic status where patients could be seen on an outpatient-type basis for prescriptions that are much needed, minor illness, and injury and so on.

With regard to the paramedics in the province, Madam Minister, I'm kind of curious, is there a plan to expand what they're doing? I do know that with the number of hospital closures in my years working on the streets - we did work in emergency - I know that the QE II, formerly the VG, has had paramedics on staff for many, many years. Not that I am biased, but I see great opportunities and further opportunities for paramedics in this province to be filling in, not just filling in, but I am biased. (Interruption) He says, yes, perhaps, but not just filling in but being employed in all the hospitals, if not even just regionally, 24 hours a day to help assist with some of the work that's going on there. These folks are very well trained, very knowledgeable and perhaps there's a transition of some type of training to bring them into that fold.

I know there was always an issue with staff. As our training evolved - which I see may need to go into place here shortly - it was difficult to be accepted into the hospital world because we were just known as ambulance drivers and that was pretty much it in those days. The fact that we were trained - we know there are shortages in nursing staff, shortages in the CNAs, shortages all around with doctors. We know that a lot of the injuries that come in are somewhat minor. I'm curious - what is the plan of yourself, your department and the government to move forward with expanding the scope of practice for paramedics, if there are any?

MS. MAUREEN MACDONALD: I do want to thank the honourable member for this particular question. Already I think there are some small areas where we're seeing paramedics used differently and expanding the work they do.

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I don't know so much about expanding the scope of their practice, although I don't rule that out. In fact, I welcome this idea. Dr. Ross's report yesterday, I think, points us very much in this direction. I think the first thing we want to ensure is that the paramedics we have now who are very, very skilled, very well trained, that they're working to the scope of practice they have now.

There are a lot of paramedics around the province. They're emergency health care providers so they're waiting to be called to go to a site where a patient is, but there's a lot of time in between those calls in some cases - not in all cases, but in some cases there are those occasions. We're starting to look at what can we do to take those very valuable health human resources and use them more fully instead of just having people wait for calls.

[10:30 a.m.]

Paramedics in some parts of the province are now becoming engaged in chronic management with patients in communities. I think about the Digby Neck-Briar Island situation as a good example. There's no reason why paramedics can't be doing home visits or having a blood pressure clinic, for example, at a particular time for some of these things, particularly for an aging population with chronic disease. We have a great ability to use our paramedics to a fuller scope of the practice they have right now.

I was in Cape Breton in the emergency room speaking to one of the emergency doctors there, Dr. Currie. He was talking about the amazing work of the paramedics that come into the ER there and the fact that many of these paramedics have been trained with this new - I think it's a medication - when people are having strokes, to be able to identify that is what you're dealing with, someone who has just had a stroke and get them the medication immediately before they get into the emergency department. We're not doing that yet in all parts of the province. There's some training involved, but here is another great opportunity for us to both improve the health care that people receive in a much more efficient way and also use the skills of paramedics to a greater ability.

This is one thing, but I think that the paramedic profession is a profession that still has a lot of untapped potential in terms of the things that they can be doing. As you know, we have advanced paramedics working in emergency departments doing triage, doing sutures, and in some cases, I think even setting some minor bones and these kinds of things.

So we need, I think, to help the public understand the great capacity of all of our health care providers. Anybody who has had a personal experience with paramedics, it doesn't take them long to understand how capable these individuals are. I've rarely heard - I don't think I've really ever heard - any negative comments about the services that are provided by paramedics. I can tell you, in the 10 months that I have been in this position, I've gotten a lot of letters complaining about a lot of things. I have not received one complaint about the services of a paramedic or the paramedics. That has to stand for something. That

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must tell you something, because I have had complaints about a lot of things, and sometimes I have had complaints about the bedside manner of other health care providers, but I have not had one thing about paramedics.

So they have great capacity. We need to fully utilize them in their current scope of practice, and the honourable member is absolutely accurate - we're looking ahead, we're thinking, what else can we be using? We have the best system of emergency health service, in terms of our ground and air ambulance, in the world. I think we should pat ourselves on the back for having this service, for valuing this service, for continuing to invest in this service. We have a lot to be proud about when it comes to EHS in this province, Mr. Chairman.

MR. PORTER: I thank the minister for the detailed answer, and you're quite right. We have a very fine system of emergency health services in this province, which has evolved tremendously in a rather short period of time after being somewhat stagnant for many, many years. It has come a very long way, and the men and women working as medics in this province are doing a great job, so I'm not surprised when you talk about the lack of complaints. They provide a great service. Again, no bias, but I have had a lot of years and I've seen these folks working and I've been a part of training and part of evaluations - both on the communications centre side as well as the street side - and they are indeed a very fine group.

Just on that, before I leave that, with regard to the EHS, I have a question with regard to the budget. What is the total budget now, because I realize that the helicopter has come on board as part of the - I think it is probably inclusive in one, but you can clarify that. What is the total budget and are there any projected changes either up or down in that investment in the coming year?

MS. MAUREEN MACDONALD: The total budget in this year's budget is $105 million, almost $106 million - $105.7 million. A world-class ambulance emergency health service does not come inexpensively, shall we say. It is $105.7 million, and that's up from last year. Last year's estimate was $98.5 million and the forecast was $97.7 million. So, as the honourable member knows, this program was established in 1995 and we continue to invest in these services. The main components are the ground ambulance system, but we also support the communication centre, the EHS LifeFlight. It also covers the Nova Scotia Trauma Program and the Atlantic Health Training and Simulation Centre. Those components are in that budget. It's a substantial area of investment in our health care system, but it makes a huge difference in terms of people's lives and their security around this province.

MR. PORTER: Mr. Chairman, $105.7 million - it's grown substantially in the last very few short years, but when you talk about the training centre being added in, and LifeFlight, all of those - I remember a time when that was somewhere around $60 million, not too many years ago when I was still working, so that has grown - but we've added to that,

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as you've said. I guess I'd forgotten about those, and a significant cost to bring that all under one umbrella.

I want to move on to nursing homes for a few minutes before I hand it back off to my colleague. I'll start with vacancies of beds. Now I know from talking with the nursing homes on a regular basis, and I guess over the last few years from being on council back a number of years ago - I have three of these facilities in my local area, and it always appears that there is, in fact, a bed available. I understand there's generally always been a respite bed available for short-term use and things like that, but I've known of cases over the last few years where there have been beds available for up to 29 days in specific nursing homes locally while I have people in emergency at Hants Community Hospital waiting for a bed upstairs. I have Unit 200 full, I have Unit 500 full while we wait to move patients around and get them into these long-term care facilities.

To top it all off, we're moving people out of the local area somewhere else, which as you know - you've had your share of letters in the last 10 months. I know I've written you with regard to folks waiting and looking for beds and trying to get them into their local areas. I can appreciate and understand, as I'm sure you can, why people want to be near their homes and their families and so on. Those are just obvious reasons.

Can you explain why we have these long waits with beds being vacant? I know there are policies that exist in some places. My wife's grandfather, just as one example, passed away a few years ago, but he was on the Haliburton Unit of Hants Community Hospital. Once he passed away - a tough time for families, but we were pretty much given notice - you've got two days. Your room has got to be vacant, and we understood that, both being health care professionals, that there was somebody waiting for that room, and I think this is pretty much standard practice. Generally the only time these beds become available, unfortunately, are when people pass away, and it happens every day, but I just don't understand these long waits between beds being filled. I wonder if you can just enlighten me a little bit on why that's taking place right now.

MS. MAUREEN MACDONALD: Mr. Chairman, I'd say to the honourable member, I couldn't agree with you more. The turnaround should be relatively short, and in most cases it is actually relatively short. I don't have those numbers here, but not so long ago I had a briefing with staff on some aspects of this in terms of the Continuing Care Strategy. I did ask and I did get the information in terms of what the average turnaround is, and if memory serves me right it's approximately five days, because if a bed becomes vacant, a family is given a period of time to collect any of the personal items and belongings and then the new family is given a period of time. They're offered the bed, they're given a period of time - I think a 24-hour period of time - to say yes or no to the bed, and then they're given a day or two to actually move in. This is about a five to six day turnaround, but that, as the honourable member says, does not always happen.

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Sometimes a bed - especially in an accommodation, if there is a shared room - goes a bit longer in terms of whether it's a bed for men or a bed for women. You may be a male waiting for a bed, but in fact, the bed that came open is in a room that has the other person. So it makes it difficult to fill that bed immediately, and there are a few other considerations. Sometimes an individual has to be on a secure unit and the bed that has become available is not on a secure unit or vice versa - they don't need a secure unit and the bed that has become available is in the dementia or Alzheimer's area. So nothing is simple in health care.

We try very hard to accommodate all of those characteristics of the human population and to be sensitive and respectful to our seniors - both the person who needs the care and the people who are already receiving care. Trying to do the matching can be really difficult. However, that being said, to have beds vacant for 28 days is just not on. Our system cannot afford that kind of inefficiency and the problem in our emergency departments is all about flow, it's all about being able to get people admitted into the hospital and people who are in hospital beds who need to be in long-term care into those long-term care beds. So we have to do a much better job of integrating our long-term care system with our acute care system.

Now, I've been in this Legislature for 12 years - sometimes it feels like it was just yesterday that I arrived. I think when I first came, we were talking about why continuing care was still being managed by the Department of Health and why it hadn't been devolved into the district health authorities and if you had the planning - and not just the planning, but closer administration between the acute care and the long-term care sector, these lengthy periods of time when hospital administrators are wanting to clear, get that flow working, get people into long-term care - you would not see these periods of 28 days when beds are going unfilled in the long-term care sector.

[10:45 a.m.]

We are working very hard to devolve. Our continuing care coordinators already have been devolved to the DHAs, and we are working to get continuing care - including home care, because that's the other side of getting people out of hospital and into the right place with the right supports - into the DHAs, and we're in the process of developing service agreements with long-term care providers around the province. I'll be looking forward to support from members in this Chamber to move that initiative forward, because it is going to make a difference in terms of the effectiveness and the efficiency of our acute care facilities, our emergency room services - and we won't leave operators of long-term care in a position where they're carrying the costs associated with empty beds, because that's not a good thing either.

So we could all win from this change and, as I said, I'll be looking for the support of all the members as we move this particular initiative forward. Change is never easy, Mr. Chairman, and I think there's always a bit of mistrust of government out on the ground where

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people are actually living and delivering services, but there's no other motivation in the devolution other than to improve the system for everyone.

MR. PORTER: Thank you. You've talked about a number of things and it's interesting to hear you say some of those things. You've heard me say in this House before, with regard to how this system flows and how it works and how I don't favour it. I also don't mind standing here and telling you, you're not the first minister I've spoken to about my unhappiness about how the system works.

You talked about the administration, minister. The system is over-administered. That's our first problem. Why do we have administrators in homes like Dykeland Lodge and all of our nursing homes - nothing against any of the people, they're all fine folks doing a great job - if we're administering them from somewhere else to begin with? It's almost like there's no real reason, there's a whole middle man, for lack of a better term, a middle administration here that may not be required.

We talked about our dollars within health, we know what salaries eat up, we know what percentage salaries eat up in this system. It's a big piece. When we talk about improving the system, we have to look at some of those. You talked about change, I'll be the first one to stand here and tell you, I'm looking forward to whatever you're proposing as change, because we need desperate change in this province when it comes to this flow.

The single-entry system, as you've heard me speak to - and I've written you and you've responded, as you may or may not recall, in recent months - in my opinion, I call it a failure because it doesn't work. That flow you just talked about doesn't exist. These vacant beds aren't being filled as they should be filled, in my opinion. The waits are too long and it's been going on for some time. Again, nothing against the people who work in single-entry because they're only doing what they can too. There are a lot of people coming in looking for these beds on a daily basis. I often wondered if there was enough staff within this single-entry system. One person in a region, I know in my region, the western region alone, I don't know that one person could handle that.

Again, the issue of flow, right from the beginning, is one of concern because there seem to be more people coming in looking for beds than there are beds being emptied. I don't know if anyone's ever done the data to see how many beds are becoming available a day, how long they're actually vacant and how many people are coming in a day in need of beds. It would certainly be worth looking at.

Strategies need to be simplified and people who are waiting are looking for simple strategies that will work for them. I can remember back years ago, these waits did not exist; Unit 500 never existed, there was nobody in the hospital waiting any amount of time - months - like we have now. I'm just using my area. I know it exists all over the province. There was nobody waiting like that and the reason was the doctors - who I speak to often and

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favour what I'm talking about - could pick up the phone and call the administrator because that person was very useful in helping move patients into beds. I'm not sure how we ever got away from that.

Your mother, your father, your grandparent, whoever it may be, looking for a bed - they would just call around to the two or three local nursing homes and say, I've got so-and-so who needs a bed, what do you have available? Not too long later they were calling us to come over and put him on a stretcher and make their way over to the nursing home. There were none of these long waits and there's something we've missed in between. I'm not sure what that is, but I think it's all this middle administration. Again, maybe I oversimplify it. It seems like a pretty simple process to me and the more administration we've added, the more it seems to bog the system down.

Again, nothing against the administrators, the people or anything like that, it's the system as a whole that needs to be reviewed and I think that part right there significantly needs to be reviewed and looked at, not unlike the district health authorities. Again, all great people, but why do we have so many? One, why do we do business differently in Colchester or in the northern district than we do in the Capital or the Cape Breton region? I know there are differences, and always have been differences, in how we manage the business, one, even right down to equipment and procuring things, I'm sure there are millions and millions of dollars worth of saving.

We talked a lot about the emergency system in this province a few minutes ago. You can get into an ambulance in Sydney, or you can get in one in Yarmouth, and you can open a cabinet door and you'll find the exact same gear, in the exact same cabinet, in that ambulance, in the same place. Why is that not the practice across the board? We procure everything a certain way and through the same folks; we don't do that as far as I know, within the hospital systems, even within the nursing home system probably we don't do that either. I think there is a lot of room.

I look forward to some of those changes that you're referring to coming forward. I hope that we're having a very serious look at it. As we all know in this room, the population is getting older quickly. Our needs are going up, they're not going to go down for a good long time, and we need to be out now, ahead of that - well, we're already behind it, we're by no means ahead of it. We're well behind it and we've got a lot of catching up to do to get it to where it needs to be. I may get to my colleague before I'm done. I'm not sure, I may be able to take up a little more time.

I want to go to one specific nursing home in general; I'm sure you know which one that is, and that's the Windsor Elms, that's coming along very nicely. That was one of the ones announced back a couple of years ago, and fortunately the Windsor Elms, that board there and that group that have been working on that - and I know the minister is here shaking her head. Service Nova Scotia is more than aware of this project as well, a very, very good

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project. We've got a great group of folks, Don McLeod and Gerry Raymond and administration, Sherry Keen at the nursing home, and others, all working, who are very qualified individuals who have been able to move this project along based on life experience and what they've done for a living and so on.

There have been numerous delays by way of the tender process. They're now reaching the end. I know there was a projected number - there's always a projected number - and I'll go back to the Colchester Regional Hospital; there was a projected number there too, but that fell far short, as we know. I guess I'd say this first, that I've not known any project, whether it's a government project or what it is, that's been projected and ever come in on or under budget. I would say they're few and far between.

I think we're somewhere in the vicinity of about a million dollars, maybe a little bit less now. I know that they're done everything to trim down and strategically tighten dollars where they can and to save money, but as we move through this project - and all the way through this project there have been difficulties with getting tenders approved. The step is, I'm sure you're aware, you've got to go out, you've got to tender, they've got to come back, they have to go to the department. Again, there's this middle administration, and again, maybe that's it, maybe that's not it, I don't know. But there is an issue with getting the tenders approved on time, and the problem - maybe it doesn't matter to some, but the problem that we know in here when it comes to dollars and cents, if tenders are not approved on time and they're delayed, generally speaking, the dollars go up, cost you more.

I don't know, when we talk about all these things and we talk about cutting money back, there seems to be a lack of wanting to help us on the other side get that tender out the door and getting it awarded and getting the work done. We're now into the construction season. The weather has been absolutely fantastic. There are a couple of huge tenders to finish this place up and I'm just looking for an update on the status of this. Recent meetings that have been had - I know that there have been a number of letters, minister, that you've received from the group and they've been trying to work very diligently. I know that they respect very well - I do want to say that as well - the process and the people that they have worked with on that board.

I have worked with them and told them I would do whatever we could to help them out, and I've written you and others, and they have the greatest respect for the Department of Health, but I think they're coming to that point now, nearing the end - the frustration is there, they want to get this complete. We're talking a million dollars is a lot of money, don't get me wrong, and $9 billion or whatever we're up to now; I know it's not very much, but I can't see this project being stalled over a million dollars or less as it approaches the end, when we have a need for this home to be completed and to get people into these rooms and so on, and so I'll ask you your thoughts and where we're at with this project and if you can update me.

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MS. MAUREEN MACDONALD: Thank you very much. The member raised a lot of issues, many roads to go down, including why do we have so many DHAs, and I think he should have that conversation with some of the members of his own caucus who brought us from four regional bodies to nine DHAs. They probably can tell the member more than I ever could about why we have the number of DHAs we have.

At any rate, we won't go there at this time; maybe we'll go there sometime, though, Mr. Chairman. Windsor Elms - I would like to talk about Windsor Elms with the honourable member. It's an excellent project, and all of the things the member said about the people who are involved is absolutely accurate, great group of people. They're been working really, really hard, and I appreciate his comments about the people in the department as well. I know Shelley and others and the deputy have worked really hard and will continue to do so, and I don't know if the member was here yesterday when I was speaking with the honourable member for Argyle. I said that there would be a little party over in the Department of Health when we brought a few of these outstanding long-term care facilities to fruition, and maybe we will invite you along; I'm sure you would like to celebrate as well, and they will, these places will open. They will be completed. We are very committed to getting them done.

Now, Windsor Elms, as I understand it, is replacing a facility of 108 beds that was very, very old and out of date and quite deteriorated and definitely required this new facility. There is a projected budget. It's mind-boggling when I look at the continuing care strategy, the cost of adding the new beds. There are some beds that cost as much as $400,000 a bed. This is not government doing things on the cheap, by any stretch of the imagination, and I'm not an engineer, an architect, a building person or whatever, but I can't imagine how it is that these things are this expensive. It is astronomical.

Unfortunately, or fortunately, however you look at it, it is my job and it's our job in the department to be good stewards of the public resources that we have and to try to ensure that we get the best value for the dollar that we possibly can as we work through these various projects.

With Windsor Elms, I understand that in order that we don't end up with a Colchester situation, and I am not suggesting for a moment that would be the case, but just in terms of due diligence, we have engaged PricewaterhouseCoopers to review the business planning process there and to provide a report and we'll be receiving that report fairly soon. It doesn't hurt sometimes to have an independent pair of eyes that can look at the decisions that are being taken in the department, the parameters that we have, as well as at the project level, to try to give us some good advice and sometimes you have to go that route and get good advice and that is where we've gone.

The member brings up the Colchester Regional Hospital. When you see - and it is not the first time that someone has said to me, well, the government found money for the Colchester Regional Hospital, so you can find it for this, and you can for this, and you can

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find it for this, and so, pretty soon, $1 million turns into multimillions of dollars. The Colchester Regional Hospital is a project that has been underway since 2004, more than $104 million was initially set aside for that hospital, an additional $50-some million was approved for that hospital and yet it wasn't sufficient. We had a shell, we had a hospital that was 27 per cent constructed when I arrived in office, and we were $36 million short in terms of how you provide electrical, plumbing, heating, ventilation and all of these things. It wouldn't be much of a hospital if it didn't have any plumbing or heating, I would think, Mr. Chairman.

So, you play the hand that you're dealt and in terms of that hospital, and let's be clear, the Colchester Regional Hospital that's currently there is very old, a very old piece of infrastructure and it requires replacing, but we are vigilant in the department, we have looked at the Colchester Regional Hospital and said, this can never, ever happen again. In fact, we want to know what happened in the case of Colchester, and we will be getting some answers with respect to what happened in Colchester. However, we can't take that approach with our other projects, and there have been lessons learned. The honourable member for Argyle said yesterday that if he had things to do over, there are lessons that he learned with respect to the continuing care process and strategy, and I'm very interested in hearing more from him about that as we plan for whether there'll be Phase II of a Continuing Care Strategy, because we need to learn from these experiences.

We are trying very hard to be fiscally responsible, but at the same time also reasonable in how we deal with communities. As I said yesterday to the honourable member for Argyle, we recognize that people in the local communities are building these homes for their communities. They are motivated by their commitment to their community, their relationships with their seniors in the communities, their caring for and respect for people who have built those communities over generations and that's their primary concern and consideration. I completely respect that and I would never want to see that lost, because that's what makes these projects successful.

When a project is completed, the bricks and mortar of these places - as important as bricks and mortar are, they aren't going to be nearly as important as what goes on in those places. It will be these community folks who will make sure that Christmas, Mother's Day, St. Patrick's Day, Remembrance Day, and all of those occasions that are important to our seniors will be celebrated, and they will be involved in those occasions just as if they were at home with their family. In fact, these places are their homes, and they know that better than any of us, and that's what motivates them. That's what makes them great, and that's why our department and our government will continue to support the Continuing Care Strategy. I look forward to the opening of the Windsor Elms, and it will open probably very soon.

MR. PORTER: I like the words "it will open." I don't know if I like the word "probably" - if we could just leave out the "probably" and go to "very soon," minister.

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MS. MAUREEN MACDONALD: Probably very soon.

MR. PORTER: Probably very soon, that would be great. Yes, I want to say that I appreciate your comments around all of what you've said and, as you've said, pretty soon this adds up to be multi-millions of dollars on that. I would say that the group working with the Windsor Elms, the board doing this project, is in agreement with the PricewaterhouseCoopers thing. I've talked to them. They were fine with that. The issue is how long that takes, of course, because again, it slows down that tender process. They're being held up, and you're right, they are the group, they're anxious. Everybody has got their own project, they all want to get it done, and we all support our organizations like that - and the project as well.

One of the things in this case - you're quite right again, the figures, even for a place like the Windsor Elms - $36 million or $37 million, whatever it's going to come in at, is a staggering, astounding price to build something like that, but if you've had the opportunity to tour it, you would probably know why. Things are not cheap. Bricks and mortar are not cheap. We have no control - that's the other thing that I can appreciate from the board's perspective, from the time you start and you get into a project that's maybe two or three years long, when the projections went out, the estimates went out for what the original cost would be, the markets have changed. The price of oil has changed. I don't know what hasn't changed by way of materials. Building materials, again, we hear are going to take another huge jump by way of lumber, shingles, and things like that. Unfortunately, that's not likely to do any of us any good when it comes to moving forward economically this Fall or this Spring again and through our season.

I think what's important to remember here is that the folks aren't asking for a blank cheque either - they would love to come in at the $36.6 million, I think was what was set aside for this, they'd be more than happy to come in at that or under. I don't know if that's going to be realistic. Maybe they'll come in much closer than they've anticipated, I don't know that, but the longer the tender waits to get awarded and go out, the longer that's going to take, or the more it's going to cost, I should say.

I thank you again for your comments on that and I know there are a number of roads that I did go down there on that last bit of going on. I look forward to hearing more about your thoughts on the district health authorities and the numbers we have and how come we're doing business so differently. I hope, one, that we don't keep spending a whole bunch of money on strategy after strategy.

Minister, I know when you were on this side of the House, I sat over there for three years and I listened to you, as the critic, do a very good job of picking apart strategies and reports and so on, and I would say, rightly so. I don't call this a partisanship issue, I call this an issue for Nova Scotians. Health care, as I said a few minutes ago, the issue is growing and it's growing too fast.

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I'm not a big fan of writing a whole bunch of reports that we're going to put on shelves. I want to see some action with regard to trimming budgets. I know every department this year, with deficits the way they are, has been asked to trim, although I do know that the health care budget is going the other way and I won't say that's a good thing. I wish there were areas that were able to be cut back to provide money for other much-needed programs and departments as well. That's not a reality at this time and I don't know if it ever will be.

I guess I'm hopeful that it will be, given that I have children who are not going to have a $9 billion or $10 billion annual budget that is entirely all health care in the next 8, 10, 12, 15 years, whatever it may be. I'll leave that and I'm sure I'll get other opportunities throughout the coming days and hours to ask questions.

I want to go a bit on the H1N1. I know we've talked about it just briefly. I know that you sat on Public Accounts as well, for a long time, and chaired that, and we had great discussions through the Public Accounts sessions during the course of H1N1 - what was being done and so on. I'm not sure, I think yesterday there may have been a question asked during Question Period about a figure that was used start to finish. Maybe that wasn't the total figure with regard to H1N1 because I know when this all came about there was a projection of something like $50 million that was set aside early on in March/April of last year when it all came about with King's Edgehill. What was the total figure?

MS. MAUREEN MACDONALD: The honourable member is correct. I can't remember exactly, I think it was something like $56 million set aside last Fall in the restructuring fund and it was set aside for both H1N1 and for wage settlements. There was never any breakdown in terms of how that might break down.

Currently, what we have in terms of expenditures, we spent almost $23 million on H1N1 and I can give you a bit of a breakdown. I didn't have that the other day in Question Period, but I have it now. I explained during Question Period that some of the expenditures are out of HPP's budget and some are out of this budget.

You may remember that we bought a number of ventilators for all of the DHAs and the IWK, as well as some portable ventilators - that was $4.6 million. Respiratory masks, you may remember that masks were quite an issue and they were $600,000; anti-virals, the Tamiflu, that was $566,000. The 811 line was swamped and additional services had to be temporarily provided to beef up the people to answer 811 calls. There were some days where we were getting anywhere between 1,800 and 2,200 calls in a day in a system that is supposed to have maybe 200 calls a day, so that was significant. The cost of additional human resources on the 811 line was $530,000. The delivery of vaccines - so payments to physicians - is $4.5 million. The primary care assessment clinics in the DHAs that were opened up to divert people from emergency departments, $6 million.

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So those are the Department of Health costs. Almost $17 million of that $23 million came from the Department of Health. The vaccine, which came out of the Health Promotion and Protection budget, was just under $3 million.

MR. PORTER: Thank you for the detailed count of that. Just still on that, a couple of questions. The current status of H1N1 - are there any cases still going on that we're aware of or are we finished with that? Do you want to comment further, or is that just a short answer?

MS. MAUREEN MACDONALD: Mr. Chairman, to the best of my knowledge there are no H1N1 cases. I think Dr. Strang may have said to me that they had seen maybe one or two cases a few weeks ago when I was talking, but there is essentially no H1N1 activity in the province, to the best of my knowledge.

MR. PORTER: Thank you, and I do know that there were discussions about a third wave. I guess there could be a third wave if it's going to come at any time, and we're just back into that season again, sort of, where it all picked up alive and well last year. I want to talk about the preparation, and - is it okay? I don't know if it's more Health Promotion and Protection-related, but while I'm on it, I just wanted to go there, if that's okay. Thank you.

The levels of Tamiflu and vaccines and things like that, are we at a level that you're comfortable with as minister? If we were to have another onset of this - or how does that work, that we can get it brought in if need be in a relatively short period of time for the next wave which hopefully will never come, but potentially could come?

[11:15 a.m.]

MS. MAUREEN MACDONALD: I'm not sure I should go down this road without Dr. Strang here, to be honest; he has so much information. But to the best of my knowledge, we have a stockpile of vaccine, both here in the province, we have some, and then we would have vaccine available to us. You will remember that I think we distributed enough vaccine for 65 per cent of the population, and we're still getting the paperwork back in terms of what the rate of vaccination was, but it was quite good. I think we're - certainly in HPP and Public Health, people are feeling very good about the rate of vaccinations.

So I don't know that we will need this, because there hasn't been a third wave, and I think perhaps it's partially because we have had sufficient immunization as well. If there is any activity, it's - you know, if people have been immunized, and that's the whole point of immunization.

MR. PORTER: Thank you. Yes, you talked about 65 per cent. That's not the number that were immunized, though, I don't think - was it? Do we have any idea of the uptake of

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just flu shots in general? I know we offered both last year. Are there any thoughts at all, any numbers that came from the physicians' offices and so on?

MS. MAUREEN MACDONALD: The last time I checked, we were still getting paperwork in from the districts, and additionally, we were still encouraging physicians who had done vaccinations to get their information back to us. But you will remember, Mr. Chairman, for some people there was a fairly rigorous requirement that paperwork be filled out. This was not welcomed in all cases by all physicians, because it places a certain burden on their administration in their offices, which I understand, but for us it's very important because we get these kinds of questions, but even more so to do an evaluation of your program you need to know. We haven't completed that yet.

Additionally there will be an evaluation, a really rigorous evaluation of the vaccination program, including communication around the program, as well as all of the operational aspects of the program, the distribution of vaccines. We will look at everything and when that is complete, we will make it available.

MR. PORTER: Yes, I can appreciate the physicians' perspective. However, I agree with you and I guess probably being a health care provider for a number of years, I can appreciate the prevention piece of this and that's what this is about, in the long term, costs associated with health care and the others, the fact that people were dying of this one, not quite like the normal flu that we would get our shots for. That will lead me basically - how much time do I have left, Mr. Chairman? A couple of minutes, I think, is it?

MR. CHAIRMAN: That's correct. Your time will expire at 11:21 a.m.

MR. PORTER: Thank you. I guess my colleague will have to wait until the next hour. Minister, just going forward from here with this - Dr. Strang is obviously still involved in some fashion with this. Do we still have a staff that is monitoring on a regular basis, in contact with the World Health Organization, other provinces throughout our country, in different jurisdictions around the world? How involved are we still - monitoring not only H1N1 but it always seems like there's some new strain of something coming along. I know we have only a short time, maybe you can give me just a brief overview of that in the next couple of minutes. Thank you.

MS. MAUREEN MACDONALD: Absolutely, Dr. Strang is our Chief Medical Officer, he is very much in charge and involved. He, on a regular basis, is in contact with Dr. David Butler-Jones, the Chief Medical Officer for the federal government, the Public Health Agency of Canada. There is an advisory working group and Dr. Strang is on this working group and other members of the department serve on other groups.

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They continue to monitor what is occurring, not only in this country but around the world. They watch very closely, the directives, and the information that comes out from the World Health Organization.

I guess what people don't really understand, and I didn't fully understand myself, is just what an international effort, in fact, it has been with respect to H1N1. Here in Canada we had probably one of the most, if not the most successful vaccination campaigns in the developed world. That is attributable to a number of things; the quality of the leadership that we have with people like Dr. Strang and Dr. David Butler-Jones, but I think as well, the fact that we have a strong public health care system has made a terrific difference, and not just that we have a strong system but the kind of system that we have. Imagine being in the U.S. where you don't have a kind of universal system, where every individual health care centre, or hospital, is its own private company or private corporation and you're trying to get a coordinated response to what could be a deadly pandemic. It's just mind-boggling.

When you look at the American statistics, in terms of the numbers of people who are vaccinated, it's under 20 per cent. So really, I think what has occurred here is a very good reflection of the strength of the public health care system and the fact that we have such extraordinary providers of care and good leadership.

MR. PORTER: Thank you. I know my time has expired and I appreciate just one more second, I just wanted to comment. In fact, I believe - and, Minister, as you've said - and certainly in talking to folks at home where we've had that start with Kings Edgehill, sort of bringing it forward, or to light anyway, people have been very pleased with the efforts that have been put forward by both the previous government and this government as well, I think, the Department of Health and the Department of Health Promotion and Protection and what has been continuing on. I just wanted to get that on the record and state that they are, indeed, very pleased, as I think in general Nova Scotians are, with where we're at. We are, indeed, very lucky, as you said, to be part of a country and a province that does manage a system very well when it comes to this stuff.

Thank you, Mr. Chairman, for that extra moment there and thank you, minister.

MR. CHAIRMAN: The committee will recess for five minutes. Thank you.

[11:23 a.m. The committee recessed.]

[11:32 a.m. The committee reconvened.]

MR. CHAIRMAN: Order, please. The Committee of the Whole House on Supply will now reconvene.

The honourable member for Halifax Clayton Park.

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MS. DIANA WHALEN: Mr. Chairman, I'm delighted to be back for another hour of questioning with the Health Department and I'm glad that there was a chance for a little break there. I would like to go back to where we were an hour ago and I'm sure that the minister remembers we were talking about midwifery. The pilot projects are in place in three locations around the province and I believe I'm right in saying there are just seven midwives in total who are practising in those pilot projects.

I had a couple of questions. One is - and I'm not sure, actually, if I did get to ask it - but I wanted to know when we would see an expansion in those projects, or the pilots, and actually have midwives available around the province. My colleague, the member for Kings West, had said to me that he knew of a family who had actually brought somebody from elsewhere in the province to come and be a midwife for them because it was so important to them. The demand is there, ultimately the demand is there.

So I want to know when we're going to expand it and I also want to know why we're taking this approach of three different types of pilots in three different places when this has been in practice for so many years in other provinces. Other jurisdictions, even within Canada - and it's certainly a big thing in Europe and in Asia, they never abandoned midwives in those countries. Why are we trying to reinvent the wheel and go about this in such a slow and methodical way? Why wouldn't we have looked at a best-practice model from Ontario, for example, or whichever jurisdiction does well, and just adopt it and let's get going?

I think one of my concerns in Nova Scotia is how we do sort of plod along and we adopt something new but we do it so slowly and we just don't get with it. So I would like to know why we haven't grabbed this good idea and run with it and if the minister could talk about why we chose this approach and what we're going to do next in terms of expanding it.

MS. MAUREEN MACDONALD: Mr. Chairman, I'm sure there could be books written on the process of getting to the place where we are today. The situation we're in today didn't come about overnight. It came about over a long period of time. It came about primarily because of the hard work of the Midwifery Coalition of Nova Scotia and a woman whose name is Jan Cantano, in particular. She's certainly not the only one, but I think Jan Cantano has been the single most consistent individual who has driven the process of getting midwifery services into the public health system in Nova Scotia.

When I arrived in this place 12 years ago, the Midwifery Coalition had been working very hard at that time to have midwifery included as part of the services available to women and children in the province. The Midwifery Coalition was very active around the rebuilding of the maternity hospital, the IWK Health Centre, when the old Grace closed and I remember, as a new MLA and my Party's Health Critic at the time, asking the government of the day, a Liberal Government, when they were going to move forward with midwifery

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as part of our public health care system as was occurring at that time under the NDP Government in Ontario, who brought those changes forward.

There were many reports - well, I shouldn't say many reports, there were some reports - and there were some working groups that talked about moving forward. I had meetings on occasions with different presidents of the Medical Society of Nova Scotia at the time. Some presidents of the Medical Society of Nova Scotia were strongly opposed to the province moving toward midwifery services and some were very much in favour of moving forward. So over a period of two or three years I began to see that it wasn't as straightforward as one might think, that we do not have, necessarily, in our modern day health care system, an experience nor a culture of bringing in this particular group into the practice of maternal and child care. And it's more likely that physicians who have practised elsewhere, where there were midwives, seem to be more open to the idea. However, that's my observation as a person who was not close, in any way, shape or form, to the process. I'm kind of an observer on the sidelines having some limited access, as a member of the Opposition, to a whole variety of issues and this issue in particular.

The former government made the decision to move forward and my understanding is that district health authorities were allowed to submit proposals, essentially, for what they would provide, sites were chosen based on what was proposed and these three districts were identified. The department doesn't necessarily go out to the districts and give them a template and say, this is what you have to do.

Actually, I think one of the strengths - and it also can be, I understand, maybe a weakness - of our DHAs is to allow the DHA to develop programs that are appropriate for their communities and within their understanding of what the community needs, the resources, the work they do with their community health boards. Community health boards at the DHA level all set their own priorities based on surveys they do and gaps that are identified in services and what have you.

So, my understanding is that DHAs submitted their ideas for pilots. Three were chosen. They are not all the same. The South Shore, for example, is quite stand-alone with midwives running regular clinics and the physician component in that particular pilot is significantly different from the physician involvement in other parts, in the other models. But again, the evaluation that is yet to come will give us a lot of information and a lot of detail about what actually occurred and what the outcomes and the impacts of those projects were. I don't feel that we should rush into any expansion, or the choosing of one particular model, until we have good information to make those decisions on.

And as far as when the evaluation will be done, we're anticipating that we will have a report in the Fall, in September probably, but perhaps a bit later than that - some time in the Fall - and the process to get the evaluation underway has already started, so we're moving in that direction.

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While I'm on my feet, I'd like to answer an earlier question with respect to the Midwifery Regulatory Council of Nova Scotia, because the honorable member had asked me who makes up the council, and I've since received that information. Mr. Chairman, the council is made up of three midwife members, three representatives of the general public, one representative from the College of Registered Nurses of Nova Scotia and one representative from the College of Physicians and Surgeons. So this is the Midwifery Regulatory Council of Nova Scotia that we were speaking about earlier.

MS. WHALEN: I didn't want to belabour this any more. It is an important area, it's just that there's so much that we need to talk about today that I don't want to go on too much more about it. I will watch for the evaluation in the Fall. One question would be - I'm indicating, I'm feeling it's urgent we expand it and get going, but at the same time you will scarcely have had one year. I don't know if you've had a full year even to be evaluating it. Maybe we won't even have the evidence by the time you're finished this year or by the Fall, if you're really taking the tack that you have to evaluate what's gone on. I know we've had a lot of births this year at the IWK, I don't know if that's been seen in any other parts of the province.

I'll leave that for now. I did want to know and the question around who makes up the council. I was interested in how many staff there were because the administrator indicated there's a new executive director, with $70,000 gone up in the budget. I was interested about that.

Also, this being the budget we see here, which we are looking at under other programs, is what's happening at the Department of Health. The real money being spent is - I forget the total amount, but perhaps you could tell us the total amount - and it's being paid through DHAs. It's similar to what we talked about with autism. You've got a little bit at the Department of Health, but a $4 million bundle when you add in all the DHAs. I would like to know if you have a figure on what we're spending on midwifery. I just wanted to signal my concern because I think there's a big demand, and I think the fact the care the midwife provides goes so much beyond the actual birth of a baby. It's so much about supporting families that I think we would get really good public health improvements by having that kind of care.

We didn't talk about the other category of support, but there's another group called doulas who work with the birth of a child and I know my constituency assistant actually had a baby last August and his wife had a doula through, I think, the family resource centre in Spryfield. They have a program and they were very, very pleased with that kind of support. Again, they're not qualified to deliver babies directly but they provide coaching, support and family counselling and help when you're preparing for a new baby, and that would have been a first child for them, so they really appreciated that and the home visits after as well. Maybe you could talk about whether there's a role for expanding doulas?

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MS. MAUREEN MACDONALD: The first question the honourable member asked was with respect to staff, the number of staff in the department. There is just that one staff person that we made reference to that's been transferred in, that line item $70,000 for a director, that's it. It's not a lot of staff.

With respect to midwifery, the cost of midwifery at the DHA level: the DHA 1 which is the South Shore, has $312,620 for their pilot; DHA 7, which is GASHA, has $353,299; and the IWK has $499,861, almost $500,000. The total cost of these three programs is $1,165,780. Yes, indeed, what we have in the department is the administration to support the council. The council is made up of those members. It's because midwifery is now a licensed, regulated profession and with seven practitioners, let's say, and perhaps a few others in the province - I don't know how many people are actually licensed as midwives, but you can imagine it's impossible to have a functioning council based on the membership fees of such a small body.

As a department, we fund their activities because they are very new, they need to have some support, administrative support, so this is the approach that has been taken.

MS. WHALEN: I'm going to switch tracks now and we'll go to something else. You did actually answer my question about why we are maintaining the council when nurses, doctors, pharmacists and others do their own, but with the small numbers I do see that because that's an unusual thing to see that buried within the department.

Just going to the other programs - of which there are so many - I would like to look at a couple. The second one on the list is another one with a basket of items or programs. It doesn't seem to have any variance, really, much through the year, but I'd like to examine, again, whether within that, and this is the one, just for the clarity of the minister, NSAHO, which is the health organizations, System Organizational Development, and Dalhousie Medical School. We have talked some yesterday about the Dalhousie medical seats and support for the university. We've got Medical Research Grant, which we talked - possibly that's the changes in the research grant, Provincial Programs and Acute Care.

What I'd like to know again, if you could peel that back, indicate which of those programs - and I'd be quite happy if you'd just go through it and tell me which ones have gone up or down or been eliminated because we can't have these - as much as I like some subjects like midwifery, we can't have as long a discussion on each one. So even if we could see, again, whether anything has changed dramatically within that package of items that are being shown there. I just find that sometimes there are unusual things that have been put into a single category.

While the minister is looking for that answer, I think I might say a few more words about that. We looked at, for example, autism programs being combined with the methadone program and also with children with complex needs. Those three lumped into a single figure

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that we can look at here in Opposition or for members - in fact, it's not available on-line for members of the public because this is a level below what is shown. I'm trying to get back to even getting to the next level and seeing what is in that because even when we talk about something like the EIBI, there's a whole range of costs that when we actually broke out what it is for autism supports, we'd see a whole bunch of different costs for offices and rent and travel and staffing. We're not going down to that level but I would like to know the global figure for each one of those programs.

This is not insignificant, in fact it's rather interesting for members who are here in the House today as well, it actually was estimated to be almost $3 million last year but we spent $1.9 million more, we spent $4.9 million on this basket of items. Now the budget for the coming year is a full $1 million less, we're only budgeting $2 million next year. So we overspent it by $2 million, we actually spent $5 million, and next year we're only going to budget for $2 million, so there's obviously been - no, actually I'm in the line down on that one, I think. Maybe the minister - I've gone to the third one, which is the $2.9 million one.

The one we're looking at is NSAHO. I was looking at the Acute Care Programs, that's the next one down. Minister, have you got your figures ready? If you're ready to talk about it I'll turn it over to you and I'll ask you to walk me through what's in that second item on your list of other programs.

MS. MAUREEN MACDONALD: Mr. Chairman, we're having just a bit of difficulty knowing which lines the honourable member is referring to. Let me try this and then we'll see if I don't have it right, so the Nova Scotia Association of Health Organizations, okay, perfect. Last year the estimate $1.6 million, forecast $1.6 million and estimate for the coming year $1.6 million, so unchanged.

Let me provide a little bit of detail on what those funds are for. This is for System Organizational Development. The Department of Health provides core funding to NSAHO for the provision of labour relations services to the acute care system. The many changes to the shape of the acute care system over 10 years has made this a viable and efficient way to put in place what is, in essence, a shared service among the DHA and the IWK, and many continuing care agencies purchase negotiating and contract administration services from this program of the NSAHO.

The Systems Organizational and Development Program at NSAHO is focused in three broad thrusts: occupational health and safety, occupational health and employee wellness, and learning and development. The broader service is, in large part, funded by their members, so essentially this is what that financial commitment is for, and there is no variance in the estimate.

So then the honourable member also wants additional information about the next items. Dalhousie Medical, the clinical academic budget - and we spoke a bit about this

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yesterday, that in 2009-2010 the estimate is for $1.5 million. The forecast is $3.2 million. Now that is - because of the timing of the last budget and because it was back a few months when we identified this as a bit of a problem, in terms of some duplication of payment, we didn't want to just haul the rug out from under the medical school, because they were in their budget year and they had already planned for that money. So we paid out the full $3 million, as planned, and there's an additional $200,000 that was extended to the medical school to help them prepare for their accreditation work.

In this year's estimate there is no money. We gave them their notice. We gave them notice that that was it, that terminated that particular piece of funding and commitment.

In terms of the medical research grant to Dalhousie, I guess - I think it is to Dalhousie - it is $157,000 estimated for 2009-2010 and it just continues on. That was paid; it was in the forecast and it is estimated again for next year, $157,000.

The next item is provincial program, acute care residents. This is bursaries to medical school residents, in 2009-2010 estimated at $647,000. The actual forecast is $1,000,012, and next in the estimate we're looking at $1,128,000, so there's a slight increase. That may be due to an increase in residents. I'm not sure of the number of residents.

You know there were additional seats back in 2004-2005, and those folks at that time were undergraduates. Now there are 11 of them, new residents, so there may be additional - that may account for why there is an additional increase. We need to continue to support those additional numbers.

Acute care, the Employee Assistance Program, $528,000 in the estimate, $489,000 in the forecast, and $528,000 in this year's budget estimate. This program, Mr. Chairman, is the transitional services to provide assistance and professional counselling to employees and their families in regard to a wide range of personal problems. These problems include, but are not limited to, alcohol and drug abuse, stress, bereavement, family, marital, vocational problems, financial problems, child care, elder care, legal issues.

The next line item is very small, $25,000, district health authority, for something called SURPS and to be honest with you I have no idea what SURPS is. It's an administration fee, and it's $25,000 and it's consistent right across estimate, forecast and then estimate for this year. And the last item is Diversity Initiatives in the department and that's $100,000 estimate; $53,300 was forecast and $100,000 for next year.

I think this is very important, we have a diversity coordinator, a person who is in charge of leading diversity initiatives in the DHAs. For example, I think last week, or maybe this week, I had an occasion to talk about the evening event I attended over at the Black Cultural Centre with the two men who had come from the south side of Chicago. It was amazing, it was absolutely amazing to hear these men talk about their work in the public

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health system, attempting to improve the primary care, accessibility, and outcomes for black men in that part of Chicago. The diversity initiative in the department, and our staff person who leads that initiative, were very much involved in the planning for what was really a very informative and interesting event. Thank you Mr. Chairman.

MS. WHALEN: Thank you very much and I certainly support the diversity efforts of the department throughout, and providing guidance to DHAs, if you're providing that kind of support and guidance so that they also support diversity and have programs in place for their staff, and for patients as well, like cultural sensitivity and understanding patients' issues as they come through the door. I've certainly had some issues myself with constituents who have attended hospitals and felt they were not treated sensitively around their family, their family circumstance or that sort of thing.

In fact, one couple in my riding, who are gay and are married, did not feel that they were treated properly. In that case, I must say in even mentioning it, Capital Health was very quick to answer my queries and to deal with that. I know that they were very concerned as well that there was anybody that felt they were not welcomed and that they were not treated very properly in the hospital.

Diversity for people is important. We like that. Now, as we go forward, those two line - and that is actually the second and third items that you did go through with me on this list of other programs - I guess one small question would be, at the end of the description that begins with NSAHO, it finishes with Provincial Programs Acute Care and then the start of the next line says DHA Provincial Programs Acute Care; is that just said twice? Is it a duplication in error? Because you gave me one figure for acute care that had gone up to $528,000 and that was the transitional funds relating to professional services for staff. And again, I think it's very important that we support our staff.

We haven't talked here about the tremendous pressure that people who work in acute care in the front line in our hospitals are under, a lot of stress; they deal every day with people who are suffering and people in pain and people who have a lot of really serious issues, so it takes its toll on the caregivers in the hospitals. Could you explain to me, while I think the minister may have her answer ready, I'm just making sure you're set, but that is repeated twice, that might be a mistake and I wanted to get that figured out if we could, because that second line item that begins with DHA Provincial Programs is one that has had a lot of fluctuation.

The second item has been pretty stable, there's no real change, no variance, but look at the third item - and that was the one where I had gotten ahead of myself previously. That item I'm now focused on is the one where we spent more than $2 million more than we had budgeted, and next year we're looking at spending a full million less than we budgeted - which is $3 million less than we actually spent this year. It's almost like a $3 million decrease because we spent it this year. So I'm not sure that I heard where those kind of

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figures were in trying to catch each and every one of these items that the minister is helping me with.

Could you delve in there and find for me where this great fluctuation occurred?

MS. MAUREEN MACDONALD: First of all, let's dispense with sort of a clerical error, if you will - Provincial Programs Acute Care you can just scratch that, it's the same thing as DHA Provincial Programs Acute Care. Okay?

Now let's talk about the more substantive issue - why the big increase in expenditure of $2 million? That goes to the Dalhousie Medical School. It's paying the last $3 million to the Dalhousie Medical School - that accounts for that increase.

Just let me go over this again so that we're really clear. The Department of Health for a number of years provided funding for a clinical academic budget for the Dalhousie University Faculty of Medicine. What would happen then is this would be in a pot and it would be available for the members of the faculty who are also clinical practitioners in our big teaching hospital - and I'm not sure when exactly this particular line item originates in the department, but it goes back a number of years ago.

Now, this is being discontinued on a go-forward in this budget, and it's being discontinued because of how we fund those same folks through AFPs. The AFPs are structured around different groups. So they're structured around the psychiatrists let's say, or they're structured around the pediatricians, oncologists, and a large sum of money is associated with that AFP, a big pot of money, and it gets so many full-time equivalent practitioners or it may get so many clinical hours - they're very complicated contracts - in addition it gets some administration and it gets some research and so now we, through the AFPs, have been providing a significant amount of money to the Dalhousie Faculty of Medicine and this was considered to be a duplication.

However they've had that duplication for a few years and it's no doubt been built into their base and the way they fund activities, and we didn't want to just abruptly leave them disadvantaged, so last year the money continued to be paid and then they were paid out a sum of money in terms of showing that we have good faith as we go forward, but from now on it's not going to be there.

MS. WHALEN: Okay, and I appreciate your going into that again. In fact, what had me confused was that the number on your chart, on this financial statement of costs, isn't lined up with the Dalhousie Medical Research - it's below. I thought that Dalhousie Medical Research went into the NSAHO bucket, if you like. They're just not lined up across, so I thought we were talking about something very different because the fluctuation wasn't really accounted for with the diversity in SURPS spending - it's very clear to me now and it helps.

[Page 80]

Strategic Initiatives - I'm wondering if you could just tell me what that is, it's down marginally. In terms of your great big budget, it's a very small amount but in terms of Nova Scotians it's $138,000 - I would like to know what exactly are the strategic initiatives we're looking at.

MS. MAUREEN MACDONALD: Yes, there is a line under Other Programs called Strategic Initiatives. Last year we paid $668,000. That was the estimate for last year, forecast for $530,000 and estimated for this coming year at $530,000. What that is, Mr. Chairman, is an initiative with respect to bringing people, who have been off the job in long-term care and acute care on workers' compensation claims, back to work in a timely fashion. That may mean supporting (Interruption) That's right, exactly, that's what that goes for.

MS. WHALEN: I just want to be sure that's just a single initiative then really - it says Strategic Initiatives. We certainly support that idea as we know we have an awful lot of people. We saw the report today from the Workers' Compensation Board for the year and I know we have a lot of injured workers and, again, we said health care is a difficult area. A lot of people are injured lifting people and moving people, so I'm glad to see there's something there to help people get back to work. I really am a big believer in work hardening - and I think that's the term physiotherapists use when they try to introduce people back to work and find the level that's appropriate for them. So that is a good thing.

I'd like to know about oncology before we leave this other program section completely. If you could just go through the top line item, which is Oncology Drugs, and let me know what is actually done there, because again I would have assumed that drugs would be front line in the DHAs - I wouldn't expect to see an item on the Department of Health list for oncology drugs. Again, as the minister knows, cancer is far too prevalent in our province - we have some of the worst records of the incidents of cancer, and certainly we want to see the best treatment for those patients, and when we get into health and wellness, hopefully, a good discussion on what the Department of Health Promotion and Protection is doing to change the lifestyle issues as well that might have something to do with some of the cancers that we see.

We also know that we've had a lot of environmental issues, and the cancer rate in Cape Breton far outstrips the rate in the rest of the province. When we look provincially we have one of the highest rates of cancer in the country - apparently if you take out the incidence rate of Cape Breton, we actually come out to be about on par with the rest of Canada. (Interruption) Yes, Mr. [Deputy] Chairman, I know that that would be of interest to you and all of us.

There is a history, of course - industrial activity in the central part of Cape Breton with Sydney Steel and also with coal mining, which is another very difficult profession, and we are seeing the effects of that, I believe, in Cape Breton and we have for many years. It's

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not a new phenomenon, but the people who live in Cape Breton are very well aware of how prevalent it is and, really, how they have paid a price from the environmental side.

I think that that is a lesson learned and I hope it's a lesson learned about how - and I know the minister and I'm hoping all members of the government are really well aware of that silo effect that we only think about one department at a time or one area at a time, but if we don't address environmental problems we are not going to be able to help improve the health of our province.

I'm a firm believer that this is not something that's pie in the sky or fictitious. I believe there's a direct correlation and I think our cancer statistics show us very much that this air quality and, you know, just the pollution that has been deposited in these communities leads to a much worse health outcome. So I'm looking at the oncology drugs, which is what my actual question to the minister was, and I know that we could say an awful lot and talk a lot about the prevalence of cancer in our province, but if you could start with that drug line.

MS. MAUREEN MACDONALD: Mr. Chairman, it is true that cancer, unfortunately, is not only a significant health problem for many people in the province, but it's a growing problem. Sometimes I'm really discouraged, I have to say, when I hear the projections for what it is we can expect into the future.

I was saying, honourable member, that sometimes I'm discouraged when I hear what the projections are for the future - it seems that we're running as hard as we can, yet we don't seem to be making a lot of headway sometimes, although that may not always be the case. There are new drugs, there are new more-sophisticated pieces of technology, capital equipment and what have you, that will, I think, make some difference, but sometimes it seems that the difference that's made is so small, so minimal, it causes me quite significant concern.

[12:15 p.m.]

The DHA drug costs I have for the fiscal year we've just completed, and they're not broken down in terms of what cancer drugs would be part of this, but cancer drugs are a part of these drug costs in the DHAs - so the total amount forecast for 2009-2010 at the DHA level is $310 million. What proportion of that would be for cancer patients, I'm not really sure. That's the total for all drugs - all drugs - $310 million. (Interruption) Yes, I'm sorry, I misread that - the total drug costs for last year was $310 million. The total drug cost in DHAs is $51 million, and of that there would be cancer drugs - $51 million.

Now, to go to your question about this particular piece of the Department of Health's budget in terms of oncology drugs in the other program's estimate. Oncology drugs are high-end drugs approved by the Cancer Systemic Therapy Policy Committee - it's quite a

[Page 82]

mouthful, the Cancer Systemic Therapy Policy Committee. This committee is made up of 23 people, including cancer patients, cancer specialists, a pharmacist, an ethicist, and other health care providers, as well as members of the department. This is for drug therapy provided in hospitals in addition to the $51 million which would include some cancer - and because there are certain drugs, high-end drugs, such as Avastin, such as Herceptin. So I have a list of certain kinds of drugs that, for example, Herceptin, the number of patients who are receiving this drug is 70, and the projected cost of this drug is $2.5 million.

So the question becomes sometimes, what is the appropriate drug for this form of cancer and are all of the conditions there for this to be a treatment that makes sense? So these decisions are difficult decisions and we have this committee, and so the estimate for last year for oncology drugs - these are the high-end drugs - was $9,367,000. The actual forecast for this year was $8,501,000, and for next year the estimate is $9,851,000 - so there's an anticipated change of $866,000 and that's due to utilization decrease driven by volume. (Interruption) Yes, yes.

MS. WHALEN: I appreciate the minister going through that with me as well and, you know, I'm glad to see - I know that many of us spoke about Avastin, that's one drug that we had talked about here, and I'm not highly conversant with all of the drugs that would be on that list, but we do know that there are, as you say, some opportunities to help people recover and live a longer and fuller life. So we do support that as well, although I realize there are a lot of pressures, because actually your variance for the coming year is an increase of almost $500,000 - clearly that is more people needing the help.

We have, I think, about 20 minutes or so left in this round of questioning, so I wanted to ask a general question, if I could - I still have lots on mental health and many other issues that I will want to spend time with the minister on but I wonder, could the minister talk about the internal review that was done? I know across government every department had a review to find savings and we've been drilling down now in the last number of hours on which ones had fluctuated, and clearly, finding a duplication within the research monies that were being given to Dalhousie is one example of that, and I appreciated something that the minister said, which was that it wasn't pulled out all in one year which - well, you know, essentially over a year it has been, but when it was found it wasn't pulled away from the university because they had already budgeted and planned for it.

So there has been a little bit of a cushion in time, but I wonder if the minister could speak in broad terms, and give some examples of how that internal review went because, as I mentioned when the students were with us a little while ago, the Department of Health is the largest budget department. We spend more money in Health than in any other department, and therefore if the internal review of expenditure was going to be successful this would be a department where I'm sure you were looking to find more of those duplicate items or opportunities for savings, and with a $3.5 billion budget, the nine DHAs and the IWK that get funding as well, your search for rationalization or savings, you know,

[Page 83]

identifying waste, would have to have gone right into the DHA level because so much of the money is actually spent at the DHA level.

So I'm wondering if you can give me an overview of how that proceeded and the support that you received from the DHAs in doing that, because again, as I say, a good percentage, and you could say what percentage is actually being spent through DHAs. We're not looking at their specific budgets here today, but we have just a global figure for that, but could you talk about the internal review because I think that it's very pertinent not only to your department but to all departments - are you all set? Okay, thank you very much.

MS. MAUREEN MACDONALD: Yes, I think this is an important area to spend some time talking about. It's difficult and it's not going to get any easier as we go forward.

Mr. Chairman, we have started the process in the department of looking for areas where we either have duplication of services or we have services that are redundant, things that - as the Minister of Finance likes to say - we don't need to do anymore and we can stop doing and refocus. We've already done these things.

We went through a process of reviewing all of the grants that the Department of Health extends to all kinds of entities, like our DHAs, but also other groups and organizations. At the end of the day, I think we found that we do pretty good in terms of maximizing the money that we give, but we did identify some of the areas that we've talked about already - the duplication around the clinical research piece at Dalhousie, for example.

The Department of Health continues to look for where we can make reductions. In this budget, we identified close to $30 million in reductions, and I can give the honourable member some broad examples. In what we call executive administration, we have identified a savings of $2.7 million, which will be found by reducing travel, supplies and services, and professional services, and having tighter controls over spending, like catering and other expenses. The deputy arrived at the department and cancelled bottled water, for example, which is both a good environmental move as well as a good cultural shift in terms of sending a message that we have to be prudent in-house.

We had the $3 million reduction, as I pointed out, with respect to Dalhousie Medical School. We've also been able to identify some other initiatives that we think will result in reductions. We hope to get $3 million in reductions from bringing Nova Scotia patients in New Brunswick hospitals back to Nova Scotia more quickly. One of the great things about being a small region is you have an opportunity to meet and network with your provincial counterparts. We learned that Prince Edward Island had hired what they call a nurse liaison, who resides in New Brunswick but works with New Brunswick hospitals in terms of getting patients from Prince Edward Island out of those hospital beds and back to the Island. That has resulted in savings to P.E.I., so we learned from that and thought, you know, we have a

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similar issue in the Amherst-Cumberland County area, and that could work for us as well. This is an initiative that we are pursuing, that we hope will result in savings to the province.

In addition, we have a number of small programs and we're seeing changes in these programs. A lot of the small stuff kind of adds up. For example, the member will remember that there was a compensation program set up for hemophiliacs through the tainted blood situation, and although the savings aren't big, the truth of the matter is that many of those people are no longer with us and they're no longer members of the program. We're not taking away any of the benefits for existing people who are members of that compensation plan, but as people pass away, then we have this plan and the demand on it is no longer what it was and we're able to say, okay, that's money that's freed up now for either other things or we can redeploy that money. (Interruption) Yes, these are permanent reductions.

Some of our IT initiatives are coming to an end and this will result in reduced funding, as things come on-line, although IT is ongoing and will be ongoing, we live in a microchip world and that is not going to change. But at any rate, as certain initiatives come to conclusion, it means that we can reduce those budgets, or eliminate those budgets, and so we have a number of those initiatives that are being reduced because the initiatives are over or close to being over.

Another very large area of reduction, though, is in the DHAs. We directed DHAs to look within their own budgets for a 1 per cent, non-wage reduction. They have been directed to look at administration and not on the front lines, if at all possible, and if I remember correctly - and Linda will help me here - I think the total DHA budget is about $1.5 billion and we were asking them to find about 0.3 per cent. We were asking them to find, I think a little over $3 million - $4.5 million, that is what it works out to be. It is should not result in huge cuts.

[12:30 p.m.]

One of the things, this budget has an increase in health care expenditures. It has a $212 million increase in expenditures. I was looking at where those increases come; $63 million of that $212 million is the Master Agreement with physicians. A lot of those increases are contractual obligations that you can't just tear up and say, we're not going to fulfill those contractual obligations anymore. So when people are critical that there weren't deep enough cuts, they don't understand the implications of saying we're going to ignore contracts we have. We can't do that. We have contracts.

The long-term care beds in the Continuing Care Strategy, many are halfway completed, under construction, and what have you, another $56 million in that increase. So you have $56.7 million for new beds in long-term care; $63.2 million, the physicians Master Agreement; well, there is one-half of the $212 million increase. So I think these are really important. The government's commitments that we made in the campaign for this year

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amount to $7 million, so of the $212 million additional dollars, it is a drop in the bucket, really.

MR. CHAIRMAN: The time allotted for the Official Opposition has now expired.

The honourable Leader of the Progressive Conservative Party.

HON. KAREN CASEY: Thank you to the minister for providing, I know she will be providing information and responses to my questions, and I would like to acknowledge staff who are here with her. So that staff can be a little prepared, I'll tell you that a fair number of my questions will focus on emergency rooms, but I will be going other places as well. I do want to acknowledge the work that the minister and her department have put into preparing for the budget and trying to set priorities, make decisions, and make the best use of the dollars that are available.

I would also like to acknowledge the work that the district health authorities and their staff do. I spoke yesterday in the House, a question that I asked about the emergency rooms - I did comment and I do believe, based on my experience, that the flow of information and the communication between DHAs and the department is positive and is ongoing and is absolutely critical in order for both to function effectively. So I do want to begin by acknowledging that.

I did obviously look through the budget highlights, and there's one thing in there that I would just like some explanation and clarification - explanation more than clarification, perhaps, but it talks about the ER Protection Fund - $3 million in the ER Protection Fund. I guess perhaps if the minister could explain a little bit about that? I understand it's to implement initiatives. So any information about the intent of that, the initiatives that might be included in that, or if there are no initiatives yet, how that list might be generated?

MS. MAUREEN MACDONALD: I'm very pleased to have an opportunity to discuss the Health estimates with the former Minister of Health, who would know the department very well, and also as a former Chair of a district health authority. I can never get the numbers right - I always think of them as regions. So I have to start going, okay, one is the South Shore, and count my way around, but you were DHA 4, Colchester East Hants.

The emergency rooms, as the former Minister of Health knows, are a challenge for any government to tackle, and it has been a longstanding difficulty - not only here in Nova Scotia. If you pick up any newspaper in any province in this country, you will have stories about problems in the emergency rooms. Not to minimize the problems here in Nova Scotia, because we do have problems we have to deal with, but boy, when I look at situations in other provinces, I count my lucky stars we're where we are, because in spite of our difficulties we seem to not have the kind of extensive problems that do exist in other places,

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where we have seen some really tragic kinds of outcomes because of dysfunctional emergency room systems.

As the honourable member knows, we have, I think, 35 emergency rooms in the province. I think there are 35 emergency rooms in the province, and of those we have six that have what I would call chronic problems with respect to emergency room closures. They tend to be in smaller centres, smaller communities. However, they're not only in smaller centres and smaller communities. For example, I don't consider Digby a small centre or a small community, it's a significant town in a region of the province and it probably has the most chronic difficulties at the moment, but there are some smaller emergency departments such as the one in the member's riding, in Tatamagouche. So these are the ones that present us with a great challenge, but they're not the only challenge because the big emergency departments, including our emergency room at the Queen Elizabeth II here in the Capital District, have significant problems as well. It's no picnic in any of the other regional hospitals in the emergency department. They've all had their difficulties.

One of the first places I visited was Southwest Nova District Health Authority and was taken through the hospital, including the emergency department, and there were stretchers lined up all along the hallways. There were ambulances tied up, unable to unload, and that was in Yarmouth. I think, maybe because the media is here in metro, centrally located, they tend to know about Code Census and the difficulties at the QE II, but I can assure them, Cape Breton has had their difficulties. Yarmouth has had their difficulties. I have heard, in the past, of difficulties in emergency rooms in the South Shore, the former DHA of the deputy. The pressure on emergency rooms around the province and here in the Capital Region is great.

In the election of 2009, one of the campaign commitments, Mr. Chairman, you will probably remember, that our Party made was an Emergency Room Protection Fund for $3 million and that is in this year's budget. It is not in the budget of the Department of Health, it is held centrally. It is intended to be a fund for short-term initiatives, and I don't know if this is an example - the deputy will tell me that it is or it isn't - but, for example, it may be there to use in the current emergency department over at the QE II with respect to the problems we're having with ambulances and the need to be able to move people out quickly, or - I'm being advised - actually, for an extra two shifts.

The member would know that recently emergency room doctors' contract has expired and we're embarking on a process now to put a new AFP in place. Those contracts take a long time to negotiate, they're very complicated. As a demonstration of good faith, and as an indication to the emergency room doctors there that we hear their concerns about how overworked they are and the shortage of staff in terms of the emergency department, that protection fund is there to allow us to be able to take some pressure off that emergency department while Dr. Ross is doing his work developing the recommendations and the plan for a province-wide emergency health services system.

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I can't provide many more examples. It's a new initiative. It's established by the government as a fulfilment for one of the campaign commitments and it is contained in the budget and it will be there on an as needs and application kind of basis.

MS. CASEY: Thank you to the minister for that explanation. As a result of that I do have a couple of follow-up questions. If I understood correctly, it's to look after short-term needs, my question would be, would the additional doctor coverage that you spoke of here in Capital be considered a short-term need and did it come out of that fund?

MS. MAUREEN MACDONALD: Mr. Chairman, certainly it's short term while we're negotiating a new AFP, and part of that will be to look at what the needs are and how you meet those needs.

MS. CASEY: Mr. Chairman, when the minister is talking about emergency rooms across the province and her visiting them, it's obviously something that I did early on as well. They are very intense environments in which to work, and there are a number of reasons why.

My question to the minister would be, at that time in the Spring of 2009 there were seven emergency departments that had in excess of 1,000 hours of closure. I think you suggested today that there are six that are still experiencing some difficulty. I wonder if you would be able to give me the names of those six so I can do some elimination here and see which one has the problem solved.

MS. MAUREEN MACDONALD: I don't know if the problem is ever solved. I think that the Roseway Hospital, if I'm correct, is the one that doesn't seem to be experiencing as many closures as we've had in the past. I don't know that that's exactly accurate, but it occurs to me that it is Roseway. I think that may be because there was the recruitment of a physician in the Roseway area and that has made a difference.

We still have problems. Digby is still a problem. Tatamagouche for a time was okay in some ways, but it's starting to be a problem again; we're seeing more closures there than we have. New Waterford is a problem. Glace Bay is a problem. Annapolis Royal is a problem. I don't think Fishermen's is really that much of a problem either, although there are some closures.

[12:45 p.m.]

What I want to say to the honourable member is that I introduced legislation in the Fall, an Emergency Department Accountability Act with respect to emergency room operation. One of the things Dr. Ross talked about is the difficulty with data and the different kinds of data that are collected at the DHA level and what have you. The bill I introduced requires that DHAs, if they're having chronic problems keeping ERs open, have to do some

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public consultation, meet with the public, talk openly about these problems, hear from the public, get suggestions, report back to me. These meetings have happened in many areas of the province. The last ones are about to conclude.

I heard a little clip with John Malcom - the CEO of Cape Breton District Health Authority was in New Waterford last night. I don't know if he himself was there or members of his staff, but knowing John he probably was there himself. They will report back to me, and then I will table a report here in the Legislature. I'm intending to do that this Spring before we leave, and we'll have, no doubt, an opportunity to have a more detailed examination of the information we're gathering, and we'll know what the picture has looked like in the last little while for the emergency rooms. I think this is not only important in terms of ministerial accountability, but it is, I think, a way to get an accurate picture of how many hours an emergency room is closed and where the problems are in the province in terms of what emergency rooms are closed, how often, when. So we'll have that in the coming months.

MS. CASEY: I'm certainly pleased to hear that the list is getting shorter, but I know that the problems are never always solved for an indefinite period of time, and I know that numbers can change. I just want to go over the list, this would have been in 2009, the Spring of 2009, and as the minister said, some of those, the Fisherman's, Digby, Roseway, Lillian Fraser, North Cumberland, New Waterford, Northside General, were some of the ones that were in excess of 1,000 hours.

I know at the time when I met with the folks in each one of those particular hospitals and the DHAs, the solutions to the problem appeared to be different, because the reasons for the closures were different. So my question to the minister would be what different circumstances are being presented as causing the closures?

MS. MAUREEN MACDONALD: I want to make sure that I have accurate information for the member on the record. So let's go back to the six because I wasn't bang on with that - close but no cigar. Digby General is one of the six. Roseway, in fact, is one of the six, Annapolis, Fishermen's, Lillian Fraser and New Waterford. So Glace Bay isn't one of the six. So substitute Roseway for Glace Bay.

So what are the reasons for closures? Well, generally speaking, in the majority of cases there isn't a doctor available to cover the shifts but it can be more than that. It can be that there is a doctor but there is no nursing staff available. I think I've seen that occur in Annapolis, for example, but it can happen in various places. So these tend to be the problem. It's about the availability of health care personnel and, specifically, you don't have an emergency department without a doctor at this stage.

MS. CASEY: I will speak specifically about Lillian Fraser and I know that the minister, the deputy, and everyone at the department probably understands why. Lillian

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Fraser had been plagued, as you know, with chronic closures and when I was at the department, I asked the question about doctor shortage. I spoke with the CEO and it appeared that the problem there was not doctor shortage, it was actually a scheduling of existing doctors' time. So with the work of the CEO, they were able to look at doctors' schedules which included doctors working out of both of the facilities in that DHA, and they came together with a schedule that appeared, not only appeared to, it did address the problem for a few months.

Your comment about perhaps one of the reasons why Roseway was not experiencing as many closures now as it had was because of the hiring of a new doctor. So I guess that leads me to - and then you've added the business of a combination of doctor and nurse together - so with the work that Dr. Ross has done now and with the information that is available at the department through the DHAs, are we able to look at those that are still outstanding and determine if it is doctor shortage, nurse shortage, a combination of the two at the same time, or if it is scheduling, or if there is anything else that's contributing? I guess what I'm trying go for here is, if we know exactly what the problem is, then we know how to address it, because it does differ from one place to another.

Those that are still experiencing difficulties, do we know exactly what's causing the difficulty and is it a need to recruit or reschedule or what is it?

MS. MAUREEN MACDONALD: It varies from location to location. For example, in Digby it's a problem of a shortage of doctors. When I first came to the department, we were anticipating a new physician was going to be coming to the department in the Fall. There had been some form of an arrangement in place with a resident who had received some sort of a financial incentive toward his education. He had agreed he would practice in Digby for a period of time and he changed his mind and he went someplace else and he paid the money back. That left us short of a physician, so that isn't entirely a scheduling problem, that's a doctor shortage in a particular area.

In other areas, it can be a scheduling problem. There are enough doctors to staff an emergency department but their preference is not to work in the emergency department but to work in their own offices because they make better money seeing patients in their offices during the day. So it's difficult to get certain shifts covered in an emergency room.

I think Dr. Ross' report pointed out the complexity of this. We have more two-physician households than we've had in the past. We have more women working as doctors than we have in the past. The patterns of activity - if you're a two-physician household you'd like to have some time off at the same time and not always have somebody covering shifts.

The problems vary from site to site but they can't be completely segregated, that the problem in Roseway is always because we're short a doctor and we have to recruit more doctors. You may actually, at any given time, have enough doctors in that area, but it's a

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scheduling problem. So they're very intermeshed, these problems. They require more than one kind of intervention, they require a multiple number of interventions.

I want to go back to the Digby General Hospital situation. This is a doctor shortage. I'm really pleased to be able to say that we've just learned that a physician has been recruited to Digby. It has been a very difficult area of the province to recruit physicians to, as the member no doubt knows. We're hoping to have a new person there in September.

The business of recruiting physicians into hard-to-service areas is an ongoing process. All of the DHAs have their own recruiters and, additionally, we provide back-up support in the department for recruitment. It's a challenge but there's a lot of good work being done.

MS. CASEY: Thank you Mr. Chairman, I'm pleased to hear, and I know the folks in the Digby area will be very happy to know, that there's some relief on the way with an additional doctor, and I do know the challenges of recruiting.

I just really have one more question of clarification here, if I could, and that is when it comes to scheduling, and again referring back to Lillian Fraser, I know that the number of doctors - it was not a doctor shortage but a doctor scheduling, and the comment of the minister was that it's sometimes difficult to get doctors who are willing to work some of those hours in a particular emergency department, sometimes it's a lack of willingness to give up their time to do that and other times it is a cost factor. So my question would be, with your Emergency Room Protection Fund, and you've described how that would work, are any of those dollars available to the DHAs to provide additional pay to doctors who are reluctant to give that coverage without an increase in salary?

MS. MAUREEN MACDONALD: I think I would say, at this stage, that it's not - I mean Dr. Ross, whom I completely respect, was very clear in his report yesterday that we need to look at the way we remunerate emergency room physicians and we intend to do that. We are embarking now on a process to negotiate a contract with the emergency room doctors here in the Capital District Health Authority, but we understand - I'm not naive and this government isn't naive - we understand that those negotiations will have implications for emergency rooms all across the province. That's everything I'm going to say on salaries while we're embarking down a process of negotiations with the emergency room doctors.

[1:00 p.m.]

I will say that we completely respect the work that these men and women do. They're valuable in our health care system. We are so pleased they're here and we want them to stay here. We understand that they have families and they've worked really hard to get to be where they are.

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I can't, at this stage, with absolute certainty, say that the $3 million Emergency Room Protection Fund will be used in this way. We will look at it on a case by case basis for initiatives that make sense to help us stabilize a situation in a community while we are building a better system. We have to get to a better system. I think Dr. Ross was very clear as well that putting your finger in the dyke over here can create pressures over there and we have to stop doing that. We need to plan for an entire system and that is what I'm hoping we will be able to do.

The initiative, the Emergency Room Protection Fund is there to assist communities and the district health authorities operate on the community level. They're there to assist district health authorities in the work that they do in terms of trying to provide stable emergency room coverage around the province. We will be open to hearing any innovative and interesting idea that they might bring forward to help us look at how you might do that. I want, as well, to correct the number, I said 35, I thought we had 35 emergency rooms, we have 38.

MS. CASEY: You spoke about the distribution of doctors and I remember a statistic - I just want to confirm if it's still accurate - that per capita, there are more doctors in Nova Scotia than there are in a lot of other provinces, perhaps many provinces across Canada. The issue was with distribution and where they had chosen to work. I see some heads nodding, can I take from that the statistic is still true?

MS. MAUREEN MACDONALD: I think generally speaking it is true. When I was first elected we did have a serious doctor shortage in the Province of Nova Scotia. There was no doubt about that, 12 years ago we had a crisis in oncology in the Capital District Health Authority, there were virtually three oncologists, it was unbelievable, the number of specialists.

We've had from time to time some shortages, anesthesiologists come to mind, that's been a difficulty. Some very high functioning specialties and specialists from time to time. For the most part, we haven't had the same kind of situation around GPs that existed 10 years ago. Last year, the Capital District Health Authority recruited 18 new family physicians. The closest to that is five new family practitioners in Cape Breton in the CDHA. You can see the difference, 18 family practitioners in metro and five in Cape Breton. It's a challenge. It's a challenge to bring people into rural practice.

We have many advantages in our province and one of the advantages is that geographically we're not that big. Halifax is not that far from an awful lot of places. In fact, if people really want to have the lifestyle that they get in a larger metropolitan area, they could still live in Halifax and have those things, but work in other parts of the province. People travel all the time for their work. The radius of metro is getting larger and larger I think.

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We need to think about this. We need to think about people, if that's how they're going to choose to have their family life, their personal life, perhaps we need to think about what we can do to support that, to get their travel pattern to other regions, to make sure that those regions aren't under serviced. We haven't done that great a job in some parts of the province, being able to recruit and retain.

You can recruit people, but you can't retain them. I haven't seen the numbers, but I would think that retention in those areas is probably our biggest problem in some ways, with some exceptions. You look at Antigonish. They have a huge number of family practitioners who you can't get out of there with a crowbar. People are just - they love it there. Many people are from the area as well, but they have a nice mix of physicians who are third and fourth generation Antigonishers, people who have moved there, gone to university there at St. Francis Xavier maybe, on to Dalhousie, back to the area to practice.

There are parts of the province that have a very stable family practice population. There are other parts of the province that have been challenged with that, you know, I tend to listen to people who have more experience and expertise in this area than I do and I put Dr. Ross in that category. His view, and it was expressed in the report yesterday, is that any of us are under the illusion that health human resources, particularly doctors and nurse shortages, are going to stop being a feature of our health care system, we're dreaming in Technicolor. That is a feature of what we're living through. We will continue to have this, especially if you look at the demographics and, in many respects we are much better off than many other places in the world and, indeed, even in the country. I think our numbers stack up quite well, regionally and across the country, in terms of the number of doctors we have per capita.

Earlier this week, I had an opportunity to speak with Doctors Nova Scotia and we were talking about a whole variety of issues including attracting doctors to the province and retaining doctors here. It was interesting because the view of Doctors Nova Scotia, or certainly the people I was talking to who represent Doctors Nova Scotia, said, we have no concerns about the number of doctors in Nova Scotia. We're not telling the department and the government that we have a doctor shortage. We've been through that; we know what a doctor shortage looks like; we don't have a doctor shortage. Now what we need to be doing is we need to be thinking proper deployment, getting the right person, providing the right service and the right location and these are the issues that we need to be addressing now and I couldn't agree more.

MS. CASEY: I would like to draw from what you said that what has happened over the last 10 years, which would have been under our government, that we have gone from a doctor shortage to having, perhaps, the best ratio that we can get, but the challenge, as you have stated, is deployment, distribution and having your GPs and having your specialists and having them in the right place. So, it is nice that one part of that has been solved, now the next challenge is to get them in the right place.

[Page 93]

I do want to move on to another topic, another budget line, I guess, and that is certainly not emergency room closures but it is related to emergency rooms - and I don't think we can separate the two - and that has to do with the Rapid Assessment Unit. You talked about some dollars for that. My understanding of that, and I'm asking for clarification, my understanding of that is that this is to improve patient flow when they come into the emergency department through to admissions, and I know that is all connected to the availability of beds within the hospital to accommodate those patients.

You know, we hear the stories of people, and we have experienced it here at Capital, people who arrive by ambulance, moving through the emergency department, through that whole assessment, and then once it has been deemed that they are ready to be admitted, getting them moved out into a bed. So, I guess, for clarification, is my understanding of the Rapid Assessment Unit a way to try to facilitate that movement through the system and if so, how?

MS. MAUREEN MACDONALD: Mr. Chairman, when I was in the Cape Breton District Health Authority, I was taken on a tour of the regional hospital and Dr. Currie, who is one of their emergency department physicians was there as well as one of the other team leaders, who is a nurse, and I have to say it was really invigorating talking to these people. I just felt great after I talked to them. They were pumped, is the best way to put it.

The CEO who was accompanying me told me that two years ago in that emergency department they could not find people who would stay and work in the emergency room. It was a demoralized staff; it was the worst place they had in their facility to try to keep people working. This has just totally changed. They have adopted a number of initiatives that have contributed to this change. Now people want to work on that unit. They have the lowest rates of absenteeism. They were really excited and they were really pumped and they wanted to tell me all about what it is they were doing.

You know what it's like to have these tours. You're there for 15 minutes. You're whizzed from one location to another. You're meeting people. It all becomes kind of a blur, in a way, and you're trying to take it in. The one thing I really remember was the rapid response unit that they do in Cape Breton, the Rapid Assessment Unit, and how it works. It just sounded so sensible.

When people come in, they have this team of people who are assigned to do this, and they see somebody very, very quickly. They make a determination about what the right place for this person to be is and they get them there as quickly as possible. It just clears the halls of the emergency department. It has been really successful in Cape Breton.

Again, one of the things that we made a campaign commitment to in the election was to open hospital beds that would help patients stuck in overcrowded emergency rooms flow through. In this budget, for the coming year, we've allocated $4,318,000 in the Department

[Page 94]

of Health's budget to be used in a number of ways. We haven't worked out all of the details of all of the ways yet, but we do know that one of the things that we will do is we're going to establish a Rapid Assessment Unit and open eight additional medicine beds in the Capital District Health Authority.

[1:15 p.m.]

One of the problems - and this is not the only problem with the Capital District Health Authority emergency room, but one of the problems as I understand it, in very layperson's terms - first of all, when that emergency department was built many, many years ago, it never really had the capacity to serve the kind of population we have here in the metropolitan area. That was at that time. Our population has really increased quite significantly.

It's in a teaching hospital. The emergency department is in a teaching hospital which has no general medicine beds. Beds are primarily allocated along specialty lines. So you come into the emergency department and you don't necessarily fall into any of those specialty lines or you have some kind of a chronic condition - you're diabetic, you have hypertension, you're asthmatic, you're having breathing problems, you have all of these things going on, who sees you? What specialist consult do you require? How do you move a person like that? Do you send them to cardiology, and try to get a consult from a specialist up on one of the other floors who is seeing their own patients whom they have admitted, they've had surgery, whatever, it's hours before somebody is able to come down. This is a very serious problem for the emergency room doctors. They're very frustrated about how they can move people through so they can see all of those folks who are sitting in ambulances lined up in the bays trying to offload their patients. Meanwhile, those ambulances have come in from all over the province, meaning that out there across the province you have issues around covering those areas in case there's another difficulty.

So we really need to provide, in the Capital District Health Authority - and Dr. Ross' report spoke to this yesterday as well - that you can't have a province-wide emergency room system that works if you don't fix the QE II and deal with the problems of getting people through that system with greater effectiveness and efficiency. So a Rapid Assessment Unit would allow for just that, the rapid assessment of people coming in and a determination of what the situation is and where they best should be seen. Of the $4 million that we have in this budget, the cost of the Rapid Assessment Unit would be approximately $2 million of that.

So that means that we're left with the possibility of some other initiatives, as well, to free up bed space and we have a number of things that we are still working through, we have to look at. As the former minister knows, we have complex cases. We have people who are in our acute care facilities whose situations are so complex. They have needs that are higher than can be accommodated in a small options home. They may have challenging

[Page 95]

behaviours that are beyond the ability of a long-term care facility to deal with them, a whole variety of issues.

So we are looking at what we need to do with respect to complex cases, particularly where there are mental health problems and, as well, perhaps some other chronic diseases. So the additional $2 million will be allocated to do a number of initiatives around the emergency room, particularly in the Capital DHA, and the Rapid Assessment Unit will be one of those things.

MS. CASEY: Mr. Chairman, the situation that the minister described, what exists in the emergency department at Capital District was very accurate. It was the way it was described to me back in January of last year and it was the situation and the frustration of Dr. Ross that prompted him to do the Code Orange at that time. At that time I met with the CEO and with Dr. Ross to try to understand the situation and to look at what some possible solutions might be. I was told at that time by the CEO that there were some procedures that needed to be changed, that needed to be addressed, that needed to be implemented within Capital Health. They were outlined by the CEO for me at that time and I believe the implementation of that new procedure was to begin in February-March 2009.

My question is, were there any new practices and procedures put in place in order to respond to the circumstances and the situation with moving patients through and if so, will the new assessment centres be in addition to those change of practices. I guess the question is, were some practices put in place and is this an extension of that and, with the combination of the practices and a new assessment centre and the new beds, will that address the problem?

MS. MAUREEN MACDONALD: Mr. Chairman, I don't know if this will really address the member's question but if it doesn't, she can pose it to me maybe in a different way. Back in the Fall we were seeing a lot of Code Census at the emergency department, both in the Dartmouth General Hospital and at the Queen Elizabeth II Health Sciences Centre. It was hard to really understand what exactly was occurring, I think, in some ways.

Our department was in very close communication, daily, with the Capital District Health Authority, trying to understand what exactly was going on. In my mind I was very concerned about what this meant for H1N1. We are always concerned about what is going on in the emergency room, but given that we were in a pandemic, I was very worried that it seemed extraordinary that day after day we had this Code Census occurring. As the member knows, Code Census was the system that the Capital District Health Authority developed after the Code Orange, as a way to prevent that level of frustration and difficulty from building in the emergency room, to try to get the attention of people outside the emergency department that they needed to provide some relief and support to the emergency room.

[Page 96]

We have Code Census, and while everybody thinks it's a terrible thing that a Code Census is called, it actually is a call to everybody in a facility to harness their resources to free up space, to assist the flow through the department.

I've been in constant contact with the Capital District Health Authority Board and CEO about what plans they can put in place to deal with the Code Census situation. They have been working very diligently to develop a plan. They have a person who has been recruited from another part of the country, with a great deal of experience in terms of patient-centered care, and she has been working hard to bring people together who work beyond the emergency department, to impress on them what needs to happen in terms of opening beds up, making it possible for people who are in an emergency room to move through.

They have presented a plan to us very recently and we will be monitoring the implementation of this plan and the outcomes of the plan. They will have some additional financial support to do these particular things, the Rapid Assessment Unit. We're also looking at a establishing a 13-bed - I can never get these acronyms - IMCU, they are medical ICU beds and that will allow for people to move much more quickly.

MS. CASEY: I'll do some talking and you can have a drink. One of the things that was explained to me at that time, and I'm sure the minister understands, with respect to the movement of patients through the system and into the beds - of course has to do with the assessment when they come in - the fact that it is a specialist teaching hospital and also the fact that once they get through that, there was still an issue with bed availability in the hospital.

Part of that bed availability, after people had been assessed and had been determined that they would be an in-patient, was due to the fact that many patients in the hospital were in an inappropriate setting. They were people who were ready to be discharged from the hospital and they were awaiting placement in another facility, other than a hospital. So that compounded it again because once you get the emergency department issues addressed, and the flow of patients is easier, then you come up against another hurdle when you don't have an in-bed for that patient. One of the things that we had recognized was the need to have more long-term care beds available across the province, and thus, the initiative to build new facilities and try to move people out of hospitals into a more appropriate setting.

I guess my question would be, and we can talk specifically about Capital here, my question would be, once we get the assessment process facilitated and patients can move on, do we still have the challenge of people in hospitals using beds, when they should have a more appropriate setting and be out of the hospital? Is that still a challenge with Capital?

[Page 97]

[1:30 p.m.]

MS. MAUREEN MACDONALD: Mr. Chairman, thanks for the break on my voice. We still have 4B over at the Victoria General, the alternate care unit there. Like your colleague, the member for Argyle, I look forward to the day when there's nobody left on that unit, when we're able to close it. I actually think we may be moving in that direction at some point in the not too distant future.

This is very much a difficulty everywhere, being able to get people into long-term care from our acute care facilities. There are quite a few reasons why we're unable to do this. Earlier today during the estimates I had a chance to talk about this issue with the honourable member for Hants West who was talking about long-term care. I was explaining why it is very important for us to be able to devolve long-term care into the district health authorities.

When we complete that work of getting long-term care under the district health authority administration, I'm hoping we will see a more seamless process of being able to plan for discharge from an acute care facility into a long-term care facility. Really, that's what the whole process is designed to do, it is to make it a more seamless transition and allow us to be able to move people more rapidly and more appropriately.

If you have DHAs with the ability to do better planning around long-term care, around home care, around respite care, all of these kinds of things, we should see improvements in the time it takes to move someone from a hospital bed into a long-term care bed. We aren't there yet in terms of the service agreements with the various long-term care providers around the province but we will definitely get there. We have to devolve that part of our health care system into the DHAs to make it a more seamless system for people.

We also, I think, need to do a better job of providing programs in the home. I know that around the province we have this program now called Hospital-in-the-Home that provides people who want to be at home and who can be at home but they need a hospital bed because of their mobility, they can't get in and out of a bed easily and there is a danger of falls at night and these kinds of things. The Red Cross has a fabulous program of providing hospital beds around the province to people who are in this situation. This is supported by the government and by our department.

There are many things that we can do to augment and support the long-term care sector and our aging population. The Caregiver Program that the honourable member for Clayton Park was referring to the other day is a good example of being able to provide support to people who are caregivers for an elderly person, or a person with a disability, or some condition that requires that they not be on their own. I think there are many supports and many things that we have that can be improved upon.

[Page 98]

Our hospitals need to be hospitals though. They're not shelters, they're not hotels, they're very costly, expensive places and we need to make them as efficient and as effective as we can.

MR. CHAIRMAN: The honourable Leader of the Progressive Conservative Party's time has expired on this round.

The honourable member for Halifax Clayton Park, you have approximately three minutes.

MS. DIANA WHALEN: Thank you, Mr. Chairman. There are three minutes left. I was finding it very interesting listening to the concerns around moving people into proper care, whether it be back home with the right supports or into long-term care.

I want to switch tracks and ask the minister about Page 13.16. The bottom of that page has a line item called Diagnostic and Medical Equipment and that line item was underspent last year by $2.5 million. This coming year is budgeted to be another - in fact, about $6 million less than it was last year. It was budgeted at $26.7 million, this year it's budgeted at $20 million. I'm very interested in this because I know that equipment and diagnostic equipment and new tests and tools are so important for early detection of disease and accurate diagnosis, and I know that we have a lot of old equipment, so there has got to be a lot of pressure in the system through the DHAs to talk about how they can acquire new equipment, how they can replace aging machines.

Yesterday the minister will remember we had quite a good discussion around the mammography - new diagnostic machines to do mammograms and that's very important. You mentioned the DHAs that were now going to be funded with the new digital machines, and we should actually give a vote of thanks to the people of HRM who together organized that big event that the minister mentioned yesterday, Bust-A-Move. They raised $1 million, I believe, and that was the cost roughly to get us a new machine here in HRM.

That was one part of it, but actually you said that mammography was covered in last year's budget, so that doesn't even affect this coming year. I want to know what other equipment we're looking at, and I particularly want to know why the budget is down when I'm certain that the stress is very great in the hospitals. They want to replace and have newer equipment. I know a few years ago when the discussion here in the House was around the need for new MRI machines, we actually found that quite a few of the existing ones right here in HRM, where we are actually a teaching hospital - we're training radiologists, and the MRIs we were using were 10 years old. They were really old technology. So I don't think the minister is going to be able to answer my question today, and my time is just about up, but I would like to leave the minister with that question for the start of our discussion on Monday morning - or I guess it's Monday afternoon. Thank you very much. My time has elapsed, so

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the chairman is telling me we have to be finished, but I was just saying to the minister to please start there on Monday.

MR. CHAIRMAN: Order, please. The time allotted for debate in Committee of the Whole House on Supply has now expired.

The honourable Government House Leader.

HON. FRANK CORBETT: Mr. Chairman, I move the committee do now rise and report progress.

MR. CHAIRMAN: Is it agreed?

It is agreed.

The motion is carried.

[The committee adjourned at 1:38 p.m.]