The Committee met at 7:00 p.m.

CHAIR (Mercer): Order, please!

I ask the members of the Committee to introduce themselves, starting with you, Gerry.

MR. G. REID: Gerry Reid, MHA for Twillingate & Fogo.

MR. H. HODDER: Harvey Hodder, MHA for Waterford Valley.

MR. WHELAN: Don Whelan, MHA for Harbour Main - Whitbourne.

MR. OTTENHEIMER: John Ottenheimer, MHA for St. John's East.

CHAIR: Bob Mercer, MHA for Humber East.

With those preliminaries out of the way, Minister, I would ask you perhaps to identify your delegation for us. I would also ask, as we proceed in the evening, that the members who might be answering a question identify themselves for the purpose of our friend here in the back who has to keep some written records of things.

MR. MATTHEWS: Thank you, Chair, for enabling us to reconvene in such a timely fashion. It is good to get this exercise done once you are on a track, and we appreciate being here tonight with you.

Before I make any remarks and comments, and not that I do not know who my officials are, because I have introduced them for two years in a row, I am going to do it this year by asking them to introduce themselves to you so that they will be for certain accurately identified as to who they are and the area of interest that they work in in the department.

I will start with my deputy. Sometimes I call him the Premier, sometimes I call the Premier's Deputy, but he is the Deputy Minister of Health, for the record.

DR. WILLIAMS: Dr. Bob Williams.

MR. WHITE: Gerry White, Community Health and Drug Programs, ADM.

MR. MANUAL: Roy Manual, ADM, Institutions.

MR. HART: My name is Chris Hart. I am ADM of Support Services.

MR. MATTHEWS: Okay. I will start with Debbie Sue.

MS MARTIN: I am Debbie Sue Martin and I am the Director of Mental Health and Community Health.

MS GARDNER: I am Eleanor Gardner. I am in Community Health, the Director of Continuing Care.

DR. HUNT: Ed Hunt, in Medical Consulting.

MR. ASHLEY: Joe Ashley, Executive Assistant to the Minister.

MR. DOWN: John Down, Director of Drug Program.

MR. OSMOND: Max Osmond, Director of Financial Operations.

MR. STOWE: Gerry Stowe, Financial Manager, Institutional Financial Services.

CHAIR: Thank you, Mr. Minister, for that introduction of your staff. Before we begin, perhaps I will just outline very quickly how we intend to proceed this afternoon. We will start by having the minister make some introductory remarks. Then we will ask the Clerk to call the first head. It will be under that head that most of the discussion of your Estimates will occur. We will then turn the proceedings over to the Vice-Chair to initiate the questioning, and we will continue with each member until all questions are exhausted, or until we and you are exhausted.

Having said that, Mr. Minister, perhaps you could give us your introductory remarks.

MR. MATTHEWS: Thank you, Chair, and again thanks for having us. We are looking forward to the opportunity tonight as a department to answer any questions that might be posed from the Committee. It is an important exercise in our view, the appearance before you as a Committee, because not only is it a necessary exercise technically, it gives us as a department, on behalf of government, to discuss fully one-third or more of all of the discretionary spending this government is responsible for doing in a fiscal year. After pension obligations and debt charges, out of our $3 billion-plus Budget you will find that Health at $900 million-plus represents probably more than a third of what is left to be spent. In that sense it is an important area to have examined.

The Department of Health started one year prior to this fiscal year on a three-year planning cycle in its budgetary exercise, based on a commitment that government gave in the 1996-1997 fiscal Budget that Health would be given a flat line operational budget for a period of three years. It would be done so that it would enable the health care system to respond to the significant degree of restructuring that had taken place within the health care sector over the past two or three years prior to.

This is the second year of the three-year planning cycle we are in. The only significant, I guess, caveat, that was placed within the three-year budget time frame, was that we live within it, but having said that, we had the latitude or the flexibility of adjusting the budget as would be necessary as we went through that three-year planning cycle, because, obviously, we were making significant changes in the system. I refer to an ongoing and greater emphasis in the area, for instance, of community health as opposed to institutional health care, and to some extent you will see that reflected in some of the changes in the line items in the budget as we go forward.

Notwithstanding the commitment of a flat line budget last year, when all other departments were taking significant reductions, this year the health budget was again increased, not by a large amount vis-à-vis its total budget, but certainly in absolute dollars, there was a fair degree put back into health care or added to the operational side of the health care budget in addition to, of course, some things in the capital side of it and so, this year again, while all departments were taking reductions in expenditures, health care, because it is of such a significant priority for government and the people of the Province, received some additional funding for very specific areas that were announced in the Budget, and I will not get into repeating them. You may want to chat about them as we go through.

The business of running a health care system is a significant challenge regardless of what your budgetary situation is, but in a time when dollars are scarce, methods of delivering services are changing, population is aging, new technologies are emerging, expectations of the population, the people whom we serve continue to rise, and in that context, delivering health care services is not only a challenge for us but for every jurisdiction in the country and will continue to be a significant challenge in perpetuity, I would suggest.

I think, Chair, that, without my elaborating much further, it would be a wiser use of time if I gave the Committee the benefit of the time to ask some questions. I was thinking last night, as I was going through my review exercise - I was reading the comments that I made last year at this point in the proceedings - that I could just as easily have reprinted Hansard and pass that out to you from last year and you would have had appropriate comments for this evening. So, without wasting any more time, not to suggest that I am wasting time, if I should be so immodest, I think it is better if I just said: these are my concluding remarks and we look forward to the opportunity of answering any questions you may have.

CHAIR: Thank you, Mr. Minister.

CLERK (Mr. Noel): Subhead 1.1.01

CHAIR: John?

MR. OTTENHEIMER: Thank you, Mr. Chairman.

I guess the procedure is as we did with the other Committee; we can all jump in as we see fit. Is that right?

CHAIR: Exactly, and we shall continue until exhausted.

MR. OTTENHEIMER: Okay.

MR. MATTHEWS: You look pretty tired already.

CHAIR: It has been a long day, yes.

WITNESS: This calls for a check up right away.

MR. MATTHEWS: There are two doctors tonight (inaudible) last year.

CHAIR: The questions are in Hansard - are the answers there as well?

MR. MATTHEWS: They are in the Budget.

MR. H. HODDER: We always read Hansard, (inaudible) second opinion, anyway.

MR. MATTHEWS: Most people do.

MR. OTTENHEIMER: Mr. Minister, maybe I could begin with a question which is perhaps really an extension of the Estimates and the Budget information. It has to do with the issue raised today in the House concerning the health forum which was announced last week.

I wonder if you could be, perhaps a bit specific in terms of, really, what do you envisage this health forum being all about in terms of, you know, who will play a role in the forum and what role will the public have. And I guess, seeing that we are reviewing the estimates, what sorts of costs would you expect such an exercise to be to the taxpayer of the Province? I wonder if you could just expand on this concept which has been -

MR. MATTHEWS: First of all I have to congratulate you for attempting right off the top to elicit from me the announcement that I indicated I would make Thursday in the House, that is the nature of the forum, the location of it, the composition of the stakeholders, who will be there and the general purpose of the forum. I can only say to you tonight, until I announce that on Thursday I really do not have much that I can appropriately share with you.

The Premier announced that it would be government's intention to have an early and rather succinct round of consultation with specific stakeholders who are attached, who work in, and have a lot to do with the health care system. Until I get the details worked through the Cabinet committee process and that sort of thing, which will happen in the next two days, I am really not at liberty to scope it out any more than that in a public fashion.

The cost that will be attached to it will be very minimal in that it will not be an expansive group, nor will it be held in elaborate surroundings, nor will we be serving gourmet meals. A caller to Open Line suggested we should have it in a hospital and eat hospital food. I am not sure we will do that because of the necessity of having it in an appropriate location that has the facilities to accommodate it. It will be an early consultation process. It will be announced in detail on Thursday. I think that will be the extent of my answer.

MR. OTTENHEIMER: Okay, fair enough. I appreciate that, under the circumstances. Perhaps then more specifically, in terms of the Estimates and the information before us, we see - and maybe Mr. Manual may be a person who may want to respond to this - in terms of the hospital and nursing homes. We will all recall less than a year ago the great, you know, public sort of reaction to the proposed increases to those residents of our nursing homes. Obviously, the increase has come into effect.

I am just wondering if there could be some comment, either from yourself, Mr. Minister, or from one of your officials, as to the impact, I guess, if any, from the point of view of the institutions themselves, from a financial point of view, that this has had on the institutions. I am wondering in some general sense could you give some comment as to where we find ourselves today in terms of the satisfaction level, I guess, which was really of great concern to the public at large many months ago, and how our residents within our institutions have reacted to this transition.

MR. MATTHEWS: You have directed the question to my ADM of Institutions, and I think probably I should let him answer the first part of the question, as to how this has worked out from a fiscal point of view. The more general question of where we are in terms of client satisfaction, if you like, I can comment upon that after. Roy?

MR. MANUAL: With respect to the matter of the financial impact that this has had, we are pretty confident that the revenue base that was projected for the nursing homes related to the revenue change in the rate is pretty well on target for this year. We have in one or two facilities provided some adjustment to shortfalls on revenue in relation to that, but by and large, most of the nursing homes in the Province have been able to operate within the approved fiscal arrangements vis-à-vis the adjustment to the long-term care rate. The exact revenue amount that we have received, or that nursing homes have built into their budgets, I do not think we have that with us. I can defer to Mr. Stowe and see if we do, but we could provide that if it were requested of the Committee. Gerry, could I ask you if we do?

MR. STOWE: Tentatively, Roy, we were looking at somewhere around $1.5 million, $2 million, but those estimates certainly were not made on a real scientific basis. The rate first went from $1,510 to $4,000. That was a fair jump, and we really were not sure how many of the private paying people would be able to pay an additional $2,500. But we estimated roughly about $1.5 million to $2 million.

MR. MANUAL: We have provided adjustment to a couple of nursing homes that were short. There was a shortfall in the amount of revenue, I know, in a couple of nursing homes this year, and we did provide that adjustment back to them.

MR. MATTHEWS: I think it is important to say again, although it was said a number of times, when that rate increase was put in place that about 87 per cent, 88 per cent of the residents of the home were totally unaffected by this inasmuch as their income was OAS, GIS, and that caused them to be paying even less than the $1,510 that was in place at the time. So it is only the 12 per cent that are referred to as private paying residents who were in any way impacted upon, in the first instance, with this rate change.

As Mr. Stowe has said, there is no scientific basis on which to indicate how much revenue we thought we would get from the change, so we made a budgetary estimate. It turns out that even with the reduction back to $2,800 it means we have basically met the targets, except in a couple of instances. Really, what that says, I guess, is that even at $2,800, that substantial decrease down from $4,000, there are still very few, if any people between the $2,800 and $4,000 anyhow who would have been - you know? So inasmuch as we met the projections, there is a pretty clear indication that there is a very small amount of money involved from $2,800 to $4,000. I guess frankly there is not a lot of people involved in the $1,510 to $2,800 increase. Twelve per cent maximum are impacted upon, and some of these are impacted upon very minimally.

In terms of client or resident satisfaction, I personally have not heard a word as to any complaints about the homes' operation, whether they are better or worse as a result of the rate increase. There was some obvious reaction to the increase when we announced it. The Glenbrook Lodge, one lady put on a bit of a pretty decent campaign, and there was some reaction in your area, Mr. Chair, from some seniors out there. But once the rate was adjusted back to $2,800 there has been virtually no reaction since then. Obviously, people do not like rate increases.

MR. H. HODDER: Yes. We took some satisfaction in seeing you be put in your place by a ninety-six-year-old, but these things happen from time to time. Do not underestimate these people. You cannot win at that kind of a debate, so you took the honourable route and said: Hey, let's back off here.

MR. MATTHEWS: Yes, we only doubled it.

MR. H. HODDER: And then you only doubled it after that. Still on nursing homes, but not quite on the finances of it, if you want, directly on that. The occupancy rate for nursing homes all across the Province - there is a waiting list here in this region, but are all the nursing homes - like in certain parts of the Province - for example, the Interfaith one in Grand Bank, is that totally occupied now, filled up, or are there vacancies there? What is the situation like region by region across the Province?

MR. MATTHEWS: Well, on a provincial basis, we have probably have more nursing bed spaces than we need at the moment, but not by many. We have about 3,104 beds I think in the system. There are areas where our beds are not all full. We have ten beds, as an example, in the St. Lawrence health care centre that have never been opened to date. There are ten not opened in the - not the Blue Crest -

WITNESS: No, Golden Heights.

MR. MATTHEWS: Golden Heights Manor in Bonavista. From time to time we have, let us say outside the overpass, bed spaces. There is no pressure on long-term care bed spaces. Here in the St. John's area we are running at about eighty to 100 spaces, I believe, for levels III -

WITNESS: Yes, there are just over 100 spaces.

MR. MATTHEWS: There are probably 100 and - who would have that figure?

WITNESS: There are 136 people on the waiting list.

MR. MATTHEWS: Yes, 136 people on the waiting list. How many of these would be level I, gentlemen?

WITNESS: Fifty.

MR. MATTHEWS: Fifty. So we have about eighty which we would consider true nursing home clients out there, levels II and III. There is a turnover in the system here in St. John's, where we have about 1,200 beds, I believe. There is a turnover of about thirty-five to forty a month. That is natural attrition. That tells you that there is theoretically a maximum waiting list of about two months, which is certainly -

WITNESS: Dr. Parfrey's study says about two to three months.

MR. MATTHEWS: I am sorry?

WITNESS: Dr. Parfrey's study says about two or three months maximum.

MR. MATTHEWS: Yes, Dr. Pat Parfrey. The health research crowd over at the University are doing some work in long-term care needs and trends for us. His preliminary report told us that we are looking at two to three months maximum waiting lists here in the city which is our, say, heaviest demand area and that, as compared to the rest of the country is very, very acceptable, very, very low; Ontario is about nine to twelve months as a comparative example.

MR. H. HODDER: In the regions of the Province now, I am going region by region, are we still taking in people say, from some parts of the Province and having to move them to homes, for example? When I was in Grand Bank last year, I met a person there who was from Bonavista Bay, actually. Is that still happening or are we able to accommodate people within reasonable distance of their extended family?

MR. MATTHEWS: That is the objective. Sometimes, the needs of the resident dictate where they have to go. For example, we have some homes that are fairly new and have good, what we would call Alzheimer's or protective care units and sometimes people have to be located where it is best for them; and you do hear some commentary about very senior and elderly couples being separated because of having to go into a nursing home. Sometimes that is caused because the level of care for one may be a level III, and the level of care required for the other may not even be a nursing home level, it may be level I, you know, so these things unfortunately happen.

The area where I get most commentary now is the Clarenville area because they feel that generally in that area, there should be more spaces but if you take it as a region, we have vacancies, say, in St. Lawrence and Bonavista and people do not take well to having to even hear the suggestion that they may have to access these beds before we build more beds and have more vacant space.

MR. H. HODDER: (Inaudible) visits to St. Lawrence and to Grand Bank. My roots are on the Burin Peninsula, as some people would know, and I have talked to people there from, say, the Clarenville area who sometimes do not have a great deal of choice. Are there other areas of the Province like Clarenville now where we have significant concern about the availability, because the people in Clarenville have been very much concerned about, or unhappy with, the alternatives placed before them?

MR. MATTHEWS: I am not aware, off the top of my head, of anywhere where there is -

MR. H. HODDER: There are no other regions like that?

MR. MATTHEWS: Most of the regions of the Province, most of the people of the Province have long-term care space available to them within a reasonable radius from where they live. If you started in St. Anthony and worked your way around the Province down to St. Lawrence, you will find, like St. Anthony, Port Saunders, Bonne Bay, Corner Brook, Bay St. George, Burgeo, all have good, long-term care facilities. If you come across the Island, you know, you will find in every significant area, there are good, long-term care facilities. So long-term care, I have to tell you, is not an area where we are under-resourced in terms of beds or under-resourced in terms of funding. Simply put, it is not a pressure point in the system, but you will always find somebody in some community who may, in fact, have had to go beyond what he would consider a reasonable distance to get a relative into a long-term care space.

Clarenville, would be the only area, off the top of my head, where I can think we are getting a sort of continual pressure - and not a lot of pressure except from, let us say, the politicians and town councils and people who have relatives in the area, because we put fourteen beds in there last year, and the bed study that we are working on said that we may need up to forty-four there you know, if you were going with the maximum. So we have done some things there, even, to address the concerns, and it has helped.

MR. G. REID: Minister, what has happened with the demand for chronic care in the Province?

MR. MATTHEWS: What has happened?

MR. G. REID: Yes, I mean, ten years ago there was an outcry out there for more beds for chronic care. A lot of the studies showed it prior to say, 1989 that, there was a need for more.

MR. MATTHEWS: The Orsborn Royal Commission in 1086-1987 recommended that by the year 1995, ten years out, they thought we should be working towards about 2,700 long-term care beds in the system. For some reason, we have gone well beyond that. We have 3,000 to 3,100. So that is what has happened. We have made provision for as many spaces as was recommended, and probably some more.

We do have an aging population, which would normally say there is an increased demand, but the other side of that is we have made substantial strides in home support programs which allows people to stay in their communities and in their own homes as long as they can. In the last two or three years, I guess, with more and more rural Newfoundlanders probably being out of work because of the fishery crisis, there may be, to some degree, seniors staying at home a little longer with their families. All of these factors have put us in pretty good shape with long-term care, no question about that.

There is a facility in your area, the Notre Dame - Twillingate area, and I am not aware of any waiting list or any pressure on the waiting list in that area. There is space available when somebody needs to get in.

MR. G. REID: But we have not built a lot of these facilities since 1989, have we? What have we done - just added on to the existing ones?

MR. MATTHEWS: We have done a bit of both. I guess we built some facilities - most prior to my arrival. I think we have done some things in -

WITNESS: St. Lawrence, (inaudible).

MR. MATTHEWS: St. Lawrence, Burgeo, and Port Saunders were three facilities we built recently.

WITNESS: And one facility in St. Anthony.

MR. MATTHEWS: St. Anthony is a new facility, which replaces a current one with fewer beds. We have done things in Bonavista. There is a fairly new facility there. We put the Bonnews Lodge in Brookfield, the Hugh Twomey Centre in Botwood. We have added space to the Notre Dame Bay Memorial Health Care Centre in your area. We have been doing it all over, really.

MR. G. REID: A study in Central Newfoundland recommends a decrease in the next eight years of some forty -

MR. MATTHEWS: They are projecting, yes. That is based on a couple of things, I guess, Primarily on the fact that as the home support side of the health care system continues to grow, allowing people to stay in their homes longer, there will be less demand for -

MR. WHELAN: Second largest industry, I think, in my district.

MR. MATTHEWS: Home support?

MR. WHELAN: Yes.

MR. MATTHEWS: Well, it has gone from the well-known figure now of about $300,000 in 1987 to $30 million plus this year. That should tell you something about how that home support program has grown, and the effects of it on the pressure that was on long-term care.

MR. WHELAN: A year or so ago, you introduced a change in policy with regard to personal care homes in that you allowed level II patients to be admitted to the level II homes. How was that program looked upon by the industry? Did they welcome it with open arms, did they partake in the opportunity? Were there many level II people -

MR. MATTHEWS: Let me make a quick answer. I am going to ask Eleanor Gardner who is charge of and is very much involved in that area to answer it in more detail. Yes, I think they welcomed it roundly. They wanted to see to what extent each of them individually could participate because there were new standards. Probably Eleanor you can comment, if you would come to the mike, please, and identify yourself, and give what I am anticipating will be an excellent answer.

MS GARDNER: The personal care home industry was made aware of the change in policy to allow level II clients to be admitted. Fourteen of the personal care homes to date have indeed become licensed to admit level II clients. Many others have applied, but the regulations regarding the building in many cases needed improvements. We have perhaps another thirty that are presently undergoing renovations in order to apply for the level II licence.

MR. MATTHEWS: Yes. The receptivity of it, or how it was received by the industry, I think, was part of the question.

MS GARDNER: It was received very well. I think for quite a while now there has been some concern within the industry about the principle of aging in place. Whereby a client would be admitted to a personal care home as a level I. Over time, over some years, they would begin to associate the home as their family home, having grown attached, even, to some other residents in the facility. When they became more frail, or at a level II, they would be required to leave the facility. It was stressful not only for the actual resident who would be asked to leave, but it was also stressful for the home itself.

By and large, I never heard any negativity from any of the seventy-two operators. I think some of them are disappointed, actually, because the advice they have been given is that the cost to renovate would exceed the margin of profit.

MR. WHELAN: Due to the fact that they have had to make some fairly extensive renovations, I would assume, in certain cases, and also considering the fact that the personal care homes are probably the best bang for the buck that we have in health care in this Province, has there been any consideration given to perhaps subsidizing the renovation that they may have to make, or increasing the payment received for each individual guest in that home, especially of their level II patients? Mr. Minister, probably you may be the best one to answer.

MR. MATTHEWS: Well, yes. To the question of assisting with renovations, no, that industry is purely totally private sector-owned and driven, so we have no program to assist them with retrofitting. We have set the standards for life, fire and safety purposes and let them meet the standards.

In terms of paying them more for the residents because they have higher levels of care, they have been, I guess, very fortunate in the context of what government has been able to do generally for rate increases for other people in health care and other areas. We have given them two rate increases over the last year, which has moved them effectively from $846 in the subsidized beds to $900 per month, as a result of the two increases we have given them, the bigger one being in this budget of $34 I believe.

We recognize that it costs more to give a higher level of care. There is not a big percentage yet of the residents at level II. Most of them are still at level I, obviously because only thirteen homes are suited up to take level II. We recognize it costs more to care for higher levels of care, and we recognize the value of that industry in the health care sector, and being probably, as you say, a very good value for money spent. They have been the beneficiaries of a 7 per cent or 8 per cent rate increase basically over the past six months, really. They have received that with gratefulness, but with disappointment that it is not more, obviously.

MR. WHELAN: Considering the fact that nursing homes - I am not sure exactly what the cost is per person, but I would say that they are considerably more than the personal care homes. The money that would be saved by a transference of x number of people from nursing homes to personal care homes might warrant another look at whether you would subsidize the cost of renovations, or indeed increase the amount of money paid per patient in the nursing home. It may in the long run be quite beneficial to the Province financially.

MR. MATTHEWS: We are moving towards our nursing homes becoming - and we saw some protests again in the Corner Brook area over this, our nursing homes becoming that, nursing homes, high levels of care. And as we, on a go-forward basis admit people, we are admitting higher levels of care. We are really getting out of a level I business, or levels I and II business in the nursing homes, and we are concentrating on levels III and IV.

They are high cost nursing home beds, so we cannot afford to be having people in there at level I. On the other hand, it is not very easy - as a matter of fact, we would not, and I do not think you would want us to, once we started doing it, if we did - start moving level I people out of homes that they have been in for many years, such as the Glenbrook Lodge or St. Luke's home or some other nursing home. Unfortunately, attrition will take of all of us eventually, but it will take care of people in the nursing homes who are level I as they age and pass on. We are not going to replace level I people with current level I, but we are not in the process of moving people out. The only way you really get the savings is if you close down a home. Because if you took six out this home and eight out of that home you really are not gaining any efficiencies of scale.

MR. WHELAN: There may be enough people coming out of hospitals and coming out of private homes who would be considered level IIs to increase the number of guests or patients, however you want to refer to them, in these personal care homes.

MR. MATTHEWS: These people are placed through the single entry system. If they are level Is, that is where they are directed now, under the new concept, to personal care homes. We do not redirect level Is or IIs on medical discharge from hospitals or from the community who are applying to our nursing homes. We direct them to personal care homes through the community health boards single-entry system. I think that is accurate, Eleanor?

MS GARDNER: Yes, that is correct, Sir, and probably one of the reasons why we are running that 50 per cent level Is on our waiting list currently in St. John's is because we are trying to encourage people to go to the personal care home industry.

MR. WHELAN: Do you need a licence (inaudible) facilities, or any facilities licensed in the past number of years? I understand there was a freeze on. Is that just in particular areas or is that for the -

MR. MATTHEWS: There is no freeze on licences as such. The licences are continuing.

MR. WHELAN: For subsidized homes?

MR. MATTHEWS: Oh, I am sorry. The licences for our personal care homes, if somebody wants to start-up, it is issued based on demonstrated need in their area. In terms of subsidized bed spaces, we have not subsidized the bed spaces since 1991-1992, when we got out of approving new licensed, subsidized homes.

MR. WHELAN: So you did not regulate the number of homes?

MR. MATTHEWS: We used to regulate through the WILB board: The Welfare Institutions Licensing Board but now, all that is done by policy only through the community health boards and essentially now, if you meet the standards for levels of care and for life-fire safety, you are free to open up a home any time, anywhere you want. It is a laissez-faire free-market enterprise system on which that operates.

WITNESS: Without subsidies?

MR. MATTHEWS: Without subsidies, yes. If you want to go into the business, you can. It is not unlike any other type of business you might want to get into, you know.

CHAIR: John?

MR. OTTENHEIMER: Going beyond that point, I am just curious: Who makes that assessment if an individual is a level I, II, or III? Because there are grey areas - there would have to be, and, who makes that eventual determination?

MS GARDNER: Through single entry, there is a provincial assessment tool which is used all over the Province and in Labrador. The staff who use that assessment tool are all trained in that assessment process, but there is also a provincial policy manual regarding how to use the assessment tool. If an assessor feels that there is any grey area, you know, a high level II or low level III, then the case is discussed on the weekly clinical panel, which has a minimum of nurses and social workers on the panel. So there are those two checkpoints, but we have admittedly found that the levels of care need even more fine tuning and that is in process.

MR. G. REID: So, what would stop a senior or the family of this individual, from putting a level III or level I care individual into one of those private homes, or do you have to go out and do an assessment of that individual?

MS GARDNER: The person cannot access the personal care home without having the assessment if they are looking for subsidy.

MR. G. REID: If they were willing to pay it all themselves?

MS GARDNER: If a person were admitted to a personal care home without going through the single entry and were a higher level of care, he would be picked up when the nurses do the monitoring of the personal care homes. They are visited regularly and the client would be counselled that if he were level III, the facility would not meet the B2 codes for the Fire Commissioner's safety standards and he would be counselled about that. If he persisted in staying there, though, he would have the right to stay there, but we would engage in counselling with the client and family for, not only that client's safety but, if you are in a shared-care environment and you were a level III, and it is really only staffed for levels 1 and II, and something happened, like a fire, then the other clients, the other residents in the facility would be put in jeopardy because there would be more stress on staff regarding the level III.

MR. G. REID: But legally there is nothing to prevent him from entering?

MS GARDNER: Not if he is private-paying.

CHAIR: Harvey?

MR. H. HODDER: How do you (inaudible) waiting list in this area and how it is impacting on hospital space? We hear that, you know, as you said before, there is a significant waiting list in the St. John's region, and part of that is probably because more and more of the people are moving out of rural Newfoundland, their children are probably living in this area and sometimes they tend to come here. There are a whole lot of circumstances.

We hear tell sometimes of people occupying beds in hospitals and, in other words, they have been medically discharged. How many people will we have, let us say, in the hospitals in St. John's today, who are medically discharged, who are, in essence, waiting for a space in a nursing home?

MR. MATTHEWS: Probably Deputy or Eleanor might be able to answer that. I would only preface it by saying that it is a fact of life that there will always be people on medical discharge in facilities waiting for transition into a personal care home, back to their own home, or into a nursing home. That is a fact of life, and our medical discharge patient population, if you like, on average is certainly not abnormal. Having said that, I think Dr. Pat Parfrey has done some work for us on that, and you might be able to comment further to hopefully validate what I said.

MS GARDNER: Actually, I think that we are to be very proud of our statistics there. We average only 4.2 per cent of our beds, our acute care beds in St. John's, being occupied by a medically discharged client. We have a system with single entry whereby we would not permit that number to exceed 10 per cent. We would be able to control that by the clinical panel which I mentioned earlier. In their admissions, they would start to rotate the admissions from community and from the hospitals to prevent it from exceeding that. The national norm of an acceptable range is 8 per cent to 10 per cent, and we are currently running at 4.2 per cent.

MR. MATTHEWS: Thank you, Eleanor, I appreciate that. She keeps me well-informed, I tell you.

MR. H. HODDER: I had no doubt that she would have the precise information. On the same topic, following through on that, on the waiting list, you mentioned that there is an attrition rate of about twenty-five or thirty per month in this region. Of course, we have a waiting list, you said, of about sixty to seventy, therefore, the waiting list is about two months long. That waiting list, of course, is only two months long if you do not have someone else who becomes more acute in the meantime.

Is there any data kept on people who are, shall we say, on that waiting list but they are nearer to the eighty level, you might say, than they are down to the - you know, the top twenty-five are going to get in. But the same twenty-five who existed last week are not necessarily the same twenty-five this week, because obviously things change. Because things happen and people become ill, or in some cases they drop off again because of attrition while they are waiting. Do you keep any stats on the people who are waiting longer than that because they are not as ill as somebody else but they are still in need of a nursing home, and therefore, the two months - two times thirty does not necessarily mean that you will be covered in the top sixty.

MR. MATTHEWS: You are really asking us how well do we manage the ongoing waiting list.

MR. H. HODDER: Yes.

MR. MATTHEWS: I would say that the statistics on medical discharge at 4.2 per cent indicate that we are managing it very well, for two reasons. Number one, we have the space becoming available fairly quickly, and number two, we are conscious of the cost of hospital beds. Eleanor, you may be able to add something else as to how well we are managing. I would say we are managing very well.

MS GARDNER: I think so, yes. Betty Havens - she is actually one of the experts in Canada for our national norms regarding waiting lists - says that if your waiting list has a turnaround time of six months then you are doing very well. Our longest turnaround time is three months, but we turn around within three to six weeks as well. So the longest the person would be on the waiting list now is three months.

One year ago, prior to single entry, where we are running a situation as you are referring to, at that time the turnaround time to placement could be as high as two years. In the past little while through single entry we have reduced that well within the Canadian norm. The ones who are highly prioritized as to higher need are turning around in a three, six, eight week pattern. The longest of the pattern is the three months.

MR. MATTHEWS: Thank you, Eleanor. There is clearly no really serious concern in those areas. I am glad you are dwelling on them, because they are areas where we are doing a good job. I would suggest you keep up your line of questioning.

SOME HON. MEMBERS: Hear, hear!

WITNESS: Stick with it, Harvey; they are getting hammered on this one.

MR. H. HODDER: I am just here, you know, looking after your best interest, John.

MR. OTTENHEIMER: On, I guess, the same topic, I am curious as well; in acute situations, due to need or perhaps the family's inability to do anything further, what sort of contingency plan does the department have in place, or what policy presently exists, to deal with those perhaps exceptional cases where admission is essential almost immediately?

MS GARDNER: We have an emergency response program. For example, we had one lady who was sent home from hospital and the situation was critical. The turnaround time to placement in that emergency situation was twenty-four hours. In the meantime, while we were waiting for the twenty-four-hour period, the single entry would mobilize home support in the family's home around the clock for the emergency response.

The second type of response for an emergency situation, especially if it is a spousal situation, is that we have emergency beds which are always kept fluid so that if we cannot accommodate the person at home, with relief through home support while we get a placement, then we can admit to an emergency bed. We have also swing beds in every region in the Province for that type of emergency response.

WITNESS: How good are you at all?

MS GARDNER: It is the people out in the community health boards. I am only reporting.

MR. OTTENHEIMER: Thank you.

MR. H. HODDER: While John is looking for another question there, on the issue of the waiting list for the Janeway, particularly as it applies to adolescent, psychiatric services, two years ago we had a tremendously big problem there. What is the current status for adolescent, psychiatric services?

MR. MATTHEWS: I will ask Debbie Sue Martin to answer that. I can only say, from where I sit on a daily basis, I have not had a concern expressed to me directly on that issue for at least a year. A year ago, or two or three years ago, there were some more concerns being expressed to me directly. But, Debbie Sue, probably you can be more succinct and accurate.

MS MARTIN: I will try.

The waiting list has improved from the last two years.

MR. H. HODDER: The 600 one.

MS MARTIN: Yes. If you recall, when we chatted the last time it was around 800, I think, and people were waiting anywhere up to a year. There has been some improvement in that, and that has resulted a lot from the amalgamation of the Janeway through the St. John's Health Care Corporation. One of their programs is now an adolescent health program.

MR. H. HODDER: Yes.

MS MARTIN: Again, at this particular point, things are being planned and put in place; for example, the adolescent health counselling service that is still on LeMarchant Road but had really not been utilized to its full potential. There are discussions now between the community health, St. John's region, and the institutional board to reactivate that and put some extra staff there. One additional staff has just gone there at the beginning of this fiscal year. So it is an area that we recognize really needs some assistance.

One group that we are looking at, this adolescent program that will be with the Health Care Corporation, will go up to the twenty-first birthday, and that has been a real gap for those people, once they get past the sixteen, and even past the eighteen, because you can do extended wardship up to eighteen, and do services that way, but that gap is also being looked at being filled as well. Things are moving along. We are in a better position but we are not where we would like to be. We still have a fair bit of work to do on that.

We also have the other regions as well looking at adolescents and children's services. There is also, in the western region this year - people might be aware of the opening of the Blomidon Centre there, which is a children and adolescent mental health service. So that has taken a fair bit of pressure off the Janeway unit, because for any kind of assessments, under young offenders or anything like that, people had to come into St. John's to get those assessments. The Blomidon Centre opened in May, I think, of last year, and they are able to provide some service there within the region.

We are also in the best situation that we have been in terms of child psychiatrists. We currently have five now at the Janeway, and one of the new people who just came, Dr. Rhonda Vardy, is looking at doing some outreach clinics to the rest of the Province. We are trying to negotiate with some of the boards about that. There are a few things in place and I think we are getting at the problem, but the nature of the business is, as you respond, there is a lot of unmet need out there, and you are getting more demand for the services as well, as people become aware of them.

The other initiative that is addressed, that older adolescent group (inaudible), has been the mental health crisis centre here in St. John's. A lot of people, again, who were falling through the cracks in that eighteen, nineteen, twenty are able to at least get hooked up to the system there. The crisis centre does not provide long-term counselling, but it at least allows someone to get into the system and gets them hooked up with some other services.

MR. H. HODDER: What would you say the waiting time would be now for a child or a teenager who is, let us say, referred from either a family doctor or has gone through the procedures, and whether they come through the school counselling system or through the family doctor or whatever - what would be the waiting time now?

MS MARTIN: In terms of seeing a psychiatrist or just getting -

MR. H. HODDER: In terms of having their needs addressed and seeing the psychiatrist.

MS MARTIN: Okay. Having your needs addressed is one, and having seen the psychiatrist - because mostly what ends up happening is that for the person who has mental health problems, we are trying to look at that holistic - sort of look at the kid in all of the needs. There may be social needs, maybe family problems, things like that. Waiting time for a psychiatrist right now is about six to eight weeks, which is pretty reasonable.

The Janeway now offers a crisis program, not quite as impressive as the single entry system, but there is a crisis program that is able to see people within a week. That does not mean they are going to be kept on and everything met with them, but they will get contact with a counsellor. It may be indeed that there is some short-term intervention, and they can stay in that program up to six to eight weeks. Mostly people should get some service in a fairly timely fashion, but there is still - you know, if it is not a crisis, you are still talking about a probably four- to six-month waiting list. Again, it is down a bit. We would like to see it down around three months if we could, but it is still fairly high.

MR. H. HODDER: The last time we were talking, we had one doctor, I believe, in Newfoundland who was trained or able to work with and identify fetal alcohol syndrome children. You are familiar with the recent study done in British Columbia -

MS MARTIN: Yes.

MR. H. HODDER: - where they found that very high numbers of teenagers who were in trouble with the law indeed were fetal alcohol syndrome, something like 23 per cent.

MS MARTIN: I do not (inaudible).

MR. H. HODDER: I do have the summary of the stats in my office. In that kind of situation, where we know that there are significant numbers of children in this Province who are probably victims of fetal alcohol syndrome, what are we doing to identify it? We have one doctor at the Janeway who was supposed to be able to do these things but, of course, he has a full schedule besides that. We have a whole population of teenagers out there whom we should be doing something about and addressing the needs in the school system, in the justice system, and also at the community level. What are we doing for those children?

MS MARTIN: Okay, I will speak on behalf - fetal alcohol syndrome really falls under addiction services. This year there was a workshop put on for professionals, family members, who are interested in fetal alcohol syndrome. I cannot remember exactly when it was. I think it was last Fall sometime.

WITNESS: October.

MS MARTIN: Yes, October, I think it was. I think there was over 100 people at that. You are right, in that there is a fair amount of interest. Because the rate in the native or aboriginal population is even higher than 23 per cent. I think it is somewhere over 50 per cent in some populations.

MR. H. HODDER: Yes, it is a scary stat.

MS MARTIN: Yes. So that issue again, it is really a target area for the aboriginal population, and also in terms of diagnosing the problem, as you say. It is something that gets missed a lot of times. I do not want to speak for them, but the Department of Social Services ends up getting involved with a lot of children with that, and is interested in trying to get some training for staff to identify that - also, doing some training for parents who are fostering children with fetal alcohol syndrome.

There is some work being done on that, but I am not sure what the follow-up of that workshop was. I know, as you say, that study in B.C. really gave some impressive numbers to that. There was a lot of interest around. I cannot remember the name but there is one person, as well, at the Health Sciences Complex who is also involved in the diagnosis.

MR. H. HODDER: But, other than the familiarization session that you had last October, we have not really addressed that issue to any kind of a level that would even be remotely commendable, and it is an issue that is very significant. It is a big issue for aboriginals; it is a big issue in the general population, because what it says is that the treatment we are giving these teenagers may be totally inappropriate and we may be putting children in prison at Whitbourne for something that is physiological, and in fact, we know that there are teenagers in Whitbourne who are there because they were born with a fetal alcohol syndrome -

MS MARTIN: Which was not picked up.

MR. H. HODDER: - which had been totally missed. I have said to the minister that this is an area that is very important to me as a person and also as an advocate for children.

MR. MATTHEWS: I think it is recognized by government and certainly by the department, because one of the areas where we have deliberately said, and we are, in fact, putting more money every year, is in the area of community services for our community health boards, and a lot of these areas will continue to be addressed in a better fashion as we further resource our community health boards to get out and do, not only education and prevention, but also trying to pick-up by way of assessment, those situations where we can probably offer some intervention as early as we can. But it is an area where there is a big need - there is no question about that.

MR. H. HODDER: I would say to the minister that the study done in British Columbia has called for messages for every province and that is something that I think every educational system, legal system and the medical system should be looking at. Because the stats are so much higher than anybody expected them to be.

MR. MATTHEWS: They are overwhelming.

MR. H. HODDER: Yes, they are.

CHAIR: Thank you, Debbie Sue.

John.

MR. OTTENHEIMER: If I could just follow up on this, because as I recall, I think the same issue came up last year when we were talking about the psychiatric treatment of children at the Janeway. I remember your saying last year that as a result of a probation order, or as a result of a disposition by a judge, that waiting list is then circumvented and that young person almost automatically has a direct route to such care. Is that still the case?

MS MARTIN: Yes.

MR. OTTENHEIMER: It is?

MS MARTIN: Yes. The court- ordered assessments do get a higher priority on the list.

MR. OTTENHEIMER: Because in a perverse way, you know, a person who needs care and attention gets that care and attention by, in fact, becoming involved with the criminal justice system.

MS MARTIN: Yes, and I think again that one of the responses was the creation of that Blomidon Centre out on the West Coast, because a lot of the demand being put on the Janeway psychiatric service was coming through court-ordered assessments. And, as the minister mentioned, we are trying much more to be pro-active and not wait until people get desperate for service, trying to provide service so that, hopefully, they do not reach that point. But it is true that the young offenders system - you know, most people are in fear of judges, maybe not everyone. But, once the court-ordered assessment is - there is something from the court, it is usually complied with in a fairly timely manner.

MR. OTTENHEIMER: How is that done? Is there a specific doctor at the Janeway who is dedicated to those who have been convicted in the Young Offenders court?

MS MARTIN: No. What happens is, the judge would put the order -the order would come, and usually the psychiatrist is named on the order, and then that psychiatrist has to do the service. A lot of times, the psychiatrists have had real problems with assessments being ordered within four hours and things like that, but we have had some discussion with the judiciary about the resource that we have available, the total impossibility - as well as clinically, that is not a very reasonable way to do an assessment, so we have been able to work out. Usually you get something within forty-eight hours or seventy-two hours. And usually, what will happen is, if there needs to be a more in-depth assessment, then that recommendation would go to the court, and that may indeed take some longer time.

There are some additional services offered through Whitbourne which you may be familiar with. They have a psychologist on site there. They also have a psychiatrist who visits there on a weekly basis. In some ways it is not sort of - it is probably not as much of a circumventing of the system as there would have been last year, because there are a few other services that are particularly directed towards justice. So it does not circumvent, if my kid or your kid is on the list down there, keeping their place in the line.

MR. OTTENHEIMER: Even though there is an increase in the number of specialists available at the Janeway, is it also fair to say that the number of individuals requiring such help has also increased?

MS MARTIN: I am not going on any concrete facts with that, and I do not have them at my fingertips right now, but my feeling would be, yes. As I mentioned, as you create a service, it sometimes creates a demand for the service greater than one would have even thought there was. I think also there has been a lot of work trying to break down some of the stigma associated with psychiatry and mental health, and people are looking for the service a little bit more than they would have in the past. They have seen it as being not just sort of to go and find out that you are crazy and be put away forever. I think people are seeing what counselling and mental health services can offer a little bit more acceptable, so people are asking for that more.

In the consultations that the community health boards have been doing, mental health continually comes to the forefront, as do services for children - health services as well as mental health. Some of you may be familiar with the interdepartmental model for services to children that is being piloted now on the West Coast. Some of the people you talk about who may have fetal alcohol syndrome or children with autism, some of those groups who have a lot of needs but are small in numbers, that particular model will be addressing those children who require more than one service.

We are hoping that once that model gets in place - and, of course, it has bugs in it that are going to be worked out - but when that gets in place we will be picking up a bigger portion of the kids that we know are having problems and not waiting until, as you say, they end up as teenagers in the justice system. Because that is a hard place for them to be, often.

MR. H. HODDER: Could we perhaps move on to another topic? I want to go to page 203 in your Budget document. It is on Community Health, and health promotion. You have a total allocation there of $1,741,000 and -

MR. MATTHEWS: Page 203?

MR. H. HODDER: Yes, page 203, 2.1.01. Talking here about health promotion. How much extra money have we allocated into health promotion this year as opposed to last year, if any?

MR. MATTHEWS: What line item are you looking at?

MR. H. HODDER: I am looking in the whole area here, because it is all put in together here now. You say: Community Health Sector in areas of health promotion, disease control and epidemiology, nursing, child health, and so on and so forth. You have a total here of the whole thing, but in terms of promoting good health, nutrition, that kind of thing, it seems that there is - it is always a battle to find dollars to go into health promotion. We tend to have a sickness philosophy rather than a wellness philosophy. What are we doing in terms of promoting better health practices to the public, including nutrition, for example?

MR. MATTHEWS: To answer the question as to how much more we are putting into it, we are putting into the community health side of it, as the figures indicate, we have gone from $56 million to $59 million total amount being voted there. In terms of how much more we are putting into education and prevention - I think that is your question -

WITNESS: (Inaudible).

MR. MATTHEWS: Yes. I do not know how to answer that, other than to say we are putting more. To break down what is actually going into education and prevention, you would have to get into almost every component of the programs delivered by the community health boards. Because almost every program that the community health boards deliver has an element of education involved in it, particularly as it relates to the children's side of it, you know, when you are dealing with the - and not only the children's side of it, as you are dealing with the adults as well, when you are dealing with pre-natal programs, with nutrition programs, and with counselling and dietary matters of certain specific segments of the population.

All of these have components of education and prevention built into their programs. So, it is not a figure you can take out as a line item. It permeates every program virtually that is targeted towards health improvement areas.

MR. H. HODDER: Let me take a particular example.

MR. MATTHEWS: Yes, okay.

MR. H. HODDER: A few years ago, Prince Edward Island had the highest incidence of low birth weight babies in the countries. The province began an aggressive policy to address that through promoting better health to mothers and getting at the pre-natal, addressing the whole issues of the people who were in their child-bearing years. It has been able to now go from having the worst record in Canada to having the best record in Canada. What has it done that lets it get that turnaround in its stats?

MR. MATTHEWS: From when to when did this happen?

MR. H. HODDER: I think it is over about a ten-year period. They have really addressed it, they have come to grips with it. It was at about 4.5 per cent. No, they were up to 5.5 per cent. They are now down to about 4.5 per cent, if the stats are right here. They have made significant gains there. Newfoundland's record in low birth weight babies is still one of the worst in the country.

MR. MATTHEWS: On the low end of it, yes. I am going to ask the Deputy to speak on it. Unless they are drinking more Farmers fresh milk or something. I mean, they are in a good area to get fresh milk and fresh food in P.E.I. That would not hurt, but -

MR. G. REID: We are self-sufficient on milk here in the Province.

MR. MATTHEWS: What?

MR. G. REID: We are self-sufficient on milk here in the Province.

MR. MATTHEWS: Yes, Carnation.

MR. G. REID: No.

MR. MATTHEWS: We are. We are pretty good. Deputy, can you take a go at that one?

DR. WILLIAMS: There are a number of programs - unfortunately Lynn Vivian-Book, our parent and child health consultant, could not be here tonight to give some details. The data I have is 1993 data, low birth weight data in Canada, and P.E.I. is the lowest at 4 per cent. The Canadian average is 5.7 per cent in 1993, and Newfoundland is at 5.7 per cent.

MR. MATTHEWS: We are at the Canadian average.

DR. WILLIAMS: Yes, we are right at the Canadian average. We are not above, we are not below. Ontario, for instance, is 6.2 per cent. The Canadian average, like I say, is 5.7 per cent. Some are above, some are below, and some are right on the mark. We are at about average. Our latest data for 1995 shows we are down to 5.4 per cent. They are small numbers and small percentage changes. There are a lot of activities going on through our public health units in terms of parenting skills for women and children through the CAPC program. There is also Canadian nutrition program. Many of the things that our public health nurses do are of a preventative nature.

Specifically how P.E.I. was able to get at theirs I do not have at my fingertips, but we could certainly get for you a summary of what we are doing, to provide it to you in follow-up to this meeting, what action we are taking. I will get Lynn to do that for you. The data that we have heard recently is not correct. I think somebody was going around saying that our low birth rate is worse than other provinces, but right now we are at the Canadian average. We are waiting for the 1996 stats to come out before we make any statement on that. It indicates that in 1993 we were at the average. In 1995 we are down to 5.4 per cent. I know that is small numbers, but you may inch along.

P.E.I. is far and ahead the best in Canada. It may be, too, that they are small, they are not scattered as much as we, so they may have better access to some programs and services. I am not sure about that. They are certainly different in other provinces.

MR. H. HODDER: Every low birth weight baby, according the stats that come across my desk, will cost about $200,000 in initial care. The stats I saw, say that every year, in this Province, we are spending upwards to perhaps $14 million or $15 million in terms of trying to - you know, that is cost of caring for low birth weight babies. I would suggest, and, in fact, the stats said, that in the past four years we have spent $56 million trying to care for low birth weight babies. So everything we do in that area and even if these stats are not quite 100 per cent on, everything we do in that area is significant, because every dollar we put in there - For example, in British Columbia, in every ladies' washroom, there are posters that talk about low birth weight babies and the effect smoking has on them and all this kind of thing and they are in every washroom that is there. I have not visited all of them but I am told by my contacts out there that, they are very aggressive with this because they -

MR. MATTHEWS: My question is that you visited any of them.

MR. H. HODDER: I have not visited one, not a single one. I take other people's word for it. But what I am saying is that there is an aggressive promotion and I do not think that we have that kind of aggressiveness to this particular issue.

Now, we took $100,000 and we did a t.v. spot or we put some more information out there, brochures, we told doctors and they - I am told that one of the things that worked on PEI was the medical community, to make sure that doctors addressed this on the first visit and all that kind of thing. There are a number of strategies that I am told they use. It is an area where we can have real input, not only in terms of saving dollars, but we can also have an input on long-term care because every child that is born of normal weight, will have significantly, on average, fewer health care problems as its life progresses.

MR. MATTHEWS: Agreed.

MR. H. HODDER: So what I am saying is, we have to get more dollars in that area.

MR. MATTHEWS: I am sure the officials have heard you and to the extent that we can bring more dollars -

MR. H. HODDER: Oh, we are not in the House of Assembly now, Lloyd, that is the answer you give every day.

MR. MATTHEWS: No, no. I never said the officials have heard you because I am not sure that they would waste their time listening to us in the House; I would hope they all do not but, certainly -

MR. H. HODDER: It is a big issue and I know that we have kind of treated it rather lightly here but -

MR. MATTHEWS: No, it is not. It is important, Harvey.

MR. H. HODDER: I hope that it is not; it is a very big issue and it says that health care starts long before pregnancy begins.

DR. WILLIAMS: It is really a prevention of something that can have a life-long effect on somebody so it is very important. In the last two years our rates are going down. We are hoping that our rates, which will be available to us very shortly, will have three years down in a row. I will get something for you from Lynn Book who is most familiar with this problem about the approach we are taking. A lot of activities are going on at the community level and with high-risk groups, to try to lower this rate, a lot of activities, but I will get her to lay it out for you; and we are having some success.

MR. H. HODDER: Okay. Maybe she could give me a call and I could drop over to her office and have discussion with her. It is a topic in which I have a great deal of interest.

DR. WILLIAMS: We had something prepared here, not because we expected a question on it but just because we are getting ready to do something publicly on it. So I just happen to have and that is why I have the rates in front of me.

MR. H. HODDER: And you probably knew beforehand that I would ask a question on that anyway.

DR. WILLIAMS: No, (inaudible) completely.

MR. H. HODDER: The answer this year is better than the answer last year, all positive, and he will quote me on that in the House one of these days.

MR. OTTENHEIMER: Certainly, we have heard a number of rural doctors state publicly, and perhaps this has been an area that the department has been giving attention to over the past number of years, but it is this whole concept of the expanded role of nursing, And we hear the term, I think, `nurse practitioners' for example, as a way to help deal with what perhaps many would call very difficult circumstances as presently exist in rural Newfoundland, so I guess, I am wondering, Mr. Minister, from a philosophical point of view, if you could perhaps share with us what the direction is of the department with respect to an expanded role for nurses in our Province and, how you see their role changing in the future to deal with rural medicine in our Province.

MR. MATTHEWS: The concept of using nurses more and more in areas of primary care on the front lines is what we are dealing with. Philosophically and unequivocally I support that concept. I have shared that with the nurses of the Province through their associations, I have shared it with the doctors of the Province in my meetings with them.

There are a number of things happening to try to move that along. We have nurse practitioners to a limited degree now on the Coast of Labrador and in Northern Newfoundland. They have been a historical part of the Grenfell delivery of primary care, simply because doctors were harder to get in previous years than they are now. Although you may not think that to hear about the doctor issue. The fact of the matter is, we have just as many doctors now as we had - more doctors than we had ten years. We have about 100 more doctors.

MR. G. REID: How many do we have (inaudible)?

MR. MATTHEWS: I thought you would ask that question. We have the information here. The comparison for 1983, we had 669 doctors in the Province.

MR. G. REID: Six hundred and sixty-nine in 1983.

MR. MATTHEWS: In 1983. Fourteen years later in 1997 we have 863, which is an increase of almost 200 doctors, 194 doctors I believe that works out to.

MR. OTTENHEIMER: Does that include everybody?

MR. MATTHEWS: That includes specialists and general practitioners.

MR. G. REID: With a declining population, according to some.

MR. MATTHEWS: Yes.

MR. OTTENHEIMER: Is that practising specialists and general practitioners?

MR. MATTHEWS: Four hundred and twenty-nine -

MR. OTTENHEIMER: But that includes the -

MR. MATTHEWS: - specialists, or general practitioners, and 434 specialists. The percentages on that, because I memorized them for you, is 49.7 per cent primary care, 50.3 per cent specialists.

MR. G. REID: What is the total salary for these fellows? Or not fellows, individuals, I should say.

MR. MATTHEWS: We are spending close to $140 million in physician services, medical services, fee for services and salaries. On average that works out to - well, you can work it out. The average billing last year of a fee for service doctor in the Province was, I think, $162,000. Now, that was a fee for service -

MR. G. REID: One hundred and sixty-two thousand dollars?

MR. MATTHEWS: Yes. That was a fee for service, family practice or general practitioner. A specialist, considerably higher than that. Of course, there is a bunch of different arrangements under which we pay doctors, particularly specialists, because some who are really hard to get we have to guarantee certain minimums and that sort of thing.

To get back to your question about nurse practitioners, yes, we believe there is an expanded role for them. The Health Care Corporation is currently, I believe, working on a new model of more of a continuum of health care delivery of services in the Ferryland area, where you have doctors and nurse practitioners and other health care providers working in more of a group setting, or more of a horizontal continuum of care. We may have to do more and more of that in the Province.

The other part of it, of course, is education and expectations. People in the Province who have always had a doctor in or near to their community are very reluctant to hear talk of not having a doctor, and you cannot quite replace a doctor with anybody else who meets the stature of a doctor, with the greatest of respect for every other profession. You know, people want a doctor at a certain point and nobody else will do, and appropriately so, I suppose, depending on how sick they are.

I might also add that in the past couple of months we made available to the School of Nursing through the Health Care Corporation $130,000-odd of extraordinary funding to allow it to take advantage of some new training that was taking place for training nurse practitioners at the University of Toronto. We gave it some funding to send off some people to be trained in the area of nurse practitioning so that they could essentially come back and run more and better programs at our nursing schools. So it is sort of a train-the-trainer type thing.

We are doing everything we can to encourage the nurse practitioner concept. It is not something that is new to Newfoundland, but it is not something that we use readily. The other thing you have to think about in health care is that sometimes when you add a new service like that, you may not necessarily displace a current service. So it is a question of when you are adding one service to complement another, or augment another, as opposed to adding it where you are actually adding a new level of service. We do not have much money to be adding new levels of service to the health care system, but if we can do as good a job with less money, and because we cannot get doctors, provide nurse practitioners, we are prepared to entertain and go in that direction, and we are encouraging it.

MR. G. REID: That 863 -

MR. MATTHEWS: I am sorry.

MR. G. REID: The 863 that we currently have, they are actually out there now or are there some shortages?

MR. MATTHEWS: Well, when you talk about shortages you are talking about places where you have had doctors or the numbers you would optimally like to have. All of the numbers we hear about in terms of shortages, whether it is sixty or eighty doctors, there are not necessarily that many vacancies existing. Sometimes we have salaried physician doctors who quit or move out of their salaried position spots and go over to fee-for-service, and that is deemed to be a vacancy but sometimes that is really not the case.

Probably Dr. Hunt can comment on it. Dr. Ed Hunt is fairly new with us. He came on this year as the medical consultant, and he has been doing a fair bit of work in that area. One of the things he is involved in is a medical services review, which is really a head counting of the actual number of doctors we need and how many we have. Probably, Dr. Hunt, you can give the Committee some comment on that.

MR. G. REID: I find it rather surprising, to tell you the truth, that we have increased the number between 20 per cent and 25 per cent in the past fourteen years and yet we are in a crisis, or that is what some would lead you to believe.

MR. MATTHEWS: Well, I think that is the observation I made a couple of days ago to the deputy. We have more doctors than ever, we have fewer people than ever, and we have more problems getting the doctors' work done than ever. It does not readily add up. With that backdrop, the good doctor, as opposed to the great doctor, can comment.

DR. HUNT: We do have 863 bodies on the ground right now in Newfoundland.

MR. G. REID: But we have vacancies as well.

DR. HUNT: We have vacancies.

MR. G. REID: So what would the number be if you (inaudible) them all?

DR. HUNT: It is difficult to get a handle on exactly what a vacancy is, as the minister said, because you can pick pockets of areas where there are vacancies but when vacancies are reported - for example, if one area is reporting a salaried physician, a surgeon who is needed, and yet a surgeon somewhere else is moving areas and also reports a surgeon who is needed, so you have two vacancies when actually there is only one.

That kind of thing is happening, and the problem is that we do not have a real good data base in place, which is what I am working on now, trying to get a good data base so we can track this and see what is going on all the time.

I suspect we have an oversupply in some areas of the Province, and this is why we have all of these numbers. There is a problem of distribution. If we could get the numbers that we have and put them in areas of the Province where we need them, we probably would not have a shortage of doctors today. We would not have any vacancies in the Province. We certainly have vacancies.

MR. G. REID: So is distribution the problem, Dr. Hunt?

DR. HUNT: The problem is distribution, yes, Sir. What we are trying to do is address that and see if we can encourage doctors to move into the rural areas where they are needed, and try to discourage them from moving into areas where there is not such a great need.

The other point I would like to make is that the biggest problem we are having now is with general practitioners. We do not have a real problem with specialists. For example, although we have had an increase in the total doctors, there is no difference in the number of GPs in the Province now between 1991 and 1997. There was a peak in 1993, in which we went from 429 to 460, and from that time the GPs dropped off, back to 429 again. That is mainly because of the great demand in the international market place. The United States, in particular, has been looking for a lot of doctors; and northern Canada, northern Ontario, northern Alberta, even though they are rich provinces, have an equal amount of trouble trying to attract doctors there as well.

Because the United States is moving towards more of a primary care model, that has created a surplus of specialists, so we are starting to see the reverse now. Some of the specialists in the United States are coming to Canada and we are having less of a problem getting specialists here now than we used to, say, four or five years ago.

So our specialist problem is probably not going to be a problem for a few years to come, if ever, but GP may be a problem for some time to come. This is where we may have to look at other means of delivery, such as nursing practitioners or physician assistants or whatever, to staff those areas where we have a shortage right now, because there is definitely a shortage in some parts of the Province. If you could get some way to mobilize the doctors into those areas, that would be another alternative.

We are exploring all of these options to see what we can do. Certainly, there are pockets of problems out there right now, but not necessarily in the total supply of doctors to the Province.

MR. H. HODDER: How are we doing the recruitment? I was listening the other evening and the minister was speaking about some of the recruitment that was being done, I think. Then we had one of the health care boards indicating they were doing recruitment. How do we address the whole recruitment program involving the local health care board and also, of course, having, I guess, a co-ordinator approach from the department as well? How is that handled?

DR. HUNT: The boards have hired a professional full-time recruiter who is working at the board site, and they are advertising all over the country, plus all the universities, and they also have an internet site which they are using. Some boards, in addition to that, are hiring what they call head-hunters, professional people who search for doctors. There is no up-front cost for that, but if the head-hunters are successful there is a cost for finding a physician.

Again, the whole problem is supply. In terms of family practice there is a general shortage of supply in Canada and in North America. We used to depend fairly heavily on our international medical graduates in the past, but I guess again because of the big demand for GPs all over the world, that supply is drying up as well. However, in terms of trying to address some of that problem, there are a number of international medical graduates in Canada who come from universities about which we are not fully knowledgeable, so they might be totally first-rate doctors but we have no way of judging whether they are or not. They may not be good rated doctors, and we do not want to put non-qualified people out in the field; so we are just now working with the university and are going to set up what we call an assessment and enhancement program, so that any doctors who may be in Canada, trained foreignly, will be properly assessed and evaluated, and if they meet the standards of the Canadian trained doctors, then they will be licensed to practice here. If they do not meet the standards but are short in some small area - if they, for example, did not do a lot of paediatrics in their country - we can give them upgrading for a number of months to bring them up to our standard, and we think we may be able to solve some of our supply in that way. We know of perhaps twenty or thirty doctors out there now who may qualify if they had the assessment done.

MR. MATTHEWS: The deputy tells me that the faculty council at the medical school recently has approved that program. There is another program similarly running in Manitoba and one other province, I believe, B.C., Dr. Hunt?

DR. HUNT: Manitoba have an assessment program but they do not have the enhancement program. The assessment assesses the doctors to see if they are qualified. The problem is, if they are not qualified they are just dropped and they may be only marginally deficient in some things. We are hoping this will be like an enhancement program so those who are marginal will be able to get a chance to meet the mark.

MR. H. HODDER: So when these doctors arrive they would write the Canadian Medical Association exams, or -

DR. HUNT: Yes, they have to write the qualifying exam just to see if they have any knowledge of medicine, but that does not mean they are competent in all of the areas we want them to be. This is why we need an assessment, to find out for sure.

MR. H. HODDER: So if we were to identify a doctor, let us say, from South Africa, which used to give us a lot of doctors but not as many anymore -

DR. HUNT: And generally they were very well qualified. We usually (inaudible).

MR. H. HODDER: They were well qualified. Well, let us say, from some other country.

WITNESS: Say, from Russia because (inaudible).

MR. H. HODDER: Yes, from one of the Russian republics, and they are not as well qualified, and you identify it, would you people then pay the cost of that enhancement?

DR. HUNT: Usually what happens is the board will search these people out, and if the board feels they are going to make the mark it is something we will take a chance on, paying their money up front. It depends on whether they are able to do it themselves. If there is a good chance that they can get into the system, the board will often assist those doctors up front, with a view that, if necessary, the doctors can reimburse the board at some later date. Sometimes it is cheaper for the boards to do that than to spend all kinds of money on recruitment.

MR. H. HODDER: In the interim period, let us say, as you said, that you have a doctor whose skills in paediatrics may not be as high as we would want. Would that doctor then be permitted to - you said he has passed the Canadian medical exam. Would he be allowed to then practice with that board, but not practice in the area where he was deficient, but be able to practice in all the other areas, or would he just wait?

DR. HUNT: He would not be able to practice until he passed (inaudible).

MR. H. HODDER: Until everything is done. You cannot have those partial admissions, you might say, or that kind of thing.

DR. HUNT: No. If those doctors were to be so deficient that it would take more than six months to upgrade them, it is not worth the investment.

MR. H. HODDER: No.

DR. HUNT: They just drop them. The rule of thumb is that they have to be well enough trained that you can bring them up to standards within a six-month period. Otherwise, you might as well send them back to university for a whole year.

MR. H. HODDER: Where would this upgrading be done? At the medical school or -

DR. HUNT: At Memorial University.

MR. H. HODDER: In conjunction with -

MR. MATTHEWS: Done through our medical school.

WITNESS: This would be done in St. John's, but it would have to be done in co-operation with the medical school to really meet the standards.

DR. HUNT: Yes.

MR. MATTHEWS: There are some doctors, I guess - some have come - I have had a few immigrants, Russian doctors, some brought in by political colleagues, you know, who are here in St. John's, one or two of them. One is here driving a taxi, another is here delivering pizzas. There are these types of fellows who - they are from Russia, the last one or two I saw, and there was a question of - they wanted to be able to be assessed, and we did not have the (inaudible). Our medical school now has that program close to up and running. That should help us a little bit. It is not to find marginal doctors to put out there if they are not qualified. We cannot risk that. But if there are those who are qualified but whose university standards we are not familiar with, then we can pick them up this way. It may help us.

CHAIR: Perhaps, Don, you could have one question and I propose we take a ten- or fifteen-minute break.

MR. WHELAN: Well, we can take the break. I can ask the question after we come back, if you wish.

CHAIR: So we will take a ten or fifteen-minute break. There is some coffee in the Opposition caucus room. I will keep a close watch on fifteen minutes. We should be back here in about fifteen minutes.

CHAIR: Order, please!

Let us take up where we left off. Don.

MR. WHELAN: Basically, I think - I will certainly forget the preambles - I was wondering how many graduates do we have from medical school each year? How many doctors are graduating?

MR. MATTHEWS: This year?

MR. WHELAN: Yes. Well, on an average, I guess.

MR. MATTHEWS: It depends. Because the ones who go into family practice where we have the shortage, the general practitioners go into the family practice program. There are twenty-five coming out this year. It is like a political poll now. There are thirteen leaning or committed toward working in Newfoundland. Committed or leaning. We know there are three going to the U.S. Two of these are bursary students who took the bursaries and they are paying them back. So we gained a great deal there by helping them out over the years. Three are doing further training in ER and obstetrics, anaesthesia, and there is one non-MUN grad expected to stay with us.

That would be thirteen, fourteen. It is a little over 50 per cent retention that we know of for sure. Our average is about the same as the rest of the Canadian medical schools at about 45 per cent. That is the retention rate.

MR. OTTENHEIMER: What is the present incentive program, I guess, which exists at our medical school?

MR. MATTHEWS: The incentive to go there or to get -

MR. OTTENHEIMER: No, incentive to stay in the Province.

MR. MATTHEWS: Well, the incentive, I guess, is apart from the - we used to have ten bursaries of $12,500 a year. We found out the first year I was in Health, which was the last year we had the ten, we could not even give away ten at $12,500 each, because students were not prepared to take them and have the attached commitment of giving us return of service. So we changed it two years ago to a $20,000 bursary, but we reduced the number to six, which is more of a commitment if you took it, if you had to pay it off. I do not know if we even gave away all the six of them last year, did we?

WITNESS: I think we did.

MR. MATTHEWS: I think we did. So the only incentive to come to our medical school, I guess, is number one, it is one of the best medical schools in the country by virtue of quality of education, number two we have that bursary program. The only other incentive for them to stay with us really is if they want to work in Newfoundland. Because in pure dollars and cents, if they are just looking for the biggest bucks, chances are they will find a place somewhere outside the Province, unfortunately.

MR. WHELAN: What is the cost to the Province to educate these doctors and then to have them -

MR. MATTHEWS: The medical schools -

MR. WHELAN: Do they pay back the subsidization that we provide in total or...?

MR. MATTHEWS: The medical school's budget is about $16 million, $17 million a year.

MR. G. REID: (Inaudible), Lloyd?

MR. MATTHEWS: Pardon?

MR. G. REID: Is that just the salaries or (inaudible)?

MR. MATTHEWS: That is the cost of running the medical school. We can give you the breakout of the salary component of that, you know, for the professors and the doctors. But say $17 million a year for the medical school. We have at any given time in the medical school about 240 students, 260 students. We take in, on average, sixty a year. There is a four-year program, and then they go into a residency program, depending on what stream they want to go into for specialization or family practice. So there are probably 240 students, 260 students here at any given time, it costs us $17 million a year to run the school, so if you want to divide that out you will find out the cost. Almost, it would appear, on average, about $60,000-plus to educate a student per year.

MR. OTTENHEIMER: Why is it showing a decrease of approximately $750,000 from last year to this year's Estimates?

MR. MATTHEWS: That is the American students. We have always had ten slots open for New Brunswick students because they used to send their kids here. They do not have a medical school. Two years ago they pulled out of the commitment to those ten spots, and we started selling them to Americans at $30,000 a crack. Each year that is - the first year there was $300,000, the next year it went to $600,000. We have fifteen there now, so -

DR. WILLIAMS: This year we took in fifteen and last year we took in fifteen.

MR. MATTHEWS: Fifteen or ten? Well, we took in ten Americans and some Malaysians, was it not?

DR. WILLIAMS: Yes. We took in some Malaysians. I think the first year -

MR. MATTHEWS: Three or five Malaysians.

DR. WILLIAMS: - we took in five.

MR. MATTHEWS: Yes.

DR. WILLIAMS: And some Malaysians. Then we took in - we now take in fifteen Americans.

MR. MATTHEWS: Yes, so the bottom line is that we are generating revenue from selling those seats that we had there, and that is why the budget is - we are taking it out of their budget.

MR. WHELAN: So it is ten or fifteen at $30,000 a year?

MR. MATTHEWS: Yes.

MR. WHELAN: And it is costing $60,000 to educate them.

MR. MATTHEWS: Essentially, yes.

MR. WHELAN: Are they here with the understanding that they are going to have to stay here for awhile?

MR. MATTHEWS: No, there is no commitment, nor do we have a commitment to provide speciality or residency training to them. We basically do it as a revenue measure because we have the space available, and $30,000 was about what the market could bear. In other words, if they had stayed home in the U.S., it would cost them about what they are paying, the equivalent of $30,000 Canadian to go to university in their own country.

MR. WHELAN: Would it be valid to say we are subsidizing them and it is costing us $30,000, or would that $60,000 be an expense to us anyway and they are alleviating the debt that we would ordinarily have? Is that the case?

MR. MATTHEWS: Yes, you can evaluate it in either way. If we did not fill the slots, you would not save the equivalent of not having them there. In other words, the fixed costs are in place to run the medical school. It is really that we are gaining by having them, although if you average out the cost of the medical school over the number of students it would work out to about $60,000.

MR. G. REID: What did you say your retention rate again was in the Province?

MR. MATTHEWS: About 45 per cent to 50 per cent.

MR. G. REID: Forty-five per cent to 50 per cent.

MR. MATTHEWS: This year it looks like thirteen or fourteen, maybe, out of twenty-five, so it may be a little better than 50 per cent this year.

MR. G. REID: That is in the Province. Have you any idea as to what percentage of those go to rural Newfoundland?

MR. MATTHEWS: All of them would basically go to rural Newfoundland in family practice because in areas of - in the St. John's metro area, you cannot come in here and set up unless you come for 50 per cent of fee schedule. Nobody has been coming in for the last three or four years to set up in over-serviced areas like St. John's. Now, I suppose they could theoretically work in the St. John's area if they wanted to go salaried in an emergency room.

DR. WILLIAMS: Only in emergency departments.

MR. MATTHEWS: Yes, which is where we have some needs as well. But fee for service? No, they cannot come in, really, because no one is going to come in at 50 per cent of what they would get, because they could not make, you know.

MR. G. REID: Are there any stats on how long they are staying?

MR. MATTHEWS: Who?

MR. G. REID: These doctors who are going to rural Newfoundland.

MR. MATTHEWS: How long on average? I do not know if we have any information on that - Doctor Ed?

DR. HUNT: (Inaudible).

MR. MATTHEWS: I do not think we do.

DR. HUNT: Two to four years.

MR. G. REID: Where do they go then - out of the Province?

DR. HUNT: They either move around the Province or (inaudible).

MR. G. REID: Alright.

MR. MATTHEWS: Or they go back for speciality training. They go in all kinds of areas. What we have found is that the bonus we introduced two years ago has slowed up doctors leaving. Interestingly enough, John Peddle from the Hospital and Nursing Home Association indicated to me over the weekend - we were in doing some work - that the new salary package we have announced, the $2.6 million we put in, they seem to be getting more enquiries even in the last month or so as a result of that. I think that is going to help us, I think that is going to be a significant help to us. But it is not going to happen overnight. Doctors who are with us will certainly be more interested in staying. Doctors who would be interested in coming for the old salary will certainly be more attracted by the new one.

MR. OTTENHEIMER: What are the local students paying approximately, say, for annual tuition at Memorial?

MR. MATTHEWS: Sixty-two hundred and fifty dollars.

MR. OTTENHEIMER: Sixty-two hundred.

MR. MATTHEWS: Tuition. Well, it is at, per year, $2,700.

MR. OTTENHEIMER: That is per year for, what, about three, four years, is it?

DR. WILLIAMS: Four years.

MR. OTTENHEIMER: Four years.

MR. MATTHEWS: Four years. It was $2,700 for the first couple of years, and then it went to $3,500. I know, when I went into the department, I proposed an $8,000 fee. The University Senate gave me $6,250.

MR. G. REID: Go for $15,000 next year.

MR. MATTHEWS: Don't tempt me, Gerry.

CHAIR: I think (inaudible) is a good number.

MR. MATTHEWS: Sixty-two hundred and fifty dollars.

CHAIR: My daughter is going to be applying in a couple of years so keep it at that number.

MR. G. REID: But if you look at the 50 per cent retention rate, we are paying $120,000 a year basically to keep that open, per student.

MR. MATTHEWS: No, not $120,000 per year, but -

MR. G. REID: No, $60,000 per year per student now, and considering only 50 per cent of them stay in the Province, for the 50 per cent who are staying we are paying roughly $120,000 a year now.

MR. MATTHEWS: No, some of the rest stay after, but they go into specialty training and go into areas of specialty care. This is the primary care, the family doctor, the front-line fellow we are having trouble getting, you know.

MR. G. REID: A four-year program, is it?

MR. MATTHEWS: Four years, yes.

WITNESS: Plus two years as a minimum to train as a general practitioner, and four to five years as a specialist after the basic four-year undergraduate program. So it is six to eight years.

MR. MATTHEWS: That is plus the four years they spend in MUN, we will say, to get their undergraduate degree. It is a ten-year program to train to be a GP, let us say.

MR. OTTENHEIMER: What do they have to return to the Province if they accept the bursary? The commitment is for how many years?

MR. MATTHEWS: A year for a year. It is three years, at the moment.

MR. OTTENHEIMER: A year for a year, I see. I am just wondering. I know a number of years ago the Department of Justice had a program whereby magistrates were sent to law schools throughout Canada, tuition paid by the department, and in return there had to be, I believe, a five-year commitment to continue practising as a magistrate - well, now called provincial court judges. Has the department ever considered that, or in terms of a completely free tuition program, as an incentive for perhaps even a longer period of commitment to medicine in this Province?

MR. MATTHEWS: You have probably heard me pontificate quite a bit lately about the whole concept of every student getting into medical school having to come with a condition attached that they give us at least two years return of service. That is the direction in which we are moving and government is on for that, once we can work out some details probably as to how you would implement such a program. The difficulty with it, I suppose, is that if you implemented it and every student who came in agreed they had to have two years of service or pay more tuition, and you didn't need them all when they graduated, you have to have a process in place to determine to who gets picked or who we select or who stays. Free tuition?

MR. G. REID: You are giving them (inaudible) $20,000 now.

MR. MATTHEWS: The fact of the matter is that we could not give away the ten at $12,500. We upped it to six at $20,000, and the uptake now is not great, is it?

WITNESS: At ten it certainly was not. We are getting six now.

MR. MATTHEWS: Ten was not. We are getting six now, yes. But, you see, if somebody comes up from the U.S. and says: We will pay off your $60,000 or $100,000 as a signing bonus to come down with us and work, and this is happening, you cannot fight it, I guess, Gerry, is the simplest way to put it.

MR. G. REID: The Canadian military fights it.

MR. MATTHEWS: The military does fight it, and short of operating as the military operates, we cannot fight it. That is the difficulty, yes. It is frustrating to have a first-class facility -

MR. H. HODDER: But there is something ethically wrong with making a commitment and then not delivering on it. There is something wrong with the morality of that.

MR. MATTHEWS: Yes, it is, and it is interesting. The Deputy put a copy of a letter on my desk yesterday from a parent of a student who wrote Chris Decker in 1990 complaining about his son not being able, being a rural Newfoundlander, to get into medical school. He eventually got in, took the bursary, and the shagger decided last month he was going down to the States and pay off his bursary. I am thinking about writing his father and I will ask him if it worked - his concept of getting his son in was a good one, but it did not work well - if he has any other suggestions.

WITNESS: You should.

MR. OTTENHEIMER: What we are talking about, and what we were talking about earlier, still unfortunately does not deal with, I guess, what are in certain parts of Newfoundland today real problems in terms of doctor shortages. It is a distribution issue, I guess, as Dr. Hunt mentioned. I guess the challenge, Dr. Hunt, and Mr. Minister, is to somehow find a way to ensure that those communities in need have the required medical attention. It is a tough challenge, but I guess it is one that has to be continually sought after. I mean, we keep hearing stories like - why do we hear about Port Saunders and why do we hear about Corner Brook?

WITNESS: Port aux Basques.

MR. OTTENHEIMER: Just two examples recently. I guess, in terms of a question, what are we doing specifically to deal with examples like that?

MR. MATTHEWS: You are quite aware of what we are doing basically. We are trying to massage all the leverage of the levers we have. The medical school - we have to get a better return out of that, and a return of service commitment is something we are working feverishly on. It does not have much acceptance or have any favour at the medical school amongst the academia over there. They believe in such purity that this would taint it, you know? It is a difficult chore with them, but we are working on that.

We have put the bonusing system in place, we have put the enhanced salary package in place recently. We have a central recruiter in place, working on behalf of all the boards, trying to attract people. We are asking communities and town councils to advertise their community, and when they get a doctor to be as user-friendly as they can to the doctor to make sure that his family and he are comfortable when they come. That all helps a bit.

Beyond that, I am not sure how much more we can do. I asked that question last week in Port aux Basques to Dr. Shandra who was leaving to go back to New Brunswick. It was not a money issue with him. He decided to come for two years, that was his commitment, he was going, so I do not think any amount of money would keep him. Which may be an exception. I asked him what could he suggest. He said: Look, minister, it is the $1 million question. I do not know what the answer is. If it were simply money, then I guess it would be simply to say, when we can get ourselves up to the average of what the rest of the country is paying, we should get the job done, but there is no guarantee of that.

There are a number of initiatives we have to take and we are working on all of them. I do not know, Dr. Hunt, if we can do much more than we are doing, only fight the good fight.

DR. HUNT: We are still working. We have a committee within the department here that is negotiating now with the Medical Association with regard to the MCP funds and so on, to see how we can best manage that. Because I would like to think they are as interested as we are in trying to get the problem solved. We are working within this department also to come up with new ideas, new concepts, to see how we can best manage the system. We are exploring all of these and we are trying to leave no stone unturned. I have only been here now for a short while so I have to get some time to formulate these ideas. Hopefully, in a short while we will get some more thoughts and more goodies on the table to make the system work. It is in everyone's best interest that we do.

MR. MATTHEWS: I guess the only other thing I could suggest we do, if it is doable, is to restore to the young doctors now graduating more of a missionary spirit that was resonant in the Deputy when he graduated in 1969, was it? as a `townie' and went to rural Newfoundland and spent his time until he came to the department. I do not know if that is an injectable quantity or not, the missionary spirit.

DR. WILLIAMS: I doubt whether it was the missionary spirit, but we had a commitment back then. The government of the day - because there was no medical school in Newfoundland, most residents of this Province went to Dalhousie. Some went off to McGill or other universities. We were given $2,000 a year, I think it was, or $2,500 a year. Of the four years for which we had funding, we had to spend at least two years in rural Newfoundland, and then we could spend two years as a resident at the General Hospital. Because they had trouble then at the General even getting residents and interns to cover the hospital.

Pretty well all of us at our class went out and spent - I went out for two years and stayed for ten. Most people fulfilled their commitment. In 1969 MCP came in place, and in 1970 a lot of the doctors started reneging on their commitment. In 1972, I think, government canned the bursary program because a lot of doctors were not fulfilling their commitment. We have only started it up in recent times again, but we are still plagued by the same thing. What we have now is recruiting firms coming up. The Americans do not invest one cent in training here.

We train the people here, we put the money up - the taxpayers, sorry, put the money up - and the Americans do not spend one cent on training people. Then they can come up and offer them the big dollars because they have not put any investment in these people, and they take them south of the border. Because they want to increase, as Dr. Hunt has said, from an 80 per cent mix of specialists and 20 per cent primary care physicians to a 50-50 mix as we do in Canada. It will take them six or seven years to gear their post-graduate training programs up enough to switch from sub-speciality programs and specialist programs to good primary care programs down there, family practitioners. This will be a fact of life for the next six or seven years.

The question is: Do you make the financial penalty so great that people will stay in the Province in return for having their financial penalty forgiven? I mean, that is the dilemma we are in, I guess, something like that, in order to match those kinds of dollars. Because we cannot match them in any pure sense. We cannot match $150,000 a year U.S. with a $50,000 signing bonus. We cannot match it. That is U.S. dollars. It is a pretty big dilemma, and it is a dilemma in pretty well every province in Canada, even in Ontario and Saskatchewan. I think somebody coming over tonight, there was just something on the wire that they have announced, a $25,000 signing bonus.

MR. MATTHEWS: I saw it on Friday night, actually, on Channel 4.

DR. WILLIAMS: So all the provinces are involved in that. I do not know - most medical schools in Canada, I do not think provinces or governments are looking at a solution within their own medical school, because in every other province but Newfoundland the medical school is funded by the department of education. In Newfoundland, we are the only medical school that is funded by Health. So we have a closer relationship, and we are more aware, I guess, of our medical school than other provinces.

But really, we have not looked at that as a solution across the country. We are trying to come up with a made-in-Canada solution that is uniform, through our medical schools, recognizing again that it does cost a lot to train a physician. You have to have a good competent staff, there are certain accreditation standards to meet, and unless you meet those, you cannot train them; the facility will not be accredited. So it is an expensive business we are in, and it is a fair investment of taxpayers' dollars, and it is, I guess, not very appropriate when the system right now can go south of the border. At least if they stayed in Canada that is one thing, but if they are going outside the country it is another thing.

MR. OTTENHEIMER: What is it that the state, or the institution in the state, is paying the student to go to the States? Is there a bonus? Are they paying off just their student loan, or...?

DR. WILLIAMS: They are giving them a fixed amount, whatever deal they can negotiate, I guess. It might be a $50,000 or $60,000 U.S., one-shot deal up front; if you will sign a contract you come down here for a year or two years. And, by the way, when you come here we will guarantee you this package.

MR. MATTHEWS: You see, the health care system in the States is a private enterprise, so everybody who wants to come up and recruit into Canada, they can do whatever they want. They are just hiring you to go to work in a business.

DR. WILLIAMS: Some of these are HMO's; they are in it for profit. They are in a for profit business.

MR. OTTENHEIMER: Could there not be some sort of a term whereby a student, say, a local student who attends our medical school, would sign an understanding or a commitment that if, in fact, upon graduation they leave and go to another jurisdiction, the U.S., for example, the commitment from that signing institution would, in fact, be to make sure there is full compensation - full compensation - for the cost of education, and in that case the university or the Department of Health would be reimbursed; so really there is an incentive and, in fact, a legal obligation on that student, if he wishes to enter into negotiations with a state or an institution, that that compensation be sufficient to fully reimburse for the total cost of that education. Has that been considered?

MR. MATTHEWS: That is basically my program. I am very deeply into that type of trying to pull that off now. The only way it seems it can work, really, is to have a student come in and sign an understanding, or a contract or whatever, that you pay the normal tuition of $6,250 but if you leave, your tuition will be, essentially, $30,000 or $60,000 - pick a number that you think is right to work with - whether it is full-cost recovery or not.

I have to tell you that there is such a vociferous and ardent and almost obstructionist view of that concept held by the NLMA, the rural doctors, the people who run the medical school, the society of medical school students, it is -

MR. OTTENHEIMER: (Inaudible) Charter of Rights.

MR. MATTHEWS: Well, the Charter comes into it to a point. The Charter would come into it, John, in your concept, you know, you sort of - you cannot negotiate with this crowd unless you pay us. I mean, it is a job to enforce that. It seems that the only way you can enforce it is to have them come in and say: Here is your tuition, $30,000 or $60,000 - pick a number - and that is deferred and forgivable upon a return of service; otherwise, it is fully payable if you do not stay with us.

That is the approach we are taking, quite frankly, but sorting it out is a struggle. It is a dog's breakfast. If you could write the contract - and I am sure you would do it free of cost for the taxpayers of the Province - we would be happy to examine it and see it if it is enforceable, Deputy? ...for the greater good, John.

MR. OTTENHEIMER: It seems to me, it is the kind of situation that where there is a will there is a way.

MR. MATTHEWS: I accept that as being a fair statement, because I support your concept wholeheartedly, or you are supporting mine - I am not sure which - but I think we are -

WITNESS: Otherwise, we would be just as well taking our $60,000 per student and giving it to South Africa, and train doctors to come here.

MR. MATTHEWS: Either that or take the $60,000 and add it on to a salary package so that you could compete in raw dollars and cents.

WITNESS: Yes, okay.

MR. MATTHEWS: But I think it also has to be recognized that the medical school has great value beyond training doctors. If you did not have the medical school you would not have the specialists coming here. It seems like all of them come here because they have an opportunity to teach, do research, and also be involved in practice. And there is a fairly significant research industry developed over the medical school in terms of attracting research funding for research work. So there is a lot of value to having a medical school, beyond training doctors, but the primary policy purpose for which it was put there twenty-five years ago, was to resource ourselves in doctors. So there are a lot of issues around the medical school beyond training doctors but we have to use it to get doctors in the first instance, that is the bottom line.

DR. HUNT: Yes, and that explains that we are probably a victim of our success there because other provinces in Canada are actively seeking doctors from Newfoundland. I know that Northern Ontario targets Newfoundland for their supply.

MR. MATTHEWS: As a matter of fact, their new recruiter is a former Newfoundlander, I understand, in Northern Ontario -

DR.HUNT: Yes, that is right.

MR. MATTHEWS: - and he gets 25 per cent of his recruits from Newfoundland.

MR. G. REID: Oh my, oh my; you talk about a traitor, eh? We talked about education earlier, but I found the biggest problem in the area I represent is that, we get a doctor out there, some of them are worked to death because a lot of them are on salary and others have very little to do because the constituents or the residents of the area pick a certain doctor and they think that he is far better than anyone who may come in there, thus you see one who cannot get a weekend off because they are calling his house or calling the clinic looking for him, but then you have another fellow who is really not working full time and I can see why some of them pull out of the area because they cannot get a weekend off or they cannot get a night off and I think, basically, we are going to have to educate people and I think this fellow Peddle was talking about something about this on tv last week, about people coming into an emergency room at seven or eight o'clock in the evening when they can really wait to go and see a GP the next day in a private clinic. It is a real problem, I know, in my district.

MR. MATTHEWS: Well, there is a certain amount of consumer education needed to educate the people about how to use medical services. If you use the medical services right, there would not be as many people in emergency over at the Health Sciences Complex or in your area, you know. In terms of directing patients to specific doctors, if you are on salary and working in an institution, I guess you are paid regardless of how many come, to a point, although doctors like to have a decent workload to keep their skills up, and they need that. So it is not a question of doctors being prepared to take the money and run or do nothing, doctors need a workload to keep their skills sharp. But these are all issues that will take all of our efforts I believe, not the least of which is politicians, to tell it like it is and adjust expectations and try to get people to understand that the world of the 1970s even is not the world we are dealing with now.

MR. G. REID: No, it goes back to what you said earlier, a town taking some role in ensuring that a doctor has a certain amount of comfort.

MR. MATTHEWS: Yes. Sure, if they like the people and like the town and like what is there for their lifestyle purposes, they would be more likely to stay. That is clear, you know, and quite obvious.

MR. H. HODDER: I just cannot believe it has been fifteen minutes and I have not said a word.

MR. MATTHEWS: (Inaudible), you asked enough questions last year, this time.

MR. H. HODDER: That is okay. I just have one question or two really. This thing about double-doctoring and why we cannot control it. What efforts are we making to be able to have better access through the - I see Information Technology here at millions of dollars and, why does it take so long for us to realize that a particular person is seeing, you know, multiple doctors, and is there any way in which we can have that information shared without being in conflict with the Charter of Rights or you know, breaking confidentiality or whatever? What strategies are we developing to control that?

MR. MATTHEWS: The double-doctoring issue is one that is audited and monitored by MCP and they are having some success in terms of identifying, on a usage basis and a visit basis. Now, the prescription drug thing is a separate issue from double-doctoring in and of itself.

MR. H. HODDER: Okay. I was putting the two together.

MR. MATTHEWS: Yes, and we are now involved in a triplicate prescription, drug program that is being worked through the Nova Scotia program because they have had it up and running for awhile, and we are wanting to see how it is going to work.

I guess probably the deputy can comment on it, but my understanding is that where they have had these triplicate drug prescription programs in place, they have not really had a great deal of value in terms of cutting down the cost. People find other ways around, and they go to other substances. It is alleged, the police will tell you, that crime increases because there are more break-ins, and that sort of thing, for people to get their drugs. They have other ways of doing it, so it does not control cost as much as one would think. That is why we are working with the Nova Scotia model before we go into a full-blown program of our own.

In terms of how else we can do the audits of doctors, double-doctoring visits, deputy, beyond the MCP audit program, I am not sure there is much more you can do, other than through the triplicate prescription program.

DR. WILLIAMS: Minister, MCP has a program in place and, Mr. Hodder, I can get you some data on their initial findings, and some of the things they have taken. They can identify people who see multiple doctors. They have done that, and they have written the physicians and written the patients, and they have seen a fairly significant drop in physician utilization after they put that in place, and they are continuing with that. That is one approach.

The other approach we have a problem with is the abuse of prescription drugs - not misuse but abuse - and we have a number of people who go around to different doctors abusing certain drugs, and one doctor does not know they are seeing the other doctor so they will write a prescription.

As the minister said, before we jumped in head first, everybody was saying that these programs are great, you should have one of those, and it sounds good on the surface. We had Dr. Parfrey's group at the medical school research the triplicate prescription programs in place in Canada and the U.S. just to see, in fact, what the outcomes were, and a lot of them are not well evaluated. They were implemented on good faith, but they have not been well evaluated, and in those that have been evaluated there are indications that the drugs you put on the list - and it depends on how big you are going to put the list; are you going to put it just to narcotics, which are prone to abuse? Are you going to put it on benzodiazepines, which is a much broader category of drugs for anxiety and this type of thing, that are probably overused and abused?

What they found out is that the drugs you put on, the incidents rate usage goes down, but other drugs that are not on go up. What is a little bit more disturbing is that the rate of crime and break-ins to pharmacies go up because they cannot get them - they are getting them not legitimately but they are getting them from physicians; they are duping physicians. Now, with the triplicate prescription program, the physicians are notified: Look, you have a problem. This person is getting multiple drugs. So that stops the patient from getting the drugs, but now there are more pharmacy break-ins in some of those jurisdictions and more crime. What is even more disturbing is that it drives some people to maybe harder drugs, some of the street drugs that are not on prescription but some of the LSDs - those kinds of drugs - that are probably even more -

WITNESS: Damaging.

DR. WILLIAMS: Yes, in the long term, I guess.

So what we have done is, we have gotten permission to move forward with a pilot project based on that study. Nova Scotia has a triplicate prescription program in place for a number of years. We are going to do this as a pilot. We are setting it up so that we can have the medical school evaluate the results for us, and rather than duplicate the program and try to start up our own, we are going to have a joint program with Nova Scotia. It will cut down on our costs, and if we find out after a couple of years that, in fact, the benefits outweigh the downsides, then we will probably repatriate it to the Province and continue it here. We want to evaluate it first, and we are setting it up in consultation with the medical school. They are on the steering committee, along with the Newfoundland Medical Board, which will operate the program for the Province, the Medical Association, the Pharmacy Association, and the dentists because there are going to be dental drugs as well; the dentists can write some of these drugs. So we are going to do it jointly and then evaluate it; it is going to be set up on that basis.

MR. H. HODDER: I have no further questions, Mr. Chair.

CHAIR: Thank you, Mr. Hodder.

John?

MR. OTTENHEIMER: No further questions. Thank you, Mr. Chair.

MR. G. REID: Before I make a motion that we accept the - I would like to say that I gained a lot of knowledge here tonight and I was very impressed with the knowledge and the positive attitude that you and your officials have. I would like to thank you for coming.

CHAIR: Thank you, Gerry.

Thank you, Mr. Minister, and I thank your officials. I think we have had a good exchange of information, if not on the Estimates per se, then certainly on general medical issues, which is good for all our educations. Thank you very much.

Now, members of the Committee, we have a couple of business items to which we have to attend. One of the first is to adopt the Minutes of the last meeting, the Minutes of the discussion under the Department of Justice estimates. I need a motion to adopt.

On motion, Minutes adopted as circulated.

CHAIR: We also need a motion to approve heads 1.1.01 through 4.3.05.

On motion, subheads 1.1.01 through 4.3.05, carried.

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

CHAIR: Thank you very much.

MR. MATTHEWS: Thank you for your kind and courteous treatment of me and my officials, and I would like to thank the officials publicly before the Committee for their diligence, hard work, and certainly very clear answers in terms of the questions that you have asked. Obviously, they have a wealth of knowledge and I think you should feel, at any point, free to call them and access and deal with it. If you want the real answers, bypass the minister and go at least to the deputy and -

MR. H. HODDER: That is why, Mr. Minister, at least once a year my faith in the Department of Health is restored.

MR. MATTHEWS: I hope this year it does not wane to have to be restored, but we will come back in the event thereof.

CHAIR: Before the Committee adjourns, I would like to remind members of the Committee of a meeting tomorrow morning at 9:00. We will meet here in this committee room.

On motion, Committee adjourned.