Pursuant to Standing Order 87, Edward Byrne, MHA, Kilbride substitutes for Loyola Sullivan, MHA, Ferryland; Perry Canning, MHA, Labrador West, substitutes for Gerald Reid, MHA, Twillingate & Fogo; Gerald Smith, MHA, Port au Port, substitutes for Wally Andersen, MHA, Torngat Mountains; and William Ramsay, MHA, Burgeo & LaPoile, substitutes for Mary Hodder, MHA, Burin - Placentia West.

The Committee met at 7:00 p.m. in room 5083, Confederation Building.

CHAIR (Mercer): Order, please!

(Inaudible) for your budget session. I will just ask the members of the Committee to identify themselves, starting with Bill.

MR. RAMSAY: Bill Ramsay, MHA for Burgeo & LaPoile. I am here on behalf of Mary Hodder, who is unavoidably absent.

MR. CANNING: Perry Canning, MHA for Labrador West. I am here on behalf of Gerald Reid, MHA for Twillingate & Fogo.

MR. MERCER: Bob Mercer, MHA for Humber East, Chair of the Committee.

MR. E. BYRNE: Ed Byrne, MHA for Kilbride. I am filling in for Loyola Sullivan, who is in Ottawa.

MS S. OSBORNE: Sheila Osborne, MHA for St. John's West.

MR. SMITH: Gerald Smith, MHA for Port au Port. I am filling in for Wally Andersen.

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

CHAIR: One other member of the Committee has not yet arrived, Harvey Hodder. He will be a few minutes delayed.

The procedure for the evening is the same as in previous years. We will ask the minister to make some opening remarks, perhaps ten to fifteen minutes, whatever she deems to be appropriate. We will then ask questions. The way in which we will start the questioning is, we will start with the Vice-Chair, Mr. Byrne, and then alternate between both sides, shall we say, for ten to fifteen minutes apiece until virtually all the questions have been eliminated or exhausted.

I would ask, when people are speaking, that they identify themselves for the purposes of Hansard so we can maintain a good record.

Minister, if any of your officials wish to speak, or you wish them to speak, could you have them come forward to the mike when you require them?

With those few very preliminary remarks, perhaps we could get started.

Minister.

MS J.M. AYLWARD: Thank you very much.

I am very pleased to be here this evening. I, too, would like to have an opportunity to introduce my officials, and I would ask that they introduce themselves. To my right is Dr. Bob Williams and to my left is Mr. Jim Strong, and there are a number of people behind here. I know I will forget someone's name now when I do this. Would you like to introduce yourselves?

MS DELANEY: I am Florence Delaney, ADM of Support Services.

MS ELLIOTT: I am Pam Elliott, ADM of Institutions.

MS. FITZGERALD: I am Brenda Fitzgerald, ADM of Community Health.

MR. WHITE: I am Gerry White, ADM of Policy and Planning.

MS RANDELL: I am Vivian Randell, Cabinet Secretariat.

MS CRAWFORD: I am Elizabeth Crawford, Director of Child Welfare and Community Corrections.

MS LAWLOR: I am Helen Lawlor, Director of Community Health.

Ms J.M. AYLWARD: Thank you to my officials.

If I could just start off by making a few introductory comments, I guess the first comment I would make is that it has been a very exciting year for this department, in the creation of the new Department of Health and Community Services.

As you know from last year, those of you who were present, this was sort of an announcement that was made based on years and years of consultation, I suppose, and staff requests to move in this direction whereby we would realign departments in a service component to try to deliver services based on the needs of the client, the individual, or the community, as opposed to the program.

We spent the last year in an administrative way getting ready for those changes and recognize that we still have a number of years yet whereby we have to, I guess, create and work on the outcomes that we have set down for ourselves. It has been quite a busy year.

Really what you are seeing for this - a piece of the puzzle here for the Estimates is a culmination of Social Services, Human Resources and Employment and this department brought together. We will see that in the Estimates for some of the numbers, I am sure.

What started out as a vision just a few years ago by a number of staff has actually come to fruition. I guess it was made very clear when we were at a conference a few weeks ago in Gander and a thirty-year member of the Department of Human Resources and Employment said that he had dreamed about this happening. He was sort of a little bit sad to be retiring because after so many years of wanting to move in this direction he is finally beginning to see it and the reality of it was quiet exciting.

With respect to the Department of Health in particular, what started out as a flat-line budget, to be flat-lined over three years, quickly turned into an increasing budget. It has actually increased by over $60 million over the last couple of years. Now this department is the largest department in government, with over $1 billion.

We still have many challenges, although there are many exciting things happening. We have seen a number of very exciting things happen this year with the new nurse practitioner program, and some of our pilot projects in particular. We look forward to the challenges that the Department of Health and Community Services will bring us this year, particularly as we grapple with an aging population, among other things, in a publicly funded system that we believe is certainly in jeopardy by virtue of what we are seeing happening across the country.

I would say that what we are seeing is so frightening that in some of the provinces in Canada - in Alberta particularly - they are about to pass a piece of legislation that would create the first private hospital in Canada. I think it is a sad day for all of us because it would be outside the Canada Health Act. It is something that will impact, I believe, on every province in this country. I do believe that this type of initiative will be the beginning of the end of the publicly funded health system, which is a very frightening thing. But it is certainly something that is happening in Alberta, and I do not know if there is any way of stopping that slippery slope. We certainly all have our challenges. Our environment is becoming increasing hard to (inaudible).

With that I will turn it over to you to begin your questions, and we will do our best to answer your questions.

CHAIR: Thank you kindly.

Ed, if you would like to start we will follow with Mr. Whelan.

MR. E. BYRNE: A challenging portfolio, Minister, the biggest department in government.

MS J.M. AYLWARD: So far we agree.

MR. E. BYRNE: Obviously it is a big concern. You probably have the department where most of the public concerns are generated today in terms of priorities, and I am sure I am not telling you anything of which you are not already aware.

I would like to start off dealing with the Western Health Care Board for a few moments. Obviously the Western Health Care Board significantly is under a financial sort of duress, if I could use that word. Audited statements are still not available for the department or for the public view.

As a former chairperson of the Public Accounts Committee, I recall holding hearings in Corner Brook dealing with the Western Health Care Board. One of the items was the financial stability of the Board itself, and a proper accounting for public monies.

Would you care to comment on where that is today with the respect to the Western Health Care Board? What sort of deficit situation do they have? What measures have the department taken to correct the situation that exists, or even the perception of the situation that exists, in the Western health care region?

MS J.M. AYLWARD: There has been quite a bit of difficulty with the Western board, it is no secret, and that is one of the reasons why we identified the need to do a major monitoring by an outside group. The Atkinson group was contracted to do that work, and they are still in the final stages of completing that work.

Because of the difficulty they have had in Western over the last number of years in actually recording their data and being able to pull it together, the Atkinson group is quite hesitant to deliver a final report until the audited statements are in. You do have the draft of one of the statements from the year before last. I believe the other one is probably in a draft form, although I am not aware that it has been submitted. It is very close to being finalized. Once that is finalized, they will then complete their report. Their report is a very comprehensive report looking at a number of things, including not only the operational needs of Western but also the financial component.

In addition to that there has been some instability, as you know, when it was brought to our attention. I guess it was about two years ago now; there were some practices that were being carried on by the then former Administration that were less than acceptable in terms of their spending activities. They had an act that allowed them to act in that way. Since then we have put some other controls and monitoring processes in place.

In addition to the outside report, we are in the process of completing our own audit and our own monitoring of what is going on out there. So I guess we will have the outside view, we will have the audited view, and we will have the departmental view, and try to bring the three of them together. Because what we will do at the end of it is, we will not only try to realign the regionalization process which really has not occurred to the same extent as it has in the other regions, but we will look at the services that need to be delivered, particularly as they relate to physician services but also in terms of how we are going to cluster the types of services that need to be delivered in the region.

That is how we will be looking, and from there I would assume that once they have their COO - they have their CFO and their CEO and now we are trying to finalize the COO. Got all of that? Chief Financial Officer, Chief Executive Officer and Chief Operating Officer. Once that team is in place, I think that will be key. I also know there will have to be significant changes to address the cultural needs in the organization, which are lagging behind the rest of the Province in terms of where they are.

MR. E. BYRNE: Are you in a position to approximate - I am not going to hold you to it anywhere else, but just in terms of when the audited statements would be ready? You said you would have a draft copy of last year's, (inaudible) another copy shortly. Within your own purview from the department, and your own operational review that you have conducted, has that been completed?

MS J.M. AYLWARD: Our operational review has not been completed within our own department for the same reason.

MR. E. BYRNE: When was it started, and when do you see it being completed?

MS J.M. AYLWARD: It has been ongoing now since, I guess, probably March. The problem is, you cannot complete your own review if the audited statements are not in and all the information is there, so we are waiting for that. Plus, part of our review is looking at some of the practices in the hospital. For example, Corner Brook closed beds three times and those beds are still open. They have some of the highest utilization bed rates in the Province. They have the highest bed utilization in bed occupancy; they are not maximizing their ambulatory care services. I guess they have been like a ship without a captain for quite a while and it is evident in the types of practices if you compare what is happening there, for example, with the Health Care Corporation in Central Newfoundland. There is no comparison.

Our view is that we see it as a priority issue because the sooner we get done what we need to do, the less drastic it will have to be. The further on in the fiscal year you go, as you know, the more drastic the measures would have to be to try and live within some reasonable budget.

MR. E. BYRNE: Criticisms out there at the time, I guess emanating from some of the comments in the Auditor General's Report with respect to that board - I would like to give you a chance to respond to it - I think are reflective of themes throughout other health care boards as well. The Auditor General indicated, she said, that the financial analysis of the Health Care Corporation not only at Western Memorial but here, from the point of view of the Department of Health and Community Services, has been minimal to non-existent over the last three years. How do you respond to that?

MS J.M. AYLWARD: Are you talking about the monitoring component or (inaudible)?

MR. E. BYRNE: Yes, in terms of, I guess, the monitoring component. At the time that hearing was ongoing she indicated that had she not gone out to the Western Health Care Board, the Department of Health and Community Services would have never picked up the situation that existed out there. In terms of monitoring the expenditure of public dollars into a publicly funded system I guess is what she is referring to, so I will just leave that. How do you respond that? Was that a legitimate criticism at the time? Has any action been taken since that time to correct that? Or where the boards are in place, government provides the funding and lets the boards manage as they see fit with very little sort of financial analysis or monitoring of these boards?

MS J.M. AYLWARD: I guess I cannot say that it is totally inaccurate, everything she said, but one of the things I will say, we have actually asked the Auditor General to go in and do audits on some of our boards specifically so that we will have the information. She has declined to do the type of auditing that we have asked her to do because, if I remember correctly, she made some comment about not having the proper staff to do the type of monitoring that we have asked her to do.

I will be the first to admit that we have to strengthen our monitoring. I have admitted that in the House and I will admit it here, that we have to improve on the monitoring. I guess that is one of the reasons why I just previously answered the question, we are out now doing our own monitoring and trying to set up a protocol whereby we can do this on a more regular basis with the boards. While I spoke to Western, we are actually doing it with all the boards. We have been to Labrador, we have been to Central; we will be doing all of our boards. In some of them we have already implemented measures, even though we have not been there because some of the things are very obvious to us.

In fairness as well, some of what the Auditor General put in her report was not accurate information. She did not reflect the $20 million that we put in for health stabilization. That was put in in August; her report was released March 31. She has had a lot of contact with our department, and that kind of major type of change would have reflected quite differently in the Auditor General's Report. That was never, ever updated.

I am the first to admit that we need to improve our monitoring, and we will be doing that. We have started to do that with a number of agencies and boards, but we have also asked to have a lot of the auditing done. Because obviously, if you are monitoring with public funds, you want to have the best information possible.

MR. E. BYRNE: The Auditor General obviously goes in with a purview, looks through a certain set of lenses in terms of the scope and legislation, and it is a very black-and-white sort of process. My experience is that some of the concerns that she has raised on a variety of issues have been legitimate. Some have been legitimate but really are - the individual working within a particular department or group did what was necessary to get the job done, so I am not trying to point a finger at your department. I am trying to get a sense of - it is a huge department. The amount of money that is expended within the department speaks for itself.

The accountability aspect of it in terms of so much pressure in the health care system today when it comes to providing services, mostly because of the federal government's downloading on the provincial system and the provincial government, but in terms of monitoring, will improvements in monitoring and maybe an increase in expenditures in monitoring in the long run actually save money that could go back into more front-line services? I guess that is the issue, and situations like that which do not need to occur, should not occur, if the proper monitoring was in place up front on a continuous basis of all the health care boards, not just Western Memorial's, because the one she did on the St. John's Health Care Corporation raised some concerns as well. If there was a weakness, it might have been that. Outside your own operational review on Western Memorial, in terms of monitoring, what tangible steps has the department taken to improve its monitoring, I guess, for the system generally in the Province?

MS J.M. AYLWARD: As I have mentioned, we have put a monitoring committee from within our own department to monitor all the boards. We are doing an initial analysis right now. I cannot say we are not doing anything because we are doing a fair bit of monitoring. We do our monthly monitoring, but what we are trying to do is set up a very clear protocol of monitoring so that both the department and the various boards are clear on what their roles and responsibilities are, and how we will be keeping a closer eye on... We do need to improve our monitoring in every part of the system, because when you have a $1.1 billion operation that is crucial, crosses all sectors, you have to have good monitoring.

Yes, we can definitely improve on our monitoring. That is one of the reasons we started visiting the boards with which we had so many more concerns. If you look at the St. John's Health Care Corporation, and you read the Auditor General's Report on that, and when you consider they brought six organizations together, you have the single largest board, about $300 million, changing from a system, a medical model which was strictly based on a medical model, to program-based health care delivery, it is a huge undertaking. The types of comments that were in the Auditor General's Report are certainly, I do not think, in any way, worrisome with respect to the size of the operation and what has been accomplished in the last two to three years.

Yes, there is room for improvement. Yes, they still have things to do to improve on. But if you look at the magnitude of what they undertook as a corporation, and you compare that to a major private sector (inaudible), and you look at the volume and the number of employees they have worked with, they have done a very superb job in a short period of time, recognizing there is still room for improvement.

We have some areas which we are very worried about - Western is clearly one - and we have others that we know we need to monitor. Yes, we will be putting monitoring in an even more stringent way and under, I guess, both Florence's direction as well as one of the other deputy ministers, each board would be realigned in a way that is looking at the big picture not just institutional and not just community but on the whole region, so we will be looking at things from the full picture.

MR. E. BYRNE: I think the Auditor General clearly indicated that the St. John's Health Care Corporation had a significant number of balls in the air, so to speak, and did a tremendous job in bringing together what they had to bring together in a short amount of time. I think the largest criticism was in that the restructuring of debt that was said was going to be done, the savings that would be realized from restructuring within the St. John's Health Care Corporation, public announcements from government and from the Health Care Corporation, as a result that x number of dollars, I believe it was $20 million or whatever the case may be, would go back into front-line services; and she found that, I guess, their estimates were way off. They were not off a little bit, they were way off in terms of what the cost of restructuring would be. Has there been a final analysis done, a final tally, of what the overall cost of restructuring will be for the Health Care Corporation and the -

MS J.M. AYLWARD: Well, the - I am sorry.

MR. E. BYRNE: No, go ahead.

MS J.M. AYLWARD: Actually, they are not way off; the $20 million is still on target. Some of that they have already achieved, obviously; because the Rehab Centre, for example, has moved over to the Janeway. So they have achieved some of those savings, and what they have saved they have put back into operations.

There is another portion yet, the $13 million, of which they have some of it accrued and some of it yet to be accrued, which will be put toward the cost of the new capital construction and that is where it will go; but you have to keep in mind that you are not going to get the savings if you have not completed all of the reform. For example, the Grace Hospital is still open and that is a significant component; the Janeway is still open and that is a significant component.

If you are talking about the increase from $100 million to $130 million, the actual $30 million more was completely separate in terms of new needs. If you look at why we are spending it: cardiovascular surgery, the parking renovations to St. Clare's and the Health Sciences Complex. The Health Sciences Complex now is a twenty-year-old building; it opened on May 15, 1978. So even though we all think it is a new site, it is twenty years old and it needs refurbishing. If you have been in it lately, you can see it needs refurbishing. So this is doing things like the HVAC or the ventilation system in the ORs and those kinds of things to keep them updated.

All I can tell you at this point is that they are on track and the $13 million that they still hope to achieve from the completion of the reform will be put towards offsetting the operational or the capital cost of the new Janeway site.

MR. E. BYRNE: One last question. You mentioned in your opening comments about the situation as it exists with the new, first time in Canada, private hospital, and the impact it is going to have. It seems from your comments it is unavoidable what the impact will be. Could you elaborate on that in terms of not only nationally on the system, because it is an important public policy issue.

MS J.M. AYLWARD: It is a frightening public policy issue, frightening to me.

MR. E. BYRNE: To some people it is not.

MS J.M. AYLWARD: A lot of people do not know about it, actually.

MR. E. BYRNE: I think it is a frightening issue. Some people have talked to me and said that in education we are allowed to have private colleges and we maintain a publicly-funded education system; why could we not have a private hospital with a publicly-funded system? Some individuals with whom I have spoken said that we should not throw the idea out altogether. Personally, I do not believe it, I do not accept that sort of notion at all, but what would be the impact of that initiative, based on your opening comments? I am interested to hear.

MS J.M. AYLWARD: The bill is called Bill 37, and it is a bill to open and privatize the health care under Ralph Klein in Alberta. What they are hoping to do is to create a private health care facility to be funded out of private funds; therefore it would not come under the auspices of the Canada Health Act. What you do, if you look at the American model and what has happened in places like New Zealand and in the US, you create a two-tiered system whereby people who can pay for the service get the service first.

MR. E. BYRNE: I understand that, but in terms of the impact... You indicated there would -

MS J.M. AYLWARD: Okay, just let me finish. That is the preamble.

MR. E. BYRNE: Oh, I am sorry.

MS J.M. AYLWARD: If you look at the models like they have in the US where they have private facilities and the HMOs, where they have people who have to medicate or whatever, you end up with the most qualified people working in a private centre. They have a lot more access to specialities and services, and all those kinds of things, which works out perfectly if you have the money. But what ends up happening is that you drain your ordinary system, you are left with a lot fewer choices, and God knows we have a few enough choices in this Province, in Atlantic Canada particularly, and now in general in Canada overall.

What you end up with is a two-tiered system. You end up with fewer services, you end up with a lot less specialities, and you end up with a greater dichotomy between the rich and the poor. Right now, as you know, our system is based on where we take turns. We are getting less tolerant in taking turns, so the public is driving governments towards privatization and politicians are feeling a lot more pressure to privatize facilities. People do not want to wait, they do not want to take turns, and it is based on the fact that people who are the sickest get the service first. Whereas the way it is in a private operation is that if you have the money you get the service.

It is just that in a country where there are more poor than rich, the pendulum swings very much in favour, even more so, of jumping lines and jumping the cues and having access, even though it is paid out of private money.

If you look at what is happening in Alberta, they have so much money in their heritage fund that they do not know even what to do with it. Their heritage fund was put in place to offset another oil disaster, and they just cannot figure out enough ways to spend it.

So basically it would be privately funded. I do not know if Allan Rock is going to make the decision on it but, from what we can understand from the justice people, it is outside the purview of the Canada Health Act. Therefore, if you look at that with the internal trade agreements that we have in the country, and free trade, it is a slippery slope once you get it in one province, unless another province is visionary enough to put something in place in the legislation to prevent privatization of clinics and hospitals.

MR. E. BYRNE: Are we moving towards that?

MS J.M. AYLWARD: We sure are.

MR. E. BYRNE: Fair enough. I will turn it over to somebody else.

CHAIR: Thank you.

Donald. Then we will go to Sheila.

MR. WHELAN: Thank you, Mr. Chairman.

Just going through the Estimates, Mr. Minister, there are a few things there that sort of prompted -

MS J.M. AYLWARD: You said the same thing last year.

MR. WHELAN: Did I?

MS J.M. AYLWARD: Mr. Minister.

MR. WHELAN: Two down!

MS J.M. AYLWARD: Do you remember this last year?

MR. WHELAN: Yes. I will never learn, will I?

MS J.M. AYLWARD: I tried to grow my hair and everything since last year.

MR. WHELAN: It didn't help a bit.

MS J.M. AYLWARD: Not a bit, obviously.

MR. WHELAN: Ms Minister.

MR. E. BYRNE: Just say `Minister', Don. You don't need to dig a deeper hole than what you are in already.

MR. WHELAN: At functions I get away from it. Sometimes, with regard to clergy, I just say Reverend Clergy. It sort of neutralizes the gender.

MS J.M. AYLWARD: Bless you and carry on, right?

MR. WHELAN: Minister, I noticed in 3.1.01.10, Grants and Subsidies, Memorial University Faculty of Medicine, there has been a decline, albeit a small decline. I was wondering, is that setting a trend? It is about a half-million dollars, or something like that, in Grants and Subsidies to the Faculty of Medicine.

WITNESS: Page?

MR. WHELAN: Page 201 in the Estimates.

MS J.M. AYLWARD: Okay.

That actually is because we have moved towards American students and we add an increase of five American students to the medical school each year. We charge the medical students from the United States $30,000, which is what we estimate to be the cost, the real cost, of providing medical education. We are expected to increase again by another five, so that is why -

WITNESS: A total of fifteen.

MS J.M. AYLWARD: Yes, to a total of fifteen. That is why the revenue is down. It will increase to a maximum level once we have the fifteen US students in place.

MR. WHELAN: So the fifteen contributes about $450,000 per annum?

WITNESS: About $450,000 each year.

MS J.M. AYLWARD: For three years.

MR. WHELAN: US?

MS J.M. AYLWARD: No, Canadian.

WITNESS: Eventually we will have sixty in, so we will have an income (inaudible) each year.

MS J.M. AYLWARD: So we have fifteen US, five Canadian, and the other -

MR. WHELAN: So that is almost $2 million, eventually, (inaudible) years. That clarifies that.

Indigents.

MS J.M. AYLWARD: Give me the page on that now.

MR. WHELAN: Same page, 3.2.02. I am looking at Total: Indigents. "Appropriations provide for the subsidization of prescription drug costs..." That is upwards of almost $31 million.

MS J.M. AYLWARD: Yes, that is the social assistance recipients.

MR. WHELAN: I am just wondering, when you say `indigents' -

MS J.M. AYLWARD: That is the category by which the social assistance recipients are classified. There are seniors and indigents.

MR. WHELAN: I was a little bit baffled about that. I thought it may have been some other group of people or something (inaudible).

MS J.M. AYLWARD: No, that is what the program has always been divided into -

MR. WHELAN: Nearly $31 million a year in prescription drugs.

MS J.M. AYLWARD: We have a total of about fifty for a whole drug program, divided between social assistance recipients and our seniors.

MR. WHELAN: So your seniors, do they pay a certain percentage of the cost of their drugs?

MS J.M. AYLWARD: They pay what it costs to have the prescription filled. If you are on GIS, Guaranteed Income Supplement, and you are a senior, you automatically qualify for a drug card. You will get whatever drugs are on the formulary as prescribed, and then you pay for the cost of having your prescription filled. That is their cost requirement.

MR. WHELAN: With regard to ambulance services you have, on page 203 in this book, 3.4.01.10, Grants and Subsidies, $150,000. Over here you have, "Appropriations provide for the payment of mileage subsidies to private and community ambulance operators...", $1,741,300. How do you differentiate between the two?

MS J.M. AYLWARD: What is your question again, Don? I am sorry.

MR. WHELAN: We have, "Appropriations provide for the development of programs and policies for emergency health services, organization of emergency medical response and management of the road ambulance program". We are looking at the road ambulance program, and there are Grants and Subsidies there of $150,000, and over here we have Grants and Subsidies for road ambulance service as $1,741,300. What would be the -

MS J.M. AYLWARD: One part of that is the 911 program, and the Emergency Response Program. The reason it is only $150,000 is because we are only one of the funders of that particular program. That is housed mostly under the Department of Municipal and Provincial Affairs. It is one of the programs that really needs, in my mind, to have a bringing together. I guess that is one of governments projects, but the reason is that we are only one of the payers associated with the full 911 program.

MR. WHELAN: You have what seems to be two headings for the same service. Is that wrong?

WITNESS: (Inaudible) operations.

MS J.M. AYLWARD: Did you hear that? One is the operational side of it and the other is the administrative side. One is the administration of the program, and the other is the operation of it.

MR. WHELAN: Okay.

The other one, I do not know if I should get into it because I was hoping to see the last period of hockey tonight. Health Facilities Operations, Grants and Subsidies, $621,960,800, that goes towards the upkeep, the maintenance, and for allocations to hospital boards and all that type of thing.

MS J.M. AYLWARD: Let me tell you what that is for, now. The $10 million of new money that we put in, that is part of that. We also have a salary increase provision put in there based on the 2 per cent this year. In addition to that, we have funding for the reinstatement of the Lakeside Home kitchens. We have a number of other provisions. For example, the one-time transfer of allied health positions to community health, plus the transfer of the additional (inaudible) million dollars that we put in earlier the year to stabilize the health funds.

MR. WHELAN: (Inaudible).

MS J.M. AYLWARD: No, it is more than that.

Are you looking at the variance, or do you want me to go through the full... Are you asking me to go through the full (inaudible)?

MR. WHELAN: Just sort of a general outline, $622 million actually. I know you can't get into it in great detail but I was just wondering generally, what does that cover?

MS J.M. AYLWARD: What I did was over and above the cost of operating the hospitals and the nursing homes, but that is what that includes.

MR. WHELAN: Okay, so you are talking about from $604 million to $621 million. You are talking about the difference in that?

MS J.M. AYLWARD: Yes, that is what I was giving you, the variance in the $7 million, and why it went up. Because the baseline is what we give to the boards for the running of the hospitals and nursing homes, but there is a $7 million variance. I thought you were asking me what that were spent on, and I just gave you some examples.

MR. WHELAN: Basically, I just wanted you to sort of - I didn't want you to get into any great detail. There are four or five lines there telling me what you spent (inaudible).

MS J.M. AYLWARD: I can give you the breakdown, if you want, of all the boards. For example, in the Health Care Corporation there is about $276 million or whatever it would be now with the increases built in, but that is what it is. It is all of the board budgets for the delivery of hospital and nursing homes. Then there is a variance and that includes the extra $10 million that we got on top of that. It does not include the $2 million, obviously, for the community health because this is the facilities budget, but it also includes the other things I mentioned, which works out to about a $18 million variance over what was identified.

MR. WHELAN: I wanted to touch on the personal care homes, what the policy is with regard to the Department of Health, what their policy is on personal care homes, and what you plan to do with home care services in the future, whether you plan to upgrade health care services with regard to home care. What is the long-term view for personal care homes as opposed to health care? Will there be a normal concentration on one as opposed to the other?

MS J.M. AYLWARD: First, let me tell you that if you are looking at that you have to look at the whole continuum of what we call continuing care, from home support to personal care homes to the long-term care provided in the nursing homes. It is a whole gamut.

In this region, in St. John's, we are just in the process of undertaking a study to look at what our needs are and where we need to go, because in St. John's we have very few personal care homes. I suspect a lot of it is due to the cost of the taxation involved to fill the personal care home in this area.

With respect to home support, are you talking about the home support for seniors, or home support for the disabled, or the full program?

MR. WHELAN: There is home support for people who are not necessarily seniors, it could be a ten-year-old child but they are (inaudible).

MS J.M. AYLWARD: Right, so you are talking about the whole program?

MR. WHELAN: Yes.

MS J.M. AYLWARD: I think the question you are really asking is: Are we competing, as a government, providing home support with a personal care agency which is competing for the same dollars?

MR. WHELAN: Yes, basically. That is what (inaudible).

MS J.M. AYLWARD: I guess what we are saying is that we feel that the home support program is an important component of the publicly-funded system. In many areas - we have one of the more generous home support programs in the country, even though we are probably the poorest. I give the example of a woman here who was in an environment where she did not want to be living in Newfoundland. She flew out to British Columbia, to live out there, because she had some relatives and the weather was much more conducive to her condition. When she got out there and applied for the home support program, she could not get twenty-four hour coverage. She did not have the same rates, she did not have the same ability and access to home support workers, so she flew back here.

MR. WHELAN: Can you get twenty-four hour coverage here?

MS J.M. AYLWARD: Yes.

WITNESS: Not in every instance, though.

MS J.M. AYLWARD: Not in every instance, but we do have twenty-four hour care provided. With seniors we have up to a maximum of $2,100.

MR. WHELAN: (Inaudible) them.

MS J.M. AYLWARD: No, it's for the disabled community, particularly. With the seniors we have a $2,100 service limit for home support. I guess at a point where you require more than that then people generally make a choice of going into some form of institution like a personal care home or nursing home.

MR. WHELAN: (Inaudible) case the people themselves do not make a decision. It is more like their family makes the decision: I don't want to see my mom go into a personal care home so she has to have home care at home. In other cases I found that people who really need twenty-four service find it very difficult to get it. I also find in some cases the expectations, when you provide that type of service, go right through the ceiling. If one person has it, well, up the street gets it somebody else wants it, across the road somebody else wants it. If they have it I should get it.

I am wondering about the cost of it and if we are being realistic in producing that type of service. Because once you introduce it, and if it is there for any length of time, it's not a privilege then, it's a right. I'm running into that all the time. I find it is very difficult to get twenty-four hour service.

I was in Whitbourne last week and there was a lady there - I was into her parents' house and I was inquiring if they wanted twenty-four hour service. She had seventeen hours or something like that. I questioned as to whether or not that was sufficient. I said: Maybe I should go up to see her. They said: You don't have to see her, she is just going down the road. She was going down the road in a wheelchair. She was deformed and her mind was practically gone, she could use one hand, you know, this kind of thing. No phone in her house, and she was there for a number of hours during the day by herself. She didn't have twenty-four hour care. I am wondering what do you need to have, what kind of an infliction do you need, in order to get twenty-four hour care?

The other thing is it's almost an open-ended program whereby there is almost no amount of money that will ever cover the cost if you want to give everybody exactly what it is that they want. I am not saying it is a bad program, it would be great if we an afford it. I go to some of the personal care homes. Obviously some of them are not as good as others, and maybe the standards need to be picked up. Some of them are great. They are ideal situations for a person to live in, the environment. They are among their peers pretty well. I'm wondering what the wisdom is of promoting one as opposed to the other. I do not know if you want to comment on that or not.

MS J.M. AYLWARD: I agree with you. Some of the homes are much better than some of the other homes. I think a lot of personal care home operators spent a lot of money trying to upgrade their homes to be competitive. We have a system in place where we have some personal care homes that are subsidized with respect to the beds and others that are not subsidized. We are looking at finding ways to address the whole issue of giving people a choice as to where to go with their personal care homes (inaudible).

MR. WHELAN: Don't they have that choice now?

MS J.M. AYLWARD: It depends. They do and they don't. If they are in a non-subsidized bed they can go where they like. If they are in a subsidized bed you don't take the subsidy with you, the subsidy stays with the bed.

MR. WHELAN: There are so many subsidized nursing homes around that you can almost pick your choice of either one of those.

MS J.M. AYLWARD: We have not given out subsidies since 1991. We have a number of subsidized beds in the Province, but the beds are in the homes. You cannot take the subsidy with you as an individual. It does not go with the person, it goes with the bed.

We are looking at revamping how we are doing the whole personal care home issue, and maybe linking it more with the person as opposed to the bed. We have some areas where we have a lot of personal care home beds, and we have other areas like St. John's where we do not have enough (inaudible). It is that kind of thing. It is a publicly funded system and there is a private system competing with one another. I think that is the point you made. We have gone from, I guess, a $500,000 program to a $31 million with home support.

MR. WHELAN: Still not nearly enough to satisfy the wants and the needs (inaudible).

MS J.M. AYLWARD: Yes, and I think that is the other part too. The home support program is never meant to replace the informal care structures. Like in any community and any society, whether it is health or anything else, the informal system, people or economists have said, equates to three to four times what we normally pay in that funded system. If you look at our system of $1.1 billion, you are talking about a $5 billion system of informal care that is given through the community. It's just by nature of you caring for your parent or your child caring for you, that sort of thing. There is that balance too.

MR. WHELAN: This creates another problem. It was the rule of thumb I suppose back when I was younger (inaudible) that when your parents got old the family took them in and looked after them until they died. Now when a parent gets old it is home care. Nobody even considers the fact that they are going to take a parent in and look after them gratis until they die. That seems to be passé.

MS J.M. AYLWARD: There are some cultural changes happening.

MR. WHELAN: If there is someone (inaudible) it seems to be the exception rather than the rule. I was wondering if we are not (inaudible) promoting -

MS J.M. AYLWARD: There are still a lot of people providing a lot of care. I know what you are saying, and you are right. Because we have done some assessments and I do not think this is the rule, I mean I think it is the exception, where we have gone in to do a reassessment on home support and probably found four or five family members living in the home, and they had a home support worker coming in. Then you have another extreme where someone has nobody belonging to them and you are not able to get enough hours.

It is trying to find a good assessment tool that will measure what you need. You have to include your family resources in terms of people that are able to help. I think that is important and that is probably what needs to be done. If you are living in a household with four or five people and they are all unemployed, for example, it would be a reasonable expectation that they would provide some of the care. Not necessarily all of the care, but some of the care.

It's a very difficult area, one that we need to do a whole lot more work on. It really has not had a whole lot of attention because it has been a growing industry. Over the last eight years to move from $500,000 to $31 million, it's quite an industry that has been built up.

I do not know if that answers anything. It is something we do have a couple of studies ongoing, one in the St. John's region and one for the Province, where we are looking at the personal care home issue, if and how that competes with the home support program. I would not want to decrease a publicly funded program for a privately owned program to the detriment of the people who can't afford to pay.

MR. WHELAN: What is the cost of personal care homes? Because they are being subsidized to a small amount by the provincial government, (inaudible) of $150 dollars a month for guests?

MS J.M. AYLWARD: No, I think it is $900-and something, is it, and we subsidize?

DR. WILLIAMS: We pay a subsidy of over $900, $940 or something a month.

MR. WHELAN: The $900 that they get for a month, doesn't that come from their senior citizens' cheque, about $800 or $750 (inaudible)?

MS J.M. AYLWARD: And if it is a subsidized bed we pay a portion of it.

MR. WHELAN: I believe the portion the Province pays is $150?

DR. WILLIAMS: We pay the difference between their comfort allowance and the money that they get from OAS/GIS. The amount of the monthly rate, they are allowed to keep $110 for comforts allowance.

MR. WHELAN: But the monthly rate is pretty well set, I think.

DR. WILLIAMS: Yes, the monthly rate is set, it is a standard monthly rate.

MR. WHELAN: Nine hundred and twenty dollars a month or something, is it?

MS J.M. AYLWARD: Nine hundred and something dollars.

WITNESSES: (Inaudible).

DR. WILLIAMS: Nine hundred and forty dollars a month.

MR. WHELAN: And the Province pays how much of that?

DR. WILLIAMS: The Province pays a difference between what the person can pay, if they get OAS/GIS they are able to keep $110 a month for the comforts allowance, which removes that amount. They get to keep that. Then the difference between what is left and the $940 or approximately that amount is what the Province subsidizes.

MR. WHELAN: So that is somewhat less than $200 a month, is it, (inaudible) Province per person?

DR. WILLIAMS: It is less I think than $10 a day, put it that way. (Inaudible), yes.

MR. WHELAN: I was just wondering. If it costs the Province that much to keep patients - they call patients guests or residents in one of these homes -, I was wondering what facilities we would have in a similar... For example, if we pumped $30 million into that particular system, what service we could provide to the people who are in those residences.

MS J.M. AYLWARD: You mean in a home support program or in a -

MR. WHELAN: Yes, you could almost have an individual for each resident who is in there. The homes themselves could be upgraded to the point where they are practically castles. You could have a much improved -

MS J.M. AYLWARD: You have to look at what you are providing though, right? When you look at personal care homes it is Level 1 and Level 2. In some cases they are people who are ambulatory, they need very little care, maybe some help with washing. Certainly the biggest component is someone to cook their meals.

MR. WHELAN: Thirty million dollars would look after all that. A lot of the people who are in home care situations, they are ambulatory, they can walk around, unless they have a certain amount of dementia or senility associated with the problems they have. In a lot of cases they are ambulatory, walking around.

MS J.M. AYLWARD: Some of the seniors aren't. They have Alzheimer's and (inaudible).

MR. WHELAN: Anyway, just a suggestion. I am finished. Thank you, sir.

CHAIR: Thank you, sir.

Sheila, and following that, we will have Gerald. Dr. Williams, when you speak could you move that mike a little bit closer to you and identify yourself, please? Thank you.

MS S. OSBORNE: I am looking at 1.1.03, 1.2.03, 1.3.03 and 4.1.03. All these deal with Transportation and Communications. I am just questioning the difference between the budget and the revised in each case.

MS J.M. AYLWARD: You want to do them individually? What are you asking again, Sheila?

MS S. OSBORNE: The difference between the budgeted amount for Transportation and Communications and the revised, and if I could have a breakdown of what was transportation?

MS J.M. AYLWARD: I can do that for you verbally if you want to do the breakdown.

MS S. OSBORNE: Okay.

MS J.M. AYLWARD: Because you are referring to my travel, in this particular case, in the Minister's Office.

MS S. OSBORNE: In 1.1.03.

MS J.M. AYLWARD: Right. The budget amount was what was allocated for budget, the revised amount was $35,000, which was increased by close to $12,000. I will just go through some of my responsibilities. Almost all of the travel included was federal-provincial travel, and travel within the Province for meetings and that sort of thing. I am on the ministerial council which -

MS S. OSBORNE: That was since the budget, was it?

MS J.M. AYLWARD: This would be from last year to this year.

MS S. OSBORNE: That is the difference from when the $24,000 was budgeted, up to the $35,700. That explains what -

MS J.M. AYLWARD: What was allocated in last year's budget, right, the vote was for $24,000. What was actually spent was $35,700. From that period of time some of the responsibilities include that as the Premier's representative on the ministerial council, which is the council that is dealing with some of the issues I have raised, like the privatization of health care, that is one of the biggest issues.

Also, this year we have had numerous meetings with respect to hepatitis C, the blood, and the whole creation of a new national blood agency replacing the Canadian Red Cross. In addition to that I had some other meetings with respect to seniors', because I am also the minister responsible for seniors', as well as some of the youth that cross-sections with Health and Community Services. This does not include the new responsibilities. I will say right at the outset now that the $24,000 will be under, it is underrated for what will be spent this year.

MS S. OSBORNE: That is what I mean. That was unanticipated travel that came up after that was budgeted.

MS J.M. AYLWARD: I have actually commented on it. I think that perhaps it's not a realistic figure to put in there.

MS S. OSBORNE: Okay.

MS J.M. AYLWARD: In addition to that, I attended two First Ministers conferences' with the Premier as his representative, because of the emphasis put on the social policy agenda, namely the health and the whole revamping of the social policy. Right now all the ministers on this council are looking at a new social union contract for Canada, including looking at issues like equalization and the whole concept of health care delivery, the Canada Health Act, and all of those. That would be just off the top of my head, but in addition to that there were numerous meetings around the Province meeting with various boards and hospitals since I became minister.

This is not all my Budget. I didn't start until May 10, which is about six weeks after. It is very clearly outlined where the travel was allocated. Most of it was on federal-provincial meetings.

MS S. OSBORNE: 1.02.03, Executive and Support Services, Transportation and Communications once again.

MS J.M. AYLWARD: I will say the same thing. Because generally before a meeting with the ministers you would have senior executive meetings at the deputy and assistant deputy levels. There are the preparation meetings.

Unfortunately for us, if you are hosting a meeting, if you are the host province, most of the other provinces travel to you, so you have less cost. If the host province is somewhere else - this year the host province is Saskatchewan - but we have, for our purposes, if you are travelling any further west than Toronto you lose two days. Most of our meetings occur in Central Canada, or the centre of the universe as they call themselves sometimes. It's the same rationale for the senior executive.

MS S. OSBORNE: 4.1.01.01. There is a difference in the budgeted salary and the revised. It is down by $49,000. Did you lose a couple of positions there?

MS J.M. AYLWARD: Just let me get that for you now to give you the exact details there. Can you find the page for me?

WITNESS: Page number?

MS S. OSBORNE: Page 205. That is in this book, the Estimates, 4.1.01.01.

MS J.M. AYLWARD: Actually we had one - or it is a vacant salary of $49,000, which would attribute for that.

MS S. OSBORNE: What was that position?

MS J.M. AYLWARD: What was that position?

WITNESSES: (Inaudible).

MS J.M. AYLWARD: Actually it was not one position particularly, it was a number of positions that were not filled. Do you want the specific positions that weren't filled? Because I don't have the specific positions. All I know is that there were positions that were vacant and that is why the budget was less than what was allocated.

MS S. OSBORNE: Yes, okay, so -

DR. WILLIAMS: Basically, it was the interim time between when a position became vacant and the time it got filled. It may have been a week, two weeks -

MS J.M. AYLWARD: Yes, it is not a loss of a position. It is a vacant position that was not filled. For example, we delayed in filling a number of positions and I don't have the dates that they actually -

MS S. OSBORNE: They are filled now though, are they?

MS J.M. AYLWARD: They are filled, yes.

MS S. OSBORNE: In terms of nursing homes, do you have a breakdown of what it actually costs to keep a senior in a nursing home, what it costs the government approximately? That isn't including the drugs.

MS J.M. AYLWARD: Per person, is that what you mean?

MS S. OSBORNE: Per person, yes.

MS J.M. AYLWARD: Is that the $2,800 amount that we are paying?

DR. WILLIAMS: Closer to (inaudible).

MS J.M. AYLWARD: Yes. By month it is $2,800.

MS S. OSBORNE: It costs $2,800. That is what people pay if they can afford to pay, they cover the cost?

MS J.M. AYLWARD: Right, yes. What it costs us depends on the level of care and the ratio of staff. For example, a Level III, IV or V is a much higher resident to keep in terms of cost than someone who is Level II. We have very few Level Is and IIs in nursing homes. We mostly have Level IIIs, IVs and Vs.

MS S. OSBORNE: The maximum that you pay for a senior, though, to stay in their own home is $2,100 for twenty-four hour care.

MS J.M. AYLWARD: Or a portion thereof.

MS S. OSBORNE: Or a portion thereof. I'm just asking this for information. Have you ever considered leaving people in their own homes, say with their spouse, as opposed to putting them in a nursing home and paying the $2,800 to the person or (inaudible) to take care of the person in their home?

MS J.M. AYLWARD: We have never gone to the point where we actually pay a relative to take care of -

MS S. OSBORNE: No, not a relative. If they are two seniors in their late 80s, for instance, and one of them needs to be institutionalized because the other cannot take care of them, have you ever considered leaving that spouse there, or leaving the two people together, who have spent so much of their lives together, and paying somebody to go in for the whole time, in lieu of putting them in nursing care? Is this what that $2,100 is to cover?

MS J.M. AYLWARD: The $2,100 is to cover up to - I mean, in some cases a lot less than twenty-four hours, as you know. Because most of the people who are working there have to be paid at least minimum wage. Most of them are hired because as you know they are unionized. Once they reach the $2,100 mark then they have to make some choices. They either have to get some family assistance or they have to have some other option. We will never force them to leave their home, but the maximum that we pay is $2,100. We don't pay the $2,800.

Generally you can't get twenty-four hour care with $2,100 unless you have other people helping. Some people have been able to get an arrangements where if someone is sleeping, which they generally sleep at some point in the day, they can sometimes make an arrangement to have someone come in for four nights a week and give them a lump sum payment to sleep in the house. Then they are able to do it within that amount of money. If it is actual hours of work here it is not able to be accommodated.

MS S. OSBORNE: Would you ever consider paying $2,800 for somebody to come in and take care of the person? Because obviously the quality of their life, if they can stay in their home with their spouse, and the quality of their spouse's life, would be enhanced by the person staying in the home.

MS J.M. AYLWARD: I guess the best answer to give you there is that you would have to do an individual assessment on each one. If you are looking at the needs in the home it would include things like preparing the meals, doing all those kinds of things. You cannot always get a worker to do high level nursing care and cook the meals as well. It is the combination of care that is required. In some cases, if it is a lower level care you will find someone who will come in and cook, clean and do the care of the individual. I would have to say it would have to be done on a individual basis.

MS S. OSBORNE: Because for $700 you wouldn't be expending any more to keep the person at home, and their life would be enhanced by staying with their spouse. That is what I'm saying.

MS J.M. AYLWARD: I see your point.

MS S. OSBORNE: In some cases. It would not cost the government any more, and this person would remain in their home till they absolutely got sick and had to go to a home.

The other question that I have is, and you are addressing it, is subsidized beds do not got with the person. It would be nice if the subsidized bed went because that would give the person (inaudible) choice.

One final question. Are you planning on taking the kitchens out of the nursing homes in St. John's and having the food delivered?

MS J.M. AYLWARD: As you know, we just have a brand new board started now in the nursing home sector in St. John's. They are affiliated on their own. They are not affiliated with the Health Care Corporation in St. John's, nor are they affiliated with Community Health. They are their own board.

I guess at this point in time I can say it has never been mentioned to me or discussed with me. I know they will be looking at trying to do better service delivery, because we have bits of programs here and bits of programs there for seniors. I am looking forward to some of those types of things. I can honestly say they have never mentioned anything about that to me.

MS S. OSBORNE: Thank you, that is all.

CHAIR: Thank you, Sheila. Gerald Smith and then Harvey Hodder.

MR. SMITH: Thank you, Mr. Chairman. Minister, just a few general questions. First of all, in terms of the recruitment of rural physicians, I know we have made some efforts over the last number of months to try to address this. I'm just curious as to whether or not this is happening. Are we seeing, or is it too early to see, any sort of a positive impact from these interventions?

In the last couple of the days I have just been dealing with a situation in my own area. As a matter of fact I had a phone call this evening before I left. There was a concern that where two clinics operated in my area on the Port au Port Peninsula there has been one physician handling both clinics for the last year or so, and that physician is leaving some time in May. In the latest contact I had with the CEO of the Western Health Care Corporation, I was advised that they still had no one. He couldn't give me a definite answer that they would have someone there. They are hoping the physician who had previously been at Cape St. George would be returning.

First of all, I'm not asking for a specific on that, because I can deal that with the CEO. I guess that begs the question, how successful are we in terms of recruiting physicians, especially for the rural areas of the Province?

MS J.M. AYLWARD: I just want to premise by saying that every single province in the country is experiencing a lot of difficulty recruiting physicians to work in rural areas. The definition of rural is very far-reaching. In some places in Ontario they cannot get physicians to work because they are rural to Toronto. I mean just a few miles away. So you can imagine how much difficulty we are having here.

We have had some excellent discussions with the physicians, as sort of a spin-off of the negotiations. We are looking at ways to try to move it forward. They have actually identified the same concerns as you raised and we, as a department, raised. One of the reasons is that if you have a doctor spotted here or there they don't last. If you have a doctor in an area where there is only one or two doctors they will not last. Those days are gone. The days when you would have a physician who stayed in the community in Grenfell or in Port aux Basques and they ran the show, they are gone. Physicians do not want to work like that any more, particularly if they have young families. They do not want to be on call, they do not want to be working the weekends.

The only way out of it that we see is by using a clustered model. That is what we are calling it and what the physicians are calling it. It is going to take a lot of acceptance, and probably no acceptance by some communities. Physicians do not want to work in clusters of one or two, they want to work in larger clusters. Our population is such that we have to try to create clusters of physicians and other practitioners to deliver services and try to out-reach to various areas. I use the example of Clarenville and Bonavista. You have a much better chance of having doctors go to one or the other rather than somewhere in between where they are by themselves.

I guess the shorter answer to your question is that we are very concerned about the recruitment issue. We know we will never be able to compete in terms of monetary packages with Ontario, Alberta, the United States, or even Nova Scotia, I will be quite honest. Nova Scotia blew the top off their budget in health care with respect to physician services. I frankly do not know how they are going to be able to cover - they do not even know what their costs are going to be, they have lifted so many restrictions.

We also know in some places in rural Newfoundland we are paying physicians one and a half times their salary because there should be two physicians there and we only have one. In an effort to keep them we are offering to pay them one and a half times as much as the salary. For a physician to go to some place like Burgeo, for example, they would get almost as much money as the CEO of the largest health care corporation in the Province. We can't get people to go there.

The point I am making is that we are actively recruiting. Money is not the only answer. Lifestyle is a big part of it. I guess as a province we are going to have to look very seriously at how we are going to deliver health services in a way that we are able to keep doctors. We will never keep a doctor here and a doctor there any more, they do not want that. Even doctors that might be unique enough to want that type of practice can't last, they burn out.

We are working closely with the boards. We are working to develop a new strategy to work even more closely with the boards. We have some other things we are actively working on and hopefully we will have some announcements in the near future on that, but it is something we are very concerned about. It is not just the government, but the doctors are also quite concerned about it.

MR. SMITH: Related to that, one of the things that has always caused me some concern - I remember the debate surrounding the establishment of our medical school. One of the strong articles made at the time was that we needed a medical school in this Province to train physicians who could stay, live, and work here in Newfoundland. I notice in this year's budget that we are looking at there is an allocation there of some $16 million in support of that program.

I have a number of questions related to that. First of all, how successful are we? How many of our graduates of our medical school are staying to practice in Newfoundland? On the average, can you give me a percentage as to how many of these graduates are staying on, giving any service at all to the Province after graduation from our medical school?

MS J.M. AYLWARD: First of all, I need to say that there is a lot more to a medical school than graduating physicians, as you know. Physician training is only one component. If do not have the medical school you will not attract specialists, you won't attract specialities, and in effect you will be working really like a third world country with respect to being able to provide speciality services like neurosurgery or complex back surgeries or anything else. It is that research and development process as well that is so important.

By and large, over the last ten to fifteen years we have not had a very bad response rate to the medical school because we went through a period of time when we had a bursary program and there was a return of service. We have some concerns too about the number of physicians who are leaving, but we have created the difficulty too in conjunction with the medical school. When we implemented the Needs Assessment Committee rule, the fifty per cent billing rule in St. John's and other under-serviced areas, then physicians were not willing to go out and work in rural areas because they did not want to be stuck in rural areas, if they wanted to come back and do the speciality, or if they wanted to come back and work in urban Newfoundland. That is one of the issues that is on the table right now at negotiations, lifting the 50 per cent rule. That will allow new graduates who are coming out of the school to set up practice in St. John's or go to work in an emergency department and build up their patients, which is what they all do, whether they stay here or move away.

I can actually give you the breakdown. I don't have the breakdown here with me and the actual percentages, but it is something that we will have to look at again in the very near future because it is a concern for all of us.

MR. SMITH: In any given year how many students would be graduating from medical school?

MS J.M. AYLWARD: We accept fifteen from the US, or we will accept fifteen from the US, five from the other provinces and forty from Newfoundland residents.

MR. SMITH: Forty from Newfoundland. I can see the fifteen from the other Canadian - how many from the other Canadian provinces?

MS J.M. AYLWARD: Five.

MR. SMITH: Five. How many Newfoundland students, on the average, do we have applying for admission to our medical school and how many of them are being accepted? You are saying we have a maximum of forty. How many students, on average, would we have applying?

MS J.M. AYLWARD: The same as the law schools across the country. Hundreds of people apply for (inaudible).

MR. SMITH: My next question would be, the fifteen seats you say that we have allocated for Americans, is that just to generate revenue for the medical school?

MS J.M. AYLWARD: Yes.

WITNESS: Critical mass improves the numbers that are there -

MS J.M. AYLWARD: Well we could get the numbers all from in here, I suppose, but you have to remember that of the forty that go through, twenty will go to a family practice residency program, which is a GP program, and the other twenty goes on to do a residency programs in some specialty. Of the forty, twenty will go into the general practitioner arena. Some of them will practice here and some of them will go elsewhere. The problem is that when you come out of medical school and somebody from the US comes up here and offers to give you a $60,000 signing bonus and pay off all your debt and give you this, this and this, we cannot compete with that. I mean, that is our problem. We will never be able to compete with that.

MR. SMITH: (Inaudible) I am addressing right now is a bit different from that. I appreciate where you are coming from and what you are saying there. I am just looking, right at the outset, at the entry level. For example, the fact that you have fifteen positions that we are setting aside for American students, and you are saying that this is pure economics. These people pay the full cost, so this helps to subsidize the program for the other students.

I guess from my perspective it has always bothered me, with the medical school, I always believed - I can remember the initial debate, and I was one of the people who believed the arguments that were being put forward at that time. I thought that programs would be put in place whereby some of our students - I mean we have many students who are coming in from rural Newfoundland who could possibly be prepared for some sort of subsidies in the program.

I was a teacher by training. When I came into the teaching profession one of the things that attracted me - and not coming from a background where I could have availed of a university education - was the fact that there was a bursary program in place. There was, at one point in time, the same thing offered to medical students. It seemed to me that with a medical school we could be looking at some of those same sorts of things. When I see that there are fifteen positions which right off the top go to students - and I am sure the majority of those fifteen students... You are saying to me we can't keep our own people, so I doubt very much if many of these Americans are staying to practice here in Newfoundland. Right away we are saying that there are fifteen gone. I'm just questioning that, and I'm just wondering.

This is not something that your officials are not aware of, and that you aren't dealing with on a regular basis. I'm just wondering, in terms of trying to address the very real concerns that are out there - because I live in an area of the Province and I deal with this on a regular basis. The community I live in right now has a doctor two days a week and by the middle of May will not have a resident position. Which means the nearest doctor for me and my family, by the middle of May, will be thirty miles away. If you are in that situation and the reality is there then it is difficult. Especially when you consider as well, right now in the rural areas of the Province, our population is aging, which means now is the time that a lot of them are more and more in need of the health care services.

My question in a general sense is: Is there some way that our medical school can be paying bigger dividends to us in terms of what it is able to do to address this problem in rural Newfoundland? That is a broad question and I'm sure (inaudible).

MS J.M. AYLWARD: It is not broad at all. The best way to answer it is this way. We are in the middle of looking at ways to address some of the concerns that you (inaudible). I'm not prepared to discuss it in detail because it has not gone through the internal process. It is something that we are very concerned about in the department. Physicians are quite concerned about it and the public is quite concerned about it. Obviously we are going to try to respond to it in a way that will address some of the issues you have spoken to, but also not put students in an untenable position.

My view is that you cannot force people to do things. We are trying to come up with a way that we can deal with it. That is the most generic way I can answer your question without getting into the detail, and I'm not prepared to get into those details.

MR. SMITH: I would suggest to the minister that those fifteen positions that are there for Americans, if we made those available to fifteen Newfoundland students who will not get into our medical school because these fifteen positions are taken up by Americans, I suspect that if they were given the option some of these students would be willing to sign some sort of an agreement with this Province whereby they would be prepared to offer service in the rural areas.

MS J.M. AYLWARD: I wouldn't doubt it, but I have to say to you in all fairness, Gerald, I have seen some of the letters that some of the students have written, practically signed in blood, saying that they would do anything and would return service to rural Newfoundland, only to write another letter at the end of it and say: I'm really sorry, but since I have gone into medical school I now recognize I'm not able to do this and I need to do that, or I have been given an offer. I have seen that in writing.

MR. SMITH: Would you not agree you would have a better chance of keeping that person if he or she was a Newfoundlander than if that person is a -

MS J.M. AYLWARD: I'm talking about a Newfoundlander now. I'm talking about a Newfoundlander from the Northern peninsula.

MR. SMITH: Okay, I know, yes, but I have difficulty when we are saying - I know these fifteen Americans, I bet dollars to doughnuts, that none of these people - and no disrespect for Americans. It is just the idea that it seems to me if we are automatically and we are doing it solely on the basis of economics that this is somehow intended to subsidize the program. Don hit on that earlier in his questioning.

My question is: If the medical school is ours and it is there primarily to serve us, I can understand bilateral agreements with other Canadian provinces. I understand we have to go to them for some of the facilities we do not have ourselves. I have to say I have great difficulty with the idea that we are setting aside fifteen seats, when you and your officials are saying to me, and I know for a fact, that there are many Newfoundland and Labrador students who are trying to get into our medical school and can't, who are applying to get into our medical school but will not. Those fifteen positions could be going to Newfoundlanders.

MS J.M. AYLWARD: I do not argue, but what I'm saying is that of the forty Newfoundlanders that you put in there you are not guaranteed to get any of them to stay either.

MR. SMITH: You are going to get more than you are going to get of those Americans.

MS J.M. AYLWARD: I wouldn't count on it, that is what I'm saying. I have seen the literature. You cannot force people to stay. What we have to do is to try to come up with a creative way of addressing the needs of physician supply and making it attractive enough for people who want to stay.

Right now medical students are paying $6,250 to $6,700-something. We are subsidizing between the $6,000 up to $30,000. Right now you are looking across the country and the medical school admission rates are going through the roof, just like the MBA rates are going through the roof. Once you get out, you can practically write your ticket, because it is an education where you can pick and choose what you want to do anywhere you want to do it. It is a very sought after profession if you can get in. Are we letting people in? No. Like I said, it's like the law schools. There are probably 100 applications for every position. It is just unbelievable.

MR. SMITH: One final question with regard to that, and there is another I want to touch on briefly. In terms of the fifteen units that are allocated for Americans, has there been any consideration, has that been revisited from the point of view of reducing that number, or eliminating it altogether?

MS J.M. AYLWARD: Everything was and everything is being revisited.

MR. SMITH: I will move to something else. This is another issue that I have some concern about. We have been talking about seniors and seniors in care in particular. One of the topics that is currently in vogue now and that is a concern, and it's something I have some concern about. My mom, for the last year and one-half, lived in a senior citizens' home. She died when she was ninety-six so she was quite advanced in that stage. I had occasion to have some dealings directly with the people in care and that sort of thing

The area I want to touch on is this whole area of elder abuse that now we are becoming more concerned about and now people are suddenly becoming aware of it. I think I am primarily concerned about it in terms of when it is exists in an institutionalized setting. I think we can all recognize it. We really have very little that we can do in terms of dealing with it within the homes. It is kind of a family thing, and very often, unfortunately, people who find themselves in that kind of situation - I have great sympathy for them - but it has to be a terribly tragic situation for those people who are there. I'm just wondering in terms of the institutions as they exist in this Province: Are there any incidents that are being reported, or where there are prosecutions dealing with elder abuse, in any of our institutions in the Province?

MS J.M. AYLWARD: Let me answer this way. First of all, I would not have access to what was being reported to the police, as you know. I just took over the whole issue of... The Neglected Adults Welfare Act was under the governance of the department of social services up until April 1. I was aware at that time when I was in that portfolio previously of an increasing incidence of elder abuse. I cannot give you the numbers. I know right across the country it has increased, and I suspect it is probably more likely to increase in a home support environment than it would be in an institution. Because there are a lot more witnesses, I guess, if you want to call it that. Because if you are one-on-one in a home with someone, I mean, you really do not know.

One of the things as well, I guess, that we have not done in the department is monitor that type of (inaudible) reporting. I do not have any liaison, for example, with the police if they get the reports, whereas it is a different set up with children. We are directly involved. People who are abused may or may not be under the auspices of a nursing home, or it might be in a private home. I do not really have the full picture of that. Most of the cases that are involved with elder abuse are dealt with through the employee-employer relations mode if it is in an institution that is unionized. It does not always come to me.

MR. SMITH: So there would be no monitoring per se on that sort of thing, other than just as an ongoing sort of thing, such as checks and visits to the home.

MS J.M. AYLWARD: I think the best way to answer it is if there are different levels of monitoring - if is serious enough the police would have it. If it is in an institution where a staff member does something, the staff member would be disciplined and then the employer would make the decision whether that staff member would be referred to the police or disciplined through the collective agreement. If it is in a nursing home environment and it is at a senior level, then it might be brought to my attention. There is no single reporting mechanism like there is, say, for example, child abuse.

MR. SMITH: Just a comment in relation to (inaudible) year and a half. I had many occasions to visit somebody in this institution. This was a large institution. I have to say to you in all honesty there were many times I left there concerned at what I had witnessed while I was there, things I had overheard, things that I had seen. This was a large institution. I often wondered when I left there, I would like to be a fly on the wall and see what was happening after I was gone and the lights went out and there was really nobody else around. I said it in all sincerity.

That is why I raise it this evening. This was a large institution, and I couldn't help but wonder. These were professionals. Sure, they had the rules of training, but over the course of the year and a half I was there many times. I guess maybe after a while people see you around and they take you as part of the trappings or whatever. There were things I saw, and I often wondered. I do not know internally what is built in. You yourself were part of the establishment for a number of years. I do not know what internally is built in, what kind of controls are there, and if you see something going on, like a co-worker cannot... Do you intervene? What do you do? Do you just ignore?

MS J.M. AYLWARD: Well, no. Most organizations have an abuse policy in a part of the policy manual where if somebody witnesses abuse there is a protocol that you have to follow and do a reporting. I do not know how much of that is done, but I suspect that if you had access, I suppose, or if there were some way of looking at it, there would be a number of incident reports that would have been filed; whether you make a medication error or whether you have an incident of abuse, that they would be reported. That is all I know at the organizational level.

In terms of anything more serious than that, it is not brought to my attention. Since I have been there in one year I do not recall one incident of elder abuse being brought to my attention as Minister of Health and Community Services.

MR. SMITH: I think what has really disturbed me most, of course, since then, like over the last year or so, I have seen on some of the American networks where they have carried some of these exposés where -

MS J.M. AYLWARD: I have seen those.

MR. SMITH: If you see it, it is very disturbing, when you see that they have managed to bring out pictures of things that happened, when somebody is behaving in a fashion where they figure nobody is around to see them. If you are a person who has put someone who means a lot to you in that kind of a situation, when you see that sort of thing going on, and you think the possibility is you did that, it is not a very nice feeling when you see (inaudible). I guess it causes you to wonder if in fact it can happen here. Can it happen here? What are we doing to try to insure that it does not happen here, and it does not happen to our relatives?

MS J.M. AYLWARD: I saw the same programs and they were very disturbing. I remember seeing them.

MR. SMITH: Thank you, Minister. That is it for me, Mr. Chairman.

CHAIR: Thank you, Gerald. Harvey, and then Bill Ramsay.

MR. H. HODDER: Thank you very much.

Just a follow-up from what Gerald was saying, there were some seminars that were held in the St. John's region just recently, dealing with this issue. They were put off by the various community health agencies in cooperation with the RNC, with various stakeholders. Some of the people I know attended these sessions, and the general attitude at those sessions was that elder abuse may be much more prevalent than we, as elected people, may think it is, and that we do not have in place a diagnostic - that is not the right word, but - an identification program that would let the channels of communication be easily followed, and a way in which those people who would make complaints would have follow-up of things happening, and also how the people who were working in those facilities would be looked after in terms of job security.

The same thing used to happen in teaching. I am old enough to remember that when child abuse, when children were strapped at home, when children were treated terribly at home, the school system said: What happens in the home is the responsibility of the home and we do not have anything to do with it. We went from that to where we are now.

I wanted to follow up and ask if you, as the minister, would take on the responsibility of probably doing a departmental review, and working with the (inaudible) agency. I know the information is there, and I am surprised that reports are not coming to you from the agencies indicating the prevalence of the problem.

MS J.M. AYLWARD: How I will answer that, Harvey, is that our department is quite interested in seniors and have, in fact, established a seniors secretariat within government to look at and try to bring together issues that are of concern to seniors. We have been working quite closely with seniors and some of their issues in trying to meet them, because they are disjointed in many ways in the types of service delivery organizations and what not they have representing them. I would certainly want to assist seniors in any way possible, but there are a lot of realistic barriers that we have.

Many of these frail elderly are not able to advocate for themselves, and often times the very people who are advocating for them are the people who are abusing them, because they are the sole providers.

There is a lot of work that needs to be done in trying to - I think you would probably need to be in a situation similar to the situation we have now for child abuse, that it would be incumbent upon you legally to refer and report any suspicion of abuse, maybe move towards that direction, which would mean a cooperative liaison with justice and a number of other departments.

Certainly the other thing, it is very much outdated and something that I had begun to work on when I was with the Department of Human Resources, is the neglected adults act, which is also linked into that as well. That is something that has been on a priority list as well. There are a number of facets to it, that whole issue of elder abuse and trying to deal with it, and it is something that I would not rule out.

In addition to that, there is a provincial strategy against violence, which does not limit it to children, of course, it looks at the whole family, and that is also (inaudible). We have representatives from our department, justice, social services and education, and community groups at large. There are things being done. I think we could still do more, but I think in our own department we recognize how we want to help seniors by creating a seniors secretariat in our department.

MR. H. HODDER: I would like to point out too, Madam Minister, that when we refer to this we are not referring only to the health care givers. This is (inaudible).

MS J.M. AYLWARD: No, no, this is like family members. It is most common, family members.

MR. H. HODDER: This is family members, it is financial, it is emotional, it is multi-dimensional, and also sometimes it happens even with the clergy who come in. I know of one instance where the clergy came in and within a short visit the senior had signed over his bank account to the church. If you think it does not happen today, it does happen, and it happened just recently right here in St. John's. These kinds of things are things that we think do not happen, but... The family had to step in and take remedial action there, which is a bit of a sad story but one with which I am familiar.

I wanted to think about the Janeway for a second. First of all, I was pleased a couple of days ago to (inaudible) the launching of the telethon. I looked carefully at the schematics for the new Janeway Centre and, as you know, there is a great deal of excitement with that. Having had a long-time interest in the Janeway and the health care of children, I am excited by it and the opportunities that are there.

The waiting time for child psychiatric care, that used to be 600 people on a patient waiting list - I asked this question before and you know where it is likely to come from - it is now down somewhat. How are we doing with that list now, and what are the prospects for getting that list down to a more manageable level?

MS J.M. AYLWARD: I cannot tell you the actual number on the list. I do not have that updated information with me tonight; I could not tell you that. I do not know, Bob, if you want to speak to that.

MR. WILLIAMS: The only thing I can say is that there was a meeting with the Health Care Corporation and one of the items on the agenda was the issue of mental health services, because they were just reviewing their mental health program, and the waiting list was over 400 last year. I saw in a document today, it was approaching 300 this year. They are making some progress, but I was not able to stay for their discussion on that particular - we can get that information for Mr. Hodder.

MS J.M. AYLWARD: The only other thing that I would add in terms of - and I said it earlier in answer to a previous question - when you talk about services to children, what you are talking about is the end of the continuum. Our focus is trying to be on the other end, which is the prevention end. That is one of the reasons why we put in place this year the (inaudible) Child Benefit Community Youth Network which is focused on children, particularly a large focus on mental health, and trying to deal with all of the issues around mental health, particularly in rural areas. Because if you have a Janeway, and if you have one service, while we need the expertise, I think what we need more so is a strong community development focus to try to do prevention and early intervention on a lot of these programs which are very closely associated with the lack of role models, dropouts, literacy rates, and the whole gamut.

So the process that we have taken to try and address it, while we will always have a need for the tertiary end component or the intensive type psychiatry approach, we also need to do the preventative community development model, and that is where we have put our emphasis this year in developing these regional networks to build on our CAPC programs that we already have in place and creating even a new entry called Community Youth Networks.

MR. H. HODDER: I totally agree with the intervention at an early stage. Obviously, (inaudible) the school system cutting back on guidance counsellors. I see what the intervention might be doing on the one hand is sometimes compromised by another department because of its budget constraints, and it seems like it could be counter-productive; but you are correct, and I am glad to compliment you on the interventions. You know that I have been an advocate of that for a long time.

I wanted to just mention on thing in that regard, and that is your department's position, because again it is an intervention strategy - you were the former Minister of Social Services, now called Human Resources and Employment - and that is the placement of things like social workers within the school system, and whether or not you see that as part of the intervention strategies that you are supporting.

MS J.M. AYLWARD: You know, I am sure, through the Classroom Issues Report, we have done a lot of work on that issue. There is a pilot project under way. I would not rule out that possibility. I do not have money in my budget to do that sort of thing, but in my mind you cannot just deal with the problem without dealing with the whole problem, and that involves dealing with the school, the family and the community. We definitely have some areas that need a lot more attention than others, in the city as well as in rural areas of the Province, and we are very much aware of it; but I have to be honest. When I talk about these Community Youth Networks, I am not talking about a strongly bureaucratic or professional model. I am talking about a community development model whereby we would focus on peer advocacy and peer support, as most community development models focus upon, and basing it on that we would try to build strengths with a similar program to the YES program they have all across this city, I know, in particular whereby they are doing the peer tutoring.

It is all of those kinds of models we are focusing on. I would not rule out professional help, but I also think we have to try to strengthen the community, because we will never have enough social workers to do the type of work we need and I am not sure if we want to have social workers or if we want to have any other professionals.

We are trying to regroup some of our communities that have lost their focus through the fishery, the impact of the loss of role models. The focus that I have with Community Youth Networks is the twelve- to eighteen-year-old age groups, with a focus on eleven to zero being the CAPC program, so it is a very clear focus. It would have to link with the schools, and it would have to link with the recreation facilities and the municipalities. It would be a community development model.

MR. H. HODDER: Of course that would be a renewed commitment to things like family resource centres and that kind of thing. I would assume that if you are going to get into - if you are going to let the village raise the child, then you have to go and make sure that the village resources are brought together in some meaningful pattern.

MS J.M. AYLWARD: That is the CAPC program. The CAPC program is a family resource centre model. That is what we are expanding through the National Child Benefit monies, in addition to creating the Community Youth Network. When you know a model works, you don't want to create something else; you build on something that is working. Our CAPC programs in Newfoundland have the most positive evaluation of all the programs across the country. We have been written up and recognized as being the most successful community development groupings across the country with respect to family resource centres in particular. So if you know something is working, you just want to build on it.

MR. H. HODDER: There is some (inaudible) that is national, written here in Newfoundlander, as you know.

MS J.M. AYLWARD: Yes, I do.

MR. H. HODDER: It appears (inaudible). Gerald and I came across that extensively when we were doing the work on Children's Interests.

MS J.M. AYLWARD: Yes.

MR. H. HODDER: I have a couple of questions. On the burn unit, a comment made to me just a few days ago was that we don't have the latest in the arts, you might say, for our (inaudible) burn unit facilities, and it came as a commentary after the unfortunate disaster at Come By Chance and the fire on Bell Island. What are the plans of the department? I know you are updating the burn unit at the Health Sciences, but the comment was made that maybe we should be evacuating these people to Halifax a lot faster than we do. That was made by a medical person. I just want to get your reaction to that. Can we handle burn patients better?

MS J.M. AYLWARD: Well I think there is always room for improvement, no matter what you are doing, but I would say that you have to answer that question on an individual basis, quite frankly. If somebody is burned quite badly, there is a period of time when you have to stabilize the person because you have major fluid shifts in a burn situation where a person will come into a life threatening situation within six to eight hours after they are burned. In many cases they are not stable enough to be transported. They would need to be (inaudible), they would need to be debrided, they would need to have antibiotics, they would need to perhaps go on a respirator.

I cannot say that we have the latest equipment. I know, if you are talking about some of the things that the Shriners have done, no, we do not have a burn trauma unit but with less than 500,000 people - over 500,000, but - I don't know how many percentages of serious burns we get every year. It is the same principle as that - we don't have a paediatric cardiovascular surgeon any more in this Province because if you are a skilled practitioner you need to have a certain number of cases to maintain your skills, and if you don't then it does not matter how state of the art the equipment is, you don't maintain the skills.

We have a burn unit that provides the bathing requirements. We are going to upgrade the burn bath again and do some other refurbishing. A lot of the treatment of burns is around good medical management. You have to have very good specialists but a lot of it is on maintaining fluid in the electrolytes and controlling infection - the two biggest killers. I worked in a burn unit myself for nine months, and most people died from infection as opposed to the burn. A lot of it is very individual, and I think the types of renovation - we will never have a burn unit like they have in Boston because we would never be able to maintain that with the number of burns we have. We have to make some choices, and maybe transport out some people and stabilize other people.

MR. H. HODDER: This person was advocating that the Atlantic Provinces should work together, given the numbers and that kind of thing. I might say as well, this person would not say that the ultimate outcome of the unfortunate fire at Come By Chance would have been any different. This was not the issue, because that would be individualized and there was never any comment made to that extent.

MS J.M. AYLWARD: But you would never want to leave yourself in a situation where you did not have the ability to have at least enough equipment and staff to be able to provide the emergency care and stabilization required even to make that decision.

MR. H. HODDER: That is right.

MS J.M. AYLWARD: That is key. I hope you are as open-minded when we think about centralizing other services in Atlantic Canada because I wouldn't be. I would want them to come here and not go there.

MR. H. HODDER: I think this person has sufficient knowledge to realize that there is a certain practicality, and again maybe there is some sharing of resources that we could do. I guess the first choice would be, we would have a full-scale facility right here in this Province, of Boston type. As you say, that is not likely to happen. I think they were expressing the opinion that maybe we could do more, and that is the opinion I bring here.

MS J.M. AYLWARD: I think it is appropriate to compliment, at this point in time, the fabulous work the Shriners have done as a community group who have put a lot of money in, most recently, to two very serious burn cases that I think have done so much better because of that type of access.

Once you get over the burn, it is the rehab that make a lot of difference. A lot of these areas that have huge volumes have much greater rehab programs for burn patients than we would ever be able to have, because of the expertise.

MR. H. HODDER: Let me go to another topic, which is travel outside the Province for medical care. What is the status of that program now? I did see some memorandums a little while ago whereby the first $500 is paid... How does that work when somebody has to go outside to get medical care that is not available here, particularly when it comes to children, heart patients (inaudible)?

MS J.M. AYLWARD: It is a program that is for in and out of this Province. It is considered non-emergency travel. How it is organized is that the person would pay the first $500 and, after that, 50 per cent of the cost would be paid. Generally the way we would do it is that people pay the cost up front and then put a claim into the department.

MR. H. HODDER: The reason I ask it is because of the up front part of this. Very often people have the $500 but they cannot put it all up front. They, in essence, have to get a bank loan and sometimes they cannot arrange that.

Is there any provision made for ordinary middle-class families who, over time, are able to pay the share that is allocated to them, but when the situation arises they cannot immediately come up with that up front money? Is there any way in which they can have financing included through the department?

MS J.M. AYLWARD: No, we do not generally do financing. You have to put some reality onto it. If your claim is $1,000, you will get $250 back. The person is required to have the majority of the money anyway.

It is a program which is limited to just help offset the cost. It is not to replace the cost or provide the cost. I think if you look at it in that context you will see that it is 50 per cent of what you spend after the $500. Each case would be looked at individually, and I would not rule out that we would assist people in a way but only assist them based on what you think would be the maximum. If you are going to spend $1,000, then maybe there is some way we could assist in providing the $250 component. I don't know, but that is what it means. It is not a program to send people out of the Province with full expenses. We do not have the ability to do that.

MR. H. HODDER: Or even within the Province.

MS J.M. AYLWARD: Or even within the Provinces, that is right. What we also do is let people know that when you are travelling in a non-emergency way, if you book ahead, in many cases you can get a medical rate for travel which is cheaper, if people apply for that. That is another service that is available that would still offset the costs.

MR. H. HODDER: We hear tell of a fair number of -

MS J.M. AYLWARD: Don is gone out to get the score is he, or what?

WITNESS: He is gone out to get the score of the hockey game.

MR. H. HODDER: Oh, he is gone out to get the score? That is good. Now that the Leafs are not into it we are not so interested.

MS J.M. AYLWARD: Fine by me, me neither. Carry on, (inaudible) shoot!

MR. H. HODDER: We hear a lot of talk in the community about a lot of suits that are against the Health Care Corporations, civil suits. These are paid ultimately by the taxpayer, the damages that are to be paid out.

MS J.M. AYLWARD: Is this third party you are talking about?

MR. H. HODDER: Third party. Well, in this particular case (inaudible) by the health care profession in some way. Are there any available stats that show how many cases are being brought against each Health Care Corporation? How many have they successfully challenged in court? And how much has been paid out of the taxpayers' dollars in terms of settlements?

MS J.M. AYLWARD: First of all, Canadians are becoming much more (inaudible) by nature. I guess it is because of our affiliation with our southern partners, and our access to that type of information on television, et cetera. I do not have a listing of how many complaints we have had. I know that there are a couple of ongoing ones that are before the courts, but I certainly do not have a listing. I have to be quite honest; of all the priorities I have had to face in the last eleven months since I have been here, that was not one to which I have sort of reached out to try to identify. It has been an extremely challenging year.

I know there are people in the system who are not happy with what has happened and they certainly have access to the courts. In a publicly funded system I am sure that is the case, not nearly as much as in a private system.

I have just heard - it was interesting and I think it is worth saying - that a physician recently shared with me that when you meet someone in a Canadian health care system about surgery they do not even ask in very much detail about what surgery they are having done, or what it involves, what size dressings, and it never occurs to them to ask how much.

If you are a physician practising in the United States they will ask - when a physician tells the patient, for example, that they need to have surgery, they will not only ask about the type of surgery and the number of tubes and the number of bandages, but the whole cost structure.

It is a different thinking mechanism that you have in a private system whereby you are paying for everything and you have to get your money's worth mentality, whereas in a Canadian system you are paying for it but it is through the public system and we do not have the same number; although I know there are more complaints made against professionals, through their professional associations, that are responsible to protect the public than we have seen before. That is generally done by the profession, and the first step of the complainant, as you know, is they would go to the professional bodies in writing. I do not always have access to that until it goes to the court system and it is brought to my attention.

MR. H. HODDER: Thank you.

In the various parts of the Province we hear, as Gerald was saying, that it is very difficult to attract physicians to rural Newfoundland. We have certain parts of the Province, and the Bonavista Peninsula is one of them, where there may be physicians there - and the Burin Peninsula is another case - where doctors are saying: No we cannot see you; (a) Our patient list is full - they are obviously in general practice - and you will have to go to the nearest hospital or whatever.

Do you keep any stats on the physicians in the Province who are not accepting any more patients, whose patient load is full, and where they are located, that kind of thing?

MS J.M. AYLWARD: Well, Newfoundland has the highest percentage of salaried physicians in the country, and salaried physicians work on a different focus, I guess, than the fee-for-service physicians, so I would presume you are talking about fee-for-service physicians.

We do keep some statistics on that, particularly in St. John's. We have a listing that was made of us for a number of reasons, but most recently when a prominent physician in St. John's died, who provided a lot of care to seniors and was one of the few physicians who did house calls. When he died, a lot of seniors were having difficultly finding a replacement who was willing to offer those services. So when we were contacted, we went and revised the list to find out how many physicians were accepting new patients, not on the premise of giving it out to the public but on the premise of helping seniors. When they would call in and say, "I am looking for a doctor", we would say, "Well, what area are you interested in?" Rather than have them go through all the yellow pages, we would say there are seven doctors in this clinic; three of them are accepting new patients, the other four are not. That is the kind of service we do and it does change, I do not mind saying.

There are problems in how services are delivered. For example, a lot of our fee-for-service physicians are providing fabulous service; however, when they close their offices at noon on Fridays, or at 5:00 p.m. on Fridays, you will often here a recording encouraging people to go to the emergency department if they need care. I think that is an issue that we have which means that a lot of the patients going to emergency really need to go to some ambulatory care facility and not an emergency department. It frustrates the system because you spend three hours waiting to get your ankle checked while they are doing cardiac resuscitation, and so they should. That is the nature of our system.

Yes, we keep lists, mostly around fee-for-service physicians, and not necessarily in Bonavista or Clarenville. I cannot say that I have a list out there, but I do have a list for St. John's.

MR. H. HODDER: But you are aware that it is not just St. John's where it is difficult to find a family doctor?

MS J.M. AYLWARD: Well my recruiting, through direction in the department, has not been in St. John's. It has all been focused, without exception, on rural Newfoundland. So I am more than aware of the difficulty.

You know we have a 50 per cent rule in St. John's; we have not been recruiting at all. The listing is to make it easier for people who are looking for a physician living within their area of residence. We are more than aware of the difficulties we have. We have dedicated people in our department who are doing it, as well as the boards themselves. The boards got together and hired a recruiter as well. Yes, I am aware of that.

MR. H. HODDER: One last question before I let my colleague over here (inaudible) -

CHAIR: Your colleagues on this side are suggesting that might be appropriate.

MR. H. HODDER: - and that is with the practitioner nursing program of which there is just now, shall we say, some evidence of it in the Province. How is that going, the training for it? And what impact do you think it is going to have in the next year or so on easing up some of the problems we have in rural Newfoundland?

MS J.M. AYLWARD: It is going very well. The nurse practitioners are actually out doing their clinical placements in various areas around the Province. We see it as the beginning to address the medical service and health service needs of the Province by creating a multi-disciplinary clustered approach to service delivery.

If you look at one of the reasons physicians commonly say they have difficulty working in rural Newfoundland, they will often refer to money as a big issue, but they also talk about lifestyle. They do not want to be on call, they do not want to have to do everything themselves, and nor should they.

If you have a practitioner, namely a nurse practitioner, who can do diagnosis within the realm of regulation, prescribing of medications within the realm of regulation, it should take a fair bit of pressure off. Not only that, you will have someone to work in partnership with you.

We have a lot of physicians who are working very closely with these nurses in the education and training component, and also in a way where they are trying to work towards how they are going to work as a team after. (Inaudible) Port aux Basques, Twillingate and Goose Bay right now.

The issues are not around nurse practitioners. That is a great program. It is going very well and we are very proud of it. The difficulty remains that we hope it will be one more tool in attracting physicians to work in an area because they will not be seen as sole practitioners or lone rangers or whatever you want to call them, because those days are gone.

We have new funding in the budget as well to continue on with the program, and will be taking in a new class again in September.

MR. H. HODDER: One little question following on that one is to ask about the recruitment program for entry to the nurse practitioner program. There is an application process out there now, and the new class will begin in the autumn is it?

MS J.M. AYLWARD: Yes. We are not having any difficulty. We had so many applicants for the last one we had to pick and choose for the most part, although we had a couple of areas where we actually recruited - namely, Ramea was one area - to try to put something back there.

One of the principles we used in the first place was to try to recognize people who are actually living in various communities who are experiencing difficulties so that we know they will go back to live there and work in that capacity, which is a way to sort of - you know we provided a bursary program as well as a deferred reverse salary leave plan to assist those people to do the course.

MR. H. HODDER: Has there been national recognition of the designation?

MS J.M. AYLWARD: There has. I have spoken on the program at a couple of national venues. The regulations are still being finalized. Once they are finalized, we will be doing something much more public on the full package. The legislation is the first part but it is the regulations that are actually the teeth behind the practice. We are working towards those, and I do believe we have -

WITNESS: They were passed today at the ARNN council level.

MS J.M. AYLWARD: Oh, they were passed today at the ARNN council. So there you go; we are moving full steam ahead.

MR. H. HODDER: Thank you very much.

MS J.M. AYLWARD: Thank you.

CHAIR: Thank you, Mr. Hodder.

Mr. Ramsay, followed by Mr. Canning.

MR. RAMSAY: Minister, I want to commend you on that specific action. I think it grew out of the health forum, although it was something that was in the works, I would suggest, to a certain point, the nurse practitioner program and this sort of thing.

MS J.M. AYLWARD: No, it was not in the works.

MR. RAMSAY: It wasn't?

MS J.M. AYLWARD: It was not even in the works. It was after -

MR. RAMSAY: But it had, at one time in the past, been contemplated and passed through the department, but then it was processed -

MS J.M. AYLWARD: It was only an education program. There was never, ever a legislation component or a specific designated program except one through the university, which was a sort of a three-month type of thing or six-month type of thing.

MR. RAMSAY: You are to be commended for the action taken under the health forum, certainly. It has provided a level of comfort to the people in the area that I represent, and I think also a level of excitement about the potential for the total health system and how that will affect us in the future.

I had a number of different things here I wanted to touch on but I will not take too much time. I know the Opposition have further questions. You did mention something which caught my ear, some doctors receiving a higher or one-and-a-half salary units for certain areas. Could you elaborate on that a little because I understood that one - I knew there was some flexibility there in certain areas to try to offset the requirements but maybe if you could just elaborate a little on that?

MS J.M. AYLWARD: Okay, in an area of the Province which is isolated that has notoriously had two physicians, one left, and in an effort I guess to recognize the added workload responsibility, and more importantly to retain that physician, the board made an offer to provide an increase in that physician's salary until another physician could be recruited. The problem with it is that the physician is a sole practitioner and is really experiencing a lot of challenges with respect to people coming knocking on his door all hours of the night. So it is one sort of recognition but it is only partly addressing (inaudible).

MR. RAMSAY: It is not the kind of thing that will potentially solve problems in other areas because, of course, it gets away from the multi- the cluster (inaudible).

MS J.M. AYLWARD: Plus, people who are not even making one-and-a-half times the salary, if you consider the rural bonus system we have in place, plus the fact - whether it is fee-for-service or salary - some of the physicians that we need to work in rural Newfoundland would make almost as much as some of the highest paid CEOs in the Province, which are really not that highly paid compared to other provinces, I might add. So it is not the money; the money is only one part of it.

WITNESS: (Inaudible).

MS J.M. AYLWARD: I was talking about publicly funded, not privately funded, let me tell you.

MR. RAMSAY: Anyway, over to the issue, you are dealing with the medical community now in negotiations. There was a study which came out recently which suggested that doctors drive the cost of the medical system; and, of course, commensurate with that is the people's demands on the medical system which in turn - the doctors are then driving the system as far as the costs. It noted some difficulty with doctors seeing huge numbers of patients, and because of the fee-for-service method of payment that was driving the overall cost of the system up.

You did maintain that we did have a higher salary portion, percentage, than other Provinces. I know we have looked at and probably discussed, and there have been studies and that sort of thing on the different models for paying physicians, but I wonder - one case in point was cardiovascular, which was mentioned in the past. If you took that kind of thing where the physicians are paid on a basis of people flowing through system, and that is probably one of the higher paid physicians or specialists, if they were to be paid a salary of the same amount that they would make on all of the different procedures they perform, do you feel the actual utilization of the system would drop?

MS J.M. AYLWARD: First of all, I believe that in order to have an effective system we have to have a balance. All fee-for-service is not good, and I do not think all salary is good either. Salary is not a panacea either because some physicians on salary are on salary because they only see a handful of patients a day. The population does not warrant a fee-for-service model. So, if you have all salaried physicians you might not get as many patients seen that need to be seen because it is sort of a different approach to service delivery.

Our challenge is to find a balance, and we are looking at a number of different models. As I said earlier, we have the highest percentage of salaried physicians in the country, albeit they turn over quite quickly, but I think we have around a 23 per cent to 30 per cent mark, which is the highest in the country. We are looking at other models. One of those models includes the capitation model whereby a physician would go out to you, for example, and make a contract with you to be your physician. The government, then, would pay that physician $1,000, for example, to care for you for a period of a year. The incentive would be for that physician, then, not to see you ten times. In fact, the more infrequently he saw you, the more money he would make for caring for you. It puts more emphasis on the prevention and the health as opposed to the illness part of it. That is one of the models, for example.

MR. RAMSAY: That can potentially be one of the research elements of the new system of the cluster; as part of the research element, they might undertake that as an overall part of the strategy?

MS J.M. AYLWARD: Yes, that is one that we would look at. Right now we are looking at physicians who actually approach the Department of Health (inaudible) two areas of the Province, and they are trying to develop a new model of service delivery which is a combination of fee-for-service and salary. If it is within the budget, if it make their lives earlier, we have been giving them the message quite clearly that we are open to new models of practice.

MR. RAMSAY: I want to make a little prediction to you, but I do not know how accurate it is. We are losing a lot of our GPs to the United States now. The United States is moving away from a lot of specialists. From what I am led to believe, there will be a lot of displaced specialists in the US as a result of HMOs and other companies in medical care getting into more specialists. I would suggest that eventually there will be specialists re-qualifying as GPs and floating back into the system.

MS J.M. AYLWARD: Some have. I know in British Columbia there have been a couple of specialists working in a GP role that I know of, but you have to factor in a couple of other things. We have an aging physician population, and we also have a prediction not only for a general practitioner shortage but also for a specialist shortage.

MR. RAMSAY: Coming up?

MS J.M. AYLWARD: In the new millennium.

MR. RAMSAY: One point out of the figures of the Budget, I note that MCP cost us $4.2 million to administer $150 million worth of medical payments. Do you feel that is high or low? If we look at our own operations in the House of Assembly - of course we are not mailing out stuff, handling financial transactions, and that sort of thing - to me it looks a little high, $4.-some million to do that.

MS J.M. AYLWARD: I guess I would say it is the same answer as I gave to previous questions, that there is room for improvement.

One of the things we are trying to do now is find a way to update our MCP cards. For example, we know we have a lot more MCP cards in the system than we have people.

MR. RAMSAY: So we could have Americans actually using existing MCP cards (inaudible)?

MS J.M. AYLWARD: Right. We could have Newfoundlanders in Alberta, who do not want to pay their health tax, using our MCP cards on the interprovincial agreement. There is that kind of thing too.

We are looking at trying to reduce our list and make it much more up-to-date and applicable to our current population. Yes, I am sure we can improve the delivery based on that alone.

MR. RAMSAY: That is the one figure to me, in the whole thing, that stood out.

Pay equity, I noted in the Salaries totals there, is rising. That figure is a separate figure. Is that pay equity figure an annualized figure, or does that then shift after you put the $27 million into it this year? Does that then go into the total salary budget and the total budget of the institutions and what have you, or is that a constant annual amount that is just increased by about $2 million versus last year?

MS J.M. AYLWARD: No, it is not a constant amount. There is an amount that was based on 1 per cent of salary up until pay equity was reached, and that accounts for different amounts of money throughout the various systems. Once you reach what is considered pay equity it will level off and become part of the base budget.

MR. RAMSAY: That budget subhead then will disappear?

MS J.M. AYLWARD: Right.

MR. RAMSAY: Okay.

Finally, you say you have had an exciting year but it is a lot of crisis management and that sort of thing. What is the strategic direction (inaudible) of the department at this stage now? Is there a newly minted mission statement for the department at this stage? Exactly what is it, say, in a paragraph or less, that you would suggest as a vision for health care in the department for the Province?

MS J.M. AYLWARD: I cannot do a vision statement for a $1.1 billion department in a paragraph or less, I can tell you. There are obvious directions that you can see from the budget that we have just put forward that have a strong emphasis on social policy prevention and early childhood education and development. That is certainly one of the focuses, but also we have a new department which is focused not only on all of those things - prevention and early intervention - but trying to meld together two departments based on two different models.

My goal is to strengthen the community sector, to strengthen the social model, to become a formidable partner to the medical model and the institutions, so that we can have a blending and try to do the best service delivery system possible looking at the need, but you have one system that is focused on illness and you have another system that is focused on prevention and early intervention.

Trying to balance that is the big thing, and sprouting out of that we have other major issues. For example, one of the major issues that I would like to see resolved and addressed would be issues surrounding seniors. I think we are on the right track with the children, finally, and I think that is important; but we also have to make sure that what these people have been asking for, for the last thirty years, works. Now it is incumbent on the advocacy groups and our staff in government to prove that prevention and early intervention work, or all of the thirty years of lobbying will be for naught and we will be back to an endless model.

MR. RAMSAY: Just to close, I wonder if you had any budget allocation to (inaudible).

MS J.M. AYLWARD: It is a good idea.

CHAIR: Thank you, Mr. Ramsay.

Mr. Canning, and following that any further short questions from any of the members.

MR. H. HODDER: We will be here until 10:00 p.m. anyway (inaudible).

CHAIR: Just because we are allowed to sit three hours does not necessarily mean that we must, Harvey.

WITNESS: People do have other things at home, Harvey.

MR. H. HODDER: So do I. (Inaudible) have to go as far as you do.

WITNESS: A hockey game, for example.

MR. H. HODDER: Oh.

CHAIR: Perry.

MR. CANNING: Thank you, Mr. Chairman.

Minister, thank you for coming. I do appreciate the gender re-balance in your department's line of officials.

MS J.M. AYLWARD: You noticed that, hey?

MR. CANNING: I do appreciate Florence Delaney being on your team. I know her from my past work as the Member for Labrador West, in other departments. I am sure she will bring a wealth of skill to your department, as I am sure the officials will as well.

I would like to just say a few words about this $500,000 air travel subsidy, and I do appreciate it. It is certainly a step in the right direction. It is commendable, given the degree to which we have had to make adjustments in spending throughout all departments. As you know, health has had a significant increase in its spending, but the people I represent do appreciate that this program is back.

I raise one issue, though, that came to me the other day. I had a call from a lady who I believe may have been the first person to have used this program and is very pleased with it, very pleased that the government has moved in this direction. She wanted to get a seat sale to come back with her son on another visit to the specialist. The doctor wanted to charge her $25 to give her a certificate that her travel was medically valid. The doctor in the hospital in Labrador City, I am sure, believes that is appropriate. I do not.

Travel to a hospital from an area like Labrador West is expensive. A full fare ticket will cost you $1,400 if you go to the counter and purchase it. You can fly to Spain and have a pretty good vacation on the Riviera for that amount of money, and for a doctor to charge $25 or $5 or five cents for a little memo indicating to the airline, because they require it, is outrageous.

Minister, I would just like for you to say here tonight: Is that the policy of the Department Health and Community Services? I have said that it is not, and I would like for you to confirm that. I believe it to be the policy of the doctors involved.

MS J.M. AYLWARD: Well, I have say that doctors can charge for doing assessments and other things, like third-party insurance claims and those sorts of things. A number of doctors do not charge for that sort of thing. I do not think it is a policy that they charge for it.

MR. WILLIAMS: They are permitted to bill for services that are not covered by MCP. Some doctors have a suggested scale from the Newfoundland and Labrador Medical Association. Some doctors bill it out; some doctors do not bill their patients.

MR. CANNING: But it is not a policy of the government?

MR. WILLIAMS: It is not a Department of Health and Community Services policy, no it is not.

MR. CANNING: Thank you.

I would like to say something with respect to hospital lists. I have had a recent experience in my own family - many members around this table would know about it - with respect to using the Janeway. I have to say, you know, many times we question: How good is the system? Many times we will say that perhaps the system is not great, it does not meet the need. Many times we question, and it is right to question, but I can tell you through personal experience that the service that we received, as a family, at the Janeway was second to none in this country. We were very pleased, as a family, that we received the kind of service that we did. There is a marvellous staff down there who are highly trained, highly dedicated, solid people who work very hard day in, day out, under very trying circumstances, so sometimes it is okay to say that those who serve us do a good job. They do and I would just like to say that here tonight.

I would also like to say, Minister - I will make another comment - that I have appreciated the determination of you in particular and other ministers within government with respect to the drive in social policy of the government to ensure that those who have least amongst us, those who have to face challenges, those who have great difficulty in terms of their disabilities and how they have tried to settle in society, that you and other ministers have taken a lead role in ensuring that they have had a hand up rather than a shove off, and I very much appreciate that.

I speak to the Canadian Association for Community Living in my region, and they are very pleased with some of the things we have tried to do. We have done a lot of things one on one, directly with families, trying to help where we can, given the level of financial capacity we have to do it.

I would just like to say here tonight that I want to express my appreciation for your assistance and that of the department in my riding over the last year. It may have been a challenging year, Bill, but I think it has been a real year of growth for the department and I can see it in my own riding.

Thank you.

MS J.M. AYLWARD: Thank you very much.

CHAIR: Thank you.

Are there any further questions that any member might wish to redirect? Sheila.

MS S. OSBORNE: Does the Perlin Training Centre come under your newly revamped department?

MS J.M. AYLWARD: Yes, it does.

MS S. OSBORNE: What are your plans for the Perlin Training Canter at the moment?

MS J.M. AYLWARD: Well, right now you know that they are in the process of working through the Gosse Gilroy report. The Gosse Gilroy report was done in conjunction with the stakeholders (inaudible) and the big issue was how to deal with supportive employment as opposed to the non-supportive employment, and there are a lot of mixed views within that community. So what we have been doing is trying to get them to work it through themselves, with direction from the department.

I was speaking with a group of people just the other day who said: My God, we hate the name Gosse Gilroy, we are so sick of talking Gosse Gilroy, but they are actually getting close to the completion of implementing a lot of the recommendations, and that is how it is being handled.

MS S. OSBORNE: The Gosse Gilroy report, I think, is leaning towards closing or phasing out the Perlin. I have hands on with the Perlin. I, for a number of years, have been taking care of - I am alternate care giver for a girl who is thirty-eight years old, who is a trainee at the Perlin. We speak of giving them choices. If she had a choice, her choice is to stay at Perlin, with Perlin as it is. Just from my experience in working with the people at Perlin over the years, in an attempt to normalize, we disrupt; because most of the trainees, I would say probably 99 per cent of them, like the way it is happening now.

As far as costs are concerned, if we did not have a Perlin - for instance, if we were paying respite care, I think at the rate of $5.84 an hour or whatever it is, they are at the Perlin - it would cost more to keep them in respite care then it would for them to go to the Perlin. You would not get a respite worker for $5.84 an hour to give them the care, the training and the social interaction they get with their peers. You would not get that from an individual respite worker, what they get at the Perlin. I know that the Association for Community Living thinks that it has a front door but no back door, because some of them do not get employment. Some of them do not want to. They want to stay there. It is a place where they consider they go to work.

The girl that I take care of goes to work, she does buttons. They move about. They have remodelled it up there now where they go from classroom to classroom, the model up there. I know that you have input, but I think that an input from that point of view, from the view of the trainees themselves, is very important. If they are displaced, where do they go? You could term it as nothing else but good, cheap respite care because per capita it costs the same. It costs less for them to go to the Perlin than it would be to put them in respite care for that same amount of time.

MS J.M. AYLWARD: Yes I know, I have had meetings with the groups at Perlin, and I have been there myself on a number of occasions. I guess you do know that the community-at-large has very mixed views about this.

MS S. OSBORNE: Yes.

MS J.M. AYLWARD: The whole concept of supported employment is one that is, as you said, front door and no back door. A lot of people are quite concerned that it is considered useless work and non-productive work and all that sort of thing. There are a lot of strong views within that community.

MS S. OSBORNE: There are a lot of views from the people up there, and some who are high functioning. I was at the lip sync concert the other night and one of the little girls came over after. She is fairly high functioning and she said: Will you please go back and tell the government to come in and look at us? Please don't close us. There are a lot of the trainees who are there who want to stay there. Some people never want to work. Some people who are developmentally delayed would not fit into the workforce and other people would. If they were interviewed individually and were given a choice, they would probably like it just the way it is, most of them. They are very socially stimulated there, I can tell you.

MS J.M. AYLWARD: I know the program.

MS S. OSBORNE: It is wonderful.

CHAIR: Any further questions?

MR. H. HODDER: Yes. The critic for health is not here tonight, Loyola Sullivan. He is doing Her Majesty's business in Ottawa by command. He did ask me to bring up an issue relative to the operation of a Kiddies Corner. I guess it is an early child care program operating in Trepassey. He mentioned that they were getting some funding and this kind of thing for that unit. I'm not sure whether it is coming from your department, through the community agencies, or whether it isn't.

Of course the program now, with the unemployment rate that is there, is under some threat. The unit, or Kiddies Corner, only started operating in October and already, of course, there are many people who can't afford to have their children there. It goes from ages two to pre-kindergarten. They set a fee of $10 per child and they would require, I guess, about $2,000 or so. The question would be: What programs are out there to assist the continuance of this kind of a program? Where do they go? Particularly as it applies to rural Newfoundland with the tiny populations and the threat that that kind of program is under when we have out-migration and all the rest of it.

MS J.M. AYLWARD: You have a lot of questions in there. First of all, it would come under the boards, unless it is a private agency.

MR. H. HODDER: No, it is not private.

MS J.M. AYLWARD: It would come under the board. It would be under the St. John's community health board, is it? Because I know the St. John's Health Care Corporation has taken over the Southern Shore, a lot of the (inaudible).

MS FITZGERALD: (Inaudible).

MS J.M. AYLWARD: Do you want to come up and talk to it? Do you know anything about that, Brenda?

MS FITZGERALD: (Inaudible) limited amount of information.

MS J.M. AYLWARD: I can say, while Brenda is getting here, that one of the ways we will be looking at - and it was announced in the Budget -, that we are putting in place a new piece of legislation to cover children under the age of two. We also have money for early childhood education, for family child care provisions, and also for providing funding for people who are employed. We would do it on an individual basis, not on a facility basis. We would not fund the program. (Inaudible) funding individuals who needed the service, and that is how we do it. We would not fund a program per se, but I said the individuals who require it for work purposes for some sort of employment.

MS FITZGERALD: In just conferring with some of my colleagues, the particular Kiddies Korner day care centre you are talking about in the Trepassey area received some funding from the Department of Human Resources and Employment, in partnership with some kind of a grant arrangement with federal HRDC. So in terms of it actually being an agency that is transferred to what is now Health and Community Services, St. John's region.

Minister, I think you were referring to the Shamrock Community Health Centre project, which is a partnership arrangement between the Health Care Corporation of St. John's and Health and Community Services, St. John's region. It would not be under the auspices of that particular pilot project, the Shamrock Community Health Centre, but in fact if it were continuing to operate there, obviously it is one of the partners in the community that would have a role with the providers in the community health centre.

However, under the new funding that we are going to see as a result of the National Child Tax Benefit provincial investment of new funds we will be able to see some kind of support to child care centres. I cannot speak specifically if Kiddies Korner, if that will apply, but there will be an ability for us as a provincial department to be able to support in some new ways the early childhood initiatives in the Province as family resource centres that Mr. Hodder talked about, and of course child care centres. That is all I can add at this point.

MS J.M. AYLWARD: Thank you. I just think though that if it was the organization that got the funding the organization would have gotten it from HRE and HRD. If it is an individual subsidy or if it is a program, it would come under the two boards.

MR. H. HODDER: I'm not sure of all the details. He mentioned it to me and gave me a piece of correspondence dated yesterday, and asked if that put the matter forward here to begin some public dialogue. I'm sure he will be following up (inaudible) on the matter in the future.

One second last thing, the MCP offices mentioned earlier. It is my understanding there is no long-term agreement with the current owners of Elizabeth Towers to operate or to house the MCP offices. What is the status of that? I do understand that the MCP corporation basically paid a rent almost on a monthly basis. They are paying out a lot of money per year. I do understand it is over $300,000 a year in rents. Is that a matter (inaudible) established, and is it possible for us to be able to find alternate accommodations where taxpayers' dollars can be more wisely spent (inaudible)?

MS J.M. AYLWARD: First of all, I could not answer tonight what the extent of their lease arrangement is with the building, and if that in some way has changed now that it's under new management. I will certainly ask my officials to get that information. I can say, as I mentioned earlier, that we are looking at the whole issue of MCP. Not only how to reduce the cost of administration but also in terms of its role vis-à-vis the smart card, because that is one part of it. Certainly (inaudible) the other part of course is the physician payment that is associated with it. We are looking at all the components, but in terms of the cost we would have to know first the lease arrangement and what we are locked into before we would even (inaudible) decisions on where we would be going.

MR. H. HODDER: In the little research I did on that I was told that there is not any long-term arrangement there, and conceivably that the MCP offices could be asked to vacate the premises on relatively short notice if the new owners were able to find a commercial client or commercial clients who would be prepared to pay them more. I put it up as a bit of an issue that is talked about in the local community. I do not know the answers to it but I do know that it has been raised, and it was raised at the time when the building was sold.

MS J.M. AYLWARD: One of the reasons why we have entered into many of our leases on a month-to-month basis is to give us the flexibility to make the move, as opposed to being evicted from the place. Month-to-month is what we have tried to do, particularly because this has been a huge transition at work, when we have looked at bringing together staff from both health and community services, by bringing together outside agencies or inside agencies, moving them out. We did not want to enter into the long-term arrangement.

If we are into the month-to-month, which we probably are, it was not because we thought we would give that company an advantage to charge more money. It was because we want the flexibility not to be locked into a three- or five-year lease which sometimes governments do, particularly when you know your whole department is under massive reorganization.

MR. H. HODDER: But you have been down there for twenty-seven years on a month-to-month, or something like that (inaudible).

MS J.M. AYLWARD: My God, no.

MR. H. HODDER: How long have you been there? I (inaudible).

DR. WILLIAMS: We have been there since MCP came in, in 1969.

MS J.M. AYLWARD: We haven't been on a month-to-month since 1969. Most of our leases, at least within our department and the previous department, were put on a month-to-month in a conscious way to give us the flexibility to do the kinds of changes that we might want to do in the event of amalgamation. When we do month-to-month it is generally month-to-month for a year and that is how we sign it.

MR. H. HODDER: One last issue and that is to deal with (inaudible). I could be persuaded, I still have about ten or twelve here, but Bill tells me (inaudible) living daylights out of me if I (inaudible).

SOME HON. MEMBERS: (Inaudible)!

MR. H. HODDER: Dealing with addictions, and the amount of money that is put into helping people who have problems, we know what revenues are generated through the liquor commission, what is generated through video gambling and that kind of thing, and with all the trauma that is caused in the community with people who are coping with addictions, is there concern within government that we are not putting sufficient funds into prevention in this particular case? We are taking a lot of money out of the system, then we are putting little back into diagnostic services or into community health services.

MS J.M. AYLWARD: Yes, government is certainly concerned about it. I think if you look at some of the things we have been trying to do in our department with respect to education and working with community groups to try to establish recognition, there is a balance between prevention and early intervention in this case and in control. As you know, we have moved away from the control model with social assistance. Remember, years ago, long before my time, we would give food stamps to people because we were not assured what they would do with their money, so we gave them food stamps.

We went out and found them houses. We had social workers out doing inspections in houses because we didn't trust them to find their own places to live. We have moved from a model of control to a model of independence, in a way, to encourage people to move on. We give people x amount of money and they do with that money what they see fit. The majority of them do very well, I think, with the money they have to work with, and some others choose to spend it in other ways. As I said, it is the balance between choice and the control.

I think from a health perspective particularly we made that very decision in our own budget not to put money directly on a baseline program but to focus it and target it in programs for that very reason. Because we can't always be sure that children will have access to the programs and services by virtue of adding money. Our choice was to add money and still to add programs. Some of the programs we have I think can easily focus on that if you look at, for example, our community youth networks.

A lot of our mental health problems in this Province are focused around drug and alcohol addiction particularly. We have an ongoing challenge. We know that we have thirteen-year-old females who are smoking higher on average than any other age group. We know that we have major problems with alcohol even in small communities, and we have heard it most recently, I think it was in Ramea or Burgeo. How was it resolved? It was resolved through the community effort, and it's not through the Big Brother or the Big Sister, but it is sort of at the community level.

We recognize the problems and we care about the problems, and I think our solution is to try and focus more on the prevention end. The reality is that a lot of people choose their entertainment, and whether it is bingo, drinking, drugs or gambling, there are choices people will make. I guess you just have to try to educate them as best you can and try to protect the children particularly who are involved in those families.

MR. H. HODDER: Finally, I want to comment on something. Dr. Bob Williams is moving on. I want to say that Bob, I have known you for a long time, and I wish you well. Also, to say that it's been a pleasure (inaudible) in terms of the dialogue I have had with the department over the years from time to time. I want to say all the best and it was great working with you. I'm sure that our paths will cross again in the future (inaudible) to the Government of Newfoundland and Labrador (inaudible) St. John's Health Care Corporations.

MS J.M. AYLWARD: Thank you very much, Harvey. Tomorrow is Bob's last day, and I want to thank you for accommodating him to allow him to come and assist and be a part of the last department Estimates.

CHAIR: I'm sure it's something which he greatly enjoyed.

MS J.M. AYLWARD: It was, and I want to thank you.

SOME HON. MEMBERS: (Inaudible)!

CHAIR: For that he has you to thank. I just wanted to make sure he knows that.

Very well, will there be any further questions? There being no further questions, thank you, Minister, and thank you officials for your patience and for your definitive answers to the questions.

MR. H. HODDER: And me for my brevity.

CHAIR: No, I will say many things, but lie I will not. Just kidding, Harvey. Thank you very much.

Before we move a motion to accept the heads there is one small housekeeping item which we have to do. We have to move a motion to accept the minutes of the meeting which was held last evening.

On motion, minutes adopted as circulated.

On motion, subheads 1.1.01 through 4.3.04, carried.

On motion, Department of Health and Community Services, total heads, carried.

CHAIR: Thank you.

On motion, the Committee adjourned.