Back to top
April 13, 2010
House Committees
Meeting topics: 

[Page 159]



2:33 P.M.


Mr. Gordon Gosse

MR. CHAIRMAN: Good afternoon, the Committee of the Whole House on Supply will now be called to order.

The honourable Minister of Health.

HON. MAUREEN MACDONALD: Thank you, Mr. Chairman. I would like to table two items of information that I didn't have with me yesterday that were requested by honourable members. Just so members are aware, to refresh your memory on what these items are, I have to table a list of vacancies in the Department of Health as of April 9, 2010 and I also have a note on medical equipment funding which includes both the DHAs and the IWK.

MR. CHAIRMAN: The honourable member for Clare.

HON. WAYNE GAUDET: Mr. Chairman, I am pleased to rise this afternoon and ask the minister a few questions. I have a few questions regarding the Continuing Care Strategy. As the minister is aware, many rural areas of our province have an aging population and I understand that our area is not alone with a desperate need for more long-term care beds for the increasing number of elderly people who do not want to, and shouldn't be expected to, leave their community. Unfortunately, Clare did not receive any new additional beds in round one where 832 long-term care beds were announced by the previous government back in February 2007.

Also, Mr. Chairman, back at that time, in February 2007 the former government also announced an additional 500 beds for 2015.


[Page 160]

So, my first question to the minister, is the government still planning to go ahead with a round two of announcing more long-term care beds, and if so, can the minister indicate when the government is planning to make a formal announcement with regard to the second round?

MS. MAUREEN MACDONALD: Mr. Chairman, I want to thank the honourable member for the question. The honourable member has been in the Chamber for the last few days when I have been answering questions about various long-term care projects around the province and I have said on more than one occasion that there will be a bit of a party in the Department of Health when we're able to bring those last projects to completion.

We're still working with a number of small operators, for the most part, to try to move their projects forward, for example, the honourable member for Argyle talks about the long-term care facility in his constituency, Nakile for example. So, the Continuing Care Strategy is a strategy over a 10-year period, going forward to about 2016, I believe, and there was an initial announcement for 800 and some beds and then another number of beds was added to that. So in all, we will see construction of 849 beds. It is well underway. Many of those beds are coming into the system. For example, Northwood, in Bedford, I'm very much looking forward to this particular facility opening later this week, I think, Mr. Chairman.

So, to make a long story short, we are still very much in the completion phase of Phase I and until we have been able to successfully bring this phase to a conclusion, we're not about to embark on Phase II. We will probably take a bit of a breather to assess the process that we have just gone through to look at its strengths and its weaknesses and to identify the unmet demands that continue around the province.

I know that there are unmet demands. I have had an opportunity to visit some of the small operators. For example, on the Eastern Shore, there is a place called The Birches in the riding of the honourable member for the Eastern Shore and he and I were in this facility. It is a very old facility, the standard in that facility in terms of the physical plant is not what we would expect in a modern day, long-term care facility environment. I know that this is probably the case throughout the province, there are probably many small long-term care facilities that certainly don't meet the new standards, in terms of the physical standards.

But in terms of announcing the next phase, we're nowhere close to completing Phase I and until we get the projects that we have committed to completed and do a good evaluation and assessment, I don't think it would be prudent for us to initiate a Phase II. However, we're always looking forward to the future. We want to hear from members of this House and organizations around the province with respect to what are the continuing gaps in services and the needs in the various communities.

MR, GAUDET: Mr. Chairman, I appreciate the answer that the minister just provided to us. As the minister pointed out, there are certainly more demands out there and I know that

[Page 161]

she is aware that the Municipality of Clare has forwarded a proposal to the Department of Health to replace our nursing home in Clare. It is called the Villa Acadienne and it is located in Meteghan.

Mr. Chairman, the Villa Acadienne was built in 1974. It has 86 beds including two respite beds. The fire marshal has raised a number of safety concerns with the existing nursing home that certainly needs some attention. Also, Mr. Chairman, the fact is that replacing homes in Digby and in Yarmouth was previously announced, Yarmouth to replace the Tidal View and in Digby to replace the Tideview Terrace. Those constructions are well underway.

My question to the minister is, the fact that a request has been submitted to the department for some time now, I guess, in hearing from the minister that there is no set time for a Phase II of the Continuing Care Strategy, I'm just curious, will the department give full consideration to this proposal that has been forwarded by the Municipality of Clare to her office?

MS. MAUREEN MACDONALD: Mr. Chairman, I would say to the honourable member that although we have embarked on this Phase I of the Continuing Care Strategy, we continue to work with other operators who did not submit a proposal, let's say, when the call for proposals went out during Phase I, or who perhaps did submit a proposal but weren't successful in becoming part of that mix.

[2:45 p.m.]

I wasn't part of the department at the time that the Continuing Care Strategy was initiated. I think that strategy was developed and initiated back in 2008 and my understanding of the process was that government decided, essentially, the envelope of money that they had available over a period of time and they asked for proposals to be submitted. They got a fair number of proposals and developed their Continuing Care Strategy, their plan for Phase I, based on what it was they received. Those particular proposals that were accepted are moving forward and we are seeing construction of new beds or construction of replacement beds in existing facilities.

This does not stop the work of the department with operators who fall outside those parameters of that program. We have many operators who aren't necessarily part of the new and replacement beds who will constantly encounter issues with respect to being able to maintain their licence, for example. That may come from the conditions of their physical premises, it may be that the fire marshal has been in for one of his regular inspections and has identified certain features of work that are required to be done.

We quite often get those reports back to the department and we have a staff who work with operators around the province to ensure that the health and safety requirements are

[Page 162]

maintained at a standard that reflects what the national and the provincial standards are. Any of the operators in the province who are having any difficulties around these issues, they bring them to the department and staff in the department work with those folks to see what the plan is to address any concerns that are raised.

Many operators continue to work on a regular basis doing modifications and upgrades in their facilities to make sure that they are safe and healthy for residents and for staff, for the storage of foods and other supplies, for the prevention of fire and any hazardous materials that are on site, for the handling of medication, and the storage of medications, and what have you, we're very vigilant, we try to be very vigilant in this province. It's so important. In a way we are blessed in the province that we haven't had tragedies in our nursing homes. We have seen those instances in other provinces, of fires for example, and elderly people who haven't been able to get out of a long-term care facility. I always - my heart stops when I see on the 10 o'clock news, these stories in other parts of the country, from time to time. I know that health and safety is something that staff in the department take very seriously, and I know that it's something that operators around the province take very seriously.

I can only trust, on some level, but I also expect that we have a culture of safety for our elderly and frail citizens in these facilities. I'm always very clear when the staff raise with me any questions that have been presented to the department about health or safety violations, or potential fire violations. I am very clear about what the law requires. I impress on staff how we have to move forward with applying the law rigorously, the standards rigorously, that we document very carefully what steps we are taking, and that we are in constant communication with operators, to put into place the plans and the recommendations, to ensure that we are protecting people. That's our responsibility as a government, it's my responsibility as minister, it's our responsibility as a department, and we take it very seriously.

MR. GAUDET: Mr. Chairman, I'm just looking for clarification. The fact that the fire marshal was in this nursing home certainly highlighted a number of safety concerns. Am I to understand that it's automatic that the fire marshal will provide the department with a copy of his report, or is that left to the nursing home to bring these safety concerns to the minister's attention? I'm just looking for clarification, please.

MS. MAUREEN MACDONALD: The operator of the nursing home brings it to us, and this is a condition for them to be able to get a licence, maintain a licence, to continue on as an operator.

MR. GAUDET: Mr. Chairman, I want to talk a little bit about the first available bed provision within 100 kilometres. Placing francophone seniors, or other individuals outside of Clare, in a nursing home - certainly we need to acknowledge that there has been some progress made to current placement policy, to allow French-speaking seniors to wait to be placed either at home in his or her Acadian community or near to, and basically with the

[Page 163]

exception to the first available bed provision, again without losing their place on the waiting list for placement. You know, everyone understands in order for a bed to become available in a nursing home, a resident needs to be hospitalized, or needs to be transferred to another nursing facility or, sadly, the individual passes away. Now, something that has been raised many, many times with me - and I still can't provide a straightforward answer, and I hope that the minister will be able to maybe provide us with a little bit of clarification - we have some seniors in Clare, Mr. Chairman, who are being sent outside of Clare for care. At the same time we have residents from outside of Clare who are being placed in nursing homes in Clare.

For example, the Villa Acadienne in Meteghan, we recently had residents from Yarmouth, we had residents from Pubnico, we had residents from the South Shore. At the very same time, we had residents from Clare who were placed in nursing homes in Annapolis, Digby, and Yarmouth. It would be a lot easier on both families to switch some of these residents to be at home or to be closer to their families. My question to the minister is, why doesn't the department switch residents from nursing homes when the opportunity presents itself? I'm sure the residents would be happier to be closer to home. At the same time I'm sure the families would appreciate having their loved ones closer to them.

When I look at someone from the South Shore who has been placed in Clare, the family that needs to travel back and forth to visit, if you could shorten that two-hour trip to a one-hour trip - I guess my question to the minister is, why doesn't the department, when the opportunity presents itself, switch some of these residents from nursing homes to either bring them back to their community or closer to their community?

MS. MAUREEN MACDONALD: The honourable member asks a very good question. In the interest of getting the system to work as a system, it is the policy and the practice of the department to have people who require long-term care to take the first available bed that becomes available within a radius of 100 kilometres. That is a policy that coincided with the development of the single-entry system in an attempt to shorten wait lists and have one wait list. We had a situation where, prior to having single entry and one wait list, you might have an individual who would be on four or five different long-term care facility wait lists because the family had applied to two or three different places. They had their first choice, their second choice, their third choice, and they might go to whichever facility had a bed first. We had no way to really determine how many people were actually waiting for long-term care in that world.

The other thing was that there was no ability to triage, to take people who really needed to get into a long-term care facility quickly without a single entry point. People would also be in scenarios where they were in hospital in an acute care bed and we couldn't get that bed opened for people - somebody coming in through the emergency room or whatever, because they were just on a particular list for a particular home that they had applied for.

[Page 164]

The single-entry point, the first available bed policy, came into being to try to alleviate the pressure on the acute care system and to have the overall health care system work better for everyone. But in that process, what was lost was this ability to provide the option of first choice to the person who needs long-term care. They would end up having to take the first available bed. Here in metro, for example, perhaps someone would want to go to Northwood as their first choice, but they might end up out in Fairview because that's where a bed came open first.

The member asks why aren't people moved after they are accommodated in the first available bed? I would say three things in response to that. The first thing I would say is that some people are moved to their first choice when a bed becomes available in their first choice. So there is a process where you take the first available bed but you have to make it known that that isn't your first choice, your first choice is someplace else and that you want to be transferred there. You want to transfer to that place when a bed becomes available. That does occur. There are people who go into the first available bed but they do get a transfer when a bed comes open in their first choice. However, there are two other things that occur that may keep that from happening.

[3:00 p.m.]

One thing that happens is sometimes people move to the bed of first choice and they actually find that they really like this facility - they get to know the staff and they want to stay so they change their minds, actually. They, or their families, decide that it's more trouble perhaps than it's worth to go through a transfer and have another move. That's the third component as well that comes into play. Elderly, frail people who are moved frequently from facility to facility have very poor outcomes. It can have a very negative impact on the health of that individual. The literature does show that the more you move an elderly, frail person, the more likely it is that you could contribute to their passing.

I think families intuitively see this and know this. If there are multiple moves and also multiple moves even between a long-term care facility and an acute care facility. We see a very large number of transfers on a regular basis of some elderly people who are in a long-term care facility who perhaps develop an infection, have some difficulty getting their vital signs regulated. They get sent to the emergency room and may be admitted for a short period of time into an acute care facility. Then back to long-term care, where they are stable for a number of weeks or days and then back to emergency. That kind of transferring from location to location can have quite a negative impact on an elderly, frail person.

I think one of the things certainly that this government is wanting to do is to have nurse practitioners in long-term care facilities to alleviate the extent to which seniors or frail people have to be transferred for treatment in an emergency department. Perhaps admitted to an acute care bed for a short period of time and then back into the long-term care facility. I think this will not only take pressure off the ERs, which we're hoping and looking for ways

[Page 165]

to do, but it will result in a lot less wear and tear on a frail person because it's a very difficult process.

I just want to let the honourable member know that I've been advised by staff that to date the department is providing $92,000 to Villa Acadienne to exist with the fire marshal issues. So this is not uncommon, as I've said, in the department although we have a number of facilities that aren't part of the new or replacement beds in Phase I of the Continuing Care Strategy. It doesn't mean that we have no resources that we can bring to bear to ensure that other operators who aren't part of Phase I are able to maintain the health and safety standards that are required and that we want to make sure we have in place. Thank you.

MR. GAUDET: I agree with the minister, some transfers are being done but, at the same time, when you look at the system, she mentioned about Northwood and Fairview, I'm talking about the South Shore, the Bridgewater area versus Meteghan. It's about a two-hour drive from one area to the other.

There's no doubt in my mind that the system still has room for improvements. Yes, there are always exceptions, you have to take into account the individual's health before you proceed with a transfer. So I hope that the minister will give some consideration to what I have shared with her.

Mr. Chairman, I want to ask the minister one more question. When I look at the first round where over 800 new beds were announced back in 2007, very few new long-term care beds went to the Acadian regions, not just in Clare but around the province. So apart from the beds that actually were assigned to Nakile, that's in the riding of the honourable member for Argyle, there were no other beds that went to Acadian regions. I hope that when Phase II comes about, the minister is aware there are over 40,000 Acadians in Nova Scotia, with the majority located in areas such as Cheticamp, Isle Madame, Argyle and Clare, that the department, that the minister will allocate some new beds to our Acadian communities whenever Phase II comes about.

I guess I'll simply ask the minister, will she give special consideration on her second phase, whenever that comes about, to allocate some much-needed, long-term care beds for Acadians, especially in the primary four Acadian regions?

MS. MAUREEN MACDONALD: We certainly are concerned about addressing the greatest need for a modernized, accessible, community-based system of long-term care around the province. I do want to make reference to the fact that in the awarding of beds, 10 beds were awarded to Cheticamp, to a long-term care facility in that community. Additionally, there were 12 beds initially awarded to Nakile in Argyle and then there were another 10 beds added to that, although those additional 10 beds, Nakile has had a very difficult time being able to bring their project of 22 on budget, so there has been an agreement that we will revert to the initial 12 bed replacement, I think, or extension, that was

[Page 166]

for that particular facility. So right now there are a few beds unallocated and some decisions do need to be taken with respect to that.

Frankly, I haven't had an opportunity to turn my mind to that but at some point in the not too distant future I will certainly have to do that. I would say to the honourable member that I have a strong desire to ensure that francophone services in our health care system are a priority. Although I am not Acadian, I grew up very close to an Acadian community, and I feel very strongly about this particular issue. I believe very strongly that it is important that we respect our elders and we provide them with end-of-life services that are of high quality in their own community, close to their own institutions and families and their own language. I can make that commitment to the honourable member, that as we move forward, his intervention here is not lost on me whatsoever.

MR. CHAIRMAN: The honourable Leader of the Official Opposition.

HON. STEPHEN MCNEIL: Mr. Chairman, first of all I would like to welcome and thank the staff of the Department of Health who have, over a number of years since I've been elected, provided good service to the people of Annapolis, and when my office has called looking for answers, I want to thank you for returning. We don't always get the answers we would like, but at least we get an answer, and we appreciate that and the work that you're doing.

Keeping on the theme that the member for Clare was talking about - and that is the Continuing Care Strategy - when it was announced a few years ago, there were a couple of changes in my constituency of Annapolis. One was that the facility at North Hills would be relocated to Middleton, that those 50 long-term care beds would be built in the Town of Middleton to deal with that need. As I'm sure you're well aware, there are 200 long-term care beds in my riding from Bridgetown to Annapolis Royal and none from Bridgetown to Berwick, and this shift from that facility which was in need of some repairs was moved into Middleton.

It was also announced at that time that there would be an additional 12 long-term care beds in the Town of Annapolis Royal, which that issue had to be retendered because there wasn't a facility in the town. It was actually in the county and out in the community of Lequille, and those beds were then changed from Level 1 long-term care to residential care beds. Those 12 beds actually opened last Thursday, I believe it was.

What I'm hearing now is that those 50 beds that are presently at North Hills, that hopefully will be moving to Middleton in that new facility sometime in early Fall - the makeup of those beds has changed now. There are 38 that will be designated to long-term care. There will be 12 that will be residential care beds. That was not the commitment that was made by the previous government. It is not the commitment that was made to the

[Page 167]

community of Middleton, and I'm wondering if the minister and her staff could tell the House and elaborate on what has changed since the announcement to present day?

MS. MAUREEN MACDONALD: Mr. Chairman, as the honourable member has indicated, this was an announcement that was made under a previous government, so I would have to go back and do a search and investigate what was announced by the previous government. As of this moment, what I do know is that there is indeed a new facility that is being constructed in the Middleton area, and it will have 38 nursing home beds and 12 residential care beds, RCF beds - or I shouldn't say it will have 12 RCF beds - it has the possibility of having 12 RCF beds.

The RCF level of care is for individuals who require a lighter level of care - supervisory care more than nursing care. However, RCF beds can be converted to long-term care beds. They're built to the same standard, and increasingly some of the homes that we're seeing constructed in communities are being constructed so that they can actually have a combination of beds in a facility, so that not only will they have long-term care nursing level, but they will have some residential care as well, so that people who require residential care can still be close to the community from which they originate.

I'm told that the nearest RCFs in your area are in Bridgetown and Kingston. So, the decision was taken to put some RCF beds in this new facility, and at the end of the day, I guess, we will have a better appreciation, in September, of how many long-term care beds are actually needed in the community, and how many RCF beds.

So what I'm saying is, we know for sure that we have 38 nursing home beds. We have the potential for 12 residential care beds, but those residential care - those 12 beds, have been built to a long-term care standard, that if required they can be transferred, in some fashion, to have long-term care designation.

[3:15 p.m.]

MR. MCNEIL: Mr. Chairman, as the minister is aware, now, North Hills is full, with the complement of those beds being filled with long-term care. Unless the assessment is changed, those patients are going to have to go somewhere, and it was the understanding of the community that those patients would move into the new facility.

As I am sure you're also aware, at Soldiers' Memorial Hospital, there is a transitional care unit that has long-term care patients looking for long-term care beds. In my constituency there are a number of private sector residential care facilities, there is one in Bridgetown, there is one in West Paradise, there is also one in Wilmot, which is all within the catchment area of Annapolis County. The real challenge that we're having is in the long-term care bed piece, moving people from Soldiers' Memorial Hospital - out of that transitional care unit

[Page 168]

into a long-term care facility, hopefully the one of their choice, and then allowing them to move about.

I understand the strategy as it was put in place, and the idea that we need to bring on the 800 additional beds. In looking at what would happen with the clients that we presently have in beds, how many we shift back to their local communities - I'm wondering, since there was a change with the North Hills facility - within the department, what kind of criteria was used or what were the stats that you used to make that shift, even before it opened? It would have made more sense to me, that once we had changed and moved those patients from North Hills into Middleton, then we could have really assessed the clients who would be wanting to access that facility and the adjacent facilities around it, and find out whether or not we needed more RCF beds, or whether we actually, indeed, needed the long-term care beds that we believe we need. Those people who are waiting at Soldiers' Memorial, and in some cases, waiting at home for that long-term care bed, I think would acknowledge and agree that it is required in that community.

MS. MAUREEN MACDONALD: Mr. Chairman, I believe that the thinking that contributed to this decision and, again, I want to reiterate, this is an attempt to be flexible in the use of those beds, to accommodate the people who need care from those communities. So, it is to strike a balance, I guess, between the people from that area that need long-term care, and the people from that area that need residential care, because there are people who are at risk of having to go to neighbouring communities for residential care as well.

Also, it is the case that we get people who need residential care who get stuck in acute care facilities, or other facilities that are inappropriate for them. So it's an attempt to strike a balance there. I would say that we always, in the department, make our decisions based on the evidence that we have, which tends to be data that we get from the district health authorities when they are unable to place people who are in a hospital, essentially. Additionally, from time to time, we have challenges and we try to work things through between the Department of Community Services and my department when we have hard to place clients of a community. So we as a department start to get a good picture of whether or not, in certain parts of the province, we're having particular kinds of placement problems.

It's interesting, one of the things that I am learning and I am seeing as I travel around the province is a much more flexible model of facility and care that is developing, particularly in small rural communities. I know that the Valley in some ways doesn't really, you know, you can't compare the Annapolis Valley communities to Guysborough County for example. It's a totally different population base. But when I was in Guysborough, the hospital in Guysborough is actually a building that has a long-term care facility and it was built to have a hospital on one end and a long-term care facility on the other end. I think that what we're going to see more of in Nova Scotia, are multi-purpose kinds of facilities that can accommodate a much broader spectrum of need and in many respects, this makes so much sense.

[Page 169]

You know, it's not unusual for someone with a lighter - light may not be te best term - but a lighter level of service need to initially be in a residential care facility. Over time, their situation may change and they may require, in all probability will require, a heavier level of care and so you get that kind of continuum and you prevent moving people around distances and what have you. I don't know what the statistical information was. I can go back in to the department and ask and I would be prepared to do that. I can tell the honourable member that it would have been made on the basis of some statistical evidence and that information would have come to us from the community itself.

MR. MCNEIL: Minister, I would ask if you would find that information and make it available. First of all, I want to also support your idea of aging in place. I believe it is a concept that we have talked about for some time and I know that you have talked about on this side of the House. Indeed all members of this House believe in that principle of aging in place and there are a number of facilities now across our province. What's raising some alarm bells in the community and why this was brought to my attention was the fact that we actually are moving a facility of 50 long-term care patients. We're concerned about not only where they are going but what's going to happen with those patients who are presently now at Soldiers' in the traditional care unit. I would ask that you find that information and pass it to me at some future date.

Another topic which has been quite hot in the riding of Annapolis has been emergency rooms. As you're well aware, Dr. Ross had created some anxiety in the community of Annapolis Royal as well as in the community of Middleton around Soldiers' Memorial. In Annapolis Royal it seemed to be the one where he had gone through first and a part of that was, I think, in connection with Digby, looking at all of those facilities. I know earlier in estimates you spoke about Annapolis Royal, there being a growing problem, and that is more recent, by the way, and it is associated in some ways with a physician challenge. As you know, one of the physicians, Dr. Ken Buchholz works presently in the Department of Health, and, you know, we miss him in the community of Annapolis Royal. One of the things that has struck the community is that Dr. Ross had come through and was beginning to assess the emergency room, which I might add has been working quite well. It has not been lost on the community that the challenge in Digby Neck around their nurse practitioner - one of the solutions was to move Dr. Buchholz on occasion to Digby Neck.

Quite frankly, he has a number of patients in the community of Annapolis and surrounding areas that were asking why, if the department is not requiring his services here to do the job he was contracted to do around physician advisor, if you were going to send him back into a community, why wouldn't that community have been his home community, Annapolis Royal? That facility, as you're well aware - minister, I don't know if you've had the opportunity to visit it yourself, but I hope you take the opportunity to in the future.

It is a model facility, in my view, that could be used across the province and how we provide a complement of services to not only that community but to other communities.

[Page 170]

There is a cohesive group of physicians that are working in that facility - not enough of them - and one of our challenges going forward has been around this issue of - I know that Dr. Ross came out and said he would not be closing any emergency rooms. Well, that's not quelling the anxiety at home. We never believed it was going to be closed. What the community believes is that the hours are going to be reduced. That's not the problem, quite frankly, in Annapolis Royal.

The real challenge is the fact that too many people are going to the emergency room who shouldn't be going. Closing it is only going to drive them somewhere else. What we need to do is look at how do we redirect those patients and provide them another level of service, whether it's a nurse practitioner or diabetic clinics. We had talked about it. I know the recent move by your department and government around allowing pharmacists to have a wider scope of practice is a positive one. It's one of the things that we need to look at all health care professionals and say, how do we - not expand their scope of practice, but allow them to practice what we've trained them to do? That's really what we're talking about. They already have the skills there.

One of my concerns is that we're focusing on the wrong piece, and the piece is the emergency room and whether the lights should be on or off, when in actual fact we need to deal with the real problem, which is people going to the wrong place. It would look after the emergency room problem because people won't necessarily have to go.

People are coming to Annapolis Royal to have prescriptions refilled because they don't have access to health care. I know there are going to be some retirements with family physicians from across our province. The only real way we are going to be able to deal with access to health care is through physician recruitment, making sure communities have access to bringing in quality family physicians from not only across our province but across the country, and indeed across the globe, in a recruitment strategy that will work.

As you know, our Party's put on the record of designating 20 seats at medical school to under-serviced areas, but there are other challenges. We have young Nova Scotians who are going to the Caribbean, to Saba, to be educated. We're bringing them back here to allow them to fulfill some of their educational requirements, but when it comes to access to residency seats, we say, no thanks.

Those young people want to be in this province. I know the member for Kings West - two in particular in his community would have made commitments to work in rural Nova Scotia, to work in under-serviced communities. They're in the United States now, and it's going to be very, very difficult for us to get them back. There's a real challenge around residency programs and residency seats and how we allow our own children access to those seats, because they want to stay here. They want to work in the community they grew up in. They want to provide service.

[Page 171]

In the case of the two we're speaking of, they grew up in a family whose father was a doctor, who has a large medical practice. They understand the grind of being a family physician in rural Nova Scotia. They understand the challenges of it. Now they're in the United States. There is a real opportunity to deal with that access problem. I think we spend so much time focusing on the emergency room that we're not focusing on the real problem, and that is that people do not have access to primary care in the appropriate place and we're not looking at how we correct that and provide them with those other options. I'd like to hear from the minister on the issue around Annapolis Royal in terms of whether or not the community can count on a 24/7 emergency room as opposed to an 8:00 to 10:00 o'clock or 7:00 to 10:00 o'clock emergency room, and what the department's strategy is going to be to ensuring that rural communities have access to family physicians.

MS. MAUREEN MACDONALD: Mr. Chairman, first of all I want to concur with the honourable member with respect to Dr. Buchholz. He's a fantastic individual and a very good physician and we rely on him in the department for quite a few things. He was quite instrumental in terms of his role in providing leadership during H1N1 back in the Fall. That whole initiative would not have gone as well as it did without his involvement. It's our fortune, not only in the department, but really as Nova Scotians that we have the access to the kind of talent that he brought to our department.

[3:30 p.m.]

With the loss of the nurse practitioner in Digby Neck, Dr. Buchholz' time in our department was reduced so that he could provide some coverage in the Digby Neck community. However, we have continued to work with SouthWest Health and they have been able to recruit other coverage into the area and I think we have news that we have a new person, a new doctor, coming to the Digby area. No, we have actually recruited a new doctor to the Digby area starting in September and I actually put that on the record earlier in the Budget Estimates, so we're looking ahead to that time. This will mean that Dr. Buchholz will then be able to reallocate some of his time to other duties.

I've been very fortunate as well to have a physician such as Dr. Buchholz who is familiar with the Annapolis Royal Health Centre and he and I have had a very good discussion with respect to the whole history of what has gone on there and what the current situation is. In addition to that I've met with Janet Knox, the CEO of the Annapolis Valley District Health Authority and David Logie, the Chair of the Board, as well as the entire Board. They, as the member will know, are very concerned, they've held some public meetings in the area.

There is a working group, I believe, and I can't remember what their handle is right now but it's sort of like Concerned Citizens for Health Care, something like this, led by a Mr. Wayne Boucher. I haven't had an opportunity to meet with the group but I have talked to my staff about looking for some time on my schedule as soon as I can find some time. I very

[Page 172]

much want to hear from people in the community so that I have this fuller picture, I'll have some information from the member representing the area, Dr. Buchholz who has practiced and continues to practice in the area. Dr. Ross, as you know, has been in the area, has met with people, but is going again to meet with a broader spectrum of citizens, and it will give me, I think, a better opportunity to have a fuller picture.

The honourable member talks about the focus being on emergency rooms when they need to be on primary health care. I think I would say to the honourable member that I agree and I disagree with him. I agree that primary health care in this situation, as it has been explained to me, is suffering because of the relationship between the emergency room and the primary health care aspect of the centre. This is of great concern. We need to have a strong primary health care model. It is the best way to deliver health care to our population and to keep people healthy. Having people get primary health care in an emergency room is not a good use of emergency room resources, we have to do whatever we can to end that practice around the province. If this is occurring in the Annapolis Valley Health . . .

MR. CHAIRMAN: Order, please. I'm sorry, I should have let the minister finish but the time allotted for the Official Opposition has expired and we will now go to the Progressive Conservative Party.

The honourable member for Inverness.

MR. ALLAN MACMASTER: Thank you, Mr. Chairman, and thank you, minister, for entertaining questions today. I would like to start out by saying we have a couple of facilities, three in fact, that service the people of Inverness County. I would like to start out with some questions on a couple of those facilities. The first question is the hospital in Cheticamp, the Sacred Heart. Would you be able to provide some update on the expansion of the nursing home facility there and anything else that you might like to provide for people by way of an update on that facility?

MS. MAUREEN MACDONALD: Mr. Chairman, I'm just looking at my information here. I don't know what all I can tell the member, let's see, there were 10 beds approved for the Cheticamp facility. The information I have is that the anticipated opening date is June of this year. What I would say to the honourable member is that if there is any additional information I can get for him with respect to that facility, I will.

One of the things that I have noticed in terms of these various projects is that you can anticipate your opening date but you can't necessarily count on it. I know that the Northwood opening date has been rescheduled probably three times but the times that it has been pushed back are pretty short. We're not talking about anything more than weeks to allow for those final small things that need to be done to have the facility ready to go. So because we're anticipating a June opening date, June 30th actually I think, so the end of June, I would say that this summer those 10 beds will be coming into play.

[Page 173]

MR. MACMASTER: Minister, my next question will be about the hospital expansion in Inverness but I do just want to say about Sacred Heart a couple of things that should be of note for the province. One is the staff there and the culture that developed in that hospital over the years, it came by way of the nuns who ran that hospital and they had a great regard for frugality, to make sure that hospital materials were used as best as they could, and I would just like to put that on the record today. It is a good example, and I've heard other people in the health profession express what a good example they are to the health care system in Nova Scotia for efficient running of an operation.

The other thing I would like to mention, too, Mr. Chairman, is the value of having services available at that hospital for the community. Of course, most of the people who work in the hospital are from the community, most are Acadian, most of them speak French and that is important for people who perhaps are under care or who are also staying at the nursing home. We are lucky to be able to have those facilities in the Cheticamp area, in the Acadian region of western Cape Breton Island.

My next question with respect to the hospital in Inverness, could you give us some update and background on the cash flow that will be used to complete the expansion at the hospital in Inverness?

MS. MAUREEN MACDONALD: The Inverness Hospital, the estimate last year for the work at that hospital was for $6,778,000 and the estimate for this year is $8,000,061 - so a variance of $1.2 million. The 2010-11 budget includes costs for the mechanical, the electrical, drywall, painting, millwork and the completion of roofing and structural steel, so quite a bit of that facility is planned in the budget for this year and I'm sure when that work is done it will be a fine facility for the community.

MR. MACMASTER: Thank you, minister, and one other quick question. The Cape Breton District Health Authority has identified a priority for the Inverness Hospital to have a CAT scanner. I believe the cost is about $1 million, which is a significant expenditure, and I also would not want to be hypocritical, I've been going on about the importance for fiscal restraint, but I was wondering if the budget does allow for the purchase of a CAT scanner this year or if there are plans to purchase it sometime soon?

MS. MAUREEN MACDONALD: I'm advised that would be part of our equipment budget and what we asked the DHAs was to give us their top three priorities, and they have done so, but we haven't gone through that process yet of prioritizing their priorities. I will certainly keep in mind that the honourable member has this concern and I would also recommend to him to jog my memory from time to time on it, because as we go through the process, I would be happy to share the information with him.

MR. MACMASTER: Thank you, minister, and this might be just a coincidence, but I was doing my research about the call centre in Port Hawkesbury, it is owned by a company

[Page 174]

in India and they're called Aditya Birla and they make a lot things, everything from carbon that is used in tires, and one of the things they make is CAT scanners. I'm sure your department shops around but it might be something to look at, maybe it's just coincidence. Those CAT scanners, interestingly enough, are for countries that probably market mostly in Asia where they do not have the same tax base we have, they might need to bring a product to market with a lower price point. I would just offer that as something to consider, it might be easier to purchase a model from a company like that.

Next I want to ask a few questions around wages for employees who work in our health care facilities. What percentage of the overall Health Department budget would be allocated for wages?

MS. MAUREEN MACDONALD: Mr. Chairman, I want to thank the honourable member. I'm advised that somewhere between 68 per cent and 70 per cent is wages. It's kind of a hard thing to calculate on some level because of physicians' payments and how physicians' payments is quite a large piece of the budget, but do we calculate that as wages? Physicians aren't necessarily employees; they're self-employed individuals. So different ways you construct what it means in terms of wages will give you different percentages, but no matter how you construct it, it's going to be a big chunk of what we do in health care; 65 per cent or more, to 70 per cent, is certainly going to be personnel - health human resources.

[3:45 p.m.]

MR. MACMASTER: Mr. Chairman, the issue of parity came up with respect to wages last Fall. One point I would like to make for the minister - and I'm sure she's aware of this, and it's something that I believe the district health authorities agree with - is that it's difficult to attract health care workers to rural areas. One of the issues around that, that compounds that issue, is wages. If there's a lack of parity in a rural area versus an urban area, it may act as a barrier to attracting people to our rural areas. Could the minister offer some commentary on that or perhaps some measures that are being taken to address the issue of parity?

MS. MAUREEN MACDONALD: Such an innocent but very loaded question. The issue of wage parity is one that I think about a fair amount for a whole variety of reasons, including the fact that my educational background, my Ph.D., is actually in labour studies, and I'm really interested in this question of how we compensate people in a fair way. So there are many elements that come into how you determine fair compensation. Some employment schemes tend to try to use what has been kind of a scientific approach, so you look at the skill level that's required for a particular job and the content of that job in terms of skill, pressure, level of responsibility, all of these kinds of things. They don't take into account some of those features that the honourable member refers to, like the context in which the work is going on and the kind of competition that will occur across a geographic

[Page 175]

area simply because of labour shortages in one area and more attractive wages to address those supplies and all of this kind of stuff.

So often people will argue that in order to get workers into under-serviced, underpopulated areas, you have to pay at least wage parity or you're not going to be able to attract and retain people in those areas, and while I understand that argument, there's a little bit of me that's a little skeptical. We've been doing wage parity for 10 years in Nova Scotia. If that argument holds then we shouldn't have labour shortages, particularly in rural areas, but we do. I say, well, it didn't really work the way it should have worked. That's one thing that I think about.

I also think about the fairness piece. Is it fair, is it reasonable to compare the work that's happening on a trauma unit in a large urban centre where people are being flown in from all over the Atlantic area to landing on wards with a very small, quiet, community hospital? Should there be wage parity for the same work in those situations? Is it the same work?

I've talked with the head of at least one of the nurses' unions, is it the case that a nurse is a nurse is a nurse, for example. Or, is there a difference in terms of the acuity, the pace and all of these questions? I asked these questions not only as Minister of Health and probably not necessarily as Minister of Health, but more as somebody who thinks about this in terms of industrial relations and kind of a sociological perspective on employment in these places.

We've seen questions about not only rural-urban, but we also see questions about wage fairness and parity between the acute care sector and long-term care sector. So if you have a hospital and a long-term care facility and you're paying lower wages to the nurse in the long-term care facility than in the acute care facility, how are you going to be able to recruit and retain nurses in long-term care? Then, what about home care?

Again, it's complex, it's a system. We have to look for balance. I think we have to look for balance. I think we need some underlying principles in how we approach remuneration in the health care field. We have to be respectful and fair when we approach all of our health care providers - doctors, nurses, every other group. Respect them, respect the work they do in the system and respect the fact they're not only a health care worker, they're also a mother, a daughter, a son. They have obligations that go beyond what they're doing in the health care field. They need to have time off, they need to spend some quality time with their families, they need a life outside of those health care settings.

We have labour shortages in health care in terms of our health human resources. The pressure this puts on people to come in and do overtime, to work those extra shifts, to work the unsociable hours, to work on holidays and never have time off with their family is

[Page 176]

extraordinary. Some health care workers feel guilty if they don't go in and help out. They put a lot of pressure on themselves and the system puts a lot of pressure on them.

I think about these issues a lot. I think about how do we support our health care workers? How do we prevent burnout? How do we reduce the amount of workers' compensation claims that exist? How can we adequately and fairly pay people and how can we do all of that without breaking the bank in terms of the cost of the health care system?

Going back to the first point, our health care system costs is driven primarily by wages more than anything else. Anywhere between 65 to 70 per cent of what goes on in health care is wages and the rest is drugs, equipment, supplies, bricks and mortar.

MR. MACMASTER: Some of the things you were saying at the tail end of your remarks build into my next question and that was around quality-of-life workplace issues. Is there anything that the department is doing or is aware of with respect to quality of workplace issues? For employees, it's not just how much money they make for their daily wage but also at least one-third of their lives will be spent at work, likely. Is there anything the department is doing with respect to quality-of-life issues?

MS. MAUREEN MACDONALD: Mr. Chairman, absolutely. I think that healthcare is being transformed now in a number of ways, some by design and some by happenstance. If you look at physicians, the number of physicians who are graduating from medical school for a number of years now are no longer male physicians. The number of women who are graduating from medical schools is about 50 per cent. This has dramatically changed the practice patterns of practitioners. Many female doctors have other responsibilities. They have children quite often and they are not prepared to work 90 and 100 hours per week like the old-fashioned family physician so this is changing the patterns for that particular group of practitioners in our health care system.

Additionally, we're seeing more two-physician households and so this again changes the kind of demands on the system and the patterns of work in the system. I think we're still structured in some way, we've been structured as a Department of Health - I don't mean just the Department of Health in Nova Scotia, I'm talking about probably health care right around the developed world is playing catch up to try to evolve into a model that accommodates those demographic changes. We still have that kind of industrial model that is a male family doctor, with a family at home, who's able to work 90 hours, 100 hours per week and that just isn't the case any more. We have to come to grips with that and I think one of the ways that we're doing that is we're looking at primary health care teams and expanding the way we deliver health care and using other providers, using nurse practitioners and practical nurses, advanced nursing personnel.

Now, nursing itself as a profession has changed and how many times do I get stopped or do you get stopped, Mr. Chairman? I'll bet you every member of this Legislature has

[Page 177]

probably been stopped and asked, why don't we bring back the nursing schools? People often talk about that this four-year bachelor's program to become a nurse is really a serious problem and it has contributed to the nursing shortage. I'm not going to get into that debate here this afternoon, but it is a very popular perception that this is a problem. So you have now these highly trained - we invest heavily in training a nurse now in a four-year Bachelor of Nursing program and they have a very high level of information and skills. The pressures on them, quite often, are to provide a lot of documentation in terms of following the vital signs of a person and monitoring people's progress in an acute care setting, for example, and they don't come cheap. If you're going to have nurses who have four years of nursing education in a university, and beyond that in some cases, then the wages are going to reflect a dramatic increase in the education that people have and that has occurred. We now have licensed practical nurses, which in some ways reflects the nursing programs that nurses used to engage in at the teaching hospitals. We are seeing new models of care in our health care system, where we're using different providers based on what their educational competence is and their scope of practice.

Our health care system, in probably 20 to 25 years will be quite transformed in terms of the number of providers that are actively supporting people in leading healthier lives and dealing with any illnesses and disease that develop and we're going to see pharmacists, we're going to see other health care providers, physiotherapists and a very broad mix of health care practitioners.

[4:00 p.m.]

This, I think, may contribute to a healthier experience for health care providers, taking the stress off the two professions we put a lot of stress on right now, doctors and nurses. They are under an enormous amount of stress, they tend to be at the centre of the health care system, and I think if we have much more teamwork, spread the burden of providing care out across a broader spectrum of health care professionals and providers, we'll improve people's quality of life and lessen the pressure that we've had on doctors and nurses.

We have, in the budget this year, in terms of some very practical things, we have a financial line of expenditure that will help us bring health care workers who have been off the job with injury back into work as quickly as permissible given their injuries. The research shows that the longer people are off the job, the harder it is to bring them back, so with good intervention at an early stage and the kinds of supports that are required, we hope to be able to help people come back to work and that way we won't lose a valuable health care provider and resource and those people will be able to continue the path of good employment.

One of the things that we don't necessarily talk about when we talk about health care, but we really need to recognize and acknowledge, is that health care in this province is a huge economic driver. The Department of Health represents, with this budget, $3.6 billion of expenditure of which 65 to 70 per cent is wages. So imagine, that's direct economic

[Page 178]

development in pretty much every community across the province. It's the salaries of the paramedics, the long-term care home in your neighbourhood and all across your constituency. It's the health care workers at the Inverness hospital. In other places it's the home care providers who are going out and providing home care in people's homes.

So I think on some level when government starts doing the work that results in changing any aspect of the health care system, there's a nervousness on multiple levels. People get worried about what services they're going to lose, let's say, when government starts talking about doing things differently and trying to do things better, but there's also a fear with respect to employment. What does that mean for our jobs? What does that mean for the jobs of family members, neighbours, friends, and just citizens who contribute to the tax base of this community. Health care in our province and other provinces as well, is very much embedded in the social and the economic fabric of the province and that's largely due to the huge wage component of the health care system.

MR. MACMASTER: Thank you, minister. From quality of life issues to - this is kind of connected to that and this involves training, and one of the comments I've heard from the staff, from somebody who works in the health care sector, is that the staff doesn't have time to train the new students who are coming in. Is that something you've noticed? Is there something to be said about that matter?

MS. MAUREEN MACDONALD: Training is a really important issue in a profession like this, in health care, not only training as an entry point to have the basic skills at whatever level you enter in, but then to constantly be upgrading and maintaining those skills. I think on some level we've done a fairly good job in terms of getting people ready to enter into - we have a great community college system, for example.

They are fully engaged in terms of working with the Department of Health in terms of our need for particular groups of trained employees, and I use the continuing care strategy. If you were going to open all of these new continuing care beds, where were the staff going to come from to staff them? They weren't just sitting around out there twiddling their thumbs waiting for new long-term care beds to come onstream.

So the province, as part of the Continuing Care Strategy, indeed, had a plan that included working with the community colleges and opening up seats and programs in the community colleges around the province, in Truro, in Springhill and various places, to train continuing care assistants and there was an estimate of how many new workers would be required. Seats were put in, advertisements were run, people were recruited and trained, and many of those programs now are wrapping up with a new supply of trained individuals who are going to be able to staff the long-term care beds that are coming onstream. Then we'll be able to return to our patterns in terms of what we were doing before all of these beds came on.

[Page 179]

We continually, in the department, have to think about our health human resources. We have in the budget for this year a little over $8 million set aside to do that very kind of thing, to be able to identify where there are gaps in terms of labour market supply and find ways to recruit, train, support and ensure that we don't encounter ongoing staff shortages.

I had the opportunity, after I became Minister of Health, to meet with a group of home support workers. They have an annual conference and they held their conference this year in Truro. They were there for a couple of days and it really was very much like an in-service organized by their own organization. They had speakers but they also had workshops. They had demonstrations, they had opportunities to network with each other and to talk about what some of their common experiences and common concerns are and ideas about how this could be addressed in a more systematic structural way by the health care system.

I was a little concerned to find out that there isn't a lot of money provided to this group of workers to give them an opportunity to get together and do this kind of stuff. I think that's fundamentally important, that people who are working in the system have a few staff development days a year where they can not only get a breather but they can meet other people doing the work that they do. They can brainstorm together on the problems that they're experiencing and get some new ideas. The women I met - they were mostly women at this conference, they're home support workers - they were very invigorated by this. When they talked to me about being there, they talked about how they were getting their energy recharged, and you want people to have energy doing that kind of work.

So I'm somebody who believes that you need to invest in your workforce. If you invest in your workforce, not only in terms of wages and benefits, but if you invest in their training, you invest in their opportunities for self-improvement. It pays off in spades in the quality of their productivity when they go back into the workforce. It makes a huge difference, and we'll look for those opportunities. As I said, we have this $8 million in the budget for ongoing health human resource strategy development.

MR. MACMASTER: Thank you, minister. My next set of questions involve the information tracking system for Health. Recently at the Public Accounts Committee I had the opportunity to ask a few questions. Some of the areas that I wanted to focus on were, if you can track information, you can better manage a system and you can manage the costs better. I think there are opportunities that the department could be looking at, not just internally at the management level, but also for employees and also for the users of the system - Nova Scotians.

My first question - and I apologize if I'm being too specific, but I'll ask it anyway, and what you can offer will be appreciated. Can physicians use some of these new information technology systems as a checklist? I say that as a means to help them to be organized. I know they're organized already, I don't want to suggest that they're not, but what I would envision is something where somebody comes into the office, the physician can

[Page 180]

pull up something on a computer that shows what medications they're on, that also shows what their past medical history has been, and also if they've been given any advice to improve their health, maybe some self-help measures. We're getting into the issues of the area of Health Promotion and Protection there, but the question again is, minister, could any of these tools that are being put in place by the department be used by general practitioners around the province as a checklist for patient care?

MS. MAUREEN MACDONALD: The honourable member is quite correct that there are many benefits to be gained by good technological systems. We have a number of them in the department. We've just pretty much finished a process where all of the DHAs now have gone onto a system for payroll and for managing their health human resources. This program will really help the department plan, for example, our health human resource needs; DHAs will be able to plan their needs; and it will offer great benefits for us in the future. That's kind of a policy planning tool at the department level, but in addition to that, there are already a fair number of physicians who have gone with an electronic patient's record. Not as many as we would like, not as fast as we would like. But we have a plan and there are resources in this budget to move another group of physicians into the electronic patient record. This will make a significant difference in terms of patient care, without any question, it will help us alleviate and eliminate duplication of services and testing. I think that it could also, with the proper checks and balances put in place, it will also offer an incredible source of information for research. Medical health research is an activity that is worth a lot of money in an knowledge-based economy.

The people who are skilled researchers, for example, they make high salaries and so they're very strong contributing members to our economy. Our world is going to be, it is already, more and more driven by good research and good information. So, we're going to see, I think, the electronic patient record as a very useful tool. To give the member an idea of some of the IT projects that are underway in the department, there is the electronic medical record that I just referred to. It is part of a larger health information management system. It will eventually allow a patient's medical information, from any clinic, hospital or other medical service to be stored and accessed as needed.

[4:15 p.m.]

In addition, we have surgical services being more followed in terms of technology. So I think we'll see a number of initiatives in the coming year that will build on the technology that we currently have. For our physicians access to some of this information and this technology will be really quite useful, I know, for example, that Dr. Ross, in his work on the emergency rooms around the province, is finding the access to some of the information that we have in the department quite useful.

We have been approached by Dalhousie to talk about their- they have some ideas on how they could be helpful in setting up information data systems that will help us around

[Page 181]

health promotion initiatives, chronic disease management, all of these kind of things. If we want to do the work of targeting resources and undertaking initiatives that will help us improve the long-term health of the province, we need to be able to not only quantify what the picture looks like right now, but we also then need to look at being able to evaluate and monitor the effectiveness of anything we do, which means gathering data and crunching the numbers and being able to demonstrate that where we're investing our dollars are yielding the results that we desire. So, I think there'll be a lot of opportunity.

In the physician master agreement between the province and the doctors, there is $1.5 million for incentives to physicians to move to an electronic medical record and we have physicians asking for this. They are asking for the supports so that they can get the technology and move to an electronic medical record and they see great benefit in terms of their ability to practice effectively.

MR. MACMASTER: I do just want to add that I think - and this is just from a layman's perspective - physicians and practitioners around the province can add a tremendous value to our health care system by encouraging people to incorporate, say, healthy eating, physical activity, reducing alcohol use, perhaps eliminating tobacco use. Very powerful messages are delivered by physicians. People really take them to heart and I think the more we can do to help physicians make that part of their regular day, whether it's asking a couple of questions to a patient near the end of a consultation or at the end of an appointment, I think that's very powerful and it's something we should try to find ways to encourage, as government, as a means of controlling the future expense of health care.

My next question involving information systems involves counting the costs of health care. I would relate this to business. Businesses have to understand their costs. If you're producing something and you don't know how much it costs, you might charge the wrong price and you might be out of business before you know it. I think the same must hold true for government as well.

I'll leave you with an expression that I heard one time from a man who was involved in the heritage community. He said, when you want people to understand things or learn things, you have to take them from what they know to what they don't know. You have to start out with something that they can relate to. I thought that was very wise and it has always stuck with me and I thought one of the ways that this could help our health care sector and help reduce the future expense of health costs would be to make this happen on a number of levels.

By using information technology we can better track costs. We could do some interesting things. We could, of course, use it from a management perspective, which I know the Department of Health does already. We could also help employees who are out offering the service within the system so that they know how much it costs. I referenced Sacred Heart Hospital earlier and I remember hearing somebody from management within the Department

[Page 182]

of Health some years ago commenting on how unique that hospital was because the nurses there were very keen about making sure that any materials weren't wasted within the hospital and I thought that was valuable. I think with this information there could be ways to pass on the information to employees so they understand, in their daily activities, the costs of the services that are being offered because they may see ways which could help reduce those costs.

Finally, for Nova Scotians, the users of the service, why not show Nova Scotians the costs of the services they're using just so they know and perhaps can better appreciate the value that they're getting for their tax dollar. Minister, do you have any comments on those ideas?

MS. MAUREEN MACDONALD: Thank you very much, the honourable member raises some interesting issues. First of all, over the past four years the department has invested $53.4 million in both capital and operating in a system - the honourable member probably had some discussion at Public Accounts Committee -on HASP, which is, I think, Health Administrative Systems Project and it is, in fact, that system that helps us standardize the reporting across the DHAs and allows us to track what's going on in terms of administration, the purchasing of supplies and all of the health human resources, which again make up such a big chunk. It will help us look at Workers' Compensation injuries, absenteeism, overtime, all of these issues, and help us try to manage things in an improved way. In addition to that, it will allow us to show the DHAs how they're doing comparatively on any given issue. It will allow us to show the public - if we wanted to, I suppose - how a DHA is doing on any given issue.

In addition to that, we have information - the surgical network information will allow us to do some comparisons - OR to OR, for example. So we'll be able to see where we have high rates of efficiency and not so high rates of efficiency, and people will be able to get that information as well comparatively. So I think technology can help us improve our understanding of what's going on and it can make us more accountable. It can make the system more accountable if we use it to make the system more accountable.

The member makes reference to having patients know more about the cost of the services that they consume. I think it's a good idea. I think we're not just patients; we're also citizens and taxpayers, and so from all of those perspectives, the more informed we are, the better it is. I think it makes sense for people to know what things cost. I'm not spending my money in the Department of Health - the amount of money I have in the Department of Health is pretty minuscule, as a taxpayer - but it's a huge amount of money. It's public money.

We need to be as transparent and accountable for the expenditures of these resources as possible, and we need to do that on this side of the House, as the government and as the Public Service, but I also think that the public share a responsibility in being an informed

[Page 183]

public and being a conscientious public. I think that many people in this province are informed and conscientious, but some people aren't, and we could inject a little dose of that into the body politic. It wouldn't hurt to do that, so that people are always mindful that this is our common wealth, and we don't have an unlimited amount of common wealth, and we need to use what we have wisely to great benefit and good outcomes. So the more information we can give people, the better, and in terms of that, I have no difficulty with that idea.

MR. MACMASTER: Mr. Chairman, my next question involves the education of some of our health professionals, and there's a specific question with respect to lab technicians. I do apologize - this question is more suited for the Minister of Education, but perhaps I'll ask it anyway, and if there's a response, it would be appreciated.

It was mentioned to me that there has been some inconsistency in the past over subsidies for seats to train lab technicians, and that has put a strain on that particular occupation within the health industry if there's not enough supply of them. Can you offer any commentary on that and if you are aware of funding per seat going forward?

MR. CHAIRMAN: I would just remind everyone that there are about seven minutes left in this round.

MS. MAUREEN MACDONALD: Mr. Chairman, I'm afraid I can't shed too much light on that. I do know that there was a time when we didn't train, we had moved the training out of Nova Scotia to New Brunswick for this particular group of health care providers. We have moved back now, we have seats in the community college. What the provisions are with respect to tuition support or remuneration I'm not really clear and it's something I could get some information on.

I would assume, again, that our department would have been involved in that. It wouldn't have been a strict Department of Education issue because we do have a very strong vested interest in promoting health education for particularly hard to recruit and retain groups and we take an active role in that. I envision that we're going to see some changes in the future. I mean, the Department of Health will always be involved in health human resource strategy and training but I think that there will more tendency to have the Department of Education lead the development of educational programs and then the supports around those programs. They have expertise in that area that we don't have and so we're more inclined, I think, these days to allow them to do what they do well. We make our needs apparent and participate in that process. We can't have a complete silo between the two departments but in terms of the mechanisms of getting programs in place, that's what they're good at and we'll leave that to them to do.

[Page 184]

[4:30 p.m.]

MR. MACMASTER: I might slip one more question to the minister before we run out of our time here. One of the things that concerns me is the cost of education for young people in Nova Scotia and it affects the supply of qualified people we have for the health care sector. One of the reasons it concerns me is because it's bad for consumer activity in the province. If young people come out of university or community college with a lot of debt it restricts their ability to buy a first automobile, buy a home, start a family and we see that. Young people take on a lot of debt today and I think that affects a lot of things and it's not good for the economy. It may be good for those who are lending the money to them but it's not good for the economy.

Is the department looking at ways that people who are training for health care positions, ways that they could perhaps enter the workforce and earn some income while they're continuing with their education? I know some of those means are in place already, I know young physicians who are on their way to gaining their medical designations, they can work and get paid. Is the department looking at other ways to help people who are training for these health care positions to earn money while they are training?

MS. MAUREEN MACDONALD: I hope I'm not speaking out of turn here. My financial advisor here will let me know if I am but I believe that, for example, with doctors, there's an increase, I think, in this budget for residents. I think I noticed that in some of my briefing materials earlier. With a recognition that they have faced, like most people, an additional financial burden as the cost of living provides a challenge.

We're doing more co-op nursing programs and this allows, I think, for opportunities for people who are in the nursing schools to have some financial support when they're doing practicums and things like this as well.

We pay approximately $22 million annually in resident salaries in the Capital District Health Authority. I guess this is part of the contract that we have with physicians. I know that for many groups going to school, taking training, upgrading their education or coming into a program new, is very expensive. This budget also has in it the tax credit for students who remain in Nova Scotia to help them offset that cost of their education after they have completed a program. I would assume that a fair number of health-care-trained personnel will take advantage of that particular tax credit.

Could we do more? Probably. If we didn't have the financial situation that we have, we probably could do more. I'm a firm believer that education is the greatest investment that you can do as a society. So, we will always look to ways that we can enhance training opportunities for people in the health care field.

MR. CHAIRMAN: The honourable member's time has expired.

[Page 185]

The honourable Leader of the Official Opposition.

HON. STEPHEN MCNEIL: Mr. Chairman, I want to go back to where we finished up in the last hour and that is around the Annapolis Community Health Centre. I want to give the minister an opportunity to respond. The issue was actually access to primary care, whether it be through the office of a family physician, whether it be through the nurse practitioner's office or whether it be through a diabetic clinic - other forms of access to health care other than an emergency room. She is well aware and I am sure that Dr. Buchholz has informed her, one of the challenges in Annapolis and in Middleton is access to a family physician or a health care provider and that's why so many people - not just in my constituency but people from across Nova Scotia - are going to the emergency room looking for access to primary care.

So, I would just ask the minister, maybe she could continue the comments she had earlier, at the beginning?

MS. MAUREEN MACDONALD: I believe I was saying when we were speaking earlier, Mr. Chairman, that I have had an opportunity to talk with Dr. Buchholz as well as Dr. Ross, who has been in the area, who is returning to the area; the CEO for the Valley Health Authority; the chairman of the board of the Valley Health Authority as well as board members; and now the member; but the piece that I feel that I'm missing is an opportunity to speak with this group of concerned citizens who have, I understand, met with Dr. Buchholz and they've been meeting with other people as well. I understand that they are working on a proposal.

I need to have an opportunity to meet with them and I don't know if it will happen while we're here in session. If I can get permission from my Leader to be out of the House for an afternoon so that I could meet with them, if they were available, I will try to do that. But it is not necessarily something that I know will happen. A lot depends on the business of the House, of course, and whether or not I can get something into my schedule that works for those folks as well as myself.

But I do understand a number of things. I do understand that one of the things that we have to really figure out is how to make the primary health care centre work. That's the most - I shouldn't say that it's the most important thing because I want to be very clear that the emergency room is important too. I don't want people to think that it is an either/or proposition. But I am very concerned about what I'm hearing around the primary health care clinic and the fact that it is not working as it's intended and that the emergency department is becoming the alternative to the primary health care clinics. Clearly that cannot be allowed to continue and we need to do something around that, and we will find a solution to this.

MR. MCNEIL: Mr. Chairman, as you're probably well aware, the people of Annapolis County are very accommodating, and any time that you can free up your schedule,

[Page 186]

I'm sure they'd be more than prepared to meet with you. If your Leader would excuse you I might even drive you there. (Interruptions) The Minister of Agriculture and Natural Resources needs to behave himself in the House. (Laughter)

There are some real challenges around how that model is being deployed. The community recognizes that, the docs recognize that; I'm sure Dr. Buchholz probably identified some of those challenges. It's around fees that are being charged, all of a host of issues, but those are issues that I believe when reasonable people sit down and focus on the real problem, we can fix that. There's also the issue of shortage of physicians, and that's doctors who are working in the emergency room are not covering that practice the next day because of course they need to recover from their schedule. That is creating a long wait list to get into the clinic and at the same time is driving people into the emergency room portal.

I'm glad you mentioned - because there's no way in these discussions I want to leave you with the impression that I'm saying it's an either/or. As a matter of fact, we're very clear on the record that we're looking for a 24/7 emergency service in the community of Annapolis, and Middleton, but we're also dealing with the issue of access to primary health care professionals outside of that emergency room. I think that's the key, and I think the key is to focus on the clinic and why is that model not functioning as we had envisioned. It is, I think, a wonderful model to look at in terms of allowing patients - I'm actually a patient of Dr. Buchholz. Maybe I shouldn't tell you that - you might not appreciate his advice anymore.

He provided great care to my family and to my wife and two kids, and has continued to provide them great care from birth until now, both Colleen and Jeffrey, so I have a great deal of respect and admiration for Dr. Buchholz as well. I appreciate the openness that he has in terms of looking at health care and how do we deliver primary health care in a new way, making sure he's one of those physicians who embraces the idea of fully allowing health care professionals to practise their full scope.

He's been a leader around nurse practitioners, making sure that - as I'm sure you're well aware, he was the overseeing physician of the challenges we had in Digby Neck. It was nothing to do with him. It was the challenges that were in that facility, and he has been working toward some of the changes that took place, where originally a nurse practitioner worked under one physician, and now he was part of helping lead a way, that the nurse practitioner in Annapolis worked under a collaborative practice, and worked under a group of physicians as opposed to an individual. He has been leading the way and would provide you with a very hands-on, up-front perspective of health care in the Basin area and around Annapolis Royal and Digby, because he would know the challenges that are faced there.

You mentioned Janet Knox ,who - and I want it to be on record - I've said this in many community halls across the province when we get talking about health care, how fortunate I am to be elected and serve under her health authority. She is a forward-thinking, energetic leader who is working toward the issue of the emergency room challenge in

[Page 187]

Annapolis Royal and in Middleton as well, of people going to this facility and to the emergency room for the wrong reasons. I've said this in Annapolis Royal as well: it's unfortunate that the two exercises collided. The health authority was looking at how do we provide primary care to the people who are going to the emergency room at the same time Dr. Ross was coming in town? In the previous hour you alluded to some of the history - that I'm sure Dr. Buchholz would have talked to you about - of Annapolis Royal, but some of that history has led to, really, a level of distrust between government and community, and it's not your Party. I lead a political Party that, quite frankly, made big changes in the community of Annapolis Royal in 1993, when it came to that facility. It was not a collaborative view, but I think many of those would say to you today that the facility they have today is meeting the needs of their community, but it happened without a community conversation.

This organization that you're referring to that Mr. Boucher is leading and chairing - he's a wonderful artist, by the way - is a great representative of the community. A very reasonable group who obviously are looking for - they won't just come to you, as I'm going to tell you, that you made a commitment of 24/7 to keep it open. They're going to come to you and want to be part of a long-term solution. They have been very good at recruiting health care professionals to the community of Annapolis Royal, but there is this uncertainty, and the sooner we clear it up - I know Dr. Ross is doing his work - it will allow the community to continue to recruit.

[4:45 p.m.]

There is a young student who is now a physician, who is not practising here right now, who wants to move home. He married a physician who wants to move, but the uncertainty of what's going to happen around that facility is causing them to slow down a bit. I think the sooner that we can lay in place a path forward for the community health centre, it would serve in many ways. We do need to continue to allow Janet to do the work that the board should be doing - not just in Annapolis Royal, but in every emergency room in that district, and I'm sure they are - which is how do we provide that primary care piece without putting them into the emergency room.

I want to be clear about this and put this on the record for the House. My health authority has never once said they want to close the emergency room in Annapolis Royal. They've now looked at it, what they've said is there are too many people going into the community emergency room for primary care. Our mandate, as a board, is to provide them health care where they need it, and that's what they're looking at.

What has created some of this anxiety in the meetings that you've mentioned earlier, has been Dr. Ross coming at the same time. The sooner that you can provide some assurance to that community, that the 24/7 piece will be there, it will help dissipate that. I know that Dr. Ross is coming into Cornwallis to a public meeting, I believe next week, perhaps. I don't know the exact date right now - I have it but I don't have it in front of me - that he'll be

[Page 188]

coming down to talk about his report. I want to encourage you, and it would be a positive thing if he could come in to talk about the hour piece. The idea that no one is giving them the commitment that the 24/7 emergency room option will be there has not lessened the feeling of the community that there is something going on that they don't know about.

I'll just reiterate this again for you: there is a level of distrust between community and governments prior to you. It has happened in the 1980s, it happened in the 1990s and now the community believes we're at the cusp of another change. In the previous ones, they have not had an opportunity to participate. Someone came through, made the changes without putting in place the alternative services. The EHS, which is now identified across the globe as a leader, a very positive piece, was put in place by Dr. Savage when he was Premier, by a government that was - Dr. Ron Stewart, when he was in your office, was a leader. Communities are recognizing that today. Now we're looking at that same service and the people who provide it, the paramedics, as a potential option, to providing them with primary care, not only in Annapolis Royal, but triage here in town wouldn't hurt either to keep some of the emergency room people going in the right direction as opposed to downtown.

So, I think as Dr. Ross comes in and as you go to Annapolis Royal, I want to encourage you to embrace the community. They are a community of solutions. They will look for options to move forward. They are not going to come to you - it's like I said in this House about the community of Yarmouth when it came to the ferry - the community of Annapolis Royal and surrounding area will not come to you and just say, you made a commitment to keep it open. They want it open, absolutely, 24/7, but they also want to work on how we move some of that other issue of who is going to the emergency room and moving to primary care. They really want to be part of that. It is quite a community when it comes to working together to provide a service that they depended on for a very long time. I've been part of some those meetings.

The district health board in the Valley is one that your department should be a proud of. I had the opportunity to nominate Greg Kerr, who was a former minister in this House, who is now a Member of Parliament. We have different political views on how we believe province and country should be governed and when. I nominated him, he was from Annapolis Royal, that part of our community wasn't represented, and I believed and he did represent the entire Valley in a way that looked at primary health care across the region.

More recently, I know the appointment of John Kinsella, who I know you know well, we also has different political views. But John is a very committed community person, particularly around health care, his profession has been in the health sector and he will bring a very positive voice to the table and I know if you had conversations with John, they would be solution oriented. It would be looking towards a goal of how we keep that service and do it at a reasonable cost and one that is effective in allowing people to have access.

[Page 189]

There are solutions there, but it will require coming to them, coming out and embracing the community and saying, let's work together to keep the commitment of 24/7 as well making sure we're getting primary health care in the right place.

I also represent the community of Middleton and Soldiers' Memorial Hospital. We're going to have a debate a little later about emergency rooms and the 24/7 promise. In more recent time, emergency room closures in Annapolis Royal and Middleton are becoming more chronic. A part of that is, obviously, physicians in the community. I'm also being told that part of that is the way physicians are being reimbursed for their coverage.

As you know, in the Valley district, as in every district, it is my understanding that there is a different fee if you're covering to the emergency room at a regional hospital, to a clinic, to the hospital that we have in Middleton. The Middleton one, it is my understanding that it is closed at times because their physicians are covering the one in Kentville because it pays more. There is something inherently wrong with that system that is really robbing one facility to provide service when in actual fact that person delivers services in this community.

As part of that, when the clinic became - those physicians actually reduced the amount they were going to receive in an emergency room even below what the department is going to be make a commitment to saying, we'll go home, we don't have to stay all night. There was a real inability by those physicians who wanted to deliver that service.

So I would ask you to comment on the challenges around keeping emergency rooms open. It is not just access to family physicians, it is money as well. People are going to regional facilities that pay more and at the same time when we bring in a physician from outside who will cover Soldiers' Memorial Hospital or Annapolis, we pay them more. Well that offends the people who are committed to those communities. So I would ask you to make a comment around how we reimburse physicians in terms of covering the emergency room services in our province

MS. MAUREEN MACDONALD: Mr. Speaker, I think Dr. Ross' report talked about physician pay, not at length or in detail, but he certainly made reference to it. I'll be very candid here out in the open on Hansard, under the scrutiny of the media. There is nothing more disconcerting than sitting in your Minister of Health office on a Thursday afternoon and having your deputy or your BlackBerry bring you back to life and let you know that we just received word that for the month of February, let's say, there are no physicians available to cover any shifts - not one shift, any shifts - in a medium-sized hospital that is not a regional hospital in a DHA in the province. You kind of look at that and you say to yourself, how is that possible?

There is a large group of physicians who live in that area and practise in that area, so how is it possible that suddenly, for a whole month, there isn't going to be one physician available for one shift in the emergency room. Coincidence? I think not. This is not a

[Page 190]

coincidence. What is that? Some people would say, well, it looks to me kind of like a strike. It looks like a group of people have decided to withdraw their services from an emergency room, and I can tell you that has happened, and it is a piece of the problem that we're trying to deal with.

It does have to do with remuneration. It does have to do with balance and fairness and frustration. I have tons of respect for the people who do this work and if they get to that point, they're frustrated, they're sending a message to the Minister of Health. Isn't that what's happening? I think so.

So pay has to be a piece of the solution, but it is very difficult, as every member in here will acknowledge. The envelope is not unlimited. We have a finite amount of resources. We have experienced fairly substantial increases in wages over a period of time in the health care sector. Wages have not been harmed in the past number of years. We've had very good wage growth in health care, and it is not sustainable. That is a message that has to go to everyone who works in the health care sector.

However, we still have to be fair and we still have to acknowledge that we are in a competitive work environment. We need to offer competitive wages to our physicians. We need to do that to recruit people and we need it to retain them. We have an amazing group of physicians in this province, from one end of the province to the other. I've met so many outstanding physicians and it drives me crazy when people denigrate our health care system and talk about that we don't have a world-class health care system. We have some of the most amazing health care providers imaginable in this province.

So how do we strike that balance to be able to find what's fair? It is difficult because inside the physician community it is not a homogeneous community. There isn't 100 per cent agreement among physicians about pay, just like in every other group in the world, probably. Some people say or are of the view that, for example, the emergency medicine in a tertiary care urbanized facility is of a greater intensity, the pace is more driven, the acuity of people who are coming in is greater than what you would see in smaller community hospitals, for example. Therefore, there are people who will argue that there should be a diversity in the pay that is offered to reflect the work that is being done, that there is a difference in the work that is being done. But at the same time, then there are people who say that this will - this creates a hierarchy of value that you attach, and what you do is you privilege urban settings over rural settings and you deprive them, the rural areas, of those resources that they need.

We are working our way through this. It is a process that requires a lot of conversation to bring people of different points of view to some kind of a consensus that they can live with for a period of time. I am not naive enough or inexperienced enough at this stage in my life to believe that there is a permanent fix in health care. If you look at the history of health care, health care is a very dynamic area of both political and other kinds of practice and it is constantly shifting. The basis on which we provide health care constantly

[Page 191]

shifts, and we have to be prepared to take the situation that we have and make the best solutions that we can bring at any given time, given the resources that we have.

[5:00 p.m.]

The key, I think, and I think the member put his finger right on it when he was speaking about the distrust that exists in communities. The key is community involvement, consultation, conversation. I think you have to have a fundamental belief that reasonable people, having a reasonable conversation with whatever information is available, will reach reasonable conclusions at the end of the day. That is what I have concluded, and that is why I am very happy about Dr. Ross going out and speaking to people.

I want to speak to the concern that Dr. Ross being in the community raised for members of your community. His being there was purely coincidental in many respects. I had asked Dr. Ross to go to Digby simply because Digby is a place that has had such difficulties with respect to its emergency department. When Dr. Ross came on he had his mandate, but he is very self-directed in many respects - his own approach to where he was going to start, and his own work plan. I really haven't directed that, with the one exception. I requested that he go to Digby, and I requested that he go as early in his work as possible because I was very troubled by the extent to which that emergency department was being closed. I think it is the most chronic place in the province, and because of the proximity of Annapolis Royal to Digby it just made sense, I think, for him to go into Annapolis Royal while he was in the area. I don't think any of us anticipated that the community would read into that as much as what was read in. It was purely coincidence. I requested he make Digby a bit of a priority and it made sense while he was in the area to go to Annapolis.

This is the most that I can say at this stage about the health centre in Annapolis Royal. I want to go, I want to meet with the people in the community. I have made no plans beyond health estimates, I'll get through the health estimates and then I might be able to look at whether or not there's a day or an afternoon or something like that that I'll be able to get off to do some of these other things. If not, then we're looking, probably, in the month of June for sure, I will be able to do that, but I frankly prefer to do it before that.

I recognize that there are great challenges. I recognize that people in Middleton, physicians in Middleton, have concerns and that's on my radar, but the health centre in Annapolis Royal is a higher priority at this stage. I'm sure we'll have many conversations about this as we go forward. I will be tabling at some point in the not-that-distant future a report on the community consultations that the DHAs have been having around the province.

Given that this is a problem of long standing, the emergency room question - period - we'll have many occasions to talk about this, I know.

MR. MCNEIL: Thank you, minister, I appreciated your candor when it came to some of the challenges that we face in terms of staffing our emergency rooms. I would also ask and

[Page 192]

encourage you as you go to Annapolis Royal to visit that community, I would encourage you, if you have time, you make, if not a full day, an opportunity to visit Soldiers' Memorial Hospital as well. I'm sure they would show you the site of that new nursing home in Middleton as well as those 12 beds very close to the Annapolis Community Health Centre in Annapolis Royal.

It is a unique community that I have the real privilege to represent from one end of Annapolis County to the other, into Annapolis Royal from Wilmot and out to Springfield. Once you're through health estimates and you see your way forward, I would encourage you to look at both of those facilities because they are unique and distinct on how they deliver health care to their community and each community is different.

Middleton is moving toward building a collaborative practice, a stand-alone clinic in the parking lot very close to Soldiers' Memorial Hospital, to be able to deliver access to health care to their patients. It's an encouraging piece, but it's also frightening in many ways. There's a group of young physicians and yet we have a number of physicians who are prepared to retire soon. Each one of them will require two people to replace them. They have very large practices and work 24/7.

I recognize the challenge in front of you. I hope you look at the solution that we've provided in terms of designating seats. I also think we need to look at residency programs and how do we expose more physicians to rural Nova Scotia and the way health care is being delivered, and on top of that, looking at the challenges with those Nova Scotians who are getting part of their education in the Caribbean. We are providing them with an opportunity to come and do their practicum. It only makes sense that we start looking at the residency program here because those kids want to stay here.

I want you to think about this for a second, how dedicated they must be to want to practise medicine. They've been denied by their own province and region, they've been denied by their own country, that they put the initiative to go to the Caribbean to study and yet come back here to practise and they want to make a commitment to us. It's not the total solution, but, as you mentioned earlier, there isn't one fix that fits all. There will be a number of these things that we can do.

I know the member for Kings West will talk a bit about that, but I really do want to encourage you and I'm pleased to hear you talk about the community because, as I've said many times, reasonable people sitting down can find a reasonable solution. We often listen to the 10 per cent on each end as opposed to the group in the middle who are really wanting to find a positive outcome. Quite frankly, they don't care about political Parties and political agendas. They care about their community and delivering access to programs and health care being such an important one.

[Page 193]

I just have one other question and it's actually pertaining to Guysborough, which you mentioned earlier. There was an announcement by the previous government to make some renovations in Guysborough and there was a commitment by the municipality of Guysborough who had money on the table. That initiative was to go forward - is that still going forward and when can we expect that to go forward?

MS. MAUREEN MACDONALD: Mr. Chairman, I'm sure this will come as a great shock to the honourable member but there were a number of announcements made by members of the previous government for which there was no money and there was no approval in terms of the department or Executive Council. I know that - well, I shouldn't say that I know that, but I believe that Guysborough was one of those places. I believe that a former member of this House may have made an announcement with respect to an expansion or - not an expansion but an improvement, a renovation.

At any rate, when I went to visit GASHA, I asked that some time be built into my schedule so I could go to Guysborough. I went and toured the facility, I met people, I talked about - the honourable member for Guysborough-Sheet Harbour accompanied me. We had a really good tour of the facility, I have to say I thoroughly enjoyed the tour of the facility and we had a meeting with representatives from the foundation and the municipality. We talked about what the next stage would be or what would be required to start moving forward.

They had a piece of correspondence from me I think they had just received. I asked them to proceed with the first stage of any capital work, which is kind of developing a bit of a plan for what was required because it gives us the basis to know what we're actually looking at. So that has been initiated, that process is initiated. I don't know if we've heard back from them yet or not. I'd be surprised if we have because I believe I was there in February. Yes, it was February so it's not that long ago really, it's probably eight weeks ago.

What we will do is we'll wait to hear from them. They will have to attain some professional person who - not necessarily an architect at this stage but somebody with an understanding and expertise around re-developing a facility to start to do the preliminary itemization of what is required. Then that comes to the department and then there is a process that begins to the point where we cost and we set aside some money. I would have to get approvals through Executive Council for that.

MR. CHAIRMAN. Before I recognize the next speaker, the committee will recess for a few minutes.

[5:10 p.m. The committee recessed.]

[5:13 p.m. The committee reconvened.]

[Page 194]

MR. CHAIRMAN: Order please. The Committee on Supply is now called back to order.

The honourable member for Kings West.

MR. LEO GLAVINE: Thank you very much, Mr. Chairman. I would like to start off by saying that I am pleased to have an opportunity to ask the minister and staff a couple of questions. I did want to preface my remarks by acknowledging the work of Deputy Minister McNamara - I had two or three very complex and challenging problems in a very short time, in fact. The way he mobilized staff to look after them was extraordinary in my view, one case in particular. I would like to report that all three of the cases are unfolding in a very positive manner in terms of people's health.

One of the areas that I think the new government has to be concerned about is the fact that our administration cost is above the national average, one per cent. Sometimes I get a sense that I can feel it in the health district that I live in because often now when I write a question, when I get it back, there are probably cc'd four, five, six other people, all with different titles, and you really get a sense that the eight point three percent of the budget going to administration - 3 percent above the national average - perhaps we need to be directing more of that dollar to the front lines and I know that's common for many DHAs across the province.

I am wondering if the minister is formulating a plan to be able to streamline just a little bit. In fact, physically, you can see it has grown in the Annapolis Valley District Health Authority because we could no longer be confined to Valley Regional. They needed to, in fact, open up a complex in Chipman, in the industrial park, and so I think it is a growing concern for people in our health district and I am wondering where the minister plans to have a look at that.

MS. MAUREEN MACDONALD: Thank you very much Mr. Chairman. The honourable member raises a very important and interesting issue and I am glad that he has done so because to date we really have not had a huge amount of discussion in estimates around this; we have had a bit, but not a lot. We have made a commitment in the Speech from the Throne, and I think again the Minister of Finance made reference to this in the budget speech if I am not mistaken, that we are one percent above the national average in terms of administration and it is something that we intend to tackle and to bring Nova Scotia's health administration in line with the national average.

The work is beginning with respect to that, in terms of meetings between department officials and the DHAs and the IWK to look at various elements of what might help us address this issue including things like group purchasing across the province rather than having each district doing its own thing. It is interesting, and this is important, it is an important initiative and it will give us, I think, some savings, but I also want to caution

[Page 195]

people in terms of not being over - to overstate the problem and not to see this as the panacea for the health care system.

I was struck this morning, I heard the President of St. F.X. on the radio this morning being interviewed, a former classmate of mine, and Dr. Riley was saying - Don Connolly asked him what the annual budget of St. F.X. was and the annual budget of St. F.X. is $104,000,000. So to put in context, the department of Health's budget is $3.6 billion dollars. The budget of the Capital District Health Authority is $770,000,000. The budget of St. F.X. is $104,000,000.

Sometimes people say to me, oh there are too many bureaucrats in the district health authority, look at the Capital District Health Authority, that district health authority pays their CEO too much money. The CEO there makes $200,000. I bet you the president of St. F.X. probably makes $200,000 or close - I don't know for sure but I would think it's in the ballpark and manages a portfolio of $104 million. I'm not saying that's a bad thing but I'm just using it as a comparative. So you have the CEO of the district health authority who makes roughly $200,000, let's say, and manages a $770 million portfolio that is responsible for health care for more than 400,000 people. Numbers matter and as John Holm - a former member of this House - used to like to say, size matters. He used to always talk about the pipeline.

When you look at what is being managed, the amount of activity that's being generated by $3.6 billion or just using that one very large district health authority, $770 million, you need to have some bureaucracy, you need to have a management system of oversight, leadership and direction. The point is always well-taken from my perspective that we need to be very careful in how we spend our money. We do not need to be over-managed. We need to push as much of our resources as we possibly can onto the front line to provide direct service but we also have to be reasonable and we have to be informed about the reality. The reality is that, for example, the Capital District Health Authority is like a corporation - probably a medium-sized corporation with a portfolio of $770 million. All of the DHAs have, certainly, great responsibilities and they're carrying financial portfolios that certainly are equivalent to some of our small universities, easily.

[5:30 p.m.]

We have a new IT system that has been developed now over a period of a number of years that has been, in fact, designed to help us to be able to achieve much greater efficiencies, particularly on the administrative side of operating a large enterprise like a healthcare system. Although this was an investment of about $53 million over a number of years, we will now going forward be able to use that system to realize some real efficiencies and some savings. So this again, a lot of the planning in terms of what we needed to have in place to bring us to a place where we can do more in terms of administrative efficiencies.

[Page 196]

People do discuss with me, I get letters and I've had people stop me to talk about whether or not we need nine DHAs and the IWK and there are a lot of people who look at this question of whether or not we have too much duplication and I ask myself that. It's not something that I have an answer for yet. I'm still gathering information and I say to people, well, everything is on the table yet in terms of how we're going to achieve efficiencies. There can be, certainly, a lot more collaboration across districts that will eliminate duplication. Anyway, it's an initiative that we have to find greater administrative efficiency and to bring the province to the national average, for sure.

MR. GLAVINE: Mr. Chairman, just probably one last question and it's all related to recruitment, the emergency room at Soldiers Memorial Hospital, and I guess education of the public in terms of what should be appropriate use of emergency rooms. I know that we had a family friend who dropped in, who was filling in a couple shifts at the emergency room. Her first comment to me as she came into the door was, where is that MLA so I can get a piece of his ear here, because 40 per cent of the patients that I saw today had no family doctor. As the minister has said, primary health care is really where it all begins.

Some communities say that they had good success in recruiting a doctor, going back five, six, or eight years. Then the DHAs seemed to be giving it much more effort, and we know that we had different levels of success, probably, with provincial recruitment. So I'm wondering where the minister and the department and government will go in terms of the primary focus to recruit for our communities? I gave a little synopsis here in the House one day: from Bridgetown to Berwick, there are 13 physicians; seven of them over 60. One at 73 has several thousand patients, and our situation is becoming alarming. So I'm just wondering about recruitment.

MS. MAUREEN MACDONALD: This is an issue that I have always been interested in. When I first was elected, there were certainly parts of this province that were having a tremendous difficulty recruiting and retaining physicians. Parts of Cape Breton were having a really difficult time. Dr. Naqvi in the Cape Breton District Health Authority has done an amazing job of trying to recruit and retain physicians, and DHAs like Antigonish. So I asked the question, why is it? How is it that some areas have been able to do a better job than other areas? What is it that makes some places so successful and others have such a difficult time?

Just to be clear, and I think the honourable member for Clayton Park pointed out when she had an opportunity to discuss this issue, that even in metro there are people who have no family doctor. However, last year, between January and December, the CDHA recruited 18 new family practitioners; South Shore Health recruited zero, SouthWest Health, two; Annapolis Valley Health, four.

We have the numbers and you can look at the numbers, but it is very difficult to say, in some respects, what makes a community successful. Some communities are perceived - and I say "perceived" - as being less open, less welcoming, less able to support. Some

[Page 197]

physicians have spouses that require a certain kind of very specialized work in a professional area, perhaps, and there is no opportunity for that person to be employed in the community, and it makes it very difficult to recruit.

It's difficult. Physicians today want high-quality equipment, they want to have a certain kind of lifestyle, quite often, very urbanized. You know, metro is not that far away from pretty much any place in the province. I think we have a pretty unique geography, in some ways, that should allow us to be able to accommodate people who want to have access to some of the things an urban environment can provide but, at the same time, a good quality of life in a small town or a small town/rural setting. There are great quality of life aspects - well, I don't have to tell the member that.

It's a conundrum in some ways why some places - I have seen parts of this province that have had a very difficult time in the past and they're doing very well now. Sometimes people are able to recruit an individual from a class and then that person is able to recruit a classmate and you get a critical mass of people who are in medical school together, they were friends, they clicked and that's what makes the difference. Sometimes we've had situations where it has been like oil and water. A physician comes in and is never able to integrate into the medical community. That's so important because it is such an interconnected, interdependent community in many respects.

All of the DHAs have recruiters, they have people who do recruitment in their DHA. They tend to have very good relationships with the local municipalities and they are able to sell what the municipality has to offer in terms of housing, schools, recreation, all of those kinds of things. We also have recruitment in the department but our recruitment tends to be more at a specialist and for specializations, at that level. So there is a bit of a division of responsibilities there. We are always assessing and reassessing what it is that is required.

Earlier when I was speaking to the Leader of your Party, I was saying that I don't think we will ever have, in any of these issues, a final point where you figured it out and that is the way it is and you have a program. Many of the features of what is driving any of these issues change so much from over a decade, let's say, that we always need to be adapting our response in order to be effective.

MR. GLAVINE: Mr. Chairman, I think there are just a couple of minutes remaining, I believe that's the case - how much? Two minutes, okay, a short time.

One of the areas that we do hear a lot about, minister, is the fact that we have inappropriate use of our ERs. I've always believed, and I am sure there are many in your government who believe, that an education component is of great importance to change behaviour. I'm wondering, minister, if you're looking at anything around the general population to say, we can actually give you better health care, better health delivery, if we

[Page 198]

have people appropriate place, appropriate time. I'm wondering if you have any kind of initiative in that area, to finish off with.

MS. MAUREEN MACDONALD: The honourable member raises a very good point. In a nutshell, no, we don't have an immediate plan, anything that's planned to do. I met with the Board of the Capital District Health Authority and I was intrigued at something that was mentioned at this board meeting by one of the members of the board who indicated that in the U.K., I think, the government there with the National Health Service had run a series of advertisements on what is a hospital, where they were attempting to do that very thing - raise the public awareness and understanding of what a hospital is.

Now, that might sound like an insane idea I suppose in one way, but actually when you think about it, our hospitals have changed dramatically from what they used to be in terms of what really goes on and how a hospital works. I thought afterwards, well, I went on-line to try to find a site where I might actually be able to see these advertisements and I couldn't find them, but I haven't given up on the idea. I just don't have a lot of time to surf the net, if you know what I mean, but I would really like to be able to look at that.

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

The honourable member for Cumberland South.

[5:45 p.m.]

HON. MURRAY SCOTT: Thank you, Mr. Chairman, and thank you to the minister and her staff for being here tonight. I just have a very few questions. I just want to pick up where we left off last night. Minister, when we finished last evening, we were talking about repatriating patients back from New Brunswick, and I know somewhere over the last couple of days I had heard your department talking about a program, I think, between P.E.I. and New Brunswick which sounds very good.

I also want to say, for the record, that I have a tremendous relationship with our district health authority, as I know all elected officials do in Cumberland County. The communities are well served by the authority under the chairman. They're very willing to attend meetings throughout the community, no matter where it's at, in regard to issues that the people have around health care delivery and what ability the authority has to deal with them. I want to say, as well, to the Department of Health, any time we come to the department with concerns in our area, I know we get a good quick response. I know the department does what it can, within its power and ability to do that, so I do want to say for the record, I appreciate that.

The issue of bringing back patients who are in acute care beds or in hospital in Moncton for treatment - it could be for cancer, it could be for kidney dialysis. I know that the

[Page 199]

district health authority had a position in place, at least they did a couple of years ago, and maybe it's not in place any longer, but I think there's a tremendous - I believe it's on the district health authority's budget versus the Department of Health's budget - pressure as a result of patients who are hospitalized in New Brunswick, and they may be for extended periods of time, where they could be brought back. I'm just curious what your thoughts are around the P.E.I./New Brunswick program versus what maybe the district health authority in Cumberland has been offering over the last couple of years, and what you see as a possibility or options in the future?

MS. MAUREEN MACDONALD: Mr. Chairman, as the honourable member would be very familiar with, a fair number of residents of the Province of Nova Scotia do get health care in New Brunswick. I'm advised that our department currently pays about $7 million a year for Nova Scotia residents to receive medical care in New Brunswick. So we are working with Prince Edward Island. Prince Edward Island has had a program, they've had a nurse liaison from that province who resides in New Brunswick, and who works to get patients from P.E.I. back to P.E.I. So we're now looking at this. We think that we actually would see an improvement in our financial situation, and also, I'm sure many residents want to be home if they can be home, as soon as possible. So that's a piece of work that we will be doing, and I understand, because the honourable member and I were chatting the other evening, that the Colchester District Health Authority has had a program with a nurse who works, I think, in Cumberland. - I shouldn't say Colchester, in Cumberland - to do the same thing. I think that we're looking more to have a nurse in New Brunswick that is part of a collaboration with P.E.I. who are already doing this. The Prince Edward Island initiative has been very successful for them and so we're going to try to build on that success.

MR. SCOTT: Mr. Chairman, thank you for that response. I guess any progress that can be made in that regard, you're right on two fronts, financially obviously and obviously for families who want to be closer to loved ones.

There are two issues that actually continue to come up in our area on a regular basis. One that your department is able to help with a lot, is around ambulance transfers, whether it's between hospitals - I've seen people get bills for $6,000, $7,000 when they're a patient in Moncton Hospital and they're there for cancer treatment and billed after months of being there several thousand dollars but then your department is always able to work through that to the benefit of the patient, which is appreciated.

I'm assuming there is a policy, an agreement, between New Brunswick and Nova Scotia in regard to if a New Brunswick resident is in Nova Scotia and there is a transfer versus if there is a Nova Scotia resident in a New Brunswick hospital and a transfer, I'm assuming that the same consideration is given to either patient no matter which province they're from in which ever province they're hospitalized, I would assume.

[Page 200]

MS. MAUREEN MACDONALD: Mr. Chairman, there has been a fair amount of discussion the last few days about what an excellent ambulance system we have in Nova Scotia, the EHS. I think we all recognize what a world-class system this is and how fortunate we are to have such a system.

The honourable member would know that there are a range of fees that are associated with the use of the ambulance system in place in Nova Scotia. I think if something happened and we had to have an ambulance come for a member here this evening, the charge would be about $138, $139, in that vicinity. Patients who are transferred between hospitals, hospital to hospital there is no charge but there are a whole other group of fees that are associated with using an ambulance. People who are transported in an ambulance who accompany a patient may sometimes be charged an ambulance fee under certain conditions and what have you. So there are a lot of different fees in the schedule.

I understand that fees that are raised annually amount to about $11 million toward the use of ambulance services and that of that, about $8 million, a little more than $8 million, is paid for in terms of user fees by people who use the ambulances.

There is a higher fee for people from out of province. If they're in province and they require an ambulance, they're charged a substantial amount of money. I've had non-residents of Nova Scotia approach me or their family members, with respect to fees they have had charged so this continues to be the case.

I'm not sure exactly what the member's question was aiming to get. Maybe if you'd re-state it, I could more directly address it.

MR. SCOTT: Mr. Chairman, I thank the minister. Specifically, what I was talking about was if a Nova Scotia resident is placed in a hospital in Moncton. Now, Moncton has the Moncton City Hospital and it has the Georges Dumont Hospital. For example, what happens a lot of times is that a patient from my area will be placed as an in-patient in, I think, the Sydney hospital, and they have to transfer them to Georges Dumont for their cancer treatments. This actually happened to a gentleman, in fact - his wife just passed away this past week, and she had been there for several months, and all of a sudden he received a bill for $7,000. Minister, I want to say that your department worked on that and worked with New Brunswick and had that looked after for them, so financially it was a good news story for him in the end.

I called a lady in New Brunswick myself, and she said, well, if you're from Nova Scotia, it is not the same if you're an in-patient as if you're from New Brunswick. I thought there was an arrangement between the provinces. In Nova Scotia, if you're transferred between the Cumberland Regional Hospital to Halifax, there is no bill. If you're a New Brunswick patient in the Cumberland County Regional Hospital and you're transferred to Halifax, I believe there still is no bill. If you're in New Brunswick and a Nova Scotian

[Page 201]

resident, but you're a patient in one of those two hospitals and there is a transfer between the hospitals and you're an in-patient, my understanding was that, from years ago, there was no charge for that.

I guess I understood that there was an agreement between the provinces that in-patient care transfer between hospitals, regardless of which province you're a resident of - that there would be no charge for those transfers. Maybe the minister might - if you don't have the answer tonight, that's fine. It is just something that pops up every one in a while. I think maybe sometimes the staffing people in New Brunswick aren't clear on the policy, and my colleague's suggestion is this: Is there an MOU between the provinces in that regard? If you could find out for me that would be great. Every once in a while it pops up and when it does it usually means several thousands of dollars for people who are patients.

Minister, the other thing I think I asked you about tonight, and I don't know if you were able to tell me at that time or not - dialysis patients who receive dialysis in Nova Scotia pay for certain service medications while they are patients here, but if they receive their dialysis treatments in Moncton there is no charge. Do you know if the Province of Nova Scotia is paying for those charges on their behalf or is New Brunswick just absorbing those in the health care system?

MS. MAUREEN MACDONALD: Thank you. I understand from my deputy that we pay the same fee to New Brunswick as if they were receiving the service here. But beyond that, you're talking about a medication that is required? I'm not familiar with that.

MR. SCOTT: I thank the minister. So people who are receiving dialysis, for example, if they go to the dialysis unit in Springhill, there are certain medications - I think dressings or whatever - they have to pay for themselves. If you go to Moncton and receive the dialysis service in Moncton, they provide all of those free of charge. So maybe that is something else you could - if you know the answer, great, if not -

MS. MAUREEN MACDONALD: Mr. Chairman, no, and I think last evening we did actually discuss this. I indicated that even among district health authorities in Nova Scotia, you will find differences in terms of some of the things that are covered. New Brunswick would have their own policies with respect to dialysis. We would reimburse New Brunswick if someone from Nova Scotia was receiving dialysis in New Brunswick. We would essentially reimburse at the rate of what people would pay in this province, but if they're providing some other things that aren't provided in Nova Scotia, that's a decision that they make in their health care system for things that are probably uninsured services.

I wasn't aware that in Nova Scotia we charged people who are having dialysis with supplies. To me what it sounds like you're saying is that if somebody goes to have dialysis at St. Martha's, for example - and I don't know if this is the case or not - but if there are

[Page 202]

supplies associated with having dialysis, they charged for that. I'm not aware of that. That is something that I would have to into.

MR. SCOTT: Thank you, minister. That's my understanding that some patients would rather go to Moncton, and they are from our area, because they are not charged for some sort of - there's some additional things that they have to pay for in our area that they don't pay for in Moncton. I'll get some more specifics around that so I'll know. Just one real quick - I know we don't have much time left - one quick question.

MR. CHAIRMAN: Thank you, honourable member, you're absolutely right. We will recess to allow for the late debate.

[5:59 p.m. The committee recessed]

[6:31 p.m. The committee reconvened.]

MR. CHAIRMAN: Order, please. We'll call the Committee on Supply back to order.

The honourable member for Hants West.

MR. CHUCK PORTER: I look forward to the opportunity to ask the minister a few questions for the next few minutes, and I'll be handing off to my colleague, the member for Inverness, after that.

I want to start with surgeries. I know people were coming from different hospitals within the Capital District, for example, coming as far as Windsor to have surgeries done. They might have lived in Eastern Shore, but they were going over to Windsor and having surgeries done, or vice versa. Is that still going on? How much of that goes on? Can the minister speak to that?

MS. MAUREEN MACDONALD: I thank the member for the question. I'm not sure that I got the whole question, so I'll give you what I think, and if that doesn't answer your question, let me know.

The honourable member will know that we do orthopaedic surgery in four DHAs: Capital District Health Authority, Annapolis Valley Health, Pictou County Health Authority, and Cape Breton Health Authority. In addition to that there are the scopes that are being done at Scotia Surgery, some of the minor surgery. Within the Capital District Health Authority, I understand that there are some surgeries being done in the Windsor hospital.

MR. PORTER: Thanks, that's fine. I just wanted to clarify whether or not that was still going on. From what I understand, that's worked quite well. It's helped speed up some

[Page 203]

of the wait times with regard to getting certain things done. Scotia Surgery has also been beneficial, and the people we've talked to as well, in helping to get the wait times down.

I'm going to bounce around - I have a number of things, and I know my honourable colleague wants some more time, so I'm just going to bounce through a few things.

Clinics - we're fortunate enough to have a clinic in the Town of Windsor. There's one down the shore, the Kempt Shore health clinic, which you may be aware of: a few nights a week in Windsor, two or three nights a week, and a couple of hours at a time. The clinics work very well. Lots of people coming in, they're quick - bang, bang, bang, they're in, they're out. Why don't we have more of this? Do you foresee that we would have more opportunities than that couple of hours a week, especially where clinics already exist? I know physician times are an issue, perhaps. There's a different one that would do Tuesday night, a different one Wednesday night, a different one Monday night, what have you. Is there something out there, incentive-wise, to open that clinic for even four hours as opposed to two hours? Do you have any say in that or is it totally left to the doctors?

MS. MAUREEN MACDONALD: Sometimes I'm not really clear on what people are referring to when they say "clinics." There are so many different versions of what a clinic is.

Some DHAs provide, outside of 9 to 5 hour, services or specialized clinics. That is one form of clinic, but we have to be careful how those are done so that it doesn't detract from the availability of doctors at other times. Community health clinics are a different beast and I think the Hants clinic is a kind of community health clinic. I am most familiar with the North End Community Health Clinic in my own constituency, and I am a very big fan of those kinds of community health clinics.

What is different about that particular version is that it is a health center in the tradition of having a collaborative team, where you have primary care health care providers who are family physicians, and in addition to that you have nurses. You can have other health care providers, like nurse practitioner; you can have physiotherapist, nutritionist, social worker, a variety of health care providers, and the patients of those kinds of clinics see the appropriate person. They see the family doctor, or the family doctor can make a reference to the nutritionist who will be working with the patient with respect to diet and maybe weight loss and these kinds of issues around any of the chronic diseases or chronic conditions that they might have, and it is a really wonderful model.

Primary health care is something that we have to provide more of in Nova Scotia, and the Leader of the Official Opposition this evening was talking about the importance of developing a good system of functioning primary health care around the province. We have a fair number of primary health care teams throughout the province, but we are still pretty under-serviced when it comes to primary health care. I do not know about the honourable

[Page 204]

member's area, the extent to which you have primary health care teams and settings in that area. I would assume that there are some, but I don't know how many there are or where they are. I would like to certainly know more. Maybe you could tell me about that and where else they might be needed.

MR. PORTER: Yes, minister, I was sort of referring to the emergency-style clinic. You walk in - you know, the belly pain and flu type. They work so well because they are quick. People want to go - they don't want to sit there for two or three hours. Like I said, people often ask, how come going to the clinic is so quick, versus going to the emergency room and waiting. Well, I think that there are a couple of real reasons why they're in and I think those need to be reviewed as well. I would not suggest for a minute that anything, your chest pains, your shortness of breath - those should all go to the hospital, and I think for the most part do go to the emergency room where they are promptly looked after.

It does work so very well in that clinic setting, and my question was specific to that, really. Is there a model that is being thought of that would run side by side, more than two hours three or four days a week? It does move patients so effectively. Even in a doctor's office, if you've got an appointment, you're sitting and you're waiting, and again, a lot of times it's for the same thing. It's not just your regular blood pressure checkup or whatever it might be. You're in there because you've got the flu and you're not feeling well or what have you, or I am here to get a prescription renewed and the doctor wants to see you.

Again, it's this, even in doctor's appointment times, you're still backed up, so I think there is a lot of room there that we could open up - probably not much by way of no more costs, I wouldn't think. Maybe some, but it would certainly move people along and your wait times would decrease, so in the long term, without doing quick math, there probably is a savings in the long run.

I want to talk a little bit about the current levels of hospital staff. We talked about it earlier, about the nurses and the LPNs, and most LPNs would say, we are nurses - they wouldn't like that term being singled out as not being nurses. I know that because I'm married to one, and I used to hear it fairly often when I used to do that and I was soon corrected: I am a nurse. I agree, they are indeed. There was always sort of a perception, more than anything else, that because you had a different credential you weren't the same. I guess maybe if she were a nurse, she may have a different opinion on the other side - I don't know. It's a no-win for me so I just - "nurse" is across the board and I win all the way around.

You talked a little bit about the four-year program, and it's a long time. Even when you talk to nurses who have graduated, older nurses who have been in the field for some time as well feel it's a very, very long time. You go to school for a year or less to be a paramedic, and you learn a tremendous amount of science and chemistry and all the things you need, drug manufacturing and usage and all of these great things to help you do your job. Why is it four years in a degree program? I think we're seeing it's probably too long, and I know you

[Page 205]

said you didn't want to go down that road, but I'll ask you very quickly. You don't have to go down the road too far. I'm just interested to know if you're looking to make a change to that four-year program and maybe bring it back to a two-year, where it may help increase those numbers that we desperately need to staff our hospitals right now where there are shortages.

MS. MAUREEN MACDONALD: The four-year baccalaureate nursing program is pretty much an industry standard now. Nova Scotia is not unique in what it is that we do with respect to training baccalaureate nursing. I don't foresee that changing any time soon, if ever. I think this is now the industry standard.

Nursing is a very complicated field of practice, as the honourable member knows as a health care provider. While it's true that there are many other important professions, the four-year nursing program is a program that has been well established now as an industry standard across the country and elsewhere.

LPNs are indeed nurses as well. They have really rigorous training and they have a role to play in the system. I see an expanded role for LPNs in our health care system in the future, and I think that we're already seeing it throughout many of our health care districts. This won't be news to anyone.

Additionally, we are seeing more continuing care kinds of providers come into the system. I think it's interesting - in his report, Dr. Ross makes reference to better use of paramedics, expanding the role paramedics play in our health care system. I think I've said this - if not to the honourable member, to other members of this Chamber - that paramedics have to be among the most respected health care providers in our province today. I have had occasions when I've been with somebody who has had an episode where we've had to call an EHS service and I've always been completely blown away by the professionalism and the competencies of paramedics. They're just fabulous, without exception.

Not surprising, in many respects to me as Minister of Health, I get many letters of complaint. I haven't had one complaint about treatment by paramedics in the time that I've been in the office. I have to say, that says something about the professionalism and the quality of the paramedics we have.

We have a challenge in terms of health human resources, without any question. Our province as a whole is going to face a demographic crunch. We're going to see a larger proportion of our population older. We've had a declining birth rate for some time, and that no doubt will continue if those trends hold, and they're predicted to hold.

[Page 206]

[6:45 p.m.]

In his report, Dr. Ross also said that we're going to have fewer health care providers so we're going to have to be very smart about how we use the resources that we have, and that means making full use of the scope of practice of each category of health care provider that we have. I don't see any change in the near future with respect to the nursing profession.

MR. PORTER: Yes, you're quite right, there's quite an extended scope going along with the LPN and has been for some time with regard to some of them doing intravenous and a variety of other things on the side, separate courses that were given to help increase the workload that they're managing in the hospitals. You're quite right about the nurses as well, it's a totally different scope that what we did as paramedics, fairly lengthy, it's broad and the care is totally different. It takes a special person, no doubt, to do what they do. It's different for the emergency providers. People say that it takes a special person to do that, well it does, but they're two totally - although both in health care - different scopes of practice and we're lucky to have them all around. We have a great system in this province, albeit expensive, we have a great system in hospital and out of hospital, in my opinion, with great people.

I just wanted to get your thoughts on whether or not you plan to change that and just one last quick question on the ambulance billing, a bit of a finance question. There are people who are billed who just, for whatever reason, low income, out of a job, whatever it might be, are unable to pay that ambulance bill. Some of them are insurance-related that are getting billed when in all honesty it should have gone to the insurance company but because they didn't get the numbers, et cetera, at the time of the incident, they get a bill. For example, as you were talking about earlier, somewhere at $500-plus it is now, I think, for an insurance-type, third-party liability call. They're certainly unable to pay that bill but they're being billed regularly, interest is being charged, and I guess at some point these things get written off. Any idea where we're at for write-offs in the ambulance transfers at all? How much of your budget actually consumes that? Maybe it's not very much but I was asked about that.

MS. MAUREEN MACDONALD: Thank you very much for the question. While we're trying to see what we can dig out here, let me give you just a bit of an overview of the cost of the ambulance service. As you know, it costs about $134.52 for a Nova Scotian who uses EHS services if they have a valid medical health card. The ground ambulance service cost the Government of Nova Scotia, last year, about $85.8 million. Of that, there are some service fee revenues that are generated. It's projected in the budget for last year to be slightly more than $11 million, $11.1 million, of which the portion payable to the Department of Health is $8.7 million. That, I believe, would be the cumulation of those user fees that are charged to people.

To what extent we are unable to collect fees, I'm really not sure right now. I can tell you that with the number of motor vehicle accidents projected in the year 2009-10, there were 2,367 ground ambulance transports related to motor vehicle accidents. That kind of

[Page 207]

information is tracked. I'm sure we could get the honourable member the information, we just can't put our hands on it at this moment.

MR. PORTER: Mr. Chairman, I'm pretty familiar with the statistics, I spent a number of years working in the provincial Communications Centre as well. I can say that's a great operation because we can almost pinpoint to the hour of the day when the next call will be, that's how defined that is right now. I worked for a long time at that, and did a lot of quality assurance and things like that on that system. So I'm familiar with the statistics regarding that. I was just curious how much of - I know where we used to be with regard to the inabilities and the write-offs, so I was just curious as to whether it was growing or not, given times are tougher, et cetera, and things like that, but anyway, without any further questions, I'm going to pass it off to the member for Inverness. I want to thank you for your time, Madam Minister, on these questions.

MR. CHAIRMAN: The honourable member for Inverness.

MR. ALLAN MACMASTER: Thank you, Mr. Chairman, and thank you, minister, for the opportunity to ask a few more questions today. My first question will be on the Children's Dental Program. Will there be any changes this year?

HON. MAUREEN MACDONALD: No, we don't anticipate any changes in the Children's Dental Program this year.

MR. MACMASTER: The next question involves ambulance service. Some years back I had come across a situation where an individual was travelling out of province and I believe they took a heart attack, whatever the case was there, who was required to use the ambulance service of the province they were in. I think it might have been Prince Edward Island or New Brunswick, I'm not sure. In the end, the person was presented with a bill, and it was to the tune of about $1,000. It was a lot of money, it would be a lot of money for anybody, and particularly in this case.

My question is - and I don't know if things have changed since - for people who are travelling throughout Canada, in my mind, they shouldn't have to be buying health insurance for travel. There should be ways that the provinces can work together to look after people if they're travelling within the country. Is there something in place, perhaps an agreement between the provinces, a service agreement, so that if somebody is travelling outside of Nova Scotia, there is ambulance service for them that's covered by our province?

MS. MAUREEN MACDONALD: Mr. Chairman, our health care system has insured services and uninsured services. Ambulance services throughout the country are uninsured services, they are not part of the Canada Health Act. The Canada Health Act essentially covers services that are provided in hospitals, and in a doctor's office, and then every province has developed kind of a patchwork of other services to support health care, such as

[Page 208]

Pharmacare. Even the ambulance system in Nova Scotia, although it's not an insured service, is heavily subsidized by the taxpayer through government funding, but there still is a proportion of those services that are paid for through the user fees that are charged to people who use the services. Other provinces are in the same boat. There is no province in Canada, as far as I know, that has taken ambulance services into their health care system as an insured service, where 100 per cent coverage is provided. Most provinces charge some form of ambulance fee. As far as I know, that's the case.

So if you travel and you're in an automobile accident, or you suffer a heart attack, or whatever, and you have to call an emergency health service in another province, you will be billed as a non-resident, and generally you'll pay more than the resident of that province would have paid. You don't get the subsidy that the provincial taxpayer, in whatever province, is providing. However, you get free health care if they take you to an emergency department and you have to have surgery and all of those kinds of things, because that's where our insured services as Canadians under the Medicare system come in.

The Canada Health Act has five principles in it. It says that every Canadian has portable health care. So no matter where you are in the country, you get covered. If you need services in a hospital, if you need services in a doctor's office, you're guaranteed coverage, and there are reciprocal agreements then between the provinces for how to cover those costs. So if a student from Manitoba is in Nova Scotia, for example, and is involved in an accident, they fall and break their leg, they have to go see a physician and have surgery, they will get access to our emergency department and our surgery and they will have health care. Our province will no doubt recover from the Province of Manitoba revenue toward that. There's kind of a reciprocity, as I understand it, between provinces.

MR. MACMASTER: Thank you, minister, and my next question involves the mental health strategy. Minister, I want to give you a little background of my interest in this area. I actually was planning to do some volunteer work with the Nova Scotia Hospital before I was elected and I've had to put that on hold because life as an MLA is very busy, but I do have an interest in people who have encountered mental illness. It was quite ironic, I discovered that the man I was named after had some experiences himself, and I don't know if that's perhaps a connection coming across from the other side, maybe that's something we'll discuss during our Gaelic Affairs, as we know that's very much believed in the Gaelic culture.

I'll just share with you a couple of points about this gentleman. His name was Allan MacMaster and he was from near the Judique area. Last Fall when I was watching some Remembrance Day coverage, I saw a story about the Epsom riot in England .This was when some Canadian troops - morale was getting low, the war was over - felt like they weren't being treated very well and they began to rebel. It turns out that Allan struck a police officer and the police officer died.

[Page 209]

Anyway, Allan ended up coming back to Canada but he had a plate in his head from an injury he sustained in the war and I think it caused him some mental problems. He did turn himself in, I believe to the RCMP, but they chose not to press charges because of the nature of the incident, the context, but sadly we think that Allan perhaps did away with himself at one point. So maybe that explains some of my interest in the area. So I would just like to ask you for the benefit of anybody who has a family member with mental illness, or for anybody who currently is dealing with mental illness, what this new strategy is all about, because I think it's very important and I appreciate you bringing it forward.

MS. MAUREEN MACDONALD: I'm glad the member has given me an opportunity again, as we're getting close to the end of our time, to talk a bit about mental health and specifically around a mental health strategy. I think that there are a couple of books that have been written relatively recently. One is called The Last Taboo and its essential argument is that mental illness remains probably the last thing that we as a society really haven't come to grips with all that well, in terms of how we understand and how we treat people who have mental health disorders.

[7:00 p.m.]

I think one of the things that we need to do in terms of developing a mental health strategy is to raise the bar in terms of our communities and our provinces understanding mental illness and then our willingness to really support people who have mental health disorders in our society.

The history of mental health, mental illness and mental health, is a history of about 150 years, let's say, of there being any attempt to intervene or regulate or treat mental illness. Our initial tendency was to lock people away and to deny the existence of people with mental health disorders. Then slowly we moved from that to a more medical model of intervention and treatment, but still segregated, a segregated kind of treatment. I think that in the 1960s and 1970s, and even into the 1980s, finally we arrived at an approach that was much more integrated and community-based.

Today we don't lock people away, we don't hide them in some segregated institution. People with mental health disorders are among us, and that's a good thing, but what isn't so good is that we still haven't gotten the deinstitutionalized piece right in terms of the medical treatment that's available to those folks and then the kinds of supports while they're in treatment, while they're managing their illness and being integrated into our community and into our society.

Our mental health strategy will have to look at that next stage of a much more integrated, humane, compassionate and effective approach to integrating people into our communities. That's going to mean some education; it's going to mean doing things, figuring

[Page 210]

out the things that need to be done to lessen the stigma, and also to get much more effective treatment where it needs to be.

One of the things that the research tells us is the importance of early intervention in terms of being effective in treating mental illnesses. The earlier you can intervene, the greater the possibilities for an effective prognosis and management of a mental illness. So that means having effective services that people can get access to at the early stages of a mental health disorder.

A mental health strategy will have to grapple with all of these issues, will have to look at what it is we do now, what we're effectively doing, where the gaps are, how we could fill those gaps, what the resources would be, what the timelines and the action plan is to move us forward. It's a significant piece of work and at the end of the day I think we will have taken this issue that has been around for a long time to another level. I've said that we won't solve all of the problems but we will make some substantial progress and it will benefit some people, many people I hope.

MR. MACMASTER: I look forward to that initiative as it develops. I think we have time, maybe, for a question or two more. While these aren't necessarily Health Promotion and Protection questions, I think we're starting to move in that direction and you may see me back for some questions when you have the Health Promotion and Protection staff with you.

I've kind of touched on this one before. I'll ask the question, what is the health care system doing to implement a vision of health promotion? If I could maybe expand upon that a bit, can we look at cost-neutral measures that focus on health promotion for employees with the goal of creating a cultural mindset where people are more focused on health promotion? Not to take away from any existing mindset - I'm sure there's just as much interest in health promotion in the field of health care as there is in any other occupation. I don't think it's any more important than in the field of health because it's so close to the delivery of a service that people experience that's connected to their health. It's about health. I ask the question, minister, and look forward to your comments.

MR. CHAIRMAN: I would just remind the members there's approximately 10 minutes left in estimates today.

MS. MAUREEN MACDONALD: Well, I think it's really important that we not talk about health without talking about health promotion and protection, especially in Nova Scotia, especially in this day and age.

One of the things that we have in Nova Scotia that we don't talk about nearly enough is community health boards. Community health boards are a really important piece of our health care system infrastructure. We talk a lot about the district health authorities and the boards of the DHAs, but two-thirds of the boards of the DHAs are made up of people who

[Page 211]

sit on community health boards. Every district health authority is broken into community health board districts. Ordinary citizens who are interested in all kinds of health-related matters, health and wellness matters, on their own nickel, without one penny of remuneration, get involved on community health boards. They develop community health plans with the consultation and involvement of the communities they represent. They often bring these issues into the DHA as members of the board of the DHAs and on their own.

So two-thirds of the people nominated to a district health authority come from community health boards. Community health boards have very interesting plans that they file, they send to the Minister of Health, they file with their district health authority, and they identify what the priority health issues are in their district. They may identify mental health programs for youth. They may say we really need a teen health centre at the local junior high school. They may say we need better nutrition programs for seniors. They may say we need to be doing more to promote breast-feeding among new and young mothers.

They advance an agenda that I think has a very broad diversity of ideas that are very pragmatic and practical based on what is needed in their community, based on the profiles of their communities. They know the profiles of their communities. They know that the communities within their board are made up of this proportion of seniors, this proportion of military families, let's say, in an area where there's a military base. This many farm families or primary care workers or people who are living on social assistance.

I know community health boards that have identified affordable, accessible housing as one of their priority issues for public policy development because they realize that you can't have good health if you don't have a decent place to live. You can't get up and go to a training program every day if you didn't have an adequate night's sleep because you're not sleeping in a safe shelter. You can't hold down a job very easily if you don't have good housing.

The community health boards are intended to be the eyes and the ears of a community in terms of what the health care needs are in that community - not only in terms of doctors and nurses but health in the very broadest sense, in the sense of the determinants of health, which are very much incorporated in issues of income, distribution, and all of those other things that include the socio-economic aspects of good health.

MR. MACMASTER: With that, I conclude my questions for the minister, but I would like to share the final few minutes with my colleague, the member for Argyle.

MR. CHAIRMAN: The honourable member for Argyle. You have approximately three and a half minutes.

HON. CHRISTOPHER D'ENTREMONT: Thank you. I'm just going to ask one simple question and I'm sure the minister will go on and talk about it and finish up the day.

[Page 212]

I have to say, the minister has done a phenomenal job in responding to these questions and bringing her insight to the floor of this House. (Applause) She has already broken my record, I think I did 14 hours, I know she's going beyond that now and she's not finished yet.

The community living bungalows over in Dartmouth, the mental health bungalows over at the old site, I'm just wondering how that's going. That was a project that I had announced originally, early in my mandate as minister, one that we got into a bit of a kerfuffle with the Department of Economic Development over the property that was actually chosen, and that has moved on. They had to tear down the nurses' residence that was next door, they were supposed to build them at that place. I'm just wondering where they are in construction.

MS. MAUREEN MACDONALD: I thank the member for the question. I understand that the project is moving forward, that we're at the design stage. So we still have a ways to go before we see the final construction of those facilities and people being housed there and occupied there. There's $5.3 million toward their construction in this particular budget. I'm very much looking forward, and I know the honourable member is as well, to seeing this project come to fruition.

It's interesting, I don't know if the honourable member knows this book that was recently published by Dr. Judith Fingard, an historian at Dalhousie. She has a co-author who is a psychologist, I believe, and they've written a book - I believe it's in our Legislative Library - on the history of the mental health movement in Nova Scotia. It's very interesting and she's a great historian. She's written a lot about the Halifax Explosion and other aspects of the history of social welfare here in Nova Scotia, and it's kind of her area of expertise.

The Nova Scotia Hospital is predated by a hospital that was sort of an asylum, called Mount Hope, and I think it goes back about 150 years or so on that site. Actually, my first social work job was at the Nova Scotia Hospital. I tell people I was the adolescent social worker - I wasn't an adolescent but I was pretty close. It was the first real social work job I had after graduating from Dalhousie.

[7:15 p.m.]

If anybody has been at either the Nova Scotia Hospital or indeed the community college, which is on a piece of that site, I don't think you'll find a more beautiful location on the harbour. The incredible panoramic view of Halifax Harbour, a lovely view of Halifax, it's a very calming, pastoral kind of setting. Different people had spoken to me throughout the period of the deinstitutionalization at the Nova Scotia Hospital and the whole idea that we would lose that site as a site where people would be able to have treatment, have security. We all have, I think . . .

[Page 213]

MR. CHAIRMAN: Order, please. The time allotted for CWH on Supply for the day has elapsed.

The honourable Government House Leader.

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

MR. CHAIRMAN: Is it agreed?

It is agreed.

[The committee adjourned at 7:16 p.m.]