Pursuant to Standing Order 87 Mr. Nick Careen, M.H.A. (Placentia) substitutes for Mr. Glenn Tobin, M.H.A. (Burin-Placentia West)

The Committee met at 7:00 p.m. in the House of Assembly.

MR. CHAIRMAN (Gilbert): Order, please!

Ladies and Gentlemen, I would like at this time to welcome the minister and his officials from the Department of Health. Tonight we are going to examine the estimates of his department. I will give him a chance in a few minutes to introduce his officials and then have his opening remarks.

Just before we start I want to talk about the procedures and how this committee operates. After the minister makes his opening remarks, Ms. Verge will be given an equal time of fifteen minutes to address the remarks made by the minister. Each participant will be given ten minutes to question the minister or his officials.

I will ask the members of the committee now to identify themselves starting with Ms. Verge, the vice-chairman who is next to me.

MS. VERGE: Thank you, Lynn Verge, MHA, Humber East.

MR. LANGDON: Fortune - Hermitage.

MR. SMITH: Port au Port.

MR. SULLIVAN: Loyola Sullivan, I am sitting in as health critic.

MS. YOUNG: Kay Young member for Terra Nova.

MR. GILBERT: I am David Gilbert. I am the Member for Burgeo - Bay d'Espoir and I am the chairman of this committee.

There are three hours allotted for this committee to pass the heads through the House and what we try to do is get the work done in the three hours that is allotted. If it is going to go over the three hour period and we feel that we can reasonably get the heads passed tonight - I will stop the session at about 10:00 p.m. or thereabout and then get the agreement of the committee to see what they want to do.

So, with that I will now ask you, Mr. Minister, if you would introduce your officials. Then you can have your opening remarks or you can pass it to the opposition critic, the decision is yours.

I would ask participants to identify themselves each time they speak as this session is being recorded and will be published by Hansard.

DR. KITCHEN: Thank you very much, Mr. Chairman, I am Hubert Kitchen presently Minister of Health. To my right is Dr. Bob Williams who is the Deputy Minister of Health. To his right is Ms. Primrose Bishop, who is the Assistant Deputy Minister of Health, responsible for all the institutions; the hospitals, the nursing homes and personal care homes. She plays the biggest part in the Budget. To my left is Ms. Joan Dawe, she is responsible for community care and I believe the Waterford comes under this also. This is the one hospital that does not come under Ms. Bishop. Behind me, to my right is assistant deputy minister, Chris Hart, who looks after the finances and keeps his eye on the internal audit in the department, this is a new position we created recently. Behind him is, Mr. Gerry White, who is assistant deputy minister, he looks after policy, drug programs and a whole variety of things in the department which we will come to later.

I would like to say, by way of opening, and I will not speak long, that the Department of Health has a very substantial budget from the point of view of the overall budget - over $800 million, close to $900 million a year, which is a very large sum of money - and like all Departments of Health in the Canadian provinces, it occupies about 25 per cent of the total budget - somewhere around there. Every year we think we do not have enough when other people think we have too much.

We are looking very much at the cost of health care in Canada because it is one of the big drivers of deficits. Health care expenditures over the past number of years have been going up quite rapidly and there is considerable concern about what may happen.

So what we are attempting to do in the Department of Health is perhaps to redirect. What I have been doing myself is to try to formulate some vision as to where we might want to go, and for the past ten months since I have been here, nine months or so - nine months is better, a good time for incubating some ideas - we have been trying to get a handle on what the health care system is like. We visited the nursing homes and the hospitals, and talked with the boards, and met with many organizations, because every disease in health has its own organization pretty well. Every disease has it's own organization and they are operating in different ways - pretty well every disease. Then there are all sorts of other groups and agencies that are interacting, so I have been trying to get a handle on the health care system so that an approach can be devised, an overall vision, as to where we might want to go.

As far as I am concerned, there are certain ways we must go, and that is that we must take the emphasis off the institutions where we have been placing it. We have been very much preoccupied with curing the sick rather than keeping people from becoming sick. I think that is the direction in which we would like to go. We do not want to neglect people who are sick by any means, but that is one of the directions in which we are going and we will be attempting to put some money into that area without hurting the care of the sick.

In this prevention thing, we have seen our initiatives in the smoking area, and we will have other initiatives in that area as well. That will be coming up before long, because smoking is a killer disease and I do not want to repeat my remarks here which I made yesterday. Then we have to look at the question of alcohol, which causes all sorts of health problems, and we have to look at the question of improper diet, lack of exercise, and things of that nature, so that we can keep our population as healthy as long as we possibly can.

Also we would need early diagnosis. That is another point that we have to focus on, I think. I may be a bit out here because these are just tentative thoughts on this. I was impressed when I met with the Diabetic Association the other night. They told me that half the diabetics in Canada are not diagnosed, and they should be, they said. Whether they can be, I do not know, but that is what they said. I am also impressed with other people who find out late in life that they have certain things wrong with them. So there has to be prevention and there has to be early diagnosis so that diseases and conditions can be treated before they get too far advanced. I believe that will be the thrust of the department while I am here. That is what it seems like now.

As far as hospitals are concerned, I believe we have twenty-five hospital boards - I think something in that vicinity, something like twenty-five hospital boards. We have had a report from a very competent health care consultant, Ms. Lucy Dobbin, and she has told us how we should reorganize the hospital board system. We will, as soon as we get a chance now when the House clues up a bit, get at that.

The way we are going to go about that is to try to have discussions with the existing boards to see how many of them can be amalgamated and put together so they can have a good philosophy, a good way of handling things in their general area, so that we can have fewer boards and less competition, less turf protection within them. There has been a fair amount of turf protection amongst hospitals and it seems, in my view, that in some cases, the hospitals are there to try to have jobs in the area rather than, necessarily, to have health care. And health care has to be the primary responsibility. Similarly, with respect to the nursing homes, we have a tremendous number of nursing homes and boards in the Province, most of whom cater to people who are quite sick. But there are a lot of people in nursing homes who are not very sick, and the cost of operating a nursing home is quite heavy. So, what we are trying to do there is to institute community health boards; and we have the legislation - it went through the House last Spring - and we have certain things in mind, but again, that is another thing that we will have to get at just as soon as we can now when the House closes, another Summer job. We are thinking about it.

So we will be establishing community health boards that will be able to provide home care in a more comprehensive fashion than it presently exists in most parts of the Province. We have fairly good home care programs in some parts of the Province but not in all, so what we want to do is to have a more elaborate system of home care, so that not quite as many people will have to go to nursing homes. Nursing homes are a very expensive proposition - home care need not be expensive. So, these are directions for the future, and that seems to be where we are headed.

We are also concerned about the high cost, in my view, of Medicare, the high cost of physicians' salaries, and we have been able to bring in a system and an agreement with the Newfoundland Medical Association by which, in exchange for a cap, they get a floor, in a deal in which we spend so much on physicians' salaries - and there are certain ways to adjust that, but that really helps us. They are pegged to management salaries, if management gets a raise, the amount is increased, if management gets a decrease, then the pot is decreased. There are a few other little wrinkles in that, which we will go into if anyone wishes. So we have some control over that. But physicians are driving the health care system, to a large extent, and they are key there.

Another thing we are trying to do there is through the Joint Management Committee that we have established between the Department of Health and the Newfoundland Medical Association. We have a Joint Management Committee which is responsible for managing this money and for doing other things, and there is a committee there - I don't know where the peer review is at the moment, but it is either started or is about to start - a regular process by which what physicians do is reviewed by other physicians, so that people who do things that are out of order can be discussed and addressed so that the system is not overused. Because, one of the big problems we have in health care, some people say, is the abuse or overuse of the system. Some people are saying we should bring in user fees to control that.

It is my view that we should not bring in user fees unless it is absolutely necessary, because there are other ways, such as I have just suggested, through physicians reviewing physicians, and also for people taking responsibility for their own health. That is extremely important and I believe that these community health boards, when they have, and maybe they will have subcommittees and so on in various areas in communities, that would go a long way, whereby communities and individuals assume responsibility for their own health rather than leave it to physicians or other health care staff.

Mr. Chairman, I think these are the directions in which we are going and I would like, if you would - you may not want to do this, but I would certainly appreciate your questions being directed against that direction, to see if these things are appropriate and whether our budget is in conformity with these points. With that, I will pass.

MR. CHAIRMAN: Thank you, Mr. Minister.

Before I recognize Ms. Verge, I would like to welcome Mr. Careen, the Member for Placentia, the other member of this Committee who just joined us. I would like to point out that Jack Harris, the Member for St. John's East, is also a member of this Committee. He came to me this afternoon and pointed out that he had another commitment and, by virtue of the fact that his caucus is rather small, he didn't have anyone to appoint like the rest of us, so he said he would be attending later.

I have talked to Ms. Verge before the meeting opened and we agreed that, with the leave of the Committee, if there is a list of speakers when Mr. Harris comes in, we will let him go ahead when the last speaker, after he arrives, is finished, so at least he will have a chance to get his ten minutes in sometime in the early part of the night - if that is alright?

SOME HON. MEMBERS: Agreed.

MR. CHAIRMAN: Okay.

Ms. Verge.

MS. VERGE: I would like to thank the minister for his opening remarks in talking about his ideas for the general direction in which the health care system should be aiming. He anticipated my first question. I was going to ask just that, the same as I asked his predecessor here last year. I am pleased to hear what he had to say, but the Budget Estimates that the government has put forward, that we are examining, do not conform to those aims. The Estimates indicate a forecasted total spending by the Department of Health of $874 million, more than any other department of the government.

We realize that our friend, the Minister of Finance and President of Treasury Board, is going to reduce that total significantly if he achieves his objective of cutting total spending by $71 million, by taking that out of public sector compensation. Most of the health budget goes for salaries and $71 million from all public sector employees will have a serious impact on workers in the health care system.

We have $874 million before us. The bulk of that is forecasted to be spent, once again, on institutions - $604 million - MCP, $135 million; drugs, $35 million. Community health, which encompasses the only specific efforts at promoting good health and preventing illness, gets only a pittance - $26 million, or 3 per cent of the total. That percentage is no better than what was provided in last year's Budget.

I realize the challenge is formidable, because our Newfoundland and Labrador health care system, the same as the model in other parts of Canada and most of the Western world, is physician-dominated, physician-driven. Yesterday, in the House, I said to the minister, in debate about his bill to prohibit and limit smoking in public places and workplaces, that it is not he and his officials, much as they might want to, who really control our health care system. It is not the highly-paid administrators in the institutions who control the bulk of the spending - it is the physicians. The physicians control almost all of the spending of the $874 million or whatever the revised total ends up being. Physicians basically provide limitless services to patients, provide referrals for limitless tests and other diagnostic procedures, and provide limitless invasive procedures, if that is the jargon.

MCP, the Medical Care Plan, gives physicians a monopoly for most services, a monopoly for publicly-funded services. Legislation gives them, I suppose, a monopoly.

I would like to ask the minister whether he would expand his horizons to entertain or to contemplate a vision of public funding for services given by other health care professionals. These comprise, for example, nurses, midwives, nutritionists, fitness consultants, physiotherapists, chiropractors - any of the whole range of health care professionals who can provide many of the services for which physicians now have a monopoly, arguably better, depending on the service and the training of the professional, and at considerably lower cost.

DR. KITCHEN: Thank you very much for that question.

This is something that we, in the department, have been discussing, I guess fairly frequently, as cases come up. Because individuals ask: Why can't I see the chiropractor? I can see him, but I have to pay for it. Why doesn't Medicare cover it? Why, if I have pyorrhea of the gums, can't the dentist take out my teeth without charging me? That is really a medical condition. The doctor doesn't really take out teeth anymore. So these are interesting points.

I don't quite know how to handle it at this stage, because Medicare, as conceived, is for physicians rather than for chiropractors and dentists and so on. It is something we are going to have to come to grips with, I think, because these other health care professionals do have something to offer. I don't quite know how to go about it at this stage but I think, as you say, it is something we have to address. We will be addressing it, but it will take a while, I think. I have to try to figure out how to go about it.

Some provinces do cover these services, but it is difficult in these times to expand our Medicare budget with the finances we have. I agree that it is something we are going to have to address somehow. It shouldn't just be additive, it should almost be a zero sum in the sense that if the midwifes are going to do it, if anyone wants a midwife to deliver a baby, then perhaps the obstetrician shouldn't also take a fee. I am not sure how that works. We can't just add to it. If the physician is going to take out the teeth or we are going to cover that through these services, with a limited pot someone else will have to give it up. It is certainly something that has to be addressed. I agree with you there.

MS. VERGE: When we were considering the chiropractic legislation regulating the practice of chiropractors, there was a debate about whether the act should provide, as it does now, that physicians refer patients for hospital diagnostic services after chiropractors first make a request for such tests. Chiropractors were arguing, I think with justification, that they are in a position to know when X rays and lab tests are required. By making patients go to physicians puts patients through unnecessary inconvenience and is putting an unnecessary imposition on the taxpayers. That is the kind of duplication that the minister was just saying is undesirable.

I am wondering if the minister would consider amending the chiropractic legislation to eliminate the necessity of physician referral for diagnostic services, X rays and lab tests, that chiropractors want.

DR. KITCHEN: It is a worrisome point. We all trust physicians to know; this is the culture that we have grown up in. If we have a referral - I don't know who is the best able to determine what kind of service is required. Is it the patient himself: I think I will see a chiropractor, I will see a doctor or I will see a midwife. I am not sure. I am not debating it, I am just discussing it, as you are. Perhaps we will have to look at that whole question as to how referrals are made to other professionals. Should the family physician be the referral point or should the person with the complaint make the decision as to who is to be seen? Should I see a chiropractor for my - whatever? Do I make that decision myself and spend government money, or do I see the physician who says: Well, you should see a midwife or you should see this person or you should see that person. I am not sure how that goes, but it is certainly something to be contemplated.

Dr. Williams, would you like to add something to that?

DR. WILLIAMS: Chiropractors can't have X rays directly ordered, they have to go through physicians.

DR. KITCHEN: Dr. Williams tells me that chiropractors can order X rays directly without going through -

MS. VERGE: You see, when a patient goes to a chiropractor and the chiropractor examines a patient and asks for X rays or lab tests to do a complete diagnosis, the patient then has to go to a physician simply to get a referral to a hospital to get the X ray, which in turn gets sent back to the chiropractor with whom the patient wanted to deal with in the first place.

DR. KITCHEN: Dr. Williams, do you want to take that? Because you may have some...

DR. WILLIAMS: Under the proposed regulations chiropractors will be able to have x-ray equipment in their offices, or can access hospitals and out-patient departments for x-ray services.

MS. VERGE: Directly.

DR. WILLIAMS: Yes.

MS. VERGE: Oh good, okay.

DR. WILLIAMS: Without having to go through physicians. So they can order that. The chiropractor will be able to order that on behalf of his or her patient directly.

MS. VERGE: Are those regulations in place now?

DR. WILLIAMS: Those regulations are just in the final stages, I guess.

MS. VERGE: Okay. Many people say that our health care system is in a crisis, that the cost of providing services with the model we have has outstripped the growth of the economy in Canada. Whether people like the system or not, whether people think we're getting good value for the investment, we have no choice but to change it. So far governments have tinkered with it and lopped off certain parts but haven't really tackled the much more difficult job of reforming the model.

This government has tinkered with and cut certain institutions and agencies and must be now grappling with the ever-increasing fiscal difficulties. Has the government done a cost benefit analysis of the Memorial University Faculty of Medicine? This Budget calls for the government providing $18 million to the Faculty of Medicine. Are we getting $18 million worth of benefits for that investment? What are we getting as taxpayers in Newfoundland and Labrador from the Memorial University school of medicine?

DR. KITCHEN: I guess what we're getting from the Faculty of Medicine are several things. Fifty-six medical students enter each year and approximately the same number graduate each year. So we're getting a flow through of physicians.

MS. VERGE: I might interject, where are the graduates ending up?

DR. KITCHEN: I'm not sure where they're all ending up. Some are ending up in Newfoundland and some are going abroad, but that's one aspect only. I think too that we are able to attract physicians to this Province and to this city largely because of a good medical school, a good medical school where people can do research and can meet with top-flight colleagues. It is a situation that is much to be preferred, particularly since we're so far away from the main centres of Canada and the United States. Without a medical school people would be practising medicine remote from these areas. But the medical school does have a continuing education function of physicians and an interaction with the community that I believe would be sorely missed.

I believe a number of different types of specialists are attracted to this Province because of the medical school and the fact that they can take time to be associated with the medical school and practice part of their time and be on salary with the medical school, that is the argument that is raised, that in addition to the training of physicians. There are all the other things that a medical school can do that otherwise wouldn't be done. Even though the supply of physicians is not as desperate as it was some years ago, far from it, yet in any thought of cluing up the medical school you have to think of all these other benefits that would be lost as well - and it is expensive.

MS. VERGE: The community health boards, where are they?

MR. CHAIRMAN: Your time is up.

MS. VERGE: Okay, I will come back later.

MR. CHAIRMAN: Mr. Sullivan.

MR. SULLIVAN: Thank you.

I guess I will probably just start where Ms. Verge left off. With reference to the medical school, New Brunswick also has students going there. Are the charges back to New Brunswick on a per capita cost of the total cost of the budget of operating the school, or are certain established capital costs factored in and just operational costs factored back to New Brunswick?

DR. KITCHEN: In answer to that question, there is an arrangement with New Brunswick by which New Brunswick has, I think, ten or so people ever year in the facility, and they pay a figure to the government. I think it is $14,000 or $15,000 a year.

AN HON. MEMBER: It is $14,500.

DR. KITCHEN: It is $14,500 which, if you take the average cost of the medical school you divide the $18 million by the 220 people who are there, you will get a figure far in excess of $14,000 or $15,000.

That was a question that I had written down myself to find the answer to, and I will probably ask Dr. Williams in a minute to see if this - because it looks to me that if we divide a couple of hundred into $18 million -

MR. SULLIVAN: $80,000 per year.

DR. KITCHEN: - we are getting $80,000 per person - not $14,000 or $15,000; even if you subtract the other services that the medical school provides to Newfoundland but not to New Brunswick. The main function of the medical school, or one of the main functions, is the training, it is certainly not cost recovery.

I also point out that we have arrangements with New Brunswick for the training of other professionals, and I suspect that the cost that they charge to us is less than the average cost.

I do not know, Dr. Williams, if you have something to add to that, or if some of the other members of the staff could address that question as to whether we are charging New Brunswick enough is basically the question, is it not?

MR. SULLIVAN: Maybe if I just put it this way. I understand you said there are fifty-six students per year taken into medical school, and that is really a cost per student to go through about $320,000 per student, or $80,000 per year, of which we are recovering roughly $14,000 per student. So really it is less than that. It is about 17 or 18 per cent really of the total cost of sending them there.

I guess students go to New Brunswick, possibly to law school, and have a similar arrangement and so on, but I guess the cost of medical school, too, is a fairly costly venture. It is something to be looked at, whether our cost recovery is sufficient in light of the demands on our health care system over all. I think it is something that needs to be looked at.

I know there are other spin-off benefits and overlapping things, but I would assume the figure here is what specifically applies to Memorial University Faculty of Medicine as it relates to the hospital there. I am sure other hospital costs are picked up at other aspects here in the budget too, so I would assume that this is portioned out specifically as it pertains to the Faculty of Medicine. Would that be correct?

DR. WILLIAMS: The background to this figure is based upon the Maritime Provinces Higher Education Commission. That is an organization of the Maritime Provinces which provides for the funding of various programs in the different universities, and there is a formula based upon certain disciplines. For instance, Newfoundland purchases seats at Dalhousie School of Health Professions in occupational therapy and physiotherapy, speech language pathology, and we pay according to that formula. The formula that the medical school reimbursement is based on is based on that formula as well.

We have attempted to have some discussions with New Brunswick very recently on the matter of the $14,500 that we get. When I say it is based upon that amount, we would like to see if we can increase that amount above that area. Given the situation that New Brunswick has arrangements with Laval for training their French speaking physicians, and Dalhousie for training English speaking physicians, and given the capacity that medical schools are downsizing in Canada, and there is an excess capacity, I guess we are concerned that if we push too hard we would have to balance off losing half-a-million dollars worth of revenue in terms of New Brunswick pulling out, so we have to watch that. Right now, though, the amount we are getting is based upon a formula that is consistent across Atlantic Canada in terms of other health professions. For example, if some Nova Scotia students enrolled in the Department of Forestry at UNB, there is a certain formula that applies for those seats as well. So, it is based upon that and the agreement we have with Dalhousie University for training people in health professions which we do not have at Memorial is based on that formula as well.

MR. SULLIVAN: Have you looked basically at the cost of delivering that service at Dalhousie for certain areas and the percentage of that we are paying? Are you saying the same percentage applies or the same basic formula or are there specific formulas for each specific field of study?

DR. WILLIAMS: That is right. There is a specific base amount and then there is a multiple factor applied depending on the type of system that somebody is in. If they are in forestry, it is the base multiplied by x. If it is in medicine, it is the base multiplied by another factor. It is greater for medicine than in the other disciplines. We are paying, I think, about $6,000 a year for instance at Dalhousie for our seats in occupational therapy. So it is based upon a formula and this formula of 14,000 is fairly consistent. However, we try to have some discussions to get it up but our concern is that if we push too hard we may lose the whole $500,000 worth of funding which will be a significant amount of funding.

MR. SULLIVAN: Yes, I know, I can see the concern there. It is probably costlier to train a person in a medical field than any other field so I guess that gives some impetus for trying to get a higher base amount before you apply your factors. I guess another area related to the medical school overall - Dr. Kitchen was not aware basically, he indicated that he is not sure, he does not have any figures on how many of these doctors might be staying here and continuing in service here in the Province. So, I am wondering if the department has done any tracking recently over the past few years to see exactly if we are training doctors to practice elsewhere and how many of these graduates, over the past let us say four years, have stayed here in the Province? Has the department taken any steps to follow that through and see if it is money that we are using in training that is sort of lost forever?

DR. WILLIAMS: There was a study done a few years ago where medical school graduates of Memorial were tracked to see where they stayed and, in terms of comparing ourselves with other medical schools in Canada, Memorial graduates were consistent where they went with other schools in terms of the number that stayed in Atlantic Canada or the number that stayed in their home province. I do not have any specific data that I can give you tonight but we can get some data for you which will give you an indication of how well we fare in retaining graduates from Memorial. As well, we have fifty-six students, ten come from the Province of New Brunswick so we would expect those ten to return to New Brunswick in order to give the school less of a parochial flavour because usually there are about six students taken in from other parts of Canada. So, there are forty Newfoundlanders who go to medical school. Sometimes as well we see that a lot of graduates, about 50 per cent, go into speciality training, so they will not reappear back in the Province until about five or six years after their training. You will have to give us a chance to get it but we will get it specifically for you, the number of graduates who are now in the Province who are graduates from Memorial University and where they are.

MR. SULLIVAN: Okay, thank you, that would certainly put a focus on where we are heading in the future. Are we spending our dollars wisely down the road? It can give us a little bit of insight.

The next area which I want to touch on, in the process now, Lucy Dobbin's report: she is recommending seven hospital boards at the moment and possibly five down the road, recommendations in two of these areas, like Central combining into one and so on. I am wondering of the structure to be put in place from a cost point of view. Those boards or the officers there: is there remuneration there and what type of structure where they are serving a larger area now, will it be built into the system, extra related administration costs, salary and otherwise that probably were not there with the smaller boards in more regionalized areas?

DR. KITCHEN: As far as the cost is concerned, we anticipate that there will be an overall saving in the administration costs because of the efficiencies of scale, particularly in things like handling accounting and payrolls and things like that which can be handled by a large organization as efficiently as, or perhaps more efficiently than having it done by twenty-five hospital boards and an equal number of nursing homes, and so by combining these there should be substantial savings in administrative costs, even though we may have to pay some individuals slightly more.

MR. CHAIRMAN: Ms. Young.

MS. YOUNG: Thank you, Mr. Chairman.

I would like to ask the hon. minister a few questions. But first I want to comment on my privilege as having served on the G B Cross Memorial Hospital foundation in Clarenville. It was indeed a wonderful experience and then moving on to the hospital board. I am very proud of the way that hospital was run and a lot of credit goes to the administrative staff there, who certainly stayed as well in budget as possible without reducing services to any great extent, and from the people in that area I have heard a lot of praise, not only for the staff but for the facilities as well, and they are very pleased with the hospital.

With regard to Medicare, I wonder if users have any idea of the cost of services, and if at the end of a visit to the hospital a user could see a statement showing the expenses that were incurred, if they could see something like that, I am sure it would give them a greater appreciation of the cost of services. I imagine that it would be very costly to do that but it would be quite a shocker I am sure; when I found out just how much it cost for one x-ray, I was quite surprised.

I live in rural Newfoundland and I am very interested in hearing more about the home health care services, because often the transition from the rural family home to an urban centre is quite a traumatic experience, so I am sure a lot of our seniors would be very interested in the home health care.

DR. KITCHEN: A few points - one has to do with the bills. I believe it is Alberta, one province used to, or attempted to -

AN HON. MEMBER: BC.

DR. KITCHEN: BC as well?

AN HON. MEMBER: Yes.

DR. KITCHEN: - attempted to send, not so much a bill marked paid to every person in the Province, just to indicate how much they had used the health care system, but just to build up an awareness. I do not know if someone here can tell us if that is still going on or if they have stopped doing it for cost reasons -

AN HON. MEMBER: They stopped doing it, I understand.

DR. KITCHEN: - they stopped doing it, in BC?

AN HON. MEMBER: Yes, I think Alberta did it as well.

DR. KITCHEN: Alberta stopped it as well, but it sounds like an interesting idea. Maybe we can do it in a different way, even if we send everybody the average cost - divide our $870 million by 500,000 and said, here is your paid bill, your average cost was whatever it was. Now you mentioned the point about the home care, and I think that is an extremely important point. Some people who go into institutions find it very disruptive, at least for a while, and some people do not last long after they go in these institutions, perhaps because they are quite sick but also maybe because of their being away from everything that they have ever had in their life, from their family and their neighbourhood, friends and everything like that, so I think it is just reacting as one person to another rather than from any study that has been done.

I do not know if any studies have been done or if anyone here has any information to give as to how effective home care is. Do people who get home care, as opposed to similar people who go into institutions, live longer? Are they happier? It's hard to say. You're suggesting, and I believe I'm agreeing, that they probably would be better. Right now in many parts of the Province that choice is not really there. I think that's fair to say. So do you know, Doctor Williams, if there's any study been done about comparing people who go into institutions as to people who have adequate home care? Or Ms. Bishop?

DR. WILLIAMS: I'm not aware of any studies that have been done to give any indication to longevity versus home care versus care in an institution. I think there's a quality of life factor there, that people, a certain element of people, would like to stay as close to their friends and family as they can for as long as they can. We know I think too that psychological, emotional factors play a major part in people's health care. There's lots of information and things that we don't know about people's health that would link their health into psychological factors and factors that are not purely physical in nature. I would expect that somebody who is at at peace, home with their family, and in comfortable surroundings, psychologically would certainly be better off. I presume that would have an impact on their health, but I don't know of any study that's been done to say they live longer in home care. My intuitive feeling would be that there's certainly a benefit in that.

MS. YOUNG: There is also the factor as to whether I guess the family unit is really prepared to keep the elderly person at home.

Back to the cost of services: I'm just wondering even if we ran it in our local papers as to just how much it costs for an x-ray and some of the things that we just take for granted when we go to hospital, I think it would certainly be an eye-opener. I'd certainly like to suggest that. Thank you, that's all I have for now.

MR. CHAIRMAN: Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman. Mr. Minister, a number of questions. Unfortunately I neglected to bring my copy of the MCP annual report which you tabled in the House just a couple of days ago. I'm just trying to recall from my memory, on the report the reference to the salaries for this past year. I know every year when this report comes out that the media certainly make for that, and that's a pretty popular page. I guess it gets pretty dogeared after the first few days. I guess falling into that trap that was the first thing I looked at when I received my copy of the report and read with interest - I don't recall the exact figures - but just a couple of things with regards to it.

First of all, in terms of the salaries being reported, I'm sure somewhere along the way that there's some sort of a comparison being made as well in terms of trying to cost factor our health services generally. How do the salaries that we're paying in this Province compare with the rest of the country?

DR. KITCHEN: I'll ask Dr. Williams to give you more detail on that. I understand that they're somewhat below what they are in places like Ontario, but they may be comparable to other areas. Dr. Williams, you probably have better figures than that.

DR. WILLIAMS: Incomes, these are fees for service incomes we're talking about, would be a product of the fee schedule and the number of services provided. The fee schedule in the Province when we've tracked it over some time, aside from the Province of Quebec, where it's difficult to get comparisons with their fee schedule, usually the fee schedule for physicians in Newfoundland is down. Prince Edward Island, New Brunswick and Newfoundland are in a group in the bottom one-third. Newfoundland can be anywhere, of the nine other provinces, from seventh to ninth. We're usually in that ball park, in that figure. Fee schedules in places like British Columbia have been as much as 40 per cent higher than the Province. Ontario is usually about 25 per cent higher. That's where we've been historically over the past ten years.

In terms of physicians' incomes, two years ago when a global cap budget was introduced for medical care the medical physicians themselves proposed a proration factor be placed on high earners. That's been in place for the past two years. General practitioners whose gross incomes - we're talking about gross incomes here - exceed $300,000, for the next amount they would get two-thirds of the fee schedule, and after $350,000 they would only get to keep one-third of their income. For specialists I think its $400,000 and $450,000. They get to keep everything up to $400,000. From $400,000 to $450,000 they get to keep two-thirds, and after that it's one-third.

Like I say, that was introduced by the Medicare Commission and government after discussions with the Medical Association, but at their request. There are a number of other provinces as well now which have implemented a proration mechanism for high earners.

There's also of the Medicare budget, of the approximately $130 million or so, there's about $26 million or $27 million for salaried physicians in the Province. They make up, I guess, if you look at the cottage hospital system, the vestige of the cottage hospital system, if you go back to the '30s and '40s, most physicians in rural Newfoundland were on salary and that system is still in place today. One would find that the majority of general practitioners in rural Newfoundland would be paid a salary out of the $26 million. Again, our salary scales, although compared to members of the general public are fairly high, when you relate them to members of the general public, in comparison with salaries for physicians in other provinces I think we're at the lower end as well. Salary range starting off in the rural practice setting, is around $67,000, I think. Close to that range.

MR. SMITH: Each year that these figures are released there's always - and I'm sure Dr. Kitchen with his background in statistics always certainly looks at the range of these salaries. I'm always struck by the extremes. How do you account for the range itself? I'm thinking of the range of the salaries. Especially at the upper level. There's usually at least one GP who's up into the $500,000 bracket. How do you account for that now?

DR. WILLIAMS: One can account for it. It depends on where the GP is and what kind of a practice that GP has. I know some cases where there is an explanation for that. Whether there's a satisfactory explanation I guess that's in the mind of the - you know, when we talk about it.

As well, there's a fairly extensive auditing program done, as you may have heard in the media, by MCP over the past four or five years. They've strengthened their audit program very significantly. They have a consultants committee in place. That's a committee of MCP composed of physicians, and I think there's an accountant on it and some auditors on it. They advise MCP on physicians' profiles and this type of thing. They have a fairly aggressive auditing campaign which I think has seen some changes in some of the profiles and some of the utilization patterns both by physicians and patients.

MR. SMITH: As a layman, and trying not to sound too cynical, when I see some of these figures I sometimes wonder, in terms of the fee per service on the average, how one individual could maintain a level of good health care seeing the number of patients that would be required in order to put him up into that kind of income bracket. That is just a statement; I don't want you to respond to that.

I was very pleased, Mr. Minister, to hear you state in the House, and again this evening, the reference to keeping people well as opposed to curing the sick. I think that's certainly in line with current thinking. I think now there are so many publications that I've seen in the last number of years coming out on wellness in the workplace and things of that nature. It's now becoming a fairly popular theme. People are recognizing that there are so many factors that contribute to a person's maintaining their wellness. It's important for employers and for everyone to be concerned about that and to try to ensure - especially in the workplace - that factors are in place that they contribute to them. I am just wondering - I would imagine there are quite a few employees within your department - is there a policy or a program with regard to wellness in the workplace, or have you discussed that or are there things in place, other practice that you are doing? Because I know, for example, some of the schools are doing it now. My own school board where I just came from, we embarked on that this past year. It was preceded by a survey that is available through the federal Department of Health, and following up on that, as a matter of fact, our school board retained a person with a primary responsibility for that, and the idea is that you recognize in the factors, concerns that people have in trying to put the supports in place to keep them content and contributing to their wellness. I am just wondering, within your own department, has there been any discussions with regard to that or, indeed, there may be something already in place?

DR. KITCHEN: There is a Wellness Centre in this building and we were over there the other day.

MR. SMITH: I will need to find that out, because I think before too long I probably will be in need of it.

DR. KITCHEN: There are bicycles over there, stationary bicycles with people peddling away with fancy uniforms on, like you would, you know. I don't know how long it has been in effect and I don't know what proportion of the staff of the Department of Health participate, but a fair number I would think. I don't believe we hire any assistant deputy ministers, if they smoke, for example.

SOME HON. MEMBERS: Hear, hear!

MR. SMITH: Where is the Wellness Centre located?

DR. KITCHEN: It is in the new building, below the Department of Municipal and Provincial Affairs, or where it used to be. It is a great place, lots of room over there.

MR. SMITH: Are members of the House welcome or is it just for employees of government?

AN HON. MEMBER: Anybody, anybody.

MR. SMITH: Anyone, okay. MHAs allowed in?

DR. KITCHEN: It is not well used by MHAs.

MR. SMITH: I think it is important, just following up - I have been pleased to hear you state within the last two or three days, I mean, you referenced that. There is a need for a change in our mind-set, I think, and especially, it is refreshing coming from your department - that I think we have to get away from it. I guess, it really hits home in times of restraint, when you have limited resources, that certainly there are steps you can undertake to improve the general overall health of our people and certainly, down the road, there is going to be a tremendous saving. I think one would logically predict that there would be a tremendous saving on delivery of our health care services as there would be less demands on them.

MR. CHAIRMAN: Thank you, Mr. Smith. I recognize Ms. Verge.

MS. VERGE: Thank you.

When I was cut off there a while ago, I was just getting into asking about the community boards. Last year, and I have Hansard here as evidence, the previous minister and the ADM responsible, have the circled graph showing the responsibilities intended for regional community health boards and we were told there would be five regional boards covering the whole Province, four on the Island, and that the first would be the Western regional board, which would be in place and providing services last fall. Of course, none of that has happened, we don't even see the circled graph anymore. What is happening?

The legislation was very disappointing. In the middle of the night during that marathon sitting, I proposed amendments which I thought would have made the legislation much better, preferable for a Minister of Health voicing the objectives that this minister has spoken. Is the government going to set up regional community health boards for the whole Province? What responsibilities will they have, what will be the boundaries of each of the regions and where will each board be headquartered? Will the minister provide for the public election of all or some of the regional community health boards? - since he talks about wanting to foster individual initiative - and, just where is this now?

DR. KITCHEN: Thanks very much for raising that question. I am under constant pressure from my left here to get those boards appointed, and I have been - I wouldn't say, dragging my heels, because we want to put the boards in place in appropriate fashion, and I don't want to do anything in too hurried a fashion and find myself, after they are in place, wishing to dickens we had done something different and had different people in it.

Since that time, we have been doing more than thinking. We will be setting up those boards soon. Since we talked, something has happened to me. I have seen what happened down on the Southern Shore, and if we set up a regional board which is very large, encompasses a very large territory, with ten or fifteen people on it, what happens to a smaller component of that board as far as the responsibilities are concerned? That is something that has come to mind recently. It is obvious that we are going to have to have a regional type of representation, but if you just have one person on a board that encompasses all of St. John's and a large part of this peninsula, will that be able to get the public participation in each of the various areas that a number of smaller boards do? Maybe what we have to do is set up the overall board and, at the same time, make provisions for other committees to be operating and feeding in to another person. That thinking, in my mind - and I have not really had an opportunity to discuss it. That is why I have deferred it until the House closes so that we can get a chance to think about these points. I don't want to rush in and do things under great pressure, because we may make mistakes. We build institutions sometimes - when people come to government and say, I have to have it in the district, I have to build this, I have to build that, and suddenly it is there and you realize it shouldn't have been there, and that is frightening. So, I am really not putting off, the decision has been made. We are going to have regional community health boards but we want to put the mechanism in place appropriately.

The other problem I have is, How many professionals should be on those boards? What should the composition be? Should it be professional health people or should it be basically citizens of the community, who take responsibility? I think these are questions and the proper mix is important to be thought of. There is no trouble for me tomorrow morning to appoint four boards, just to name them up. We know lots of people in all parts of the community. Traditionally, these people have been suggested by other members of the House, and there is nothing wrong with members of the House having input into it, but it has to be, I think, broader than that. Now, whether they should be publicly elected, I don't know - maybe. I am not sure about that, because usually where they have public election of board members, you usually have some financial responsibilities, as they do in Western Canada, where the health boards traditionally have had taxing powers. We don't have that in this Province, so, I don't know about that part of it.

MS. VERGE: One of the large hospitals in the Province, Western Memorial Regional, by provincial legislation, has some of its members chosen by public election and that has worked very well. Some of the members on the board are appointed by the Cabinet. I think one is appointed by the City of Corner Brook but others are elected, and this has been done at public meetings called for the purpose. So, there is a precedent in this Province for public election of hospital board members.

DR. KITCHEN: Some of the members of the hospital board?

MS. VERGE: Yes.

DR. KITCHEN: Yes, that is the sort of thing that I think we should get into without delaying too much. I don't propose to delay this procedure because we need the community care - that is the point.

MS. VERGE: Yes.

DR. KITCHEN: And maybe we will put the boards in place the best way we can and tidy them up later if we have to, but we need the community care. I won't put a date on it but it is the first thing we are going to do now, as soon as we get the decks cleared.

MS. VERGE: Okay. I had a checklist of questions. My first question was: Is the government going to do it and will there be boards covering the whole Province? I think I heard a yes to the first question. Will there be boards covering the whole Province?

DR. KITCHEN: Yes, I think - that is the plan, anyway. The reason I am hesitating about that, we have Grenfell up there which presently does it for the North, and it is not a board, as such.

AN HON. MEMBER: It does all of the institution -

DR. KITCHEN: I have some concerns about that model, personally. It has been proposed by another board, too, to have it all lumped together, the home care and the hospitals all run by one board. I am not sure, because that tends to be dominated by the health care professionals. I don't think that the experiment which took place in Ferryland would have been as successful if we had it dominated by health care professionals. I am not sure about that. That is something we should think about. We should talk about it sometime.

MS. VERGE: Are you thinking about roughly five, as stated by the previous minister?

DR. KITCHEN: That is something that is worth thinking about - four plus Grenfell.

MS. VERGE: Okay, four for the Island -

DR. KITCHEN: Yes.

MS. VERGE: - other than the St. Anthony area, is that it?

DR. KITCHEN: Yes, and Labrador, but there are questions about that, too.

MS. VERGE: Where will each Island regional board be headquartered or based?

DR. KITCHEN: I hadn't thought about that. I don't know. I suppose it will be - I do not know, traditionally, I suppose, one on the West Coast, maybe in Corner Brook, and one in Central Newfoundland, probably in Gander or Grand Falls - that is a hard one to solve at this stage of the game. One in Central - I am sure Ms. Young would love to have that in Clarenville, but I don't know. These are questions. We haven't worked that out yet.

MS. VERGE: You could put the Eastern one in Clarenville and then St. John's in St. John's.

DR. KITCHEN: Each member can get one. How about that?

MS. VERGE: Okay, great.

What about responsibilities? Is that circle graph dead? Do you have a new graph or chart?

DR. KITCHEN: Oh, we still look at the graph.

MS. VERGE: Chart, I should say.

DR. KITCHEN: Whatever it is, yes, the intersecting circles.

The basic reason we are putting them in place is to look after home care - single point of entry for home care. That is the main reason. And while we are at it, we might as well put in the public health units because they have certain home care responsibilities, as well. So that is important.

MS. VERGE: What about all that great stuff you were talking about in terms of education -

DR. KITCHEN: Yes, the other things are there, too, (inaudible) health.

MS. VERGE: - and eliminating smoking, and getting people to eat better and exercise more.

DR. KITCHEN: Yes, sure.

MS. VERGE: And sleep adequately -

DR. KITCHEN: And do all these great things.

MS. VERGE: - do all those good things.

DR. KITCHEN: Yes, that will be a responsibility, to some extent, for carrying out the policies.

MS. VERGE: What about family planning, birth control, information, education -

DR. KITCHEN: The sort of thing that the public health nurses do now, that would be part of it. Whatever public health nurses do now, that would be passed over to that, and the medical officers of health would be part of that, as well.

MS. VERGE: Two quick questions: The original intention, or stated intention, of the government was to place responsibility for the former Alcohol and Drug Dependency Commission, which has been disbanded, under the regional community health boards. Is that still the intention?

DR. KITCHEN: It is the same thing. That is one of those circles.

MS. VERGE: One of those circles.

DR. KITCHEN: Yes.

MS. VERGE: And what about mental health services? That was another circle.

DR. KITCHEN: Yes, the same thing.

MS. VERGE: So you are committed to the circles.

DR. KITCHEN: Pretty well committed to doing -

MS. VERGE: Any alteration, or the same circles?

DR. KITCHEN: Well, I haven't thought about changing the circles, so they will be much the same.

MR. CHAIRMAN: Thank you, Ms. Verge.

MS. VERGE: Thank you.

DR. KITCHEN: There may be six circles, or seven.

MR. CHAIRMAN: Mr. Langdon.

MR. LANGDON: I want to go back to the institution versus the community-based program and talk about mind-sets and so on. I think, over the past, that the mind-set for a lot of the population, especially seniors, is: I am sixty-five years of age. I can leave my house, and seniors' cottages, here I come.

I am wondering, in the number of seniors' places that we have, in the health care units and so on, has there been any assessment done of the numbers of people who are in the seniors' homes who could be looked after properly and just as well in home care, that would then alleviate the problem you have with Level III people who are out there in the homes, where the home care that is there cannot adequately care for them. I was wondering if you had done anything along those lines.

DR. KITCHEN: Well, part of the problem with a number of the institutions, the nursing homes, some of them are equipped to handle Level III care and higher. Some are equipped for that, but some are not. A number of institutions can handle some Level III care, but the way they are configured inside, the way they were built years ago, is such that the doors are too narrow for wheelchairs, the bathrooms are not appropriate and the beds can't be effectively turned in the rooms. They are almost like hotel rooms rather than hospital rooms. So there have to be some major renovations done to a number of these homes.

We are renovating the Bonavista one this year. Other major renovations that will have to occur, I think, are: There is one in Lewisporte that needs renovation; one in Corner Brook that needs renovation; and, I think, the Interfaith Home needs renovation.

AN HON. MEMBER: Brookfield.

DR. KITCHEN: Brookfield, yes, Bonnews Lodge. We are working on that now too, I might add. We are putting some money into that this year.

AN HON. MEMBER: Blue Crest.

DR. KITCHEN: Blue Crest. There are a whole slew of them that, in order to accommodate high level care, will need more renovation.

I don't know if there are people who are Level I or Level I and a bit who are in nursing home rooms that can accommodate Level III people. That is an interesting point. I don't know. I am concerned with the number of not-too-sick people who are in nursing homes. Even now people are entering nursing homes. If they can't get in one way, they will marry a resident and move in. That has happened too. They really don't need to be in a nursing home, in my opinion.

MR. LANGDON: Further on that point, has there been any research done or any figures compiled to show what it would cost to keep a person in a nursing home, even at Level I or Level II nursing home care? I mean, we are looking at a number of dollars, as has already been said by Lynn and Loyola as well. As you know, dollars are scarce. We are operating on an $800 million budget and so on. We can never seem to get enough dollars for it.

Have you done any comparison on home care versus the institution?

DR. KITCHEN: I am going to ask Ms. Bishop to comment on that, but first I would like to say that there is an intermediate institution called a personal care home where usually twenty people are in a sort of nice personal atmosphere run by somebody who looks after people. The cost to government is very minimal really because the old age pension and a supplement can pretty well take care of the cost, or almost all of it, except for security that we put there. That is a much more cost-efficient way and probably a better way because the people are in smaller groups and so on than they would be in a nursing home.

Now, I don't know - Ms Bishop can probably tell me: Do we pay nursing homes differentially? In others words, if someone has Level I residents and also some Level III residents, does that nursing home get more money for the Level III residents from government than they do for the Level I residents and that kind of thing?

MS. BISHOP: Persons who are admitted to nursing homes, we now assess them and only those that require Level III care are being admitted, except in homes where the physical design is such that it is not conducive to caring for a high-level care patient. We do charge people a per diem rate, but we review the budgets and the budgets are set based on what the staffing requirements are to care for the number of people who are in that nursing home.

For example, if we have a 100-bed nursing home and there is a physical unit in that home which is not appropriate to care for high level care - as I say, there are not bathrooms where you can get wheelchairs in, the doorways are too narrow for wheelchairs to go in - we could only admit lower level of persons to these homes. Consequently, our staffing level for that unit would be much less than it would be for another 20 or 30-bed home where all the people require a high level of care. So we do not provide the funding based on a per diem, so much per person at Level I and so much per person at Level II, we look at the overall needs and convert that to what the bottom line figure is to run the nursing home.

MR. LANGDON: I'm wondering again, if, with all the difficulty that we have with the health care problems in the Province - I'm thinking of Labrador and the Island as well - if in certain areas, like in the past, there might be overcapacity, where in others there is under capacity. I think of the South Coast and I think of the Bay d'Espoir area where Dave serves and my area in Harbour Breton. We have no facilities for Level 111. Then, on the Burin Peninsula, you have one at St. Lawrence and one at Grand Bank, and so on. I'm wondering if you can probably comment on that. Probably there is overcapacity in some areas, under capacity in others. Would you like to comment on that?

DR. KITCHEN: Just a comment and I'll then pass it along for further comment by others. As I understand it, we have sufficient capacity in the Province to take care of - we have something over 3,000 nursing home beds, which is certainly an appropriate number for all hands. The question is, the problem is of location. It's something like the school buildings too. Lots of school buildings but they're not always where the people are. As people move and family patterns change, and so on. There's no doubt that there is a problem.

Another point though is, what is the appropriate size of a nursing home? Is it ten or fifteen or twenty? Or is fifty or 100? If you have a certain level you can employ staff that can bring in recreational programs. You can have a physiotherapist or an occupational therapist. If you have a very small nursing home it may be difficult to employ staff in that manner. You may have to make some adjustments in staff. I don't know if it makes it impossible, because it's possible to share staff with other institutions, I'm sure, and have them visit. I'm not sure if that's a valid argument, but it does require different staffing arrangements to run a small nursing home than it does to run a larger one. These things have to be taken into account.

There's no doubt I think - and I'm subject to correction here, and people should correct me if I'm wrong - that where the nursing homes are is not necessarily where the people who need nursing care are. Would you care to comment on that, Ms. Bishop?

MS. BISHOP: Dr. Kitchen is correct. We have a formula that we use for nursing home beds within the Province. This formula and standard is very much one that's used in other provinces. That standard is forty beds per 1,000 for populations of sixty-five and over. When you take into consideration that we now, with the 1991 Census, have fifty-nine seniors in the Province, if you multiply that by that factor, we need 2,360 long-term care beds in this Province. In fact, we have just over 3,000 beds, when you look at what's in nursing homes, health centres, and designated long-term care beds in acute care facilities.

Similarly, we have a formula for personal care homes, which are homes for people who need social housing, which is thirty per 1,000 for those over sixty-five. So that would give you a much less number. We have the capacity for nursing homes in the Province for over 1,300 personal care home beds. As Dr. Kitchen has said, they're not always in the right place, and that's a problem that we're having to deal with.

I'm also amazed that with that large number that our waiting lists are quite long. However, in the past year or so - and we've been looking at the single point of entry for people going into nursing homes - the waiting lists have been purged somewhat, and the numbers are really, when you look at them very closely, much less. Because what has been happening in the past, is that if somebody wanted to get into a nursing home they made out say five applications, so we have been counting people maybe as much as five times. So the numbers who are really waiting are much less than it appears.

Once we get the regional boards in place - the regional community health boards - and we get into moving into a single point of entry for persons going into these nursing homes throughout the Province, I am sure that we will see that our list of people waiting for nursing homes will be somewhat lessened. Also, too, we will have a much better handle on those people who can be cared for in a home type environment.

Right now what is happening is that many seniors - the family unit as we knew it some fifteen to twenty years ago has changed considerably.

MR. CHAIRMAN: Thank you, Ms. Bishop. Your time is up.

MS. BISHOP: Thank you.

MR. CHAIRMAN: Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman.

One of the questions I had noted and probably has been somewhat answered did deal with the situation of care for the senior citizens homes and looking after the seniors.

One of the things that I had noted here as a question, and I think Ms. Bishop addressed that, dealt with the waiting lists, because I know in my area of the Province I had a personal experience within the past year. My mother is a resident in the senior citizen's home in Stephenville Crossing and became a resident October past, so I have gone through the process and had some experience.

Overall, you were quoting some figures, but in regions of the Province it appears - at least from the figures that I have - in that area of the Province there certainly seems to be - or at least, the figures that were given to me by the officials at the institution was that the waiting list was fairly extensive. And in my understanding I was informed when I first went there that it could be up to one year. Is that fairly standard?

MS. BISHOP: The waiting list, as you say, does vary from region to region. Some waiting lists are not long but beds only become available when residents do die in nursing homes. So the waiting time is also a factor of the turnover of the number of people in that nursing home. It could be up to a year or a two year wait.

MR. SMITH: Okay, thank you. Just for my information: From the estimates, page 255, Item 2.2.02. Community Based Services refers to the Canada Assistance Plan. Talks about services that are cost-shared under the Canada Assistance Plan. What is the Canada Assistance Plan? Just for the information of someone who is completely ignorant to this process.

DR. KITCHEN: What was your question again?

MR. SMITH: The Canada Assistance Plan, just what exactly is it. It makes reference to the cost-shared under the Canada Assistance Plan.

DR. KITCHEN: Can you answer that, Ms. Dawe?

MS. DAWE: Yes, thank you. That's the federal program which is cost-shared with the Province for home support services. Not requiring home care, which are considered professional or nursing services, but support in the home. Homemaker type of services. So a person who is eligible for services under the Canada Assistance Program would be eligible - the Province then is eligible for cost-shared arrangements. Up to 50 per cent of the funding for that service will actually come from the federal government.

MR. SMITH: Okay. So that would be 50-50 -

MS. DAWE: Yes.

MR. SMITH: Okay.

MS. DAWE: Up to 50-50, depending on the level of service that's provided.

MR. SMITH: Okay. Thank you very much. One of the other things that I was a bit curious about is with regards to the recruitment of medical doctors for rural areas. I know in the area of the Province where I live, in Lourdes, a little community on the Port au Port Peninsula, we have over the years experienced some great difficulty in first of all recruiting doctors, and certainly in keeping them in that area. It appears that many of them in recent years who have come - very few of them are home grown. Most of them are doctors from outside of the country who it would appear are using a placement in a rural setting just to go through the waiting period until they get their landed immigrant status or whatever it is they require to move on elsewhere. They're in a holding pattern. There's really no commitment to the area. When they come they see it as kind of just a stop along the way. That's not their destination.

I don't say it to be critical of the doctors. We've had some tremendous individuals. The gentleman we have there now seems to be a superior doctor and is certainly providing a top level of care. The only thing is, it strikes me that - and it kind of ties in, I had noted it when I was doing this, it's been referenced, when I look at the amount of money that we're spending on our medical school. I recall when that debate was ongoing years ago, and one of the things at that time, we were talking about the medical school for the Province. It was, and one of the strong arguments was, that we would be able to redress this recurrent problem in the rural areas in getting doctors. If you get locals in and train them that maybe they would stay and they would provide us with that consistency that we need in these areas but it would appear that that certainly has not happened. I am just wondering for example, in terms of where the department is with regards to this thinking that, is this the problem overall in terms of recruitment of people to the rural areas and if so are there any plans in place to try to deal with this?

DR. KITCHEN: There are a number of points that could be made here and I will ask Dr. Williams to fill in the blanks, to fill in the gaps that I will create. We have to be careful, as you say, a number of the foreign positions, where people came from foreign countries, really made a tremendous contribution in rural areas. Some have not but many have and some are still there, we agree, and we are very glad that they are there. Sometimes the home grown variety takes off to the mainland and says: to hell with you Jack, thanks very much for my medical education.

Some hospital boards have deals made with medical students and they give them some money while they are at the University and they go and work for so many years with that hospital board. Another thing that has happened very recently in Canada, is that there is a surplus of medical school places. As a result of that, because doctors cannot be placed, there is really a surplus of physicians in Canada right now and because of this the physicians, as we quite properly pointed out, are driving the health care system. In some provinces now, if you practice in the city, the fees that you get are just a fraction of the regular fee schedule. I believe in Ontario now, if you practice in Toronto it will be 25 per cent or 30 per cent of the fee schedule that you would get if you practised in a rural area. We are expecting that there will be a great influx of Canadian doctors into Newfoundland. In fact the doctors in Newfoundland are a bit nervous about this great influx. So I do not know, this may very well be at an end but there are procedures and have been procedures in place to attract and hold local doctors and doctors from abroad. Perhaps Dr. Williams you can elaborate on those procedures because I am not too sure of the details.

DR. WILLIAMS: The problem you allude to is a very real problem in this Province. It is a similar problem that they have in other provinces in rural parts of Canada. There are no easy solutions. Other provinces have been grappling with it in a variety of ways. Newfoundland is dependent in many parts, I guess in rural Newfoundland, on foreign trained physicians. Someone who has come and stayed for a year or less, some who have stayed for quite a while, it has been variable.

In terms of some of our urban centres such as; St. John's, Corner Brook, Grand Falls, Gander, Clarenville and Carbonear, to that extent, we have seen some major changes over the years. Most physicians in primary care in those centres now are Canadian trained graduates of the Province or other physicians who have been here for a number of years and are fully licensed but we still have a problem in rural Newfoundland.

We have with the University a financial assistance program whereby students in their second, third and fourth year of medical school are eligible for financial assistance in return for a return in service commitment. Bursary programs that the Province previously ran years ago, where the agreement was between the Department of Health and the physician - the agreements in the future are now going to be with the local hospital board, health care agency and the physician. So that there is a commitment on behalf of both parties; one to have a placement and two, the physician to go back to that area. We are hoping that as they go through their medical training they will bind with that particular local health care board and identify with that local health care board. It will be much more difficult for them to break a contract than it is with the Department of Health who is not involved in the direct delivery of services.

Another area that has been ongoing for a number of years is what we call the Med. Quest Program which was funded to take place at the medical school. They bring in potential physicians and other people who are going into other health care careers, to the University for the Summer for a week or two exposure to the various health care careers. They found that since they started this program some three years ago, they are starting to see more applicants from rural Newfoundland to medical school and hopefully that will translate to more graduates from the local medical school from rural Newfoundland and they are already seeing some of those things take place; hopefully the bursary program will provide some inroads. As well, at the medical school, they are starting to provide more training opportunities in rural placements for medical school undergraduates, so that they will be able to get some more of their training say for a month or so in a rural practice setting and if they go into family practise residency, maybe up to six months of their training will be taken in a rural practise setting hoping that they will latch on to that option.

As well, with the medical association, we are now putting in place a two-pronged approach. 1) We are developing a long-term medical human resources plan that it is going to take about six or nine months to develop to target where we need physicians for the next seven or eight years, and the number of physicians we have in the Province in retirement ages and this type of thing but in the short term, we are looking at trying to overcome a problem of distribution that may be exacerbated if we have physicians coming to the Province from other jurisdictions in Canada where the opportunities are less in the urban areas than they used to be, and we do not want those physicians or our own graduates to relocate in urban centres in the Province where we feel we have enough primary care physicians.

MR. CHAIRMAN: Thank you, Dr. Williams. It is now 8:30 and I think we should have a break and will reconvene at 8:45 and then I will be asking Mr. Careen to start us off when we come back, so at this point, I think everybody has had enough for the first session, don't you?

AN HON. MEMBER: Yes.

MR. CHAIRMAN: Well, welcome back everybody, because we have a bit of work to do yet and I think we will get started and I will now ask Mr. Careen if he would like to start.

MR. CAREEN: Thank you, Mr. Chairman.

Mr. Minister, I heard you earlier and my friend from Port au Port talking about wellness and everything else, but I come from another class, I come from a race of 'long livers with loose livers', but that is another story. But the thing about it is, health, and whether it is the physical or the mental well being, with poor old Newfoundland the way she is, no matter whose watch it is, it is mental health. We have 20-odd thousand people on NCARP and a number of these fisher types never slipped a line, but there are a good many others who did go through all the phases during the year with deficiencies, getting ready for one sort of fishery or another and now a lot of these people are looking out the window or whatever. We have Social Services, our offices are busy as any air terminal and Canadian statistics have shown that one or two in every five Canadians see a psychiatrist once or twice during their lifetime, but at least once.

Are there any statistics - are Newfoundlanders still holding out, are they still on an even keel, or are they like lemmings running for cliffs? Talking about mental health, a number of weeks ago - well the CBC is always a negative crowd, I was disturbed to find out that they were talking about the rate of suicides rising among the young in the Bonavista Area, so, I am just trying to get a fix on it. Is there any great change in peoples' mental health?

DR. KITCHEN: I have not heard of any great changes in mental illness, whether it has increased greatly, but I do know that a number of people are, as you indicated, worried about the tremendous changes in people's lives as a result of no fish, and also the serious situation which has confronted so many people who are currently on welfare. I am going to ask Ms. Dawe, because she looks after the Waterford and also community health comes under her, if she has noticed any great changes in the incidence of mental illness or depression and things of that nature in recent months? I guess that is what you are really asking.

MS. DAWE: Thank you, minister.

To respond directly to your question, we have no data which demonstrates that there is a marked increase in suicide in particular. Mental health service needs are great around the Province. I think that we would all acknowledge that, and we are working within the community and the various institutions to improve access to counselling services throughout the Province, but this is not anything that has a marked increase over the last few months.

MR. CAREEN: Thank you.

The earlier regional boards, you were saying that you were going at that earlier with Dobbin. Newfoundland is a great place for rumours. If there is neither one by 10:00 a.m., someone is sure to make up one, so I caught the tail end of it when I came in earlier. Did you say that you are moving on it and you going to a more consultative type thing before you put those regional boards in place, and there could be a mixture of odds and ends on those boards, is it?

DR. KITCHEN: Well there are two kinds of boards. There are the community health care boards which are basically looking after home care and public health, and then there are the hospital boards. We have twenty-five hospital boards now, some of whom look after nursing homes as well.

What we asked Ms. Dobbin to do was to see if we could reduce the number of these boards for greater efficiency, and she produced a plan whereby there would be seven, and then later on some fewer, regional boards.

So the commitment that we have is that we would not put any of these boards in place until we had appropriate consultation with the people in the region, because even though she has made her recommendations, there is still a lot left to be said. We are going to start in St. John's because that is an area where perhaps considerable changes can take place. We have six hospital boards in the city right now, and she has recommended one for the city. Whether there will be one, two, three, we have not decided yet.

I have had some preliminary consultations with the Chairs of all of these boards, but the election interfered, and now we have the House, and I would just as soon leave it until the House clued up and we will continue our discussions here. Then I think we are going to have discussions on the West Coast. As I say, we have an interesting proposal before us, and then we will gradually go through it, but there will be discussions.

In your own area, for example, the Placentia area, there is some question from the people there as to where they want to go - whether they want to be merged with eastern or whether they want to be merged with St. John's, or whatever happens here. So there will be discussions so that everybody will be able to say their piece and we will take into account very seriously what people say.

MR. CAREEN: Thank you.

Another thing that arises from time to time and seems to be getting more in the news every day, and it happens that every time there is something new, the minister is constantly under the gun with AIDS -the money that is allotted for treatment, the money that is allotted for whatever. I have not seen the figures. You have all the figures that I need, but have you placed any extra money in it this year than last year, with regard to AIDS patients - I cannot say preventative because there are certain things that you cannot prevent, but there are certain areas of the community - the AIDS community - is there any extra money in it for those people this year?

DR. KITCHEN: The AIDS patients are taken care of much the same as other patients, and we will get into what drugs are provided and what drugs are not. I will ask people that in a minute, but I would like to preface it briefly by saying that last Summer we set up an elaborate set of committees to advise government as to how we should proceed with respect to care and treatment of people who had AIDS, because we had been told that the care of AIDS patients was not adequate. We asked that that be studied by a committee. We had another committee looking at prevention and education, and another committee looking at another aspect of it - treatment and so on - the actual way to treat AIDS and so on, and HIV, as opposed to the care.

These three committees form part of a large overall committee of roughly forty-five people composed of professionals, interested citizens, people with AIDS and representatives of the AIDS committee. The report of that committee landed on my desk a few days into the election. I've read it and the report needs to be looked at very soon too. The problem with it is that it's - in my view, I'm not putting it down - not very behavioural. It doesn't say to me: do this, that and the other thing. It more or less says: set up a committee to do this and set up a committee to do that. I want to look at it very carefully so that we can....

The procedure is in place to take it. In answer to your question, the specific question as to whether we put more money in the Budget this year to look after people who are suffering with AIDS, I can't answer that question. Dr. Williams, I don't know if you can add or we can ask somebody else.

DR. WILLIAMS: Normally, people with AIDS or any other disease are looked after in the health care system based upon their needs. So if somebody has AIDS and is a patient at the General Hospital they would be treated according to the needs and medical care that they required. I'm just checking on the drug program, I'm getting somebody to check on the drugs, but my understanding is that drugs that are specific for AIDS patients are funded. Most of the AIDS patients - the two specialists who deal with patients who have AIDS and obviously are sick - there are two infectious disease specialists at the General Hospital who deal with most people who have that disease. My understanding is that in the budget of the General drugs that are specific for AIDS patients, specific to that diagnosis, are provided in the budget of the General Hospital. But I'm having that checked now.

MR. CAREEN: That's all, Mr. Chairman.

MR. CHAIRMAN: Now, Mr. Sullivan.

MR. SULLIVAN: Okay. Thank you, Mr. Chairman. I was asking the minister there earlier with reference to moving from twenty-five hospital boards and moving into possibly seven and maybe five boards in the future, as Lucy Dobbin reported in her report. I didn't intend my question to be either economies, in terms of payrolls and other related costs, because you can centralise and do payrolls without incurring any costs, without consolidating boards.

The question I asked was: are there going to be any paid board members? What's the cost of operating those boards from the board perspective where they have a much larger degree of responsibility? We need people skilled in the business aspect of the economics of operating these boards, and we need people in the professional aspect to see that the services are going to be rendered under a system that's I guess more streamlined, as opposed to the boards for each individual hospital, how they currently exist. Are there increased costs in those areas there? I'd like to know specifics on that too. Assuming it's seven as the report says, or five. There shouldn't be a big difference in administrative costs from five to seven, as opposed now to twenty-five.

DR. KITCHEN: Yes. We hadn't intended paying board members, that's the first part.

MR. SULLIVAN: You did not?

DR. KITCHEN: We had not intended to pay them, to put them on a salary, or to remunerate them, although that might be considered, I suppose, some nominal figure. It's meant to be a volunteer board supervising professionals. I might add that some of the boards now administer quite heavy budgets. For instance, I don't know what the budget of the General Hospital is right now, it's something like $80 million. Some of the hospital boards are relatively small at the moment. They don't administer very much, financially at least. So merging some wouldn't, I think, alter too much a configuration there. It may to some extent. I agree with you, that the responsibilities become more impersonal than they did. We may very well require a different type of board member, to some extent.

That brings up the whole question as to whether an individual hospital or institution would still retain some sort of an advisory committee. That has been brought to me as well. They say: we don't mind merging into a larger system, but can we have an advisory committee here, and from that advisory committee there may be a member put on the large board, so that we can have some say, or some input into, and some association with the institution that we now run. I can't see anything wrong with that kind of an arrangement, really.

MR. SULLIVAN: No. I know there are certain concerns, I guess, when you look at a total board and try to integrate and operate boards with varying interests now, as they're currently structured. The Waterford Hospital, for example, has a different type of, I guess, a mental health interest to serve there as opposed to balancing economics. Sometimes it comes to a decision of life-or-death versus mental health and sometimes we would be very concerned that justice would get served in line with tax dollars that are there.

I'm not going to pursue that too lengthily there. I'd like to move on to another area there, especially in line with the whole, I guess, philosophy of health care and the direction it's moving in the Province. It seems like we're moving probably into an area where we may have five hospital boards that possibly overlap geographically with five proposed community health boards. That seems to be my perception of where it might be, or very close to that overall.

The biggest concern too, I guess, would be people in the community and getting them involved in community health care boards. It's important to get the community pro-active and have the same developing and changing, actually their lifestyles and improving health in the communities. I had the opportunity for two years to chair a primary health care project in my district, prior to being elected. I saw an increased focus by people in a small geographical area getting involved and taking an interest in their own health care. To get gobbled up by five larger community health boards, when they'll lose that aspect of concern for their own specific health, which we're trying to move today, and trying to get prevention in health matters, as opposed to the curative and rehabilitative methods we've currently been following and in carrying it on with increased emphasis.

I do have a concern that smaller, more localized areas may not develop and advance into this area, because once we establish five community health boards that cover large geographical areas it's very difficult administratively to go out and try to set up other specific sub-boards. May be something to keep in mind is that under each community health board there probably should be sub-regional boards with representatives from each of these sub-regional boards sitting on the regional board.

For example, in the primary health care area from St. Shotts to Bay Bulls, for example, a representative sitting on the community board for the Eastern or St. John's area or whatever the defined and designated area is, because it's important that you move in the direction where we're going to get local people just growing from the ground up. It can't grow at the top and go down to the basics.

I've seen the effects over the past three years in my area in terms of enhancing the lifestyles of people, taking a concern for their health, whether it be smoking, people out exercising on a regular basis, walking, those weigh-in clinics they have, taking health care out into the community centres and people showing up on a regular basis. They're keeping their own little checklists on their weight. There's been a change in overall attitudes and a change in lifestyle developing there. I've a great concern with funding - I know initially this Province committed I think $170,000 three years ago to kick start this program here. I know it's been incorporated under the St. John's and district health unit for the operation of that. I have a great concern that it may lose its effect and autonomy, I suppose, a certain degree of autonomy, for that specific area.

I certainly suggest to the minister that he consider ensuring that these boards don't get too big administratively. That we don't get appointees on these boards who have a different basic philosophy for health care in the Province. We have to get a de-institutionalized attitude there. It's only going to come with the community. Because people out in the community themselves do have a great interest in health care. It's the cheapest and most efficient method of saving us costs down the road in the long term.

I know Health and Welfare Canada and the psychologists, through Dr. Ross, are doing an evaluation there. I'd also caution the minister and the department too, that evaluation of this project cannot be determined in the short term. It is a project that we have identified in that area, and Ms. Dawe is certainly aware of, that areas that cardiovascular problems and other health related things that impact, and you can only measure the effects upon people's lives in the long term, so hopefully we will not be too shortsighted to try to save short-term dollars at a very long-term cost that we will never get out of this dilemma that we are in now where we have spiralling health care costs.

We have to focus a fair share of our dollars that are going to be spent in health out in these specific areas, and I have grave concerns that these boards may work adversely to the specific direction that I would like to see health care move in this Province.

I would certainly appreciate your comments on that, and exactly what the department's feelings are.

DR. KITCHEN: I could not agree more. I agree totally with what you said, these boards have to be grass-roots boards, the people who are managing these boards have to be speaking for the people and carrying the message back for the people, and there may have to be subcommittees and things like that, because the whole purpose of community health care boards is not institutional care, which is provided by the professional, it is community health, which is provided partly by professionals but to a large extent by the enthusiasm and involvement of members in the community.

I thank you for your remarks and concur completely with them.

MR. CHAIRMAN: Ms. Young.

MS. YOUNG: I would like to pass my time at this point to Mr. Harris.

MR. CHAIRMAN: You cannot pass it to Mr. Harris. We have a list here. As much as I would like for you to be able to do that, Ms. Verge is the next one to speak.

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: Yes, but he came to me and asked to have his name put on. I told him where he was standing.

MS. VERGE: Ms. Young, would you like to have your say now?

MS. YOUNG: No, that is okay. I will go after you.

MS. VERGE: Okay. I have three or four questions I would like to ask, and I will try to do it quickly.

The Inter-Faith Home for Senior Citizens in Corner Brook, to which the minister alluded earlier, when will the government be altering that facility to convert it to properly provide high level - I think it is called Level III - nursing care?

DR. KITCHEN: I cannot answer that question. It is one of those that are being considered, but there are a number of others as well. We have not worked out the priorities there. I do not think it will be done immediately.

I think we have to look at the overall needs for institutional care in the whole area, and we have not done that. Also we want to look at the impact of appropriately applied home care, but there is no doubt that that home, if it is to be a nursing home, is going to have to be altered. I cannot say when. That depends on the budgeting, but it is on our list anyway.

MS. VERGE: Okay. It seems to me it was about three years ago that the Department of Health budgeted for a feasibility study, or `a` study, of the implications - the need, the cost and so on - of physically altering that complex so that it could serve the needs of the growing number of residents requiring nursing care - high level nursing care. Does the department have -

DR. KITCHEN: Have any figures?

MS. VERGE: Have a report, study results, and if so may I have a copy?

DR. KITCHEN: First of all, let us ask Ms. Bishop. Do you know if we have a study done indicating how much it will cost to renovate -

MS. VERGE: A study or a plan. Plan might be the word.

DR. KITCHEN: Plan and so on, yes.

MS. BISHOP: There was a review done and the planning was undertaken right to the design phase, and the cost was in the order of about $7 million if I remember correctly.

MS. VERGE: May I have a copy of the report?

MS. BISHOP: The report is with the Inter-Faith board right now.

MS. VERGE: Does the department not have a copy?

MS. BISHOP: We would have a copy on file - one copy, yes.

DR. KITCHEN: Let me check into it.

MS. BISHOP: We will check it, yes.

MS. VERGE: Thanks. A photocopy would be fine for me.

Is there a block amount of capital funding in these estimates, out of which, possibly, an allotment may be made for the Corner Brook Interfaith Home?

DR. KITCHEN: No, there is nothing in the estimates this year for planning or for anything for the Corner Brook Interfaith Home. There may be some minor adjustments that could be made - I think that is true. We do have a very small amount of kitty there, which, I suppose, if the doors blew off we could get it fixed or something like that but there is nothing for renovations of the Corner Brook Interfaith Home; I think that is correct.

MS. VERGE: The next question has to do with services for cancer patients outside the overpass and, in particular, in Western Newfoundland. As the minister knows, people throughout Western Newfoundland were very angry when the Cancer Outreach Clinic was cut back for seven months, from September until the election, through the loss of radiation specialists. For twenty years, radiation specialists, who had always, in this Province, been resident in St. John's, visited outreach clinics in three other parts of the Province on a regular basis. Those radiation specialist visits were suspended for seven months. I don't know if they have been fully reinstated to the former level - perhaps the minister can tell me. Have the Cancer Foundation radiation specialist visits to the outreach clinics in Corner Brook, in Grand Falls and in Burin been reinstated to the pre-September levels?

DR. KITCHEN: I will ask Dr. Williams to answer that. I know that they have been reinstated, but whether it is to the level that existed before or not, I am not sure. Dr. Williams can you answer that question?

DR. WILLIAMS: My understanding is that they have been reinstated and the plan was to reinstate them at the former level. They have a full compliment of radiation oncologists on staff now.

MS. VERGE: Is that six?

DR. WILLIAMS: No, there are radiation oncologists and medical oncologists.

MS. VERGE: Okay.

DR. WILLIAMS: Both treat cancer but one does it by radiation and the other by chemotherapy. The approved compliment is four radiation oncologists and two medical oncologists. The Foundation is still recruiting for medical oncologists.

MS. VERGE: Are the two medical oncologist positions now vacant?

DR. WILLIAMS: Yes, they are vacant.

MS. VERGE: But the four radiation oncologist positions are filled.

DR. WILLIAMS: The four radiation oncologist positions are filled with another radiation oncologist coming in July, I understand. There are a number of other positions called hematologist oncologist, who deal with leukemias and lymphomas, with what we call the non-solid tumours. But we are now looking for two - full compliment, would be two medical oncologists. They are currently recruiting and have been recruiting for awhile.

MS. VERGE: So you say the plan is to reinstate services at the outreach clinics to the pre-September level. Has that plan been implemented?

DR. WILLIAMS: They have already had clinics, I understand, in Central Newfoundland and in Corner Brook. They are planning to continue those clinics now that they are back up to four radiation oncologists.

MS. VERGE: Even with pre-September service, cancer patients throughout the Province have to come to St. John's for many services, for radiation therapy and for other services. These visits are costly for the patients alone to travel back and forth. It is expensive for them to stay in St. John's while they are getting radiation therapy. Often patients have to have six weeks of therapy and that means staying in St. John's for that length of time. Sometimes patients are not well enough to travel alone and a relative or friend has to accompany them. All of this travel and accommodation away from home is expensive. The Department of Health subsidy, first of all, is not widely known about. Physicians, in some cases, either don't know or don't tell their patients. Patients I have talked to have never been told about it. But even when people discover it, when they figure it out, they find that the amount of assistance is very low. It is only half of approved expenses above $500 a year. Cancer patients, more than most users of our health care system, I think just about everyone would agree, deserve to be assisted in every way, because they have a hard enough time coping with their illness. Will the government provide better levels of financial assistance to defray the cost of travel to St. John's for necessary treatment which is not available to most cancer patients in the Province in their home areas?

DR. KITCHEN: That is a good question and one that we have been trying to come to grips with, too, not solely cancer patients, but that is one group of people. As you said, the basic amount, anything over $500 that is spent in a year on transportation and accommodation and so on, is shared 50-50 and that comes to a fair amount for some people. We have a certain amount in the Budget and we have been exploring recently ways in which we might be able to help a bit more, because I agree with you, it is very harsh for people to have to impoverish themselves to receive necessary medical treatment because of transportation, and I believe it will always continue that way. It looks like the radiation will have to occur in St. John's and only St. John's, because of the extreme cost of this facility, and that means there have to be fair ways for people from outside to handle it.

A similar situation occurs - I don't want to take up too much of your time - having to do with drugs, too, where, people who have to take high-priced drugs, like diabetics and others, also have to pay for these, and they are outside the Medicare system. So there are certain unfair practices in our health care system which I hope we can address shortly, although there is no money for it in the Budget this year.

MS. VERGE: No. How much did the government spend last year on this program and how much is budgeted for this year?

DR. KITCHEN: That is here, somewhere. I will try to find that, ferret that one out for you.

MR. CHAIRMAN: The time has elapsed but, by leave, can they get an answer to that question?

AN HON. MEMBER: Sure.

DR. KITCHEN: Okay, the answer is $350,000 in the Budget, they tell me.

MR. CHAIRMAN: That is the answer.

MS. VERGE: How much was spent last year?

DR. KITCHEN: Last year, the amount of expenditure was $350,000, that is the revised estimates, and that is what we have put in for the Budget this year. In other words, we didn't change the formula, but if you are suggesting we should change the formula, we probably should.

MR. CHAIRMAN: Thank you.

Mr. Harris.

MR. HARRIS: Thank you.

Mr. Minister, I have a number of specific questions in, not necessarily related areas, but I will just go through them. First of all, in the area of Health Policy and Planning, which appears in the Estimates on page 252, I noticed that the appropriation for health policy has been decreasing from a budgeted 1992-1993 of $152,000 to an actual of $120,000 for that year, and an estimate for $106,000. And it strikes me, that in an area or a time of great changes in the health care system, and the great need for revision of policy and approach and to try to discover new ways, particularly in delivery of health care and the new policy initiatives required to go along with that, why are we having such a big appearance slide into almost nothingness, I suppose, when you get down to - it looks like there are two salaries there or perhaps one salary, I don't know, a very small amount of money directed towards the area of Health Policy. On the other hand, in the next vote there is $924,000 in the area of Health Human Resources Planning having to do with the availability of health human resources. I think at one time that used to be called going over to Europe and looking for doctors, and maybe it still is, I don't know.

Can you explain what these two areas are about and why you have such a large amount of money for one and so little for the other?

DR. KITCHEN: Well, the reason the amount for Health Policy has declined is that we had a lawyer employed there to help us prepare Cabinet papers and things like that and to flesh out some regulations. That was basically what he did. He has since gone on leave and we haven't filled the position, because we think that is one saving we can have. We have left there - I know the people's names but I don't know their titles. There are two people there, one is a secretary and one is a health policy co-ordinator. That is what that is. Everybody in the department is involved in policy, all the deputy ministers, assistant deputy ministers and others, as well. So it would be wrong to think that this is the only person who ever made any policy. He was really just fleshing out regulations, I think, and helping us draft the acts. There are people in Justice now who cover that for us.

DR. WILLIAMS: The technical aspects?

DR. KITCHEN: Yes, the technical aspect. Exactly.

Now, on the Health Human Resources Planning: There is quite a large sum of money into Allowances and Assistance, $771,000. That is basically what we pay institutions on the Mainland to train our physiotherapists, occupational therapists and our speech pathologists, and some bursaries that we give to the people who go away for these courses. They sign deals to come back into the Province. That is basically what that is.

MR. HARRIS: I am going to ask my annual question - I am sure the officials will be getting used to this by now - on the two areas that I have been asking about. One is the use of nurse practitioners. I know we have had the demonstration project ongoing now for a number of years. Perhaps we are at the point of getting some results from that that might be useful in the planning of changes in community health delivery. The other is in the area of the use of midwives and the development of a policy for this Province. We do have an act, we do have legislation, but we do not have a board, and one hasn't been appointed for many years. I believe Ontario has recently become the third province to develop a policy on nurse midwives for participating in a formal and recognized way in prenatal and delivery of babies, that type of care.

Could I receive a comment from the minister, or from officials, on where these two issues are at the moment?

DR. KITCHEN: You asked about nurse practitioners and midwives.

MR. HARRIS: Two separate issues now, nurse practitioners - you understand.

DR. KITCHEN: I understand. I don't think there is any move at the moment to replace obstetricians with midwives. I don't think very many people would want that. At the same time, I believe the issue is under study by the department and there should be a resolution to it. There is nobody jumping up and down on that point.

MR. HARRIS: I say to the minister - perhaps I should make it a little clearer - the initiative involving midwives and delivery of babies has nothing to do with replacing obstetricians with nurse midwives. It has to do with choices for women who are about to give birth. I had the same difficulty with the previous minister whose immediate reaction to that suggestion was that we thought we got rid of that years ago, and showed a misunderstanding of the approach.

We do have an active group of nurse midwives. We have a course put on at the school of nursing. We have a group of individuals who are trained. Yet we do not have a "place" for them in the health care system except, at the sufferance of individual doctors and individual hospitals, under certain circumstances. I have been told in previous years that the department is considering a policy change in this area, and I would just like to know whether that has developed in any respect.

DR. KITCHEN: Somebody should probably tell me, to what extent this has changed since last year, since the last time that question was asked, basically. Have we moved, are we still studying or have we dropped it?

DR WILLIAMS: We have a fairly broad-bases committee looking at the whole issue of midwifery in the Province. In the Province right now we have midwifery practiced in St. Anthony at the Curtis Hospital. That is a co-operative program between the midwives and the physicians. They physicians are in a supportive role and the midwives provide some prenatal and some postnatal care, as well as delivery for uncomplicated pregnancies. I think that is the program that is in place there.

We have, as I say, a broad-based committee that is vice-chaired by a representative from the department, one of our nursing consultants and a member of the provincial Prenatal Committee, looking at the whole issue of midwifery in Canada, seeing what they are doing in other provinces, looking at what is going on in the Province, looking at what the policy options and issues are. We want to make sure, obviously, when we look at that issue in some detail, that quality is assured to women who avail of that service.

The committee has a timeframe; I think it is March, 1994, within which to report. They have been given a timeframe. I think they started their work in February or so. We have an interim report in, but it is not a report dealing with policy, it is just a report dealing with the current situation in the Province and in Canada in general. It is a one-year project.

AN HON. MEMBER: Do you know the name of the committee?

DR. WILLIAMS: I will get the precise name, but certainly it is a committee on midwifery.

MR. HARRIS: Okay.

Let me ask about the vote for Drug Dependency Treatment Centres, page 255. It see that there is an increase of about $100,000 over last year's budgeted amount, and a little more over the actual expenditure providing for Humberwood and Talbot House.

Do these facilities provide treatment, residential treatment, I guess – is it mainly an alcohol-related program or is it for additions other than alcohol, as well? What kind of numbers; how many individuals can be accommodated at any one time in a facility?

DR. KITCHEN: I haven't been in the Humberwood facility. I visited Talbot House and mostly that is a detox centre, as I understand it. I don't believe there is any other drug treatment, but I ask Ms Dawe or the appropriate person to comment on what goes on in Talbot House. I believe Humberwood also basically deals with alcohol. Perhaps you would straighten me out on that.

MS DAWE: Thank you, Minister.

The Humberwood facility is a ten-bed, in-patient facility which provides the twenty-one day treatment for alcohol primarily. The detox centre here in St. John's, Talbot House, has twenty-one beds for men and women and is specific to detoxification.

MR. CHAIRMAN: Thank you, Mr. Harris. I now recognize Mr. Sullivan.

MR. SULLIVAN: Thank you, Mr. Chairman.

I was wondering if we have any statistics. We talked about MCP earlier, out Medical Care Plan, and we talked about the building and the total cost paid out, of course, as in proportion to visits, etc. I am wondering if the visitation rate is higher than in other provinces, the number of visits per capita, if you wanted to put it in a nutshell.

Do people avail of the medical care service, visit doctors more than people do in other provinces? That is basically my question.

DR. KITCHEN: Mr. Sullivan, I can't answer that question directly. As far as I know, our rates of utilization are not higher than other provinces. The one factor that we have in the province that other provinces don't have, is the very large number of salaried practitioners we have in Newfoundland, and we don't keep specific visits that people in rural Newfoundland would make to a salaried physician because we don't need that information for billing purposes, but our Province does not spend on inordinate amount of money on physicians' services in contract to other provinces. I think we are probably, the last time I saw, some years ago, at the lower end in terms of payments to physicians.

MR. SULLIVAN: Okay, thank you.

With reference to page 251, line item: 1.2.01, under General Administration, Executive Support, I see that there has been an increase in salaries for executive support; the revised amount last year was $549,600 and this year it is $572,700. Now, compared to 1991-1992, I guess that fiscal year, it was $463,400. Was there any specific reason for the increase in Executive Support – an increase from last year and a substantial increase from the previous year?

DR. KITCHEN: Thank you. The main reason for that, is that we have hired Mr. Hart as an assistant deputy minister in charge of finances and so on. We want to really strengthen that system. So that is his salary and that of his secretary. I thought you might also comment on how much the Minister's Office has gone down –

MR. SULLIVAN: I wouldn't dare.

DR. KITCHEN: - and compliment me on my frugality.

MR. SULLIVAN: We are trying to save administrative costs, I guess, in the Province and get more where it is really needed.

Earlier, there was a question asked and I missed the number – speaking quite low at the time – so maybe I will just get back to a specific question on Personal care Homes.

Was the figure used that we have 3,000 personal care home beds in the Province?

DR. KITCHEN: No, nursing homes.

MR. SULLIVAN: Those are nursing homes, okay. I thought you said personal care –

DR. KITCHEN: I think there are 1,300 Personal Care Homes or something like that. I think that is correct.

MR. SULLIVAN: Thirteen hundred personal care?

DR. WILLIAMS: Thirteen hundred and forty-six.

MR. SULLIVAN: Okay, and roughly 3,000 nursing home beds in the Province, would that be correct?

DR. KITCHEN: Yes, and some of those nursing homes – those are chronic care beds; some of them would be in hospitals and some would be in nursing homes. That is the chronic care component, I think.

MR. SULLIVAN: Did you say the need, the basic need is 2,360? It that correct? Ms Bishop, you said 2,360 I think –

MS BISHOP: Yes, Sir.

MR. SULLIVAN: - was the need, that we have a surplus of nursing home beds, really, in the Province.

MS BISHOP: That is correct.

MR. SULLIVAN: Could someone give me the specific figure on the cost involved with Personal Care Homes? I know, in Personal Care Homes you cover security and other related costs, and certain costs are picked up by the individual. What is the cost of keeping a person in a Personal Care Home in this Province, when you factor in all departmental-related costs? On per capita cost, I was wondering because I didn't have the number of people utilizing them before; we had the total expenditure but not the number.

DR. KITCHEN: On page 264 of the Estimates, the total vote for Personal Care Homes is $6.6 million and thenw ehave Revenue from Federal Government, $3.2 million and $240,000 from the residents, I guess, so that the net cost of Personal Care Homes is about $3,180,000.

MR. SULLIVAN: Yes, all I needed was – I thought you might have it at your fingertips but it can be worked out quite easily – the number of people availing of that and the total cost to keep a person in a Personal Care Home; that is really what I needed.

DR. KITCHEN: It is very little, actually, it is not?

MR. SULLIVAN: Parson me?

DR. KITCHEN: It is very little by comparison to the other figures.

MR. SULLIVAN: Yes. And currently, is there a waiting list on Personal Care Homes in the Province? Some Personal Care Homes are not full, I know that, but there is a single entry, too. I think it is based now and handled through the Department of Social Services, I believe. I know, Social Services cases are –

MS DAWE: The single entry system that we referred to earlier is going to be developed through the community health board so that a person requiring entrance to either a community-based services, a personal care home, or a nursing home, will be accessed and assessed through that single entry system. I think, what you may be referring to now, for the personal care homes, is a service conducted by Ms Bishop's division, at the moment. When the community health board is organized and in place, all entry to the system for continuing care then will be through the one source.

MR. SULLIVAN: Yes. It is my understanding now that if someone wishes to get into a personal care home and there is a vacancy in the community; they must first go through departmental channels and be directed naturally through there. Isn't that correct?

AN HON. MEMBER: (Inaudible).

MR. SULLIVAN: Also, in the nursing homes, too, it is my understanding that, I guess, as of this past year or two, instead of each of the nursing homes having their own individual waiting lists, there is now one waiting list; like the homes here around the city – St. Patrick's Mercy Homes and those homes, too.

MS DAWE: I think we have developed in St. John's a waiting list, tried to centralize the waiting list, in readiness for the introduction of single entry for the whole system in St. John's. It is not fully operational yet, because we are waiting for the St. John' Community Health Board to be established. But the waiting lists have all been purged in readiness for the single entry.

MR. SULLIVAN: Yes. But the board is not in place –

MS DAWE: No.

MR. SULLIVAN: - and there is sort of a single waiting list now, I understand. Each home is not operating its own respective lists at the moment. Would that be correct?

MS DAWE: No, they are at the moment. They still are operating their own.

MR. SULLIVAN: I have been informed differently, on enquiring.

MS DAWE: I think what you may be advised it that over the last year the nursing homes in St. John's have been working collectively to get ready for the single entry system. We have a proposal just received from them, collectively, in March past, to start the single entry system. But whereas the minister had announced in April, the St. John's Community Health Board was going to be established, that we didn't move ahead with any interim step. So I think that may be what they were referring to.

MR. SULLIVAN: Okay. So they are sort of at a transition stage, basically –

MR. DAWE: Yes.

MR. SULIVAN: - so it is not a complete flip over when the time occurs.

MS DAWE: No. The organizations have been working, as I said, for a year in the readiness for single entry.

MR. SULLIVAN: So it is possible that those community health boards may not be in place over the next several months. Is that possible, Minister?

DR. KITCHEN: I think several months may be a long time, depending on how quickly the House closes. It is up to you.

MR. SULLIVAN: It is partly up to you, too, Mr. Minister.

DR. KITCHEN: That is true.

MR. SULLIVAN: Another area in the Budget, too, that I am very concerned with, I guess, overall, is Prevention and Promotion. There is one section here dealing with prevention and promotion. Most of the costs associated with this, I would think, are in, I guess, publications and circulation of –

MR. CHAIRMAN: Mr. Sullivan's time has elapsed. By leave, can we let him ask that question and then get the minister's answer? Do we have leave?

SOME HON. MEMBERS: Agreed.

MR. CHAIRMAN: Carry on.

MR. SULLIVAN: Okay, thank you.

I guess most of the costs there are taken in the salaries for your publications – people on staff to distribute your circular?

DR. KITCHEN: Yes – somebody can correct me – I believe that is the figure that it costs to operate on institution down in Pleasantville which prints up the stuff like the public health brochures and things like that, promotion materials that are used.

MR. SULLIVAN: Yes, $109,000 is from the Salary Details. I was wondering, the remaining $90,000 approximately – does that involve somebody who is actively in the field of Promotion and Prevention – the remaining SALARY? It is that an allocation from someone's responsibility? Or is there a specific person assigned, other than those people in the Salary Details on Page 159, who is involved specifically with Promotion and Prevention?

DR. KITCHEN: Hang on now and we will get there.

MR. SULLIVAN: For example, just to clarify things, there are an administrative officer, offset press operator, health education assistant and typesetter. These four constitute $109,000 plus, and I am wondering: What does the remaining salary involve? Is there a person specifically in the Promotion and Prevention aspect whose sole responsibility it is to develop and get out to the public information and education material on this?

DR. KITCHEN: Now, I will have to think about that answer first. Let me just look up some notes that we have here, if I can find them.

The salary is the amount of $197,800 – that is the cone you are referring to?

MR. SULLIVAN: Yes, that is correct.

DR. KITCHEN: It includes the salary of the manger of the resource centre, health education assistant, one typesetter, one offset press operator, and temporary employees for production purposes and overtime – a total of give staff. Is that okay?

MR. SULLIVAN: Yes. It is mostly in the process aspect. My big concern was, I was wondering how much of that is going into special or professional people who have certain basic skills in the prevention and promotional aspect – not the production aspect? I guess that is picked up under another responsibility within the department?

DR. KITCHEN: Oh yes, that is – where would that be now?

MS DAWE: That is under Administration.

DR. KITCHEN: That would be under administrative and – over here on the other page, on the left-hand side of that same page, 254? That can't be right.

MS DAWE: No, the Administration, Sir.

DR. KITCHEN: Okay, let me get it right.

MR. SULLIVAN: Under Administration and Consultative Services?

DR. KITCHEN: That part, the consultants – the health consultants, the dieticians and people like that, the health promotion people, health educators would be included in 2.1.01 under Administration and Consultative Services at $1.350 million?

MR. SULLIVAN: Yes.

DR. KITCHEN: But, now all that money is not for them. There are other people, as well.

MR. SULLIVAN: No, they may have other responsibilities.

DR. KITCHEN: Yes.

MR. SULLIVAN: Is there a single, designated person responsible for the – there is?

AN HON. MEMBER: Yes.

MR. CHAIRMAN: Thank you, Mr. Sullivan.

I will now call on Ms Young.

MS YOUNG: Thank you, Mr. Chairman.

Mr. Chairman, as I recall, from the hospital board, there always seemed to be a shortage of psychiatrists to fill the positions. I wonder if that is still the case and what is being done?

The other question is regarding respite care. Are there enough beds to meet the demands? I know, especially in rural areas, it is especially in the rural areas, it is very difficult to get good care if you need a break. I am just wondering about that?

DR. KITCHEN: I will pass on the psychiatrist bit. I understand that there are, in certain parts, shortage of psychiatrists, but perhaps, Dr. Williams or Ms Dawe, you might be able to respond directly to that.

DR. WILLIAMS: There are a number of areas in the Province where we have shortages and psychiatry is probably the biggest area where we have shortages at present. In general practitioners, we have enough general practitioners but there is a distribution problem. In some of our specialties which we had shortages in some years ago, we are now in a balanced situation but in psychiatry we still have a shortage of psychiatrists. We have a training program at Memorial University which trains psychiatrists. We also have a bursary origami for psychiatrists. We also instituted just recently a program where physicians who have been out in the community and practiced for a number of years, perhaps they have a family and have expenses but want to get back and do psychiatry, we will top up their salary above that which a resident gets in independent practice. So, we have used a couple of physicians who have partaken of that program but it will be a few years before they are finished their training.

DR. KITCHEN: Ms Bishop, can you comment on the other question having to do with the respite care beds? I know there has been an increase in the number of respite care beds but maybe you would have more details than I would.

MS BISHOP: I do not have the exact amount and numbers of respite beds but I can get that number for you, if you wish, but all of the nursing homes in the Province do reserve one, two, to three beds for respite care. They use a rotational basis and people are booked to come in to these beds on a regular basis.

MS YOUNG: That is the questions I have for now.

MR. CHAIRMAN: Thank you. We are back to Mr. Sullivan again.

MR. LANGDON: Mr. Chairman. A point of order.

MR. CHAIRMAN: Point of order?

MR. LANGDON: I understand, probably I am out of order but I like to know the facts – Mr. Sullivan is not a regular member of the committee. It is my understand that the regular members of the committee as questions and if there are no other questions by the regular members than on leave, he is allowed to ask, is that right or wrong?

MR. CHAIRMAN: That is wrong according to the Standing Orders that we have here. Would you give me the Standing Orders?

MR. SULLIVAN: I guess on that point, Mr. Chairman, I would like to speak.

MR. CHAIRMAN: Well now, let me rule on the point of order because I would like to get it straight. It seems to me there is some misunderstanding about it, maybe I am interpreting it wrong and if I am I will have to ask the Clerk. But I say that under Standing Orders 84 to 89 for committees I see under 86(b), "Any member of the House who is not a member of a Standing Committee, may, unless the House of the committee concerned otherwise orders, take part in the public proceedings of the committee, but he may not vote or move any motion, nor shall he be part of any quorum". So as far as I am concerned, he has the same rights as you do, the only thing is that he cannot vote. Now that is according to the Standing Orders, that would be the ruling. Your point of order is well taken and I have ruled on it, carry on Mr. Sullivan.

MR. HARRIS: To the point of order, Mr. Chairman. I know we are having a recognition issue and having a speakers' list but it is proper for one speak to be on the list twice in a row before others? While other speakers are waiting to ask questions?

MR. CHAIRMAN: To the point of order, Mr. Harris, Mr. Sullivan was on and then it was Ms Young who had the right to have ten minutes if she wanted, she did not use it, then Mr. Sullivan indicated that he want to be on again. So, I assume that if we are going to follow the list we have to do it. So, I have recognized Mr. Sullivan.

MR. HARRIS: The question was, we may well be following a list but is it proper for the list to have one person on twice while there are other people waiting?

MR. CHAIRMAN: Well then you are listed again, Ms Verge is list after Mr. Sullivan and then you are listed again after Ms Verge.

MS VERGE: In defense of the Chair, he has been listing people in the order in which people ask to be on the list.

MR. HARRIS: Can you ask twice before you speak or can you only ask after you speak?

MR. CHAIRMAN: You ask after you speak.

MR. HARRIS: So, as soon as you are finished speaking –

MR. CHAIRMAN: If you want to get on again then you say you want to get on again because there is a list, there may be five other people ahead of you by that time.

MR. HARRIS: Sure. So in other words what you are saying is that if you want to get on the list, you should say it right away as soon as you finish, that you want to be on it again?

MR. CHAIRMAN: Yes.

MR. HARRIS: Okay.

MR. CHAIRMAN: To that point of order, there is no point of order, the list is good as far as the Chairman is concerned. Now back to you again this time, Mr. Sullivan.

MR. SULLIVAN: Thank you, Mr. Chairman. I would just like to clarify this, just for the sake of the members here. I spoke with the Chairman earlier and I certainly didn't want to hog any time. I just asked him the procedure he was following initially when I came here and I followed that. I would have probably preferred to go around in order, and if anybody doesn't have a question, pass, and go on to the next guy and come back again. I have no problem. I'm not on the committee as a critic and I appreciate the opportunity to ask questions. It wasn't my intention at all to hog the time but I had some questions to ask. I can patiently wait and come back for three nights and ask questions.

Under the drug subsidization, 3.2.01, page 258. There's a fair increase in the administration part there too of that budget. I also notice that there's a cutback of $110,000 federally in the budget, and there's $120,000 more being expended there. What would be the nature of the cutback? Have they stopped funding a certain aspect of that on a shared basis? Exactly why the decrease?

DR. KITCHEN: Now, let's see. That has to do with the Indigent drug program.

SOME HON. MEMBERS: (Inaudible).

DR. KITCHEN: Okay. I'm told that the reason the federal component is down is that there was an audit of claimed portion and that audit revealed that the salary cost was claimed in error. That's why it's been reduced. I don't know if that's an entirely satisfactory explanation but I can pursue it further if you like and let you know.

MR. SULLIVAN: No, that's fine. You probably received more than the amount the previous year and that was picked up, I guess, and it was applied against this year, I would assume. Would that be the case with the Medical Care Commission, administration cost also, on page 259? Medical Care Commission, 3.3.01. It's down from $149,000 to $17,000 federal? That's a substantial drop in federal contribution.

DR. KITCHEN: I note the net expenditure was further decreased by $149,000. That's the one you're referring to. Of federal revenue from the Canada Assistance Plan, on account of the sharable portion of administrative costs related to prior year dental services.

MR. SULLIVAN: To prior?

DR. KITCHEN: Prior year dental services. I don't quite know –

MR. SULLIVAN: Basically, an overpayment from previous year and upon audit they took their money back. Okay.

SOME HON. MEMBER: (Inaudible).

MR. SULLIVAN: Okay. I had a question on dental services. There has been a cutback I understand in certain dental services that were provided. Like with a certain service – I think it's Pierre Robin disease – I think a specific one that was funded.

AN HON. MEMBER: (Inaudible).

MR. SULLIVAN: Pardon?

AN HON. MEMBER: (Inaudible).

MR. SULLIVAN: Yes, there are various thing with certain – I think that's the specific name of the disease, I'm not sure, where certain adjustments had to be made on individuals – like a movement of the facial structure, the jaw might be receding, it probably has moved and various types of work assocait3ed with that, and some extraction or redirecting and (inaudible) of teeth. I understand some of the services have been eliminated now for some people and it may be done on a need basis. Would that be correct?

DR. KITCHEN: You're speaking of a specific procedure?

MR. SULLIVAN: Generally. That's just one specific one that I was aware of.

DR. KITCHEN: That is presently no longer covered?

MR. SULLIVAN: Yes.

DR. KITCHEN: What's covered now basically is children up to twelve and children under Social Services up to and including seventeen. That's right, isn't it?

AN HON. MEMBER: Yes.

DR. KITCHEN: Then there's a few other things done for adults, but not very much. Adult Social Service recipients are covered for extractions only to relive severe pain. That's about what's done.

MR. SULLIVAN: No, I'm referring to children under twelve.

DR. KITCHEN: Under twelve.

MR. SULLIVAN: A specific individual actually has approached me –

DR. KITCHEN: That is orthodontic treatment?

MR. SULLIVAN: Orthodontic treatment would have to be done. Orthodontic treatment is necessary for the person, who has some specific defects. He's has a tracheotomy and various things done. He's had some – I think – is it called Pierre Robin's disease, I believe is the term that's used. This person was told that he wouldn't receive treatment. He hasn't contracted Dr. Bowman yet, I don't think. I was going to follow upon that aspect. I only received the call today, actually, and I was going to follow up on that. It was indicated to him that it would not be covered for him. It would have to be I guess taken up with the Medical Care Commission. I was under the understanding that under twelve and special cases, various surgery would be covered. I didn't have a chance to research it any further but …

DR. KITCHEN: We could take that up with Dr. Bowden to see precisely if it is covered.

MR. SULLIVAN: I'm just wondering if it's universal or whether it's specific cases.

DR. KITHCEN: We had some problems with cleft palates there and that has been straightened out. So that's covered. I think that particular point that you're looking into should be brought to Dr. Bowden's attention just to see if that's covered or not. If it's not we'll have to take a look at it, perhaps.

MR. SULLIVAN: Yes. Okay. That's fine for now. Thank you.

MR. CHAIRMAN: It is 9:57 p.m. Decision time again. As these committees are constituted to serve for a three hour period, hopefully we will be able to conclude tonight. We have in the previous two meetings we had at this time decided that – I right now have two speakers. Ms Verge and Mr. Harris.

AN HON. MEMBER: I move we adjourn, Mr. Chairman.

MR. CHAIRMAN: In other words, you're saying that this Committee will not conclude tonight. Do we have a seconder for that? There's no seconder.

MS VERGE: I'll second the motion just for the purposes of discussion. From my own personal point of view I'd be satisfied with another ten minutes. Now if we can go around and see how much time members want we may be able to finish up by 10:30 p.m., which is what we've done in two previous meetings, so that we don't have to come back another time.

MR. SMITH: Mr. Chairman, if I could speak to that. I have no difficulty if Mr. Harris wants to have another go. But I think if Mr. Harris is looking for another half hour, I think the fact that, understandably, he couldn't be here tonight when we began, but I think it's unfair to expect that we would reconvene another night just to allow him more time to speak. I'm certainly prepared to have Ms Verge and Mr. Harris have another go, but not for us to come back another night.

MS VERGE: The Committee should examine departmental estimates until we are satisfied that we have sufficient information.

MR. CHAIRMAN: Well I think –

MS VERGE: But we have a block of fifteen hours to do give departments. So it's up to us how we allocate our time.

MR. CHAIRMAN: It's up to the Committee and the Committee is a creature to itself. So I think now – I've asked – the motion to adjourn has been called. We will adjourn? Those in favour?

AN HON. MEMBER: Aye.

MR. CHAIRMAN: Contrary-minded?

SOME HON. MEMBERS: Nay.

MR. CHAIRMAN: I think the ‘nays' have it.

MS VERGE: Why don't we just stay for the same as we did the last two meetings, for an extra half hour?

MR. HARRIS: I'd be prepared to stay an extra half hour. I realize I had other commitments earlier this evening, but I didn't anticipate that I would have difficulty getting more time than I had. So that's why I thought it'd be better if we had another meeting. It seems that other people who are not on the Committee are interested in participating and taking up the time of the Committee. I have no problem with that. It's certainly within the rules. But if we we're going to do that I just thought we would have another meeting on the Health department estimates to deal with all the questions that people seem to have.

MR. CHAIRMAN: The think about it is, you've made a motion to adjourn. We have a three hour limit. Now the situation, as I understand it, is the committees meet for the three hours and then if they're not concluded they can adjourn to meet another time. There are actually no riles, as I understand it. The Committee is a creature to itself. So it can make the decision that at the three hour time limit the motion can be made that the heads be passed. If they are passed and the majority carried there is three hours left to debate this in the House.

I know the rules are mute on it. There is no provision for the Committee. The ruling that we make will have to be one that would have to be examined, I suppose, to see that it is. As I understand it, we have the right as a committee to do this. It's not covered in the Standing Orders, so as a committee we have the right to control our own destiny.

AN HON. MEMBER: (Inaudible).

MR. HARRIS: I don't have an exact number, and I guess it partly depends on how long it takes to answer them. I don't think ten minutes will be sufficient.

AN HON. MEMBER: I recognize as well Mr. Harris has not had much time in the –

MR. CHAIRMAN: Ms Verge has just –

AN HON. MEMBER: Mr. Sullivan has indicated he's finished.

MR. CHAIRMAN: If Mr. Sullivan is finished – Ms Verge, can you cover it in tem minutes?

MS VERGE: I've got a couple of more questions that I'll ask very quickly.

AN HON. MEMBER: Mr. Harris should ask more if his first.

MR. CHAIRMAN: No, I think we should go on in the order that we arranged.

AN HON. MEMBER: You've got your order there, you're not going to change that.

MR. CHAIRMAN: No, I'm not going to change the order. I think what we'll do is we'll get and we'll assume that Ms Verge will clue up. Then Mr. Harris, if he wants an additional five minutes to clue up his questions, that will be fine. Then we'll conclude the headings on this Committee. Alright?

MS VERGE: Okay. I'd like to come back to the question of services for cancer patients in Western Newfoundland, but generally in areas outside the overpass, to use that cliché.

The minister said very glibly that he cost of having a radiation unit in Western Newfoundland is prohibitive. I've discussed this question with some people who are involved in providing specialized services to cancer patients, to physicians. I've been told that in the Maritime provinces there are two centres in Nova Scotia – Halifax and Sydney – two centres in New Brunswick – St. John and Moncton – and then Charlottetown in Prince Edward Island, which have radiation units; and that having a radiation unit in Corner Brook as well as a radiation unit or units in St. John's would be comparable.

I'd like to ask the minister if he would be prepared to study this question, to do a feasibility study of decentralizing the service in this Province. We have a huge territory. Our people are far-flung. It places a great strain on people in Western Newfoundland and other places remote from St. John's to have to come here for radiation treatment. As I indicated before, frequently patients have to spend six weeks at a time in St. John's getting radiation therapy. They are not in-patients. They live outside the hospital but have to go to the General Hospital or the cancer foundation space in the hospital every day to get treatment.

I understand that the Cancer Treatment Foundation, which is a creature of the provincial government and now located in the Health Science Complex, is embarking on building a $13 million complex in St. John's, a $13 million cancer clinic. It seems to me this may not be fair to people in other parts of the Province. Instead of rushing into one large central desirability of decentralizing, and perhaps build a $10 million clinic in St. John's and spend $3 million to place a radiation unit at Western Memorial Regional Hospital?

DR. KITCHEN: I have enquired about the possibility of decentralized radiation centres and the advice that I received, is that, it would not be feasible to offer appropriate radiation outside the city. Part of the problem is, where do you stop? If you put it in Corner Brook, what about the people who have to stay in either Corner Brook or St. John's for radiation, who live in Grand Falls or in Goose Bay? It is true that the people who live in Corner Brook would not be as inconvenienced as they are now, but the question also comes up as to the availability of radiation oncologists in Corner Brook and the cost of the equipment that would be necessary to service it, and so the advice that I got, was that this would not be an appropriate expenditure of government money.

MS VERGE: May I ask the minister, from whom he got the advice?

DR. KITCHEN: Yes, I got it from the Newfoundland Cancer Treatment And Research Foundation people. Dr. Williams, would you like to elaborate a bit on the types of clinics they have in Nova Scotia, in Prince Edward Island and in Sydney? Are they full-fledged radiation treatment centres, or what are they?

DR. WILLIAMS: Minister, to be honest with you, I can't comment in detail. I think the centre in Sydney is a new centre; something new that has just been developed recently. I am not sure if it is opened yet or planned to be opened. They have a centre, I think, in Moncton and a centre in St. John. Again, they are having, I think, more trouble right now than we are in staffing their radiation oncology service in New Brunswick. I think they had two radiation oncologists for the whole of New Brunswick and people were going to Maine, and that type of saw. Maybe they have improved their recruitment effort since then. I am not aware of what kind of service is going on in Prince Edward Island, to be honest with you, I haven't researched that.

MS VERGE: Yes. I would like to ask the minister if he wouldn't consider getting an objective assessment. Most bureaucrats in St. John's will recommend that they keep their empire right here at home with them, and I do not think that the minister can say he has properly probed this question, and I can tell the minister that a great number of people in Western Newfoundland, who spoke out publicly over the seven months that we lacked the periodic visits of St. John's-based radiation specialists, poured out their frustrations, and there is a considerable force of public opinion there who are not satisfied simply with having the radiation specialist visits reinstated, they want more, and I think those people – and there were thousands of them who signed petition – those people deserve, from the government, a thorough and fair consideration of their plea.

DR. KITCHEN: I agree that the treatment of serious disease should be handled in a fair way. When I received this advice, I took it as being appropriate. I will look further into it and see if there is any basis for or any justification for moving it. I do appreciate the inconvenience and the financial inconvenience and the problem about receiving treatment in St. John's. And possibly, we might look at the end of it, as I indicated earlier, as far as the cost is concerned. We already have some process in place to look at that but I will also have another look at the feasibility of having radiation treatment in centres other than St. John's.

MS VERGE: Thank you. That is all.

MR. CHAIRMAN: Thank you, Ms Verge.

I recognize Mr. Harris, and point out to him that he will have ten minutes and then he will be at the leave of the Committee after that.

MR. HARRIS: I suppose the Committee could move to adjourn right now if it wished, Mr. Chairman, but thank you.

MR. CHAIRMAN: Oh no, you have ten minutes.

MR. HARRIS: Let me go back to the questions I was asking when I ran out of time the last time concerning the Humberwood Treatment Centre, and perhaps the appropriate person to answer would be Ms Dawe, who might have the details. Is that facility at Humberwood, with the twenty-one day treatment program, fully utilized at the moment?

MS DAWE: Thank you, Mr. Harris.

Yes it is. To my knowledge, it is well utilized.

MR. HARRIS: And is there a continuing demand, or an increase? Is there a waiting period or whatever? I suppose waiting periods would be an appropriate thing even with alcohol treatment?

MS DAWE: Yes.

MR. HARRIS: There is, is there?

MS DAWE: There is a normal waiting period, but nothing that has – no increase in the normal waiting period over the last year, but the service is well utilized, yes.

MR. HARRIS: What about in areas of other drug dependencies? I know the department pays the cost of treatment in other provinces, and other services. Is that a regular program or is that a specialized program that must come under some other head of government cost?

MS DAWE: You are referring to the Donwood?

MR. HARRIS: The Donwood and other facilities is Ontario that I am aware of.

MS DAWE: That is not reflected in this category of drug dependency. What you see here, as I noted earlier, is strictly the in-patient unit at Humberwood and the detox centre here in St. John's

MR. HARRIS: Where would you find the cost of payment for out-of-Province services of that nature? It has been indicated that the cost the Province pays to provide treatment for non-alcohol drug dependency outside of the Province, the Donwood Institute or other institutes – Bellwood is another, and there are two or three others, one in Guelph, outside of the Province – where is the cost reflected of government providing that service?

DR. KITCHEN: It is on page 263 of the Estimates.

AN HON. MEMBER: Yes, Sir – Services outside the Province.

DR. KITCHEN: Services outside the Province – that would be in that $17 million amount there. It wouldn't all be for that, of course. That would be the cost we pay for any person we send outside the Province for treatment.

MR. HARRIS: So this is not the cost that we would pay, say if I were visiting Ontario and used OHIP services while I were there, or I were a student in Alberta. That is counted in that as well?

DR. WILLIAMS: Yes, Hospital services that if you are sick in another province and they treat you, they bill this Province. We do the same thing if somebody from Ontario gets sick in Newfoundland. We treat them here and bill the Province of Ontario.

MR. HARRIS: So, for example – I suppose Donwood is the one that seems to come to mind most often – a person getting access to that Donwood program, or gaining admission, I suppose, is the criteria, anybody who can gain admission to that program will have his services paid for by this Province's Department of Health. Is that the policy?

DR. KITCHEN: There are two kinds. There are people, I suppose, Newfoundlanders who are in Toronto touring, but what about people we send there? That is the question, isn't it? Do w send people? Must they go to Humberwood first? Is that the kind of thing you are asking?

MR. HARRIS: Well, I gather that Humberwood only deals with alcohol treatment program. But let us say, for example, if I were a person with a non-alcoholic addiction – or even if it were alcoholic – and I could gain admission to the Donwood Centre through my family physician or through whatever contacts one does for this, is that automatically paid for then, by the Newfoundland Government?

DR. KITCHEN: Dr. Williams, will you explain the procedure, please?

DR. WILLIAMS: Anybody who goes – and Donwood is considered a hospital facility – to a hospital facility in another Province, through a reciprocal billing arrangement with other provinces, the cost is covered. If somebody comes here or happens to get sick here we provide it and we bill them. If somebody does to Donwood then we will pay. People do not get into Donwood unless they are referred and assessed before they go in.

DR. KITCHEN: By us?

DR. WILLIAMS: Yes. We promote Humberwood as the provincial facility for alcohol problems in the Province. So, we get referrals to Humberwood from St. John's and other areas of the Province, not just the immediate Corner Brook area.

MR. HARRIS; When you say referred by us, do you mean by a medical practitioner in Newfoundland or by someone in the department?

DR. WILLIAMS: No, by a medical practitioner, by some medical practitioner in the Province.

MR. HARRIS: So as long as an individual medical practitioner says this person should have that type of treatment?

DR. KITCHEN: It must not be available in the Province, though is it? How does that work?

DR. WILLIAMS: For instance, it is the same as it somebody choose to go to Ontario to get their gall bladder out. If they can get into a hospital in Ontario and get their gall bladder out, even if it is not an emergency, we would pay. Under the Canada Health Act we have the right, we reviewed that issue to restrict out-of-Province referrals to emergency cases only and require prior approval by the Department of Health. That is something that other provinces have done and we will be looking into that I guess, Primrose.

MR. HARRIS: But as far as this particular service that we are talking about here, the drug dependency one, a referral from a physician in the Province is satisfactory?

DR. WILLIAMS: Yes.

MR. HARRIS: I don't think I got the full exposure of that question. The first question I asked about nurse practitioners and nurse mid-wives, they were two separate questions. I wonder if, Minister, you or one of your officials could tell the committee when we may have some new policy directions or something coming out of the demonstration project that we have had with nurse practitioners providing primary care. There has been a demonstration project, I believe it is in Trepassey, at what stage is that and do we have any results that are going to give us new directions in health care?

MS DAWE: You are referring to the primary care project of the Southern Shore. We do not necessarily refer to that as nurse practitioner program, it is the primary care project. The status of that project: as you know, it was a three year project due to be completed the end of March 1993. We have had a request from the nursing association and our St. John's health unit who are actually carrying out the practice, to have the project extended for another three months so that appropriate research can be undertaken. We have compiled with that request and provided the funding for the project for April, May and June. So the research project component will be completed the end of this month and reports submitted to the department, we hope, early Fall. We are awaiting the report on the three year project before taking further action.

MR. HARRIS: Is that kind of research project report that is of a scientific nature, something that you might see published in journals or that sort of thing? Is that something that is going to be made available for public discussion or is that an internal departmental document?

MS DAWE: No, to my knowledge this will be a document that we see will be made public. Professor Abe Ross at the University will be and is conducting the research. He recently held meetings with the public and the community health board in the area, the advisory board, to talk about preliminary findings. I think we all realize that the evaluation of that project will be mainly based on the process that has been undertaken over the last three years to involve the community, the community development process as opposed to any real outcomes in the change of health status, because the three year period is really too early to make these kinds of projections. So, the report we expect will be on the process and that process of community development is very much consistent with the whole philosophy of community health, involving the community in assessing needs, determining how resources should be utilized and programs and services and so on.

MR. HARRIS: Okay, thank you. Well I look forward to that because I understand that the process is very important and I think we can draw some conclusions about the overall health changes that will take place, even though you may not have the scientific results, if you can show an improved health life style and an improved choice is being made by people in terms of life style, nutrition and other aspects, so I look forward to seeing that.

I am interested in the appropriations, Mr. Minister, with respect to Pay Equity also on page 263. There is an amount voted for, of $6,235,000 –

MR. CHAIRMAN: I will point out now, Mr. Harris, that your official time has expired and you are now operating at the leave of the committee.

MR. HARRIS: It seems like I have been operating on the committee's leave all evening, Mr. Chairman, but nevertheless, the $6.235 million that is voted here, similar to the same budgeted amount in 92-93, is this an ongoing appropriation of the same – when I say the same pay equity – the same adjustments on an ongoing basis or is this a new amount that is being added to the adjustments for this year and then will be an ongoing expense for the department?

DR. KITCHEN: I believe it is ongoing but we have the Pay Equity person out in the common room and he will be in in about three seconds.

MR. HARRIS; Okay, maybe I will go to another question until that person comes back.

AN HON. MEMBER: (Inaudible).

MR. HARRIS: (Inaudible).

MR. HARRIS: In drug costs – I do not know if it is drug costs, Drug Subsidizations is listed here. Cystic Fibrosis: I see an increase in Allowances and Assistance for drug supplies and accessories for that particular disease, a significant increase and I am just wondering, is that a function of an increased incidents of cystic fibrosis or are we seeing the drug companies doing their usual extortion of – and I use it I suppose, figuratively – money from people out of drugs. Is that a major increase in drug costs there for new drugs or is this an increase in incidents and need?

DR. KITCHEN: What has happened is that people with cystic fibrosis are living longer under drugs, so that there are more people living longer with cystic fibrosis, not that the incident is increasing but they are living longer and that is largely the explanation for it, and there is a $30,000 in there as well for another thing that is grouped there that is called chronic neutropenia. There is a youngster in the Province who has that so $30,000 if that is to cover that.

MR. HARRIS: What is the disease?

DR. KITCHEN: Chronic neutropenia.

DR. WILLIAMS: (Inaudible) no number of cells that fight infection.

MR. HARRIS: So that is included in that?

DR. KITCHEN: That is $30,000 and the rest is basically what I just said, and there is some increase in cost of drugs but the major part is that people are living longer, consequently have to be on drugs longer.

MR. HARRIS: I see on page 258, we refer to certain people as Indigents. It was determined I believe last year we did not like. I think we all agreed that it was an inappropriate term.

MS VERGE: That was health prevention.

MR. HARRIS: Health prevention, oh yes –

MS VERGE: But I see it was changed this year, that was an improvement. There used to be a category of spending in the Department of Health called Health Prevention.

MR. HARRIS: Is that right?

DR. KITCHEN: So you would like the word ‘indigent' changed to ‘people on social assistance' or something like that?

MR. HARRIS: Well I do not know. It just seems to be a bit of a term that is not being used much anymore.

I notice that there have been significant increases there from last year. Would that be because of the number of people on social assistance increasing, Dr. Williams or Mr. Minister, or whoever wants to answer, I suppose – or is it the cost of the drug?

DR. KITCHEN: Well there are certainly more people on social assistance, but I do not know if that is the breakdown or not. Just a second now.

We do not have it broken down as to what proportion is due to the increased number of people on social assistance.

MR. HARRIS: But it is a combination of the increased cost of drugs plus the –

DR. KITCHEN: Yes, it is a combination. We probably should break it down and find out. It should not be too difficult to get a rough figure.

MR. HARRIS: Last year, I believe, we were able to at least discuss the increased cost of drugs. I believe it was running about 13 per cent last year, Dr. Williams. Is that a similar figure this year?

DR. WILLIAMS: It is usually in the double figures for most drug programs in Canada – not just this drug program, but for seniors drug programs. Basically it deals with the number of recipients. The number of recipients of social services has gone up given the economic situation. Number two, the number of senior citizens in the Province is increasing, so both drug programs increased because of increased utilization.

The other factor, of course, is the drug marketing and the newer drugs coming on the market that replace the other drugs. The newer drugs are always more expensive. We will be, through the joint management committee we have the Medical Association, trying to tackle the problem of appropriate utilization of drugs in terms of the prescriptions and prescribing practices, but also more importantly as well in terms of what kind of drugs physicians are writing. Maybe the first generation beta blocker for somebody with high blood pressure or schemic (?) heart disease might be just about as effective as a third generation beta blocker, and it is one-third the cost. These are the kinds of things we have to try to change, I think, utilization and prescribing practices.

The drug companies are very good at marketing the new product coming on the market.

MR. HARRIS: I suppose we can go back to the other question about pay equity. Do we have someone who is able to deal with that?

DR. KITCHEN: Your question was whether the $6.2 million was a continuation of pay equity of the program that was in place, or whether there has been a change in the pay equity program?

MR. HARRIS: Yes, perhaps you could explain what that $6 million is for, as opposed to the $6 million that was budgeted in 1992-93.

MR. SAUNDERS: The $6,235,000 that is in there in the current year is the cost anticipated for 1993-94 for the cost of the Pay Equity I study, the Health Care I that was done. There was a pay equity study done, Health Care I it was called. The result of that had, I think, a five year program of increases, and I think we are into the third year of those increases.

MR. HARRIS: So once this $6 million is spent, that then becomes a new appropriation for this year, but then next year that $6 million shows up in the general salary budget somewhere?

MR. SAUNDERS: No, all monies for pay equity are currently being voted in this activity in the Department of Health. In other words, all pay equity is being charged in here as at the present time, for all the public service.

MR. HARRIS: I do not follow that. You say there is a pay equity program, there is a five year adjustment being made, and the overall cost is $6 million in this year, and that makes adjustments just this year – not forever?

MR. SAUDNERS: It makes adjustments for the first three years of the five year increase. Next year, in 1994-95 this figure will have to increase again to take into account the fourth year increase as a result of the Pay Equity I study that was done.

MR. HARRIS: So that figure should go up. Could you explain why then it was only – it was $2 million underspent last year?

MR. SAUNDERS: Last year during the 1992-1993 Budget there was monies provided for two studies that we in there. One was the Pay Equity I study, and there was supposed to be another study done, Pay Equity II, which was supposed to deal with the nurse and the other professional staff. I think that one has not gone forward. There is no money provided in the current year's budget for Pay Equity II.

MR. HARRIS: When you say the study you mean the implementation of the results of the study, do you?

MR. SAUNDERS: I don't think the Pay Equity II study is finished.

MR. HARRIS: Though when you were referring to the study, when you say the Pay Equity I study, do you mean implementing the results of that study?

MR. SAUNDERS: Implementing the results of it, yes.

MR. HARRIS: Olay, thank you. That explains it for me. That's all I have, Mr. Chairman. I thank the Committee for the leave to continue to now.

MR. CHAIRMAN: Thank you, Mr. Harris. I'll now ask for the Clerk to call the heads.

AN HON. MEMBER: (Inaudible).

MR. CHAIRMAN: Yes, would you like to make the motion that we call it?

On motion, Department of Health, total heads, carried.

MR. CHAIRMAN: Very good. Before we adjourn there are a couple of little bits of housekeeping we have to do. We had a meeting last night down at the Legislative Chamber at the Colonial Building and we studied the estimates of the Department of education. I ask now for a motion that the minutes be adopted as amended. The Clerk has noted that the Member for Port au Port's name was omitted. So Mr. Smith, we'll ensure that you're on it and then I'll ask someone to move that those minutes be adopted.

MS VERGE: I think one of the officials of the department is left off too. Edna Turpin-Downey, ADM for Primary, Elementary and Secondary.

MR. CHAIRMAN: Olay. Would you just get it verified so we know who attended?

On motion, amended minutes of May 31 adopted as circulated.

MR. CHAIRMAN: Before I ask for the adjournment I'll point out that tomorrow night we are going to be back here again and we are going to be doing the Department of Justice. I point out again to members that the way we do it is if you want to get on the list, indicate – hold up your finger, or something – the Clerk or myself, between us we'll find out when you were there. Because we have a long list and it runs down, and that will make for a smoother operation. Thank you.

I would like to thank the minister and his staff for coming and answering the questions that were put forward by this Committee in such a diligent way. I must say, I'm very impressed with the way we're behaving now. It's a lot different than it used to be years ago. I thank you for coming, and I thank the Committee, and I now as for a motion to adjourn.

MS VERGE: Thank you.

The Committee adjourned.