April 3, 1995                                                     SOCIAL SERVICES ESTIMATES COMMITTEE


Pursuant to Standing Order 87, Gerald Smith, MHA Port au Port substitutes for Percy Barrett, MHA Bellevue.

The Committee met at 9:00 a.m. in the Colonial Building.

MR. CHAIRMAN (Oldford): Order, please!

This is the Social Services Estimates Committee responsible for social policy review. Today we are here to look at the Estimates for the Department of Health. We will begin by introducing the Committee, starting on my right with the Vice-Chairman. Members, I ask you to identify yourselves. If you are substituting for another member, please identify the member for whom you are substituting.

MR. HODDER: Harvey Hodder, the Member for Waterford - Kenmount.

MR. CAREEN: Nick Careen, the Member for Placentia.

MR. LANGDON: Oliver Langdon, the Member for Fortune - Hermitage.

MS. COWAN: Patt Cowan, the Member for Conception Bay South.

MR. SMITH: Gerald Smith, the Member for Port au Port. Today I am sitting in for Percy Barrett.

MR. CHAIRMAN: My name is Doug Oldford, the Member for Trinity North, and I am the chairperson.

I will ask the minister to introduce his staff in a few minutes, but first of all, I wanted to say to you that the recording technician is not familiar with either the members of the Committee or the witnesses, so he has asked me to have members and witnesses identify themselves when they either ask a question or respond. I want you to stick to that because he is not our regular recorder. Jack Oates, in the House of Assembly, would at least know the members of the Committee. Please stick to those rules.

I now call upon the minister to introduce his staff. The minister will have ten minutes for an opening statement and then I will have the Clerk call the first subhead. We will begin the questioning with Mr. Hodder, the Vice-Chairman. Having said that, I now call on the minister to introduce his officials and then we will allow him a ten-minute opening statement. Mr. Minister.

MR. L. MATTHEWS: Thank you, Mr. Chairman.

I am pleased, this morning, to introduce my officials, who are here for the Estimates hearing. On my near right is Deputy Minister, Dr. Robert Williams; seated next to him is the best looking one of the group that I brought this morning, Mrs. Joan Dawe, Assistant Deputy Minister, Community Health branch; on my far right is Roy Manuel, Director of Hospital Services, on my left, Chris Hart, Assistant Deputy Minister, Finance and Administration branch, and Gerry White, Assistant Deputy Minister for Policy, Planning and Drug Programs; sitting over there on the far side is John Downton, Director of Drug Program and Services; at the north end, Max Osmond, Director of Financial and Operational Services, and Kent Decker, Director of Institutional Financial Services. With an A-team like I have with me this morning, I don't anticipate that you will go away with any unanswered questions or any concerns that will not have been adequately addressed.

MR. CHAIRMAN: Is that an A-team or an `H-team'?

MR. L. MATTHEWS: It is an A-team, Mr. Chairman. `Chairperson', you prefer to be called, I note.

I feel comfortable with the people who are making up the Committee because I have the ultimate in friends on my right and I think I have some very good friends on my left. The Member for Placentia will be happy because he is going to get a new nursing home this year finished. The Member for Waterford - Kenmount is my own personal MHA, so I have every confidence that he will be -

SOME HON. MEMBERS: Hear, hear!

MR. L. MATTHEWS: I have every confidence that he will be gracious toward my staff and myself.

The Department of Health, as you would be aware, of course, is responsible basically for the delivery of all health care services within the Province of Newfoundland and Labrador. That covers a wide gamut of institutional and outside institutional activities that we engage in on a daily basis. We are responsible, of course, for all of the acute care hospitals. We are responsible for the long-term care facilities which are sometimes otherwise known as nursing homes. We have responsibility for the governance and the licensing, and that sort of thing, of the personal care homes that operate in the Province. In addition to that, we administer extensively through our Public Health Units, involved in the community-based services into the schools and into the communities by and large. They are involved quite heavily not only in prevention and education, immunization and public awareness-type activities, but they are also involved to some extent in the delivery of services to individuals at the community level that tie in with the Enriched Needs Program that up until this year, of course, was part of the mandate responsibility of Social Services.

In addition to that, we have full responsibility for the road ambulance and medical air services in the Province. We also have responsibility, of course, for the operation of the Medicare Commission and all that entails. On top of that, we are the only Province in Canada that has direct responsibility for the medical school that we have in our Province. Every other medical school in Canada falls under the responsibility and jurisdiction of the Department of Education or some other similar department. We are, at the moment, the only Province that maintains direct control of our medical school under the Department of Health.

Last year was a fairly active and busy year in the Department of Health. I went into the ministry about mid-year and the main activity that was ongoing at that particular time, of course, was trying to finalize the restructuring for administration and governance purposes of the new regional health care boards and the new community health care boards. I am happy to report that we have now concluded appointing all of these boards. All but three of them, as I reckon - three or four at the most - are up and running in that they have taken, officially, charge of their new mandate, and the governance in the new and expanded region that they have been given jurisdiction for. The other three or four boards that are not quite up-and-running but are active and getting organized, I anticipate will be on stream by June 1, and that will have us completely reorganized on both the community health care side and the institutional side for governance purposes. That activity is really only the beginning of the new and expanded role that these boards will be expected to play in the delivery of health care. I won't say any more about that; you may want to talk about it as we go through the proceedings this morning.

The 1995-'96 year will be an interesting year in the department. There are a number of things on the go that we will be directing our attention to. One of the things that we have been able to move forward on in this year's budget, the estimates that you have before you, is the continuation of the implementation of pay equity within the health care sector. We have to this year reflect upon the recommendations of the PRAG committee, which reported late last year. That was a committee which essentially looked at the availability of physician resources in the Province, the mix that we have, the mix that we should have, the areas in which they should be deployed in terms of giving us good coverage across the Province, and a lot of recommendations as to how we can achieve both the numbers and the mix and the deployment on a basis that will meet the health care needs of the Province.

We have been able to accomplish outside of the budget recently a package that seeks to address some of the inequities and some of the concerns of rural physicians in Newfoundland. Now, this was not a budgetary initiative. It was not covered in the budget, it was an initiative that I have been setting my mind to for the last three or four months, since I have been over in the department, and it coincidentally happens to have been approved by government within the last two weeks. We are pleased that we could achieve what we have in terms of the package for rural physicians.

One of the concerns I have had since I have been in the department and one which I have spent some time dealing with and dwelling on is the extent to which our medical school should be playing a role in providing physicians and physician resources for the Province. I have had a number of meetings with the outgoing Dean of the medical school, Dr. David Hawkins. I have had some casual discussions with Dr. Art May at the University. I have spent some time over at the medical school and in forums and events relating to the medical school and it is my own personal view and feeling to some extent, that we are not yet achieving, through the medical school, the provision of physician resources in the Province that we should be. We are not much different, in terms of retention of our own students than most other provinces are but that, in itself, does not satisfy me completely because I believe that the medical school, in the first instance, was brought into existence to help meet the needs of Newfoundland and it is my view that we need to revisit that concept if we are going to achieve what we need.

There will be a new Dean at the medical school we think within the next month or two because Dr. Hawkins, who is the present Dean, will be moving out of the Province. He has accepted a position elsewhere. I look forward to having some further dialogue and discussion with the people over there, with a view to seeing what we can do to get - if it takes this change in mind set and direction, so that rural students, rural Newfoundland would become again a matter of more urgent consideration in their admissions policy and in their overall operation over there.

We will continue this year to work with the new health care boards that are on stream and we will continue to work with the new community boards that we have brought into existence. You may be aware that one of the significant new programs that Health will be responsible for, for the first time this year, will be the delivery of the home care and enriched needs programs. Now, these programs, up until the end of fiscal '95 which was March 31, were the responsibility of the Department of Social Services. Government took a decision in the budgetary process that the delivery of these programs and responsibility for their further development and delivery would rest with, in the future, the Department of Health, and this will be a significant new activity in our department this year. We are in the process now, on a very fast track basis, attempting to gear up, if you will, staff up, so that we can take responsibility for those programs and get on with the job of delivering them within our mandate.

I think that is about all that I need to say except that also this year, for the first time, we are introducing two other programs on the prevention side or the preventive side. One is a hepatitis B immunization program which we will be initiating in the Grade 4 classroom stream this year. It is the first time that this program will have been run and we think that is significant in terms of prevention. We, of course, have a new strategy, developed last year, that is directed toward the whole very serious AIDS situation in the Province. It has a number of elements including education, information and not the least in importance also is attempting to deal with the families and the individuals who find themselves in a circumstance of having to deal with this unfortunate disease or sickness. The other thing that we will be doing this year for the first time is going with a fluoride mouthwash or mouth rinse program in Grades I to VI in our schools. This is a continuing part of our initiative in health to try to bring some additional preventative activities to the dental side of health care delivery. We believe that it will have long-term effects in the reduction of tooth decay and the other things that happen in the mouths of children whose teeth are not looked after properly otherwise.

I think I should probably stop there. I believe my ten minutes is up by my clock, not by the one up there. That hasn't moved since I've come. We could have a long day if we go by that one. I think that is about the extent of my time and so I will stop there and thank you for your attention. We will move on at the direction of the Chair.

MR. CHAIRMAN: Thank you, Mr. Minister.

We now go to Mr. Hodder.

MR. HODDER: Thank you, Mr. Chairman.

I'm not sure whether I will take up the ten minutes, but every time I say that I generally run out of time.

I would first of all like to apologize for the critic for the Department of Health, Loyola Sullivan, who, I'm sure we all understand, has other matters that he is considering these days. He has decided that he will not appear at either the House of Assembly or during these sessions, since he does not want to use the House or these public sessions for a forum in which he might be perceived as using these types of settings at this particular time, given the leadership contest that is on within our party.

I do have some issues that I wanted to bring forward. Some of them I am pleased to be able to support. I think I should start where the minister left off, and that is the initiatives that have been taken in terms of preventative medicine. Because all of the research that we have available to us tells us that a healthy public policy is the only way in which we are going to do anything long term. When the minister spoke of the initiatives in the Grade IV classroom hepatitis-B and the initiatives that are taken in dental care, these are positive actions. They should be supported by all members, they should be supported by the public. My only concern is that there are many other issues that we should be identifying and letting the people know what we really mean by a healthy public policy. Though it is in the jargon of the health care professionals, it certainly needs definition, it needs communication.

I would be pleased to support further initiatives on the area. For example, we should be doing a lot more to promote safety and something simple. It was brought up in the House last spring - the issue of bicycle helmets is something the Department of Health should be aggressively supporting. The idea of having roller blades and children getting hurt with no pads, no helmets, no protective equipment. The cost of one child being treated at the Janeway with a serious injury is far more than a good sound promotion policy. I looked at some commentary on that just a little while ago and I would recommend to the minister that he develop some kind of video, some kind of policy, talk to the children in the language they understand, namely cartoons. It is certainly a worthwhile initiative. I think it is something the Department of Health - regardless of what the Department of Works, Services and Transportation might be saying about it, this is a health issue. It is good dollars spent.

Going along with that concern as well, I think we have to see connections between every other department and the Department of Health. I compliment the department. It has been the leader in the government in terms of having its legislation reviewed by all different divisions of the government and in terms of initiatives. That certainly is a positive step forward. In some ways, this department is further ahead than some other departments of government. I compliment them for that. However, we all know that if you don't have good roads you are not going to have a good healthy public policy. Even just painting the sides of the highway with the white lines saves people from getting hurt. They know where they are in the fog. We have lots of fog in Newfoundland.

Certainly, I want to say to the officials and to the minister, you are going in the right direction. However, we are still spending too few dollars in preventative medicine. There are still too few dollars. We often look at the people who are already ill; and while that makes good public press, in the long term - I'm not saying we shouldn't attend to those needs, not at all - we save public dollars, keep people healthier, if we make them more aware of the things they do.

In that connection, I totally support the initiatives in terms of the anti-smoking legislation, you know, healthy places to eat. In fact, I've written several of the national chains when I've gone to restaurants and found that you can get into a smoking section a lot faster than you get into a non-smoking section. I've written several national chains complaining that non-smokers shouldn't have to wait longer than smokers. However, my colleague here doesn't necessarily agree with that. It is easy for me, I have never smoked, therefore I don't want to sound too sanctimonious; but I don't have these difficulties.

I would like to talk about AIDS education, and probably the minister can make some notes and we can chit-chat back and forth about it. Yesterday's paper again had the article about Conception Bay North. There is a certain amount of stigmatization occurring. While it may be based on fact, if you talk to some of the students in the schools in CBN you will find that there is a great deal of negativity occurring there. On the other hand, I was talking to some people in Conception Bay North just last week. They had a public information session to which only four people turned up. That is part of the problem. We still have the - it is not that the teenagers don't know. We haven't bridged the gap between knowledge and preventative actions. I don't know how we can do that but it certainly is a factor in that particular part of the Province. Yesterday, of course, we had the blood bank, and the recruitment policy there was carried in the paper as well.

The minister mentioned the transfer of the responsibility for personal care homes from Social Services to the Department of Health, the $20 million assigned to that. We would like to have the minister give some further commentary on how that is going to happen and give assurances that there will not be a reduction in care, and that this will be occurring with minimal disruption, that there will not be anxieties to staffing, there will not be any, shall we say, significant change to delivery of services, and the fact, of course, we would like to see improvement in services.

In terms of the care, I have to bring to the minister's attention the cutbacks that have occurred in some of the nursing homes, and in particular the effect it is having in some of the more acute facilities like the Miller Centre. Last week it was brought to my attention the low number of nurses, or care givers assigned, particularly in the evenings. Stories of seniors who are lying in bed for hours in very, very distressful conditions, wet and that kind of thing. I had a story told to me last week which is shocking and when it was investigated by the family the people in charge blamed it on cutbacks. I think we have to look at and make more rational the assignment of staff to certain of these centres.

The homes for ex-psychiatric patients which is a category here. It is a connection between your department and the Department of Social Services. We believe in the program, however, we have to have a greater co-ordination between justice, between health, and between social services. There has to be an assurance given to the public that we are on top of that kind of thing, and while incidents will happen - we do not want an incident to happen, period - but when they happen we should be assured that we as a government, or we in the sense of all of us in that sense, the government has to be assured that there are programs in place to assure the people who live in those neighbourhoods that these types of homes are not a threat to the quality of the neighbourhood.

It does not take much to make the gap between, shall we say, an acceptable home in a neighbourhood and one that is not acceptable. From my years in municipal government I can tell you that there is a very fine line and everything goes well until something happens, then you suddenly have it played in the media and you tend to have a lot of unexplained things because after awhile you can do all the explaining you want and people will not accept the rationale, in other words. We need to look at that.

The special needs assistance for residents who are required to travel out of Province for transplants. I see there is an allocation here for that, and that is an area where I think we should look at having some better guidelines.

It grieves me that we have to have people who have been approved for transplants and then we have to rely on community agencies to try to do fund-raising, to try to help out, to try to ease the financial burdens. There is some provision here, but if you look at the total amount there are no great big dollars in terms of the need.

That is not to say that people should not have to have some responsibility for these costs, but at the same time we have to be aware of the fact that families are suffering, the patient himself or herself is suffering, and often the additional pain is brought on by the lack of finances.

Mr. Chairman, I will leave it at that. I do have some other areas I will get to in the subheads.

MR. CHAIRMAN: I want to remind you that our ten minutes includes questions and answers in response, but we will consider yours to be an opening statement on your side. We will go to Mr. Smith for questioning. Maybe throughout the morning you will have an opportunity to respond to some of Mr. Hodder's concerns. Mr. Smith.

MR. SMITH: Thank you, Mr. Chairman.

MR. CHAIRMAN: You have ten minutes, including questions and responses.

MR. SMITH: Thank you, I'm sure that will be adequate. Mr. Minister, maybe if you could just elaborate a little more. You referenced in your opening remarks this fluoride mouth rinse program that the department is initiating. What is that going to involve? You mentioned the grades, so I assume it is going to be administered in the school. By whom and when will this be taking place?

MR. L. MATTHEWS: It will be administered in the schools in the first instance, the introduction of it, by our public health units with the public health nurses. It is essentially something that used to be done, I guess, in the dentist's office. You would go in and you could have a fluoride treatment type of thing. The concept is to get it into the schools so that every child will benefit from the fluoride mouth wash so that it is not restricted in terms of benefit to just children who would otherwise go to a dentist. Every child will get the opportunity to have fluoride mouthwash administered to them every year from Grades I to VI. It is really a preventative type of program. It is not designed to cure anything or correct anything. It is basically designed to be a preventative agency. That will be commencing this September and throughout this school year and on into the future school years.

My Deputy Minister reminds me that it has already started actually in Central Newfoundland this year as a sort of pilot project type thing.

MR. SMITH: What is the cost of that program?

MR. L. MATTHEWS: The cost of the program - I'm not sure what the exact cost is, probably - Mrs. Dawe?

MRS. DAWE: (Inaudible).

MR. L. MATTHEWS: She says about $375,000 for the Province. The program is sort of developed in conjunction with the assistance that we give through the dental program in our budget. You will notice that in the Estimates the dental program was reduced. It was one of the few things that was reduced in our Estimates, and I would tell you that up front, from last year's budget, from $5.7 million to $5.2 million. We believe that shifting resources in this area - which is something that the dentists endorse, by the way, and the dental association agrees with - is an appropriate thing to do. They didn't say: Do that and reduce the budget that you are going to spend on dental care, but they certainly appreciate the appropriateness of the fluoride mouthwash program. It is one of the many initiatives that are ongoing in terms of prevention within the schools. It is just an add-on to many of the other things that we are doing, really.

MR. SMITH: Thank you, Mr. Minister. The other thing I had under subhead 3.3.03 relates to the dental services and you just referenced the fact that there is a reduction there in the amount that is budgeted this year. How will that translate?

MR. L. MATTHEWS: How will it translate into services that will be affected?

MR. SMITH: Yes.

MR. L. MATTHEWS: The child dental program is a program that covers a number of things. It covers things like two dental visits a year per child up to the age of twelve, I think it is. It covers fillings and cleaning, that sort of thing, up to a certain cost. What is covered by the program doesn't necessarily cover what the dentist wants to charge. Sometimes the dentists, of course, because they are not covered under Medicare, they can top up the billing, but basically it provides for a basic program of prevention and maintenance for children up to age twelve. The fact that we have reduced it by $500,000 this year is really the emphasizing of what we do in the surgery, and trying to bring the prevention aspect of it back so that all kids get the benefit of it right back to the classroom. So that part of the program that might be delivered in the dentist's office may change this year because we are doing it in the schools, and if there are any other minor adjustments that have to be made in terms of coverage, then we will work that out, as has always been done with the Dental Association. The Dental Association is very much involved in the development and the composition of what is covered under that particular program.

MR. SMITH: Under subhead 3.2.02, Indigents, in terms of the prescription drugs, I note there is budgeted a significant increase, and I would assume that this reflects an anticipated increase in the caseload for the Department of Social Services this year?

MR. L. MATTHEWS: 3.2.02?

MR. SMITH: Yes. Last year you budgeted $32.5 million, the revised was $33 million, and this year you are budgeting $34,745,000. I am asking if this -

MR. L. MATTHEWS: It is a 6 per cent increase over last year. What page is that on in your estimates?

MR. SMITH: I am sorry, page 232.

I guess my question is: Does that reflect an increase, or an anticipated increase, in the cost of the drugs themselves, or is that anticipating an increase in demand in terms of if it would mean -

MR. L. MATTHEWS: It is a provision for an anticipated increase in utilization. That is basically why that increase exists in the vote. As I say, that is the basis on which the estimates were developed, and we anticipate a higher level of usage for the program.

I guess we have an aging population, a population that is getting older. Not only that, people live longer on average as time goes on, so that translates into higher percentages of our budget being spent on the maintenance of seniors as opposed to (inaudible).

MR. SMITH: But this particular subhead relates to support to indigents, so does that -

MR. L. MATTHEWS: Oh, yes, under social services.

MR. SMITH: Yes.

MR. L. MATTHEWS: Yes, and the same thing there. Social services were expecting provincially, I think, an increase in workload. We have already had an increase this year, and the projection is that the caseload for social services will continue to increase this year as a result of all of the not so good things that are happening out there with people coming off TAGS and all that sort of thing, so it is a provision for that anticipated utilization in the program.

MR. SMITH: Okay, thank you, Mr. Minister, that was my question on that. Section 3.4.02 the Road Ambulance Program, I notice that the department has budgeted a slight increase -

AN HON. MEMBER: (Inaudible).

MR. SMITH: My question there is a general question. Having had some experience in working with establishing an ambulance service in my own area of the Province where I live, the fund-raising end of it and also trying to maintain the service after, my question is, in terms right now of looking at the provincial perspective, how adequate is the level of ambulance service that we are providing within the Province right now?

MR. L. MATTHEWS: The Road Ambulance Program is one that has undergone a complete review in the last year. In less than the last month actually, Assistant Deputy Minister Hart has presented me with a report on a number of aspects of the road ambulance program. What we are doing is really looking at things like standards, we are looking at things like coverage, we are looking at things like cost effectiveness and all of these sorts of things have been revisited in the road ambulance program. We have some gaps in certain areas in terms of service, we are trying to adjust these.

We don't feel that generally the levels of training for attendants on ambulances is as high as it should be so we have some recommendations going forward to government to try and enhance training levels from Attendants I and Attendants II up to EMA Is to EMA IIs which are really medical assistants. This is the highest level of training provided for ambulance attendants in the country really. We have some of these now at the Health Sciences and some of the other areas but in terms of maintaining the Road Ambulance Service, at the moment we feel that - the department and I have met just recently with the independent road ambulance operators - there is really no serious gaps in terms of service. They would all like to get a little extra for what they do like everybody else who does anything in the health care system or any other part of government these days but we feel the funding that is in place is sufficient to provide.

You are talking about I guess the community base services because there are really three types of operators for ambulances in the Province; one is the hospital base, the second one is the private operators and the third one is the community based services. Where a community based service gets into trouble because of not being able to fully fund their operation they come to us and we deal with them on an individual basis and if we have to render additional assistance to them to get them through, we do that. So we are more than sympathetic, we are responsive to the community based services. In particular, knowing that they are operating in an area where there is not always a lot of utilization but yet they want to ensure that a service is available for whenever it is needed.

MR. CHAIRMAN: Thank you, Mr. Minister. Mr. Smith your time is up. We will have to go to Mr. Careen.

MR. SMITH: Mr. Chairman, if I could? I have just one other question, by leave if I could, and I won't ask any more questions this morning because that would exhaust what I have here and -

MR. CHAIRMAN: Is that okay?

AN HON. MEMBER: (Inaudible).

MR. SMITH: - because it is in keeping with this one.

MR. CHAIRMAN: Sure, alright.

MR. SMITH: It relates again to the community based services. When you are talking about the standard of service and that sort of thing like that, I appreciate that the community based service, from my own experience, is run by volunteers. Now one of the big problems with that program is being able to avail of the necessary training. I was involved in the beginning and I did the Level I training myself.

The department did show some flexibility at that time but later we did have to put some pressure on in terms of making it available in the evenings because people who are doing this as a volunteer still have to make a living. Now, in order to do the Level 11, which is a little more intensive, these people have to somehow get time off from their work and go away for an extended period of time to do the training. Keeping in mind we are talking volunteers, and at the present time and into the foreseeable future, I do not see anyway that this government or any future governments will be able to put in place fully funded service in all of the rural areas of the Province, so I am wondering in line with that, is your department, and are the officials within your department looking at some ways where they can be a little more innovative in how they deliver this training?

I think we all share the concern that, even if it is a volunteer service, I like to think that if I am picked up by an ambulance at some time there will be somebody there who will know something about what they are doing. We are all coming from the same perspective on that but you can appreciate the situation, if you are talking volunteers it is a bit different. These are people who do other things during the daytime and really the only time they would be available for training would be in the evening. I think it is something that has to be addressed because from my own experience it is not - I cannot say for today, but it certainly was not within the last few years adequately addressed.

I am just wondering where, in terms of your department, where the thinking is now with regards to that?

MR. L. MATTHEWS: Well, we contract out for the most part the training to St. John's Ambulance. I guess your specific question was regarding the flexibility of training, the availability of it?

MR. SMITH: Yes.

MR. L. MATTHEWS: I do not know if that has ever been discussed, the problem in terms of when the training is available. It is more the levels of training that should be available and the levels to which we want to build up to. We have in this report that was just developed a concept of what level all of these ambulance attendants should be trained up to, and we are proposing a slightly lower level of training for community based services, given the fact they are volunteers, and also given the fact that community based services for the most part have a mandate to operate within their own local area.

Their mandate is really to take a person to the nearest health care clinic or hospital that is appropriate, and then if there is a transfer to be done once the patient is stabilized from that setting, the transfer gets done at the direction of the health care clinic or the hospital on further.

MR. SMITH: But at the same time we are talking about an emergency service. A lot of these people who are being picked up are people who have been involved in accidents and it is a crucial period of time. For instance in my own situation, just transport alone, can be anywhere from forty-five minutes to one hour and fifteen minutes. Now, that is kind of a crucial period of time which means that those people who are first there can make the difference in that person surviving or not, so in terms of the broad question, as to the level of care that is provided, and accepting as a given, that if we are to have any service at all in these areas it has to be provided by volunteers, and we do not have the resources to go out and fully fund it.

Right now you cannot entice private operators to come in because it is just not worthwhile for them, but to me it is key that we be concerned about that level of training. I am not active with the committee now in my community, other than the fact that I talk to them on a regular basis, but I was on the understanding that they had been advised that the minimum now will be Level 11. Is that correct?

MR. L. MATTHEWS: There are a whole new series of levels of training that we are proposing to government, and this is a report that was just developed in the last week or two. Now, Mr. Hart our Assistant Deputy is involved in this program and is going to comment on what we are trying to build up to in terms of levels of training.

MR. HART: Christopher Hart, ADM in Finance and Administration, and I am also responsible for the Road Ambulance Program which is somewhat outside the normal realm of finance, however, I have taken it on with some great interest.

As the minister has mentioned we have over the last year or so, really - it has been a fairly major initiative - we've looked at implementing standards for the Road Ambulance Program. Initially what we had thought was that there should be one uniform standard, but we had the same concerns that you had. At the end of the day we realized that to implement a similar standard for volunteers as for the private operators, you would be imposing an impractical, I guess, and unrealistic regimen on them.

What we decided through this, in order to get our standards in place, that we would accept a somewhat lower level of standard for the community operators in recognition of the fact that they were as you said volunteers, and as Mr. Matthews pointed out, that they are the first line of getting to the patient. Their major responsibility is for getting the patient to the nearest medical services where they can be properly administered medically.

As a result of that we've cut back somewhat the standards but at the same time we've recognized that we want, eventually, to get to the highest possible standards. One of the things we've done is with the private operators we've said that the training standard is an EMA. For the community-based, we are saying it is an attendant II level. Which is somewhat less, but at the same time we are saying that for each community service we are asking that there be one person trained at an EMA level - just one - so that one person in that community then would be there to give in-house training sessions, that sort of a thing. We are trying to build it up in that respect.

The other side, when you get down to the actual training, we also recognize that it is difficult for these volunteers to take the time and to take a week or two or whatever it takes to get up to that level. What we are looking at - we haven't worked out the details of that - but we are fully aware that we are going to be looking at other ways of delivering that outside of the traditional methods, through the St. John Ambulance and that sort of thing. The Health Sciences does a lot of EMA training for us. What we are looking at is, is there some way we can bring the training to the communities? We will be entering into discussions I guess with the Department of Education and Training to see if we can get some involvement through the colleges system and that sort of thing.

It is not carved in stone exactly how we are going to do it but we are very flexible on it. We do recognize the problems inherent with the volunteers, and we also recognize the valuable service that they provide. We are working towards that end.

MR. SMITH: That would be my final comment with regards to that. That the department and all of us be cognizant at all times of the very valuable service that these volunteers are providing in terms of that particular aspect of health care in the Province.

MR. HART: The other thing I should mention is that just last summer, because of some of the ongoing problems that we have, we supported a development of an association for the community operators. I'm pleased to say that is now in effect and has been since last June. We are now actively meeting with them as well as the private operators and dealing with issues specific to them.

One of the other major issues with the community or volunteer operators is that of funding. A lot of them are funded at levels, as Mr. Matthews pointed out, that sometimes makes it difficult, because they are not in a high-volume area, and relying on the funding coming from the department is not always enough to make them viable. We have addressed concerns in the past but we have just received a proposal from the community operators as a means of providing a funding on a different basis. We are studying that and we are going to try to come up with some better way of funding them within available resources. Because we always have to be cognizant of our financial considerations and that sort of thing.

MR. L. MATTHEWS: Thanks, Chris. The other thing, just to clue that one up, I guess, is that if we can use distance education we are open to that concept. What we are working toward - in the context of the regionalization of the health care system and the new health care boards that are put in place, it is my view that really the operation of ambulances are an extension of the work of the emergency departments of hospitals, to a large extent, and part of the concept of trying to bring higher standards to the business and a better rationalization of resources to the service is consistent with our thinking that eventually, probably the operation of ambulances generally should be moved out as a responsibility also of the new health care boards.

Right now, as you know, we have the three levels, the three operators. We have the hospitals who operate the services, we have the community-based people, and we have the private ambulance operators, and they are not always completely in sync in terms of the way they think and their mandate for operating. So that is the long-range view, that these ambulance services should, once we get them up to snuff, if you like, in terms of training levels and rationalization of services, put them under the new health care boards that have an expanded mandate.

Thank you.

MR. SMITH: Thank you, Mr. Minister. Thank you, Mr. Chairman.

MR. CHAIRMAN: Mr. Careen.

MR. CAREEN: Good morning. Just a little bit on the ambulance bit, it is always nice to be exploring things like efficiency. It is not your department, but we still have to maintain good roads for those ambulances to drive over. The way everything is going, with $15 million less going into road construction this year, the ambulance drivers and the poor patients are going to have a rough ride. Anyway, that is another story.

Minister, last year two - three - psychiatrists left this Province to relocate elsewhere in North America. I think there is another man, a senior fellow, who is part-time, and we are given to believe that two out of every five Canadians, or three out of five Canadians, see a psychiatrist some time in their lives. Have you bridged that gap since those people have left? Do we have new people in?

MR. L. MATTHEWS: In psychiatric services?

MR. CAREEN: Yes, Sir.

MR. L. MATTHEWS: Psychiatrists.

MR. CAREEN: Yes.

MR. L. MATTHEWS: Well, there is always a movement of doctors in and out of the Province, and around the Province, and specialists are usually harder to attract and retain because of our ability, number one, to pay them what they might get somewhere else, and secondly, I suppose, because geographically we are not located in the most favourable or enticing spot in the world.

In the urban centres, for the most part, particularly the St. John's area here, we have what we deem to be more than an adequate supply of psychiatric services, psychiatric doctors and that sort of thing. For a long time there has been some difficulty on the West Coast, the Corner Brook area, in retaining psychiatrists. Since December, they have been able to attract - whereas they only had one, I think, for the last year or two, I think they have at least two new psychiatrists on staff there now, and probably a third one heading, so they have significantly improved what they have been able to do on the West Coast. Now, that is not to say that they have enough based on population and need, but outside of the shortage that we have - I think it is fair to say still a shortage of being able to provide what we would deem adequate services for children at the Janeway. Outside of that situation we have a pretty fair supply of psychiatrists.

Now PRAG recommends that we need seventy or seventy-five psychiatrists in the Province. At the moment we have how many - forty?

AN OFFICIAL: (Inaudible).

MR. L. MATTHEWS: The officials point out to me that we did go down, and as a result of that we put some money into the psychiatrists' salary budget last year. It was $115,000 last year and there is an extra $280,000 going into the incentive package for psychiatrists this year. So, while we have certain urban areas where we have pretty good coverage, overall you are right, we do have some shortages and we are addressing them in terms of the financial incentives we are offering. Now, financial incentives will help, but this kind of money will not overnight attract enough resources to give us the full coverage that we need.

We have shortages in the area of specialists, not only in psychiatry but in some other areas. General practitioners - we have enough GPs in the Province if only we could get them spread out properly, but in terms of specialists we do have some inadequacies of service in certain areas of the Province.

MR. CAREEN: Specialists are very important. I mean, a doctor is very important. Health is a wealth. I was concerned because all of us here have friends or relatives who have sometime in their lives needed a psychiatrist. If someone has a broken arm or that kind of thing, you can help him along a bit, but if it is something with the head where you have to try to kick start him in the morning - I am very concerned about the shortage of that type of speciality.

The incident you mentioned at the Janeway, that was another thing, too. I am not going to the nth degree of what you were saying about PRAG, that these fellows said there should be seventy-five, and that is utopia and all this kind of stuff, I am just talking about a measure to spread it around. Is the Janeway still short?

MR. L. MATTHEWS: We still have some difficulties there in terms of providing services quickly. I am going to ask my deputy to speak to that because he is a little more familiar, having worked over the years to try to bring that up to a proper level.

DR. WILLIAMS: The area of psychiatry and the area of medical oncology are the two areas of the Province in which we are most short of specialists. There is a worldwide shortage of medical oncologists and there is a shortage of psychiatrists. I think the number of oncology cases is increasing as the population ages and there are only certain centres that train oncologists. We may not be training enough to keep up with the demand over time. An oncologist is a person who treats cancer, who specializes in cancer, chemotherapy, this type of thing.

MR. L. MATTHEWS: On a medical basis rather than a radiation basis.

DR. WILLIAMS: There are radiation oncologists and medical oncologists. There are two groups of oncologists. One treats people with radiotherapy and the other treats people with chemotherapy, so they have to have a detailed knowledge. You usually have to train as an internist and then go on and sub-specialize in medical oncology, so there is a shortage and they are difficult to recruit.

The other area is psychiatry. In rural Canada, for instance, in Ontario, in the golden triangle, I guess, probably between Windsor and Kingston, in that area, there seems to be enough psychiatrists, but in places like Sudbury, which are large places but they are a little bit outside the area, they have shortages of psychiatrists and they have to bring them over from Ireland and England. That is my experience when talking with Ontario. We have a shortage of psychiatrists in Newfoundland. We put in an incentive package last year in an attempt to recruit psychiatrists. We want to maintain a viable training program here at Memorial University for psychiatrists. We increased the intake into that program from twelve to sixteen some four or five years ago. So we are able to -we have a normal stream going through and on an average, trained four psychiatrist a year. We have a reasonably good bursary system where we give psychiatrists a grant of $12,500 a year, I am told, and in return they will practice in Newfoundland, and that has been somewhat successful.

As the minister pointed out, we are enhancing the salary scale for psychiatrists in terms of a bonus - if they stay for a year they will get a bonus on scale. Also, for the people who serve a psychiatrist, we are making some adjustments to these scales in an attempt to make it more competitive with other parts of Canada. But we did have a shortage. We were concerned with the number of psychiatrists, we went from thirty-three down to twenty-nine last year. We were worried about our maintaining the viability of a training program at Memorial, so we put these measures in place. I understand, second-hand, from talking with the person who is acting Chair of psychiatry at Memorial that he has identified three or four new people for the program. We have added another child psychiatrist at the Janeway. We are now up to four at the Janeway. So we are making some progress but that area is difficult and as well, the medical and oncology areas are difficult. Other areas have a problem with radiation oncologists but so far we haven't had that problem. We have five radiation oncologists in the Province but we are looking for medical oncologists.

MR. L. MATTHEWS: We have Newfoundland Cancer Foundation Treatment, they have a medical oncologist on the way - have they not identified one?

DR. WILLIAMS: They are interviewing people and we are hoping that it is going to bear some fruit.

MR. CAREEN: Minister, in your opening statements, you mentioned approaching MUN Faculty of Medicine, trying to make it more attractive - you were on a number of weeks ago trying to make it more attractive to -

MR. CHAIRMAN: Could you speak louder, please?

MR. CAREEN: That is the first time I have ever been told to speak louder. It's Monday morning.

A number of weeks ago you mentioned in your opening remarks about trying to make it more attractive to Newfoundland medical students to stay here. We were hoping we would see here a bunch of Newfoundlanders and I still hear some of them say, `I'd sooner stay home on one meal a day than be on the mainland for three.' How is it working so far?

MR. L. MATTHEWS: Well, that must apply to everybody except the medical graduates from MUN, because they seem like they want to go elsewhere. I guess the bottom line is that as of March 1, this year we had in rural Newfoundland - when we say rural Newfoundland it is rural, and I guess, rural, rural or out there where doctors have to work on salary because fee for service wouldn't render them any meaningful level of income. We have about 130-odd locations out there like that. We have twenty-seven vacancies as of March 1, but the thing that disturbed me when I found it out - it was only about a month or less than a month ago that I became really aware of it - was that eighty-eight of these positions are still being filled by foreign medical graduates, by doctors who have come in here and don't even have full licensure in Newfoundland because they haven't met the requirements of CMA and the NLMA in terms of being fully licensed. We had, I think it was eighty-eight locations out of 112 positions filled that were being filled by provisionally licensed doctors. Now that is not to say that these doctors are not good people - a lot of them are - it is just that they have not gone through Canadian medical schools, so they haven't completed examinations for full licensure, but the bottom line, that tells us, at least it seems to tell me, that despite twenty-odd years, or however long we have had a medical school at MUN, that we really haven't done the job in providing to ourselves doctors to meet our own needs.

Now there is a lot of discussion; I had extensive talks with Dr. Hawkins one morning about the admissions policy at MUN Medical School, should we be taking in more rural students? How can we guarantee that students who say they will go to rural Newfoundland will, in fact, go there when they graduate?

Another thing that is a little bothersome, I think, is that we make available second, third and fourth year bursaries - ten at the moment - to students at MUN. These bursaries are worth $12,500 a year. Last year we could only give away seven. Kids will not take them because attached to the bursary is simply a year for year service. If you take it for a year, you go to rural Newfoundland for a year, so if you take $37,500 over three years, you would be expected to spend three years in rural Newfoundland, and the kids will not take the bursary, so they have their minds made up right at the outset that they are not going back to rural Newfoundland to practice, or that they are not going to rural Newfoundland if they are not from rural Newfoundland. I say go back; that is those who come from rural areas, and those who come from urban and other centres are less inclined.

My comments initially were in the context of - I view it as being a concern, because if our medical school is not meeting our needs, and if we have to depend on Cape Town and Johannesburg medical schools to meet our needs, I am wondering if we should not be funding these universities and getting our doctors from there, and if our own kids want to go and become doctors so they can flirt off to the U.S. or somewhere else, well let them go get a medical education as best they can elsewhere, or at least pay the fair market value for their education.

We provide ourselves with teachers in excess. We have provided ourselves with nurses, more than we need at the moment. We don't have a law school; we have lots of lawyers on Duckworth Street. We have an engineering school and we have lots of engineers, but doctors we are having difficulties with, so I guess my concept is that as soon as a new dean goes in place over there, I want to have some meaningful discussions with the medical school to say: Now, how are we going to use this facility to meet our physician resource needs? If we cannot get it done, then we will look at whether or not we need a medical school, or whether or not we need to keep it under the Department of Health. I will tell you, they are not very anxious to go over around Memorial University to have to fight for their funding over there. If we cannot get the job done on the basis that it should be done, then I am prepared to make what they would consider, I guess, drastic recommendations to government, but I think recommendations that government would be very receptive of, because I have had some preliminary talks with my colleagues in Cabinet about this issue. It is a serious one, and I am intending to address it.

MR. CAREEN: Thank you.

Carrying on with that just for a second, this might be a ludicrous statement, and I have made them before in my life, but I share the worries, you can't expect to tie everybody down but, holy God, we were raised here. There must be some kind of an attachment somewhere.

We have a lot of nurses and the majority of them are women. That is not being patronizing or anything; it is just a straight fact. We have some very, very qualified nurses, across this Province. Some of them have taken extra training in different roles or whatever they do. Is there any way it can be looked at - it doesn't cost anything to have a look - how some of these people could be given opportunities to start in at second year or third year or the fourth year of a medical school? And they will go back because their homes are back in rural Newfoundland, for them to take the step instead of continuing on as nurses.

MR. L. MATTHEWS: You are talking about -

MR. CAREEN: Yes, get them to become doctors.

MR. L. MATTHEWS: You are talking about changing the entrance requirements to medical school so that people who normally wouldn't qualify could get in because they have other medical training in their background?

MR. CAREEN: Yes. I'm just wondering if there is some way we could tackle some of this stuff that is going on. Now, I never talked to Patt about it, she is a nurse, but I would just like to have it thrown across here.

WITNESS: She is a teacher.

MR. CAREEN: Teacher, is she?

MS. COWAN: I'm a teacher.

MR. L. MATTHEWS: Doctor Williams, I don't know how many people we would send to a psychiatrist on the admissions committee at M.U.N. if we tried to do something like that.

MR. CAREEN: I know. It seems difficult to change, Minister, but -

MR. L. MATTHEWS: You know about M.U.N., they have this mind-set about academic freedom and so on?

MR. CAREEN: Yes.

MR. L. MATTHEWS: Just to give you an example. You might be interested to know that the New Brunswick government always funded ten spots up at the medical school. We held ten spots for it and it paid $13,700 a year for these spots. Well, this year, right out of the blue about a month ago it said: Budgetary considerations, we are not funding any more spots for our students at M.U.N., we are going to send them to Dal. So we had ten spots left up there on the open market. Or, ten spots left that we thought were for M.U.N. The dean of the medical school, said: I want to put these on the open market and sell them down in the States for $30,000 a crack. I said: Go for it, we will support you. Then the admissions committee over there comes back and it says: We believe we have some responsibility to the students in New Brunswick because they have airline tickets bought and they are coming over for interviews next week. I said: With the greatest of respect, if any government has a responsibility to those kids it is their own government who pulled the seats out.

All hell almost broke loose because I sort of suggested that they should have less flexibility in considering students from New Brunswick as a group. I said: Throw them in with the Canadian stream. Because we allow six seats for Canadians outside of New Brunswick. I said: Put the New Brunswick students in with the rest of the Canadians and if they get in on that basis, fine, we will admit them. Otherwise, don't give any special consideration to New Brunswick kids, I'm sorry. Give them to our own kids if you have to.

When you talk about doing something like you are saying, Nick, take a nurse with a Bachelor of Nursing and give her special admission rights to M.U.N. I can only imagine, Doctor, what you would hear in the first instance.

DR. WILLIAMS: They are very protective about the admissions committee functions over there. Basically I think they have a hands-off policy on that. That was a decision that he as dean would not get involved in, or could not get involved in. It is supposed to be a pure process, I guess, the admission process, as far as that goes.

WITNESS: In addition of course you've got the Board of Regents and then you've got the Senate. You never hear tell of the Senate. Memorial has its Senate -

WITNESSES: (Inaudible).

MR. CHAIRMAN: Order, please!

WITNESS: Okay.

MR. CHAIRMAN: Mr. Hodder is out of turn. Ms. Cowan.

MS. COWAN: (Inaudible) to my left here is just chomping at the bit so I'm letting him go first.

MR. LANGDON: Thank you, Patt. To follow up on the rural thing, rural Newfoundland. I have a particular interest in that. I was talking to someone connected to the paediatrician in Grand Falls. I don't know his name but I understand that he is leaving. He just can't cope with the fact of being on call seven days a week, twenty-four hours a day, one paediatrician for the central area.

I have a son-in-law who will be a fully qualified paediatrician next year, from Grand Falls, and could go back to Grand Falls and it has nothing to do with money at all. He said I am not prepared and sacrifice going back to Grand Falls to be on call seven days a week, twenty-four hours a day. He said I am just not prepared to do that. However, if there were two or three of us where I could be guaranteed one in four days off or one in five off and three nights a week or four nights a week, then I would consider it but I am not prepared to consider seven days a week, twenty-four hours a day.

I think that in itself is something that the department could look at because it is the work hours that many of the people have to put up with and it is the same thing in many of the rural areas. We have two doctors in the area, Dr. Sidhu in Hermitage and Dr. Parsons. Dr. Parsons is a South African who is leaving and going back to South Africa again and I have talked to Dr. Williams about this before. The dollars are good and obviously the incentive that the minister put in it is an added incentive but I think the most important thing for a lot of these people out there is the time element, the fact that you are on call twenty-four hours a day, seven days a week and I am not sure if any of us or any other profession would want to be involved in that. So I think that is a major problem and I am wondering -

MS. COWAN: (Inaudible).

MR. LANGDON: We are, well okay. We are a different breed I guess but anyhow, have you looked at that?

MR. L. MATTHEWS: Yes, there are two big issues that come to the fore in terms of rural physicians - physicians generally but I guess rural physicians - number one is remuneration and number two is lifestyle. I had lots of discussions with my deputy about this because he went to rural Newfoundland twenty-five years ago and he knows what the doctors were prepared to do back then as students when they went out and basically he tells me that they did not know any better so they worked seven days and seven nights a week but now it is not the same. Doctors are not prepared, young physicians are not prepared to go out and give that level of commitment because it is a different generation, a different mind set, different expectations and they want back-up people to be able to work with them. They want to have a reasonable lifestyle outside of their profession and they want to be paid well for what they do and why not if they can get - I think in Manitoba they start them anywhere from $90,000 to $120,000 a year - if they can go and get a job at that level? We start them in the $60,000 to $90,000 range. So we are way behind the eight ball in dollars and cents. We will never be able to make it up purely on the economics but we are trying. The incentive package that we introduced last week I think is going to be a good first step. There is also provision in that by the way, Oliver, to recognize extra workload.

So to some extent that package includes recognition of extra workloads such as that. For instance, if there are five doctors that should be in a location and there are only three there for an extended period of time we will take some of the salary allocation and - well they do that now, they split some of the salary allocations up but we will give some extra money to compensate for extra workload but, as you say, that is not the total answer because people are not going to work seven days and seven nights a week in perpetuity. Do you want to add anything to that Deputy?

DR. WILLIAMS: Yes, probably the Connaigre Peninsula illustrates a problem that we have in a large part of Newfoundland, in the rural parts of the Province. For instance, in Mose Ambrose and Hermitage we always had one physician practices there and we increased the practices to two physician practices some years ago recognizing that maybe the population could not justify two people - justify maybe more than one but not two - in terms of the volume of work, but just to give people a better lifestyle. Even then it is more than they can take.

Maybe we have to look at some creative solutions in terms of moving the physician population to Harbour Breton and increasing it from three in Harbour Breton to probably five, six, or seven doctors in Harbour Breton and then they would outreach to Hermitage and Mose Ambrose, and do call in Harbour Breton; so they would be doing one night in five or six and have outreach clinics. But that creates some inequities as well because the people in Hermitage and Mose Ambrose wouldn't have the accessibility they have now to a doctor, so you trade off one for the other.

You probably would get more stability in terms of your physician population in that kind of an environment, but there is the question of whether the people in those communities of Hermitage and Mose Ambrose would be prepared on weekends and at night to drive to the hospital at Harbour Breton to get seen. Certainly, I suspect they would have less of a turnover of doctors because there is a better lifestyle. They are working in a group, there is more collegiality, they are working harder when they are working but they are working less often. So that is the kind of trade-off you have to make.

Sometimes you think you can do something for somebody by having, say, two doctors in Mose Ambrose, but then they are working every second night and that, over time, wears people down as well. So those issues, as well as in some of the speciality areas, in some of our district hospitals we might have enough work to justify two specialists but, over time, one or two is not too conducive either. In this type of thing where there are small populations, you may not be able to justify any more than two on an economic basis. Certainly, on a fee for service basis, two probably wouldn't make it, so we usually have those positions as salary positions. That trade-off, in terms of population and geography, makes it difficult sometimes to have an adequate number of staff and a reasonable lifestyle for physicians.

MR. LANGDON: But with two, it is better than one.

DR. WILLIAMS: With two, it is better than one.

MR. LANGDON: It is the same problem. People have come to me with the ENT specialist in Grand Falls. The man is backed up about six or eight months and there is just one of them out there. Again, we had one there from our own area, from Belleoram, as you know, Dr. Savoury and he left. Basically, it is the same thing, you just get tired out, you just get worn out from being on continually, and I think that is a problem that has to be addressed by the Department of Health.

MR. L. MATTHEWS: We have been recruiting quite actively for ENT in Grand Falls. I am aware that they are backed up there and I thought they had a good prospect of bringing in somebody.

DR. WILLIAMS: Yes, they had, from South Africa, but the person wouldn't come because he would have to be on a salary.

MR. LANGDON: So they do need ENT.

DR. WILLIAMS: There is one ENT in Gander and one in Grand Falls, and then two in Grand Falls as well.

MR. L. MATTHEWS: I had some people complaining because they had to go to Corner Brook for ENT services but I am not sure it is much better there.

MR. LANGDON: Another question I have to follow-up, I think, on what Gerald said earlier on the ambulance service. I am glad the department is taking it upon themselves to look at a new funding arrangement, for want of a better word, for the community health people. Because in the area that I serve again, in the Connaigre Peninsula, there are three ambulances, all community-based, and more often than not, they are coming to the department when they have overdrafts, and I must say, the department has been very helpful in that and have addressed the needs a number of times.

Only this past week, the ambulance board for the Hermitage area canvassed the different houses. In Seal Cove, one of the people knocked on my door. I think it is $20.00 a year that we give to help run the ambulance in that area, and they are having a difficult time in making ends meets. Basically, I guess, it all comes back because there is a different arrangement, a different formula for community-based versus the privately owned operators. That is being addressed and obviously it will take away a lot of the stress from the private ambulance people in the area I serve, and others as well.

You were saying, you are taking over some of the nursing care and so on from Social Services, which you now do. Can you go into a little more detail and tell me some of the people who are in this group that Social Services did care for, versus what you have now?

MR. L. MATTHEWS: Yes. The programs that we are taking over really cover three groups of clientele, if you like. There is the mentally disabled and the physically disabled, and there is the seniors, the enriched needs program. These are the three basic groups that were being funded under the programs that we are taking over.

In terms of the budget split, I would say, of the budget last year at least 40 per cent of it was directed towards seniors, the enriched needs, if you like, homemaker services and the like. The other 60 per cent of that budget was dedicated toward the mentally and physically challenged who have been de-institutionalized for the most part and who are now being supported in the community with a broad range of services that they need to exist, and to have a better lifestyle, as well as better services in the community.

MR. LANGDON: Who in your department is responsible for that?

MR. L. MATTHEWS: Assistant Deputy Minister, Joan Dawe, is directly responsible for developing the policies that we will be following and implementing in health and getting the staff up and running. She has all the answers, Oliver, that you would ever need, and she has only been in charge two days.

MR. LANGDON: I will make an appointment over the next week or so to -

MR. L. MATTHEWS: Yes. Now, as I said, she has some staff working with her who are involved in that, but it falls in her shop primarily, these new programs, from Health purposes. They are not new programs for government, but they are new in terms of coming over into Health.

MR. LANGDON: In the department.

MR. CHAIRMAN: Thank you, Mr. Langdon.

We are going to take a ten-minute coffee break, then we will come back with Mr. Hodder.

 

Recess

 

MR. CHAIRMAN: Order, please!

Ms. Cowan, Mr. Hodder has decided that we would have you go first with your two short questions; we will get two short answers, and then we will go with Mr. Hodder.

MS. COWAN: I demand equal time. I have just a few questions. I could go on forever because I've had so much personal experience with the health system in the last few years.

I like Nick's idea about that upgrading thing. Now, I know all about academic freedom and the ivory tower and all that kind of thing, but just something that crossed my mind, and it is more of an idea than it is a question: Is there some way that anyone who had finished a nursing degree could upgrade and then go into a medical program? That just sort of crossed my mind. It is not really a question. I don't know whether you would think the same sort of academic snootiness would prohibit that, but it is a thought.

MR. L. MATTHEWS: There is no difficulty at the moment at M.U.N. in the medical school in terms of attracting students who are applying for admission. A lot of students year after year don't get in. It is not a case of not having enough people applying. I guess, from a provincial Department of Health point of view, trying to meet our own needs with doctors, what I would like to see them be able to achieve is an admissions policy such that they would give some weight and consideration to the question of where people are prepared to practice once they get out; and having gotten that commitment, some ability to be able to, for want of a better word, enforce that commitment.

Because some kids now who take the bursaries - they don't all get taken up, but some who take them - the three-year bursary is $37,500; at the end of their third or fourth year they get these offers from down in the States and places like that. They get hospitals and clinics coming up, buying out their bursaries, saying: We will pay that off for you. That relives them of their legal obligation, and certainly a moral obligation doesn't count for very much.

MS. COWAN: No.

MR. L. MATTHEWS: It is pretty difficult to even enforce a commitment up front. That is where it is. It is not a matter of not enough people applying; it is a matter of the choices they make at the end of the day. As to whether or not we could ever get to a circumstance where you can consider criteria other than purely academic - like historical service in nursing or something like that - that is a question that I can't answer, and I don't think you could get a ready answer at M.U.N. Well, you would. I guess they would say: We wouldn't consider it.

MS. COWAN: You can be allowed sometimes to upgrade to get into arts courses and things, so it just struck me that it was a possibility.

MR. L. MATTHEWS: Nurses can go on to the baccalaureate program at M.U.N. for their B.N. Now, in the nursing profession we have a new collaborative curriculum coming into existence in 1996, so that when we amalgamate the three schools of nursing in St. John's - the General, St. Clare's and the Grace - there will be just one school of nursing, one curriculum. That curriculum will have a couple of exit points. They can exit with an R.N. or they can go on to the university level and exit with a B.N. Whether or not something could be developed to further enhance that, such as they could go on to medical school, I think is a whole new area, Patt, that really we are getting into discussing.

MS. COWAN: I don't want to harp too much on this because we have talked a lot about it this morning, but just one thing before you close Memorial's medical school.

MR. L. MATTHEWS: Lest you misunderstand me, we are not in the mind-set of closing the medical school.

MS. COWAN: My colleague, here, from Bay St. George and I were talking, with our background in education. Is there any possibility - and I would think there is a great possibility - that the lack of science courses and other courses that would lead kids to choose medical school are not being offered in rural Newfoundland, and therefore the kids just don't have the qualifications to get into the medical school.

MR. L. MATTHEWS: That might be, but to the credit of the medical school - because they are doing some good things over there - they have been running for a number of years, and I attended part, last year, of what they call a rural Med Quest program. It is a Med Quest program where they go out and encourage - schools identify likely, good candidates for admission to medical school eventually, and they encourage - they go out and sell the whole concept of getting into medicine such that kids in rural Newfoundland in particular are given an exposure to a mind-set that they can qualify and do well in medical school if they wish to choose that career path. The Med Quest program is a very impressive program -

MS. COWAN: Yes, it is.

MR. L. MATTHEWS: - and a very good initiative. I will have to say that in defence of and to the credit of the medical school over there.

They are making good efforts to get rural kids in. We just want to have some way that we can get them in and keep them in Newfoundland after they graduate.

MS. COWAN: Yes. It is the education system I'm questioning now, the high school system. Are they providing the proper courses in rural Newfoundland that would enable a young person to get in.

The other thing that I am very interested in - and I guess from the experience we have had in the Children's Interest Committee, and it was referred to by one of the two gentlemen there on the other side - is that the Department of Health seems to be sort of on the cutting edge of change. It is something we found all across Canada actually when we did a little bit of a fact-finding trip there a while ago. So I commend all of your officials, Minister, for the fact that they do keep on the cutting edge. That doesn't mean we are not going to have some recommendations when it comes to things to do with children, but it is very good to see such a progressive department.

Having said that I want to turn to breast cancer. Because I don't suppose there is anybody in this room who hasn't in one way or another had their lives touched by breast cancer, and for women it is something that we live with with a constant fear. It is almost the same as being very cautious about when you go out at night and that kind of thing for fear of rape. Breast cancer is something that is a real concern I would think to all of us. In the Canadian Living magazine - and I'm not sure that I'm quoting it correctly or if it was right, but it certainly was frightening - that one in eight women will get breast cancer in Canada and that the number is dropping. That the statistics may show that it will be seven, or something. Anyway, it is getting worse instead of getting better.

I know we make a lot of fuss about things like, you know, these machines that you take around from place to place, but research shows that they really don't change anything. I know that we do something here in the Province and I just wondered if you could enlighten me, and perhaps tell me, Minister, we must be plugged into national networks and so on in that particular area.

MR. L. MATTHEWS: I guess I can ask Mrs. Dawe to speaks to it in a minute. Last year, in 1994 as a result of the ad hoc committee report on breast cancer the government put $700,000 into a three-year pilot project, if you like, to address the whole issue of breast cancer and to do something new or enhance things in terms of trying to deal with the problem. It used to be the biggest killer in women up until recently, breast cancer. Now it has dropped off to second place of course and lung cancer has taken over, believe it or not, as being the biggest killer for women. I thought you might be interested in knowing that.

The initiatives that we are doing provincially involve basically breast health education for public and health professionals, involves the teaching of breast examination in women over fifteen years of age, it involves a bi-annual, I guess, or every two year examination, screening by mammogram of women between the ages of fifty to sixty-nine.

MS. COWAN: (Inaudible) they are required?

MR. L. MATTHEWS: No, these are the things that the initiative is encouraging and trying to promote. Joan, probably you can speak more fully to where we are with that project specifically and to breast cancer in general for Patt.

MRS. DAWE: I'm chairing the implementation committee to deal with the report on the breast screening project. On that committee we have representatives from the health system broadly: community health, institutions, the medical association, the nursing association, consumer reps, Cancer Foundation, Cancer Society, and on they go. We've brought together quite a group of people to deal with the implementation of that report. That actually started in November. Just two weeks ago we finalized the budget requirements to start the implementation of the four components that the minister had mentioned. Mammography is just one component and we want to start well back with education prevention initiatives.

We've selected as of last week - and it is not public yet but the decision has been made by the committee - that the two pilot sites for mammography will be here in St. John's through the Grace Hospital and in Central through James Paton in Gander. They will be the pilot sites for mammography. Then we will use through the public health nursing system nurses for the education of the public, of women, and other professionals, so there will be much more, I guess, information flowing within the next month as we finalize other components of the decision. That is a significant initiative.

The budget requirements were over $700,000 for the first year and $600,000 for each of the next two years. It is a three year pilot project with the intent then that a provincial project will be phased in after we complete the implementation of the pilot.

MS. COWAN: So this is largely an education project. We could not afford, I would think as a Province, research. We probably feed into some central (inaudible).

MS. DAWE: On the committee where we have representation from the Cancer Society, the Cancer Foundation and the University these are our links with our national bodies to ensure that we have the latest information in terms of research, treatment and education. So we certainly do not need to duplicate efforts there. It is a matter now of using the information, the research and getting on with the implementation of programs that are relevant, starting with prevention and then moving along the line to the mammography.

MS. COWAN: Just in passing, in something else that we were discussing, I met one of the women involved and she was just so enthusiastic and ever since then I have been sort of anxious to find out some of the details of it.

Just in my closing, either comment or question, I am not a great believer in the over use of specialists. I think that we have that problem here in this Province and also the over use of emergency for things that could be attended by a family doctor. I don't know if there is anything that can be done to educate people. I talked to friends who have said for example: Oh, I just love my family doctor. She sends me to a specialist right away. Well what the heck is she trained for, unless you have something really, really serious. I know with my thyroid for example, I was going to a doctor and waiting six hours to see a specialist at the hospital which I felt I did not have time to do. So I said this is crazy, we now know what is wrong with me. Why isn't a GP monitoring it who can then contact the specialist if we run into trouble?

So it seems to me that there is something wrong in our thinking that, gee you just got to have millions of specialists and we all have to be rushing to them. Is there anything that can be done about that? The same as people having a sore on their big toe for two months and then finally going to emergency with it at midnight on a Friday or something, these kinds of things. They are big users, I would think, of the money in the health care system.

MR. L. MATTHEWS: Well the system is to a large extent, like you say, physician driven in terms of not only referring on to specialists but the ordering up of examinations, tests and procedures, all that sort of thing. That is an area where the medical profession basically has to take significant responsibility in ownership because they are the ones who are on the front lines and they know to what extent they may be over-subscribing for speciality services or for procedures. So to a large extent that is in their shop and they are not unaware of the view of government, especially these days, that they have to take responsibility to curtail the unnecessary use of their procedures. Having said that of course, when it comes to your health it is a pretty fine line and a pretty difficult thing to say to somebody that in my opinion - especially us being laymen, all except Dr. Bob I suppose here this morning - that was an inappropriate prescription or that was an inappropriate ordering up of tests and that sort of thing.

MS. COWAN: Well maybe it was an inappropriate statement for me to make.

MR. L. MATTHEWS: I would not go that far, Patt, but I mean your observation is valid to the extent that that is how you feel. So I am not sure that there is much more that can be done about it then for all of us to use our good common sense. Now as far as people going to emergency at 12 o'clock in the night when they could have gone at 12 o'clock in the day, I don't know if it makes much difference or not, probably they should have gone to their family doctor. Education is the thing that will change the way, not only that doctors practice medicine but the way that we as clients subscribe to using medical services. That is the bottom line.

MS. COWAN: I do notice some younger doctors having these signs in their office that come from the Medical Association, sort of suggesting that you not overuse the medical system. I cannot remember the quote exactly but I was quite impressed by this. I do not see it in older doctors offices but it would seem to me it is a slight indication that there is some responsibility being taken there. Maybe those are just prejudices of mine.

MR. L. MATTHEWS: New Brunswick is doing a pilot in one of their Moncton hospitals, and I think they are one of the first or few doing it. They have people phone in to a nurse or somebody to get advice as to whether they should go to emergency, whether they should go to a doctor, or whether they do not need to go anywhere. That is a fairly innovative thing and we are going to be watching to see what the results of their experiment is in trying to cut down some of the things you were talking about.

MR. CHAIRMAN: Thank you, Mr. Minister.

MR. L. MATTHEWS: My assistant deputy tells me we have Dr. Drover now so that is our early answer to that type of thing.

MR. CHAIRMAN: Mr. Hodder.

MR. HODDER: Well, of course, that would be consistent with your doing away with the Ombudsman, would it not? The Premier said that you could call your MHA and do all this kind of thing, so now we can call Dr. Drover to enquire as to whether we have need of services.

MS. COWAN: Now, be nice.

MR. HODDER: Be nice. I shall, but there is some instinct there somewhere.

Your health care boards - all appointed?

MR. L. MATTHEWS: Yes.

MR. HODDER: The question is on their operations and the publics right to know and have access to information. This is a board of governance that governs wide areas. Will the operations of these boards and their meetings that go with it, will they be public forums whereby people can witness the boards operating?

MR. L. MATTHEWS: I was just checking that with my deputy, because I know in the case of school boards, and I sat on a school board myself as a trustee for eight years, all school board meetings are public meetings unless they are designated as private meetings or privileged meetings. The deputy tells me that under the Health Act meetings of health boards are not public meetings unless they are designated as public meetings, so I guess they are not automatically public forums are they?

DR. WILLIAMS: It has not been the trend in the health system in Newfoundland to have any board meetings public meetings. What some boards do is have an annual meeting where they present an annual report and members of the public are invited to come along, receive the annual report and ask any questions they wish to ask, but there have not been up to this stage anyway. I do not know if there is anything in the act that prevents it. I think it has just been policy.

MR. L. MATTHEWS: It is a good point, Mr. Hodder. Probably it is something that should be considered in terms of whether or not all meetings of health or trustees should or should not be public meetings.

MR. HODDER: I come from the point of view that at these meetings you are not talking about client/patient confidentiality, you are talking about governance and if you are going to have a good system of governance therefore the pubic has to perceive that they have access to information and there has to be a certain level of accountability. I do not see a system, with regards to whether it is through government or through the party I am part of, I cannot see anybody in the Confederation Building being publicly accountable on a day to day, or monthly basis for something that is happening in Corner Brook, Grand Falls, or Clarenville.

I do believe that there is going to be a sense of ownership generated at the regional level. There has to be a system set up whereby people have to feel that they have a right to have access to, have information from, and carry it in the local press, so I come from the point of view that says that all operations of the regional boards, if we are going to give it a chance to work then the department has to make sure that they operate in a public forum. Then people will feel they are part of it; they won't be an imposed kind of thing.

The other thing is again the freedom of information on certain issues. We had incidents a little while ago involving a child in Conception Bay South who was given wrong - well, there was a very fundamental error made.

It bothers me that the Newfoundland Medical Association can operate almost in a very private manner investigating errors that are made, and we know there are errors made from time to time, and we have to accept the fact that there are going to be errors made. I am asking the minister, is there going to be some way in which there can be greater public awareness of, an accountability to the public, for this kind of thing, other than waiting until something comes up in court?

MR. L. MATTHEWS: Well, all professional bodies basically have the mandate and the responsibility to police themselves. I am thinking of the legal profession, the engineering profession, the medical profession, and others. They all basically have the same system of policing themselves and monitoring their activities as amongst their members. For the most part, as best I can judge from any experience I have had in the seven or eight months that I have been Minister of Health, things do get addressed appropriately through the NLMA and through the procedures they have in place. That is not to say that people are not going to end up with civil suits in the courts; they will, and they have that right, and thank goodness they do, but I am not aware that there is any great public outcry to change the way that complaints for perceived malpractice or inappropriate prescriptions or that sort of thing is handled. There is no group coming forward as saying how medical complaints or doctor complaints and hospital complaints are being handled is not working appropriately.

MR. HODDER: It bothers me that when something goes wrong, the first place we hear it from is CBC. Automatically you have somebody who is going to call into the media, you have the child on TV, and this kind of thing. It seems to me that people feel that if something goes wrong they don't have ready access of redress through the channels, so they have to make a public cause before the system moves.

MR. L. MATTHEWS: Most people, when they have a difficulty, if they went to a hospital, say they didn't get admitted, or the diagnosis was inappropriate, or the treatment was inappropriate when they were in, or that sort of thing, in the first instance we direct them, if they come to us, back to the hospital itself, because the hospital board in the first instance, and now the new regional boards, have a responsibility to see that things are done properly in their area, but there are procedures beyond that to the medical board -

AN HON. MEMBER: The pharmacy board.

MR. L. MATTHEWS: The pharmacy board, the medical board, and these procedures, like any other profession, are working, I think, as best I can judge, as well as they would in any other profession, whether it was the legal profession or anything else.

If you have any suggestions as to how things could be done differently or better I would be glad to hear them.

MR. HODDER: It is possible in Newfoundland - I mentioned this last year and Dr. Bob Williams will remember it - it deals with doctors who lose privileges at hospitals. A doctor who loses privileges at a hospital of course, doesn't have to admit people, he can still carry on his clinic. It is possible in Newfoundland -obviously it is changed now - for a doctor who has lost privileges at a hospital to decide that he doesn't need to use a hospital. He can get away from that. In St. John's he can make a choice. If he has lost the privileges at St. Clare's he can move people around. That is possible. Losing privileges in itself doesn't mean that the doctor has been penalized.

Is there some way in which we could try to address that issue? Again, we know that doctors lose privileges for a whole variety of reasons, and they are not always, shall we say, something dramatic. It is just a matter of failing to write up your charts consistently, which is an essential patient service, but it can result in your losing your privileges after the appropriate procedure is in place. There is nothing that says that a doctor can't continue to practice medicine.

MR. L. MATTHEWS: Dr. Williams?

DR. WILLIAMS: A doctor can lose, as you say, privileges at a hospital for a variety of reasons. They mightn't be dealing with the actual conduct of their practice in the sense, there mightn't be malpractice issues or poor practice issues. They might be, as you say, (inaudible).

MR. HODDER: (Inaudible) poor practice issues but not malpractice.

DR. WILLIAMS: They didn't complete their charts properly on time or on schedule. In St. John's now of course where they have one health care board they can't just pitch at another hospital because they will have privileges with that board. It would be certainly devastating for a surgeon to lose privileges at a hospital or an intern to lose privileges at a hospital, because it would be really difficult for them to function in terms of economic realities.

You have in Ontario many psychiatrists practising outside a hospital environment. That is a tendency that is coming into vogue in terms of that profession because in many instances they don't need hospitals. The more difficult patients are just sent to the hospital and they are operating an office practice. If certainly a physician loses privileges for a clinical issue then I'm sure that issue is followed up with the medical board, and they might in fact lose their licence for a period of time, depending on the issue. They have the right to fine a physician, hold a hearing. The person making a complaint can appear at the hearing and make the complaint. It is done consistently across that profession and the pharmacy profession and in other professions. There is a mechanism through the professional governing bodies where physicians or pharmacists or that can lose their licence. When we get complaints at the department that are dealing with professional issues such as that we have the complainant referred directly to the appropriate board; then we follow up to make sure that we get a copy of the board's response and tell the complainant if we get it in writing, and if they are not satisfied to let us know. There is usually that mechanism in place.

As well, in the PRAG report that we talked about earlier - the minister talked about the Physician Resource Advisory Group is making a recommendation - I think it is recommendation 14 - that physicians should be required to maintain privileges at hospitals and required to do their fair share to make sure the hospital functions adequately.

AN OFFICIAL: Exactly.

DR. WILLIAMS: Sitting on peer review committees in the hospital, sitting on quality assurance committees, sitting on credentialing committee, sitting on tissue audit committees, and doing their call in the emergency department. The PRAG recommendation 14 deals with that requirement, and if physicians do not fulfil those requirements then there is going to be a financial penalty if that recommendation is carried forward. We know in some rural areas for instance that some physicians run on a fee-for-service basis, and others on a fee-for-services or salary. Some physicians will not even cover the emergency department or do obstetrics in some of these smaller communities to the detriment of the other physicians who are doing it. So that recommendation will hopefully deal with that.

MR. HODDER: The Burin Peninsula Hospital is a prime example of where doctors deliberately will not accept hospital privileges.

DR. WILLIAMS: Yes, that's right.

MR. HODDER: Some of the people up there with the most lucrative practices - practices that begin at 6:00 a.m. and get the people on their way to work and while that is good, there are doctors who do open clinics at 5:30 a.m. on the Burin Peninsula and these doctors refuse to accept hospital privileges. They do not see themselves as part of a macro kind of health care system. What I am saying is that where doctors deliberately choose that route they are not contributing in the global sense. So therefore we have to say to these doctors if you want to do that you are not going to get the same revenue per patient as doctors who do do it. So we have to have sanctions in there that make it possible for their total system to operate.

I will get back to my other point that I started with, is it still possible for a doctor who had been denied privileges, say as a GP, to decide that he does not need that anymore and he can now go out and set himself up as an eye specialist?

DR. WILLIAMS: Well I think a GP -

MR. HODDER: Not as an ophthalmologist but an optometrist.

DR. WILLIAMS: It is possible for a physician to bill the vision assessment. It used to be possible but I think we removed that from the MCP payment schedule so that they don't get recompense for a vision assessment. We had some physicians years ago who thought optometry was a lucrative field. They would do a course in optometry, refractions and then do general practice but also do a fair number of refractions. Well we removed that component from the MCP billing schedule.

MR. HODDER: So that has been removed in recent months?

DR. WILLIAMS: Yes, that was removed a few years ago. They do not get paid by MCP for doing refractive services. The other point that you -

MR. HODDER: But with their limited training - my point is that if you are going to go into a school to study optometry or whatever, it is a four to five year course. You have a general practitioner who decides that, for whatever reason, he does not want to carry on a general practice or job anymore, is situated in one of the more urban areas and that person then decides well there is good money here in the eyeglass business - I call it - and so decides now I did a course in that area or whatever which is basically a month course, if that. I mean you went through the system, you know how much time you spent at each component, very limited. Then suddenly this person is set up as equal to the person who has had four or five years training in that area alone. That is still possible in Newfoundland isn't it?

DR. WILLIAMS: It is still possible I guess, not only in Newfoundland but anywhere that somebody can go in to do refractions. They have a medical knowledge of the eye, the needs of the eye and then they take a course in doing refractions which, with the equipment that they have today with computers, it is not as hard as it used to be, in a sense. So they can do refractions, yes. We do not pay for them. We have not had any complaints, that I can remember, from a member of the general public since I have been at the department who says that they have not gotten quality service or have complained about that kind of service but, personally speaking, I am not in favour of that, no.

MR. HODDER: I brought it up last year and just briefly again, I think it is an area that we need to address in terms of our total health care and mandate, fetal alcohol syndrome, latest research, have we done research on that particular syndrome in Newfoundland,

and what is its status?

MR. L. MATTHEWS: One of the deputies will answer the question, but there is more and more evidence that there is a link between alcohol and deficiencies and deformities and that sort of thing. The effects it has on newborns, I'm not sure where we are in terms of research in Newfoundland as isolated from national or international research. Is that what you are asking?

MR. HODDER: I'm just wondering if we are participating in the national research. Obviously we wouldn't have the capacity here to do our own independent research.

MRS. DAWE: That is correct. Our director of drug dependency services within our division participates and is currently in with our counterparts across the country on fetal alcohol syndrome. I don't have the ready information. I will be happy to share that with you, but it is a current activity of our division, yes.

MR. HODDER: Because it is -

MR. L. MATTHEWS: Getting back to your former question though, Harvey. If we made it a requirement that a physician has to have an attachment to a hospital board in order to get a billing number for MCP, that would move us a long way toward addressing situations like you are aware of in Marystown, on the Burin Peninsula. Because if every doctor had to have a billing number, before they got it they had to have a relationship with a hospital board, then they would have some responsibility to do certain things in order to maintain that billing number. Like covering the emergency for a period of time or being involved in some of the other activities that the Deputy Minister mentioned.

That is a significant recommendation of the PRAG report and it is probably not one that the medical profession will want to buy into right away. Because all of the recommendations there that have impacts on practice and that sort of thing, the NLMA - they don't all think alike all the time over there, let me tell you.

MR. HODDER: Not likely.

MR. L. MATTHEWS: No. If they were a union they would be the most fragmented union in the world. That is my view.

MR. HODDER: It is connected to keeping doctors in those hospitals. You might need a recruitment, and then when the doctor gets there he or she finds that they are working diligently, long hours, no breaks, find themselves not having the quality of life, and get very frustrated that a high proportion or a certain proportion of their activities on a daily basis is really looking after someone else's patients. That is the bottom line. You've got a group of doctors who are operating on the basis: I will send you to the hospital, but when you get there someone else will look after you because I just don't have time to do that.

MR. L. MATTHEWS: Especially on the weekends or in the nighttime.

MR. HODDER: Yes.

DR. WILLIAMS: You are well-versed in that issue on the Burin Peninsula. It applies in a number of other areas. When I worked on the Burin Peninsula it applied there as well. That was quite a number of years ago but we did have a similar problem there with a number of physicians in Marystown. We were working at the cottage hospital in Burin and on weekends and nights we would often get people dropping down from Marystown and Creston, places like that, because their doctors weren't available.

MR. HODDER: That is right.

DR. WILLIAMS: Yes.

MR. HODDER: But it happens all across the Province.

DR. WILLIAMS: Yes, it wears you down. This recommendation number 14 I think will deal with that in a major way, and there will be a major financial penalty for these physicians who do not participate in those activities. I think a physician has a responsibility to society and to their patients. They have to cooperate to make sure that is done.

MR. HODDER: It happens here in St. John's as well.

DR. WILLIAMS: Yes it does.

MR. CHAIRMAN: Excuse me. We will go to Mr. Careen for some questioning.

MR. CAREEN: Thank you, Mr. Chairman. Minister, the grants to hospitals, and long-term care facilities, and the health clinics are down this year compared to what was budgeted last year or revised last year.

MR. L. MATTHEWS: The grants to -

MR. CAREEN: Yes. Page 236.

MR. L. MATTHEWS: Yes.

MR. CAREEN: Are we going to see reduced health care services in those areas by such reductions?

MR. L. MATTHEWS: We are not going to see reductions. There is only a slight reduction there, as you can see, and basically we anticipate that as a result of the restructuring, just by the adjustments that will make in some of the middle management positions, it will create a fair degree of savings in terms of dollars and cents, but in terms of the reductions here you will see that it is very, very little on a percentage basis. You are talking about the figure that goes from $573 million down to $569 million, about $4,000 on a $573 million budget.

MR. CAREEN: No, there is one there, grants for hospitals, which last year was $423 million.

MR. L. MATTHEWS: Okay, just that one, 4.2.01.10.

MR. CAREEN: Last year it was $423 million; and $82 million to $81 million, and $34 million to $33 million.

MR. L. MATTHEWS: Yes.

MR. CAREEN: Well, Sir, we have seen that in middle management positions.

MR. L. MATTHEWS: For the most part there will be more than that saved. Basically, the Department of Health - we were able this year in the Budget to hold the same Budget in dollars and cents as we did last year, and we were fortunate to be able to achieve that because a lot of departments didn't have that success. I think it goes beyond the department. I think it speaks to the whole issue of government's commitment to do whatever it has to do to the maximum extent possible to provide appropriate health care, but certainly the reorganization of boards and the restructuring is going to cause some savings, not at the point of delivery, or not at the bedside, if you like, or not in the emergency department, but by eliminating a lot of departments that are unnecessary to keep at the staffing levels they have now.

MR. CAREEN: This leads me to the parochial question of which I touched based with you on Friday. When they formed the regional health board of Placentia, Carbonear, Whitbourne, New Perlican, there was fair representation on it. Every existing board had people picked off the board, or other people to represent them - nothing wrong. Now, I mean, it is true that the board members themselves will have to bring their own expertise to the table, and hopefully they all have that kind of stuff; but the community health board, that I brought up the other day in the House, that

is where I have a bit of trouble.

Now, in the Act you can go to a maximum of fifteen, and when that fifteen is attained you have them stretching from Topsail in the east right to Port Blandford in the west, two on the Burin Peninsula, the Bonavista and Clarenville area is covered, and up to Port Blandford. There is a woman over in Riverhead, St. Mary's, someone in Whitbourne, then there are six in the Trinity-Conception area. Now, on the eastern side of Placentia Bay there is not one person, and this seems short-sighted - I don't know what happened. I was told that the public health board (inaudible) sent in names. I was told that the hospital board in Placentia recommended a name. Our facility in Placentia, the Lions Manor, which has seventy-five beds - and there are six not being used now because they are building onto the hospital there - covers the Cape Shore area and part of St. Mary's Bay North, Long Harbour and then you go right up to the other end of the district and there is no one there at all. I am wondering if there is any kind of accommodation that can be made to cover that shortfall, like a person might be on the regional institutional board who could change places with somebody else. You have to have someone to be able to hone in to, and under the legislative law you cannot put sixteen because fifteen is there.

I was talking to Ms. Simms on Friday - she seems like a nice lady to talk to - she is on the regional health board, and she is Chair of the community-based board. Is that usual practice?

MR. L. MATTHEWS: Yes, I can explain that to you.

MR. CAREEN: So you have a continuity.

MR. L. MATTHEWS: There is a cross representative from all institutional boards to the community health care boards. As Ms. Dawe said, it is for purposes of cross representation so that one board, at least, has somebody on each that knows what the other is doing. Because these boards are going to have to work together pretty closely, and the community health care boards are new creatures as opposed to the institutional boards really being a consolidation of existing hospital and long-term care boards, but to your question that you asked in the House Friday, or whenever it was, and back to that one, the concept was to put equitable representation on the boards for every geographic region. Now, the area that you just described is pretty big. You go Trinity - Conception Bay, Placentia Bay, and you are up to Trinity - Bonavista Bay, and you only have fifteen slots to fill.

The only answer I can give you is that I would hope the area you are describing generally in Placentia Bay, on a per population basis, if you took the 50,000 or 60,000 people in that region - because that is about what it works out to, well, a little more than that on the community health care boards, that's what, on average, the institutional boards work out to - if you took the people serviced by that board, and took the fifteen trustees and divided up on a population basis, you may find out that in the area you are describing you may have pretty equitable representation, but if you don't, and it is clearly an anomaly of under-representation, I think you are doing the right thing by bringing it to my attention, and you would probably want to bring it more formally, and write to me and say: Look, this is an inequity, as I perceive it, and as soon as you can address it, please give consideration to an appointment from my area to this community health care board. That is the only remedy for it.

MR. CAREEN: You have already told those people who wrote to you that as soon as there is a vacancy -

MR. L. MATTHEWS: Yes, because these new boards are covering such large geographic regions, there have been a couple of other areas where people have felt, on a geographic basis, well, we are under-represented. The people in the Bonavista Peninsula feel they should have three rather than two representatives on the institutional board.

Again, you have eighteen people whom you can put on the board. You have all of these big geographic areas to cover off, and as best they can, I think, the boards are appointed to reflect fairness and balance, but if there is an anomaly or an inequity that exists, certainly as soon as it can be addressed I have no hesitation in dealing with it.

MR. CAREEN: Right away (inaudible) glaring at you, and I am not saying anything against these people.

MR. L. MATTHEWS: No.

MR. CAREEN: But there are six people there in the Carbonear, Harbour Grace area.

MR. L. MATTHEWS: On a per population basis, though, Nick -

MR. CAREEN: Well, of that regional health board, the largest population outside of St. John's on the Avalon is in that Conception Bay area. I am not taking -

MR. L. MATTHEWS: I am just wondering if it is balanced, if it is equitable. I am wondering if it is as inequitable as probably it appears to be. I don't know, but I am prepared to look at it when we can.

MR. CAREEN: The other thing that makes it so much more community-based, you are talking about health protection and health promotion, and alcohol and drug dependency, all this kind of stuff. You are also going into this community care. We are also going to have to have someone who has a touch on reason.

Now, probably we are getting into the institutional stuff, and you said they have to work together. We could be looking at, down the road, are they going to be administering the single point of entry? Are they going to be saying who goes where, and John Doe has been there and (inaudible).

MR. L. MATTHEWS: We are into that now.

MR. CAREEN: And all of a sudden there is a resettlement program and that old fellow who lived in that community is gone to the west, Sir. You see?

MR. L. MATTHEWS: No, they are getting into - the single entry system is now up and running in St. John's region and it is running in - Central Newfoundland?

MRS. DAWE: In the West (inaudible) East.

MR. L. MATTHEWS: In the West. Central East, yes, that is the Gander to Eastport region, and it will happen in the other regions eventually.

MS. DAWE: Yes, and it will happen in the West Central very shortly.

MR. L. MATTHEWS: If you want to comment further on his particular area, Joan.

MS. DAWE: Thank you, Minister. The Eastern Community Health Board, while appointed, hasn't officially assumed its responsibility yet, so it hasn't become operational. One of the very first things that will happen as it becomes operational is to get ready to put the infrastructure in for the continuing care for single entry system, as you referred, but that is a few months down the road yet.

MR. L. MATTHEWS: So as soon as these boards take over their mandate officially then the single entry system is a given, new concept in terms of admissions policies.

MR. CAREEN: You might be able to have a look at it yet.

MR. L. MATTHEWS: The board?

MR. CAREEN: Yes.

MR. L. MATTHEWS: No, the board has been appointed, it is just a question of formalizing their mandate by dropping a Minute-in- Council for a certain date.

MR. CAREEN: I can go back to the original statement I made, that if a person is on the regional health board, there is no reason why he couldn't change places with someone else on a regional health board. Wouldn't that be possible?

MR. L. MATTHEWS: Well, I suppose you could.

MR. CAREEN: You could fill a gap.

MR. L. MATTHEWS: We could look at asking somebody to step down from this board and go over to this board.

MR. CAREEN: A changeover.

MR. L. MATTHEWS: It would have to be for very extenuating circumstances to consider that. Because the other board is up and - no. (Inaudible) board?

MR. CAREEN: (Inaudible) started April 1.

DR. WILLIAMS: (Inaudible) board, no. April 1, yes.

MR. L. MATTHEWS: April 1, yes, it is up and running now.

MR. CAREEN: (Inaudible) just started.

MR. L. MATTHEWS: Yes, there were two or three who took their mandate officially April 1: St. John's Health Care Corp. and that board, yes.

MR. CAREEN: Another thing, too: How closely does your department work with Environment? I will go on to this. I've heard it in different parts of the Province, but living out in the Placentia area you hear it more pronounced. We had high industry down in Albright and Wilson and we had the Americans there for over fifty years - high incidence of cancers. It must because of this, the statements there, or it must be because of that. My friend over there and I, he is from the West Coast - the Americans had a large presence out in Stephenville. Gerald and I spoke about it on our drive on Friday, we spoke about it before, incidences of cancer that seem to be out of proportion. I don't know if they are out of proportion or if it is because we live so close to people -

MR. L. MATTHEWS: That you think that is the case.

MR. CAREEN: Yes. I don't know if it is addressed. The Federal Government did a survey in Argentia last year to see if there is any environmental damage. It proved there was. There is mercury down there and PCBs and other stuff. And they have another grant out now to find out the extent of the damage that is in Argentia.

MR. L. MATTHEWS: Deputy Minister, you can speak to the studies that he is referring to.

DR. WILLIAMS: We co-operated I think it was about two or three years ago with the Department of Environment on a health study in the Long Harbour - Placentia area where we had the health research unit - Dr. Roy West and Dr. Sharon Buehler - do an assessment of the incidence of cancer in that catchment area. They concluded that there wasn't any undue increase in the incidence of cancer. There was some borderline incidence of brain cancer probably worth watching, and have another look at it in a few years time.

They did a review at that time - independent. We funded the study. We co-operated with Environment, but they are independent of the department. They did this study. Environment - obviously, now you are saying they are doing some studies in terms of the chemicals and this type of thing out in the area. I don't know if we are involved in detail with those studies at this time, Joan.

MR. CAREEN: Joan, may I interrupt you for one second before you go on? The interesting thing about Argentia that we all should be mindful of and we all forget, is that thousands of people came in from other parts of Newfoundland and parts of Conception Bay to work in Argentia. It is not only the people that would be there now and it is the same as Pepperrell, the same as Stephenville or Goose Bay.

DR. WILLIAMS: They did a population study. They did not do an occupational study, it was a population study.

MS. DAWE: Just to answer your question about our relationship with the Department of Environment, indeed our environmental health inspectors, public health inspectors work extremely closely with the staff of the Department of Environment. Just to get back to reference that - and a comment that was made by Mr. Hodder earlier this morning - where the environment is an important determinant of health it brings the two departments very, very closely in a working relationship. I could certainly check and see what the latest involvement is with the study that you have referred to but it is very much a given that through environmental health it is a very close association and there is lots of documentation here on that.

MR. CAREEN: Thank you. One more thing, Mr. Chairman, lots of times I let my old heart fool my old head but most times I come out on my feet.

There last fall, minister, when I approached you on some occasions to keep me informed because you called me from the House or I called you. During the blackout there was a problem up at a home in Dunville, public home, the people were without heat one Thursday night a little after midnight until 1 o'clock Monday morning or so when it came back on. A report was done by a person from your department who checked out one side of it and then after that they did come out eventually when a bit of a furor was started. They did come out and met in Placentia with some of these people - relatives of these people who were up there - the committee met in December and they met again in January, they were looking for more information. A Mr. Caddigan is the chairman of that board and he was in court when I called. We all know that open heaters are not allowed but that was a dire emergency. We all know that to put in special kinds of generators is going to cost a hell of a lot of money. There were some areas that did not have any problems at all. Some of them had some problems but is there anything that you came across that closely touched what happened out our way?

MR. L. MATTHEWS: I don't know the number but given the geography of Conception, Trinity Bay, St. John's and your area, there was a tremendous number of personal care homes, hospitals and all that were affected with power outages during the sleet storm. I think, as I said to you when you called me at that time and since, the only complaint we had with respect to an adequate emergency response by the owners in a personal care or any other type home was the one complaint that you brought forward from the Dunville - Placentia area. As you said, as a result of that the very next day I had one of my officials go out. There did not seem to be satisfaction with what he reported back to me so I had another team go out to talk to the residents and talk to the operators of the home to ensure that - mainly I guess at that point, if in fact they did not do all they should have done or could have done, they were made aware of it, number one, and that we could let them know what we expected of them based on the requirements of their licensure for the future.

You mentioned Mr. Caddigan who is the chairman of the Welfare Licensing Institute Board which comes under the Department of Health, and which has the responsibility for licencing nursing homes and personal care homes and that sort of thing.

The bottom line Nick is that they indicated that for the most part the people who operate that home did as much as they could for the residents who were there. As I say, there were a couple of residents who felt that they didn't do all they should have done. There is no back-up power in that home in terms of an emergency generator, nor is that home or personal care homes of that size required to have a second back-up electrical system in place for I guess basically economic reasons; and the fact that it happens on average about once every ten years in Newfoundland we have that situation.

I think you can take some level of comfort in the fact that immediately you brought it to our attention that I ensured that we left no stone unturned to go out and address your complaints. If there are difficulties in any of these homes that anybody brings to our attention, absolutely, we jump on them right away. We give them the most serious consideration that we can because we are dealing with the most vulnerable and most needy people when we are talking about nursing homes and personal care homes too, although personal care homes are not at the same high level of service that nursing homes are.

MR. CAREEN: We were raised to believe that you looked after the young ones and the old ones first. We see the incidents going on up in Dunville, you feel like reaching out and shaking the living hell out of someone. I wasn't out to take their licence. I was out there -

MR. L. MATTHEWS: No, no.

MR. CAREEN: - gee whiz, if that happens again. Get the fire department. Get the volunteer fire brigade over here. I could stand around with a fire extinguisher over a kerosene heater to make sure that some poor devil got a bit of heat. Some of these rules and regulations - when there is an emergency, common sense should prevail.

MR. L. MATTHEWS: Obviously I guess most of the operators used their common sense because we never had one complaint from anywhere in the Province in any nursing home, and I take that to be a pretty good comment on the operators of these nursing homes.

MR. CAREEN: Thank you very much.

MR. CHAIRMAN: Mr. Hodder.

MR. HODDER: I just have a couple of questions. The 911 system -

MR. L. MATTHEWS: Yes.

MR. HODDER: - and again in terms of prior comments on integration between all levels of government, I'm pleased to see the initiatives that have been taken by government, the new system of identification and having a regional approach to that system. I don't want to get into the whole issue of the ambulance system and the fire department and who is called first, that kind of thing. But that initiative that the Department of Municipal and Provincial Affairs is spearheading also has an impact on the manner in which the health service can be rendered most efficiently and effectively. It is occurring in a direct sense, but it is an issue again where coordination across the system is beneficial to the health receiver.

My last issue is a comment on the practice which was there several years ago of having public health nurses assigned to very specific schools in which they would keep the hours of the schools and the holiday system of the schools. I believe they would really get in on a year-round basis about half-time credits. In the school I was at, which had a population of 700, that worked very well. It meant that there was a very immediate delivery of services, and I am wondering if the minister or Joan could apprise me as to how that system is working across the Province, and if it is still in effect.

MR. CHAIRMAN: Mrs. Dawe.

MRS. DAWE: Through the community health board structure again, these services will continue to be delivered. You may have recognized that over the several months in the fall the St. John's board, as an example, being the first community health board, went out publicly for public consultation and encouraged communities, educators and interest groups to come forth to speak to a number of these issues.

The public health nursing service in the school system will certainly continue if not increase, particularly in the areas of health promotion and education, and we have a number of initiatives, including the fluoride mouth rinse program as an example of that. So I guess the broad answer is that the services will certainly be maintained, most likely increased in terms of education, prevention, school health curriculum and so on.

MR. HODDER: I found, in my days as a junior high school principal, that there was a greater sense of identification with the public health nurse.

MRS. DAWE: Yes.

MR. HODDER: If I have one suggestion to make, I would suggest that we would try to not assign them on the basis of a term, or even for the school year, but they would be assigned to more of a long-term kind of thing so that they would have established a relationship with the school population over time. One of the criticisms was the turnover.

MRS. DAWE: If I could just add to that, over the last year as well the Department of Health, with the Departments of Education, Social Services, Justice and the Newfoundland and Labrador Teachers Association had a major initiative looking at classroom issues and the kind of integration, I think, that you refer to.

MR. HODDER: Yes, I have a copy and have read it.

MRS. DAWE: That report was submitted just recently and approved, and there is a significant co-ordinated effort within government departments and with the Teachers Association to really address some of the concerns that you have raised, and I think some very positive initiatives have come as a result of that type of dialogue over the year.

MR. HODDER: It does have benefits as well in terms of having expert knowledge readily available. It has a benefit in the public health areas, from AIDS to proper toileting. It also has a benefit as well within our adolescent sexual education programs, within the programs we offer as well in science, and it gives that extra resource person available to the teaching staff, and also in terms of putting on programs for teachers. The public health people do a very good job of that, and we should be encouraging it.

MRS. DAWE: We have, over this last year, increased the resources to the public health units for a child health co-ordinator for each of the regions again to improve co-ordination, because we feel we need to do a better job of the resources that exist now not only in health but across the other systems within government, and the teachers as well, so there are significant numbers of initiatives that have been instituted over the year, and much more to come if you will sort of review the report that was released.

MR. HODDER: I have read it.

Thank you, Mr. Chairman.

MR. CHAIRMAN: Thank you.

Any further questions?

On motion, subheads 1.1.01 through 4.3.05, carried.

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

MR. CHAIRMAN: Thank you, Mr. Minister.

MR. L. MATTHEWS: I would like to thank you all for your objective questions and thank my officials for all the answers they provided me with and provided you with directly.

On motion, committee adjourned.