LEGISLATIVE
ASSEMBLY OF
Tuesday,
April 21, 1992
The House met at 8 p.m.
COMMITTEE
OF SUPPLY
(Concurrent
Sections)
HEALTH
Mr. Deputy Chairperson
(Marcel Laurendeau): Good evening.
Will the Committee of Supply please come to order. The committee will be resuming consideration
of the Estimates of the Department of Health.
When the committee last sat, it had been considering Item 1.(c)
Evaluation and Audit Secretariat: (1)
Salaries.
Mr. Neil Gaudry (St.
Boniface): Mr. Deputy Chairperson, this afternoon I
received a letter from one of my constituents and a copy went, I believe, to
the Minister of Health (Mr. Orchard). We will put some of the comments on the
record.
His letter says: I am writing this letter to you to raise what
I believe to be a deficiency in the public health care system in this
province. The case involves my father,
currently 75 years old. He is in need of
a hip transplant and is currently on the waiting list for surgery at the Health
Sciences Centre. The surgery had been originally scheduled for September after
about a two‑year wait, but with the recent delay, I understand resulting
from lack of funding, the surgery has been delayed to December.
To be fair, the gentleman called me this
afternoon, and he has been given a date of October 7.
I understand that the principal criterion
defining emergency versus elective surgery in this sense then is the issue of
mobility. Simply, if the person is
immobilized by the hip, they go to the A list, if you will. To be truthful, my father is technically
mobile. However, there is a quality
issue that, in my opinion, should be considered. For example, my father is an Anglican priest
and has been forced to curtail many of his activities, performing services for
only a certain period. He can endure the
pain of standing on his feet for only a short period. He has done most of his ministry to seniors,
both those shut in and not, performing a valuable service unpaid to
society. He is unable to do this as
frequently.
It continues: I could continue the litany of examples, but
I trust that my point is made. Because
he is technically mobile, he is on the B list.
Here, in my opinion, are two ironies to the situation. First, I have a 92‑year‑old
grandmother in a nursing home, virtually a vegetable, who would be operated on
tomorrow if she were to break a hip. A
productive member of society has to wait.
A second irony is that the cost will be the same for the operation if it
is done now or later, so why delay it?
Finally, while I would prefer the operation being performed locally,
there are other options available out of province which our medicare system
will not fund, so my father and those like him continue to rely on expensive,
potentially damaging medications and wait.
I am concerned with cost constraint and
cost control. I pay substantial taxes‑‑
* (2005)
Mr. Deputy
Chairperson: Order, please. Can I ask you to pull up the mike? The answer is not very clear.
Mr. Gaudry: I am concerned with cost constraint and cost
control. I pay substantial taxes and
laud the efforts to keep them reasonable.
However, I also concern myself with where the money is being spent. I certainly advocate spending the dollars
where they make a difference to society.
I fail to see where delaying so‑called elective surgery provides
any net gain to society where the individual concerned is a productive member
putting something back into that society.
One final note about my dad. He
does not complain, he endures. He
happens to be a veteran and saw so much suffering in the war that he feels
lucky that he is not worse off. I
believe that many examples such as my dad are out there.
My request is simply this. Change the priorities from taking care of the
budget to taking care of the people. My
dad will probably not live another ten years, but society owes it to him and to
those like him to make those years the best they can be. I am looking for
special treatment for my dad, you bet.
He and those like him deserve it.
The inevitable response from the officialdom will undoubtedly be, sure,
but who is going to pay for it? Most of
us, myself included, who watch our loved ones suffer the humiliation, the
personal embarrassment and anxiety needlessly, would pay more taxes if it would
make the difference. I hope that you can
help make the difference.
Would the minister comment on the process
for this kind of request from constituents who request on behalf of their
parents?
Hon. Donald Orchard
(Minister of Health): Mr. Deputy Chairperson, that is not an
unusual letter the Minister of Health gets in the
Let me give you the dilemma. I have every sympathy with the individual for
whom you are bringing that case forward.
Ten years ago, maybe I am wrong in my years, but there was a time when
medicare came in that this individual would not have had a service which could
be accessible under any program to help alleviate the suffering from joint
deterioration, hip and knee. That is one of the absolute quandaries that
ministries of Health are facing in this province and across
* (2010)
This is joint replacement, hips and knees,
today. We are going to be faced over the
next decade‑‑and this gets us into the issue of
pharmaceuticals. There is another area
where there are going to be very narrowed and potentially effective
pharmaceuticals coming on the market. I
do not have the prices in front of me. I
thought we might get in this debate when we reached the Pharmacare line. This new generation of pharmaceuticals is
several tens, if not several hundred dollars, per dose. Under an insured health care system, once
they are there, there is an automatic expectation that they should be made
available to those to whom the process, the pharmaceutical, the procedure is
prescribed. That is why, right across
Take the compassion aside. Take the obvious desire that this family has,
this individual has, to have their mobility reinstated. That is very, very natural. The difficulty that it puts the system of
health care provision is that reinstating that mobility is now proposed in
terms of medical need. It is no doubt
going to alleviate suffering, increase mobility, increase quality of life. Many procedures will do that, all of which
are going to be demanded of the taxpayers.
I have often said, the changing technology
and the basic miracle medicine that we can now practise in
In this particular case, the family say,
well, raise the taxes, and I mean, they are sincere, because they would believe
that would be appropriate if that is what would be required to cover the cost
of this operation. But, boy, I will tell
you, one of the messages we get when we detach ourselves from the individual
circumstances across this nation and this province, no exception, is that the
citizens across this country are saying, we are already being taxed at too high
a rate.
We cannot deficit finance the system,
because that also is a significant challenge and problem that all of us
acknowledge. We cannot continue to
deficit finance current consumption. I
mean, all it is is a tax on our children and grandchildren.
So it is one of those dilemmas. The way we manage it is we provide budgetary
allocation which will allow a maintenance of program at a minimum and,
hopefully, some expansion annually in terms of the program. That does not allow access to the system as
quickly as a number of individuals who are prescribed the procedure are able to
access the system. I mean, there are
significant waiting lists in both hips and knees.
* (2015)
There is some inconsistency in that
waiting list that we found out when we took a look at the process at Health
Sciences Centre with them undertaking their annual budget and more dollars
within the nine months of the 12‑month funding year. Some doctors have significantly higher
procedure waiting lists and, hence, longer waiting times. Although the suggestion is made from time to
time that maybe your constituent here ought to seek a reference to another
physician, hopefully to access the system quicker with a physician who is not
as busy as possibly the one he has been referred to, but that is a partial solution,
because all the other physicians are under the same constraint of accessing
operating time.
I guess, I have to indicate to my
honourable friend that amongst the many demands on the system that are made for
elective surgeries and for funding of any number of very worthy and worthwhile
programs, we have in general terms placed more money at the disposal of those
programs over the last few years. There
have always been requests for a greater level of funding, and that will never
go away. That will be here as long as we
have a publicly funded health care system.
It has been traditional for 20 years; it will continue.
It is part of the resource allocation
decisions that we are asking physicians to try and come around the issue on
behalf of their patients because this government, and I speak apolitically
here, does not have the unlimited funding ability to provide the surgical
capacity to deliver all of the knee and hip surgeries that are certainly being
recommended across the province.
Mr. Gaudry: Could the minister tell me who establishes
the priorities for the surgery, for example, at the Health Sciences Centre?
Mr. Orchard: I am going by what I understand to be the
system. We allocate a global budget figure to the Health Sciences Centre. From that, they will divide that budget
amongst the many program areas that they have over at the Health Sciences
Centre, part of which is an orthopedic surgery program which involves knee and
hip replacement.
The orthopedic section will receive an
allotment of, I believe first off, surgical theatre time, access to the
surgical theatres and, of course, part of the global budget. That process is undertaken by senior
management coming around the global budget issue and making the allocation as
they best can, given the clear indication that there has not been, nor will
there probably ever be, an infinite budget which they can access, so that they,
the professionals, in terms of management and physicians, try to make the best
allocation resources decisions that they can around the global budget that is
provided to the facility.
Mr. Gaudry: For example, this man had been on a waiting
list for two years, and then he was given a date of December. Now in the last week he has been given a date
of October 7. Is this because they are
doing more surgery lately, or is this that he has been established as a greater
priority than he was the other time?
Mr. Orchard: I cannot answer that, but I would suspect that
the December date, the individual may well have been part of the decision
process which said they would suspend knee and hip operations for the last
three months of the year, although December is the fourth month. About the end of November they had utilized
their budgetary allocation decided on the first of the year on knees and hips,
and they ran into the end of December actually with over‑budget
allocations, allocations beyond what was originally budgeted at the start of
the fiscal year.
* (2020)
I cannot indicate whether that clearly is
the reason, and if I have a letter in the office I will try to make that
determination, but I would suspect that this individual's surgery no doubt was
cancelled in December because of last year's circumstances of doing the program
and more in nine months versus 12. The
rescheduling, and this one I am more clear on, would have been made by the
physicians in terms of a prioritization of the patient load that, I believe,
seven surgeons or eight‑‑it is somewhere in that number of
orthopedic surgeons doing hips and knees at the Health Sciences Centre‑‑they
would make an effort to prioritize their patient waiting list to make sure that
the most urgent needs are cared for first, or are served first, and they have
developed their internal assessments so that there is some hope for consistency
in that approach at the Health Sciences Centre.
I might add to my honourable friend that
that is one of the issues that we are asking Dr. David Naylor and the head of
surgery‑‑am I using the right terminology at Health Sciences Centre
and St. Boniface?‑‑the vice‑presidents of medical at Health
Sciences Centre and St. Boniface; and Dr. MacKenzie at
Another thing that we find is that
sometimes the waiting list can be not necessarily accurately reflective of the
waiting because, for instance, when we investigated cardiac by‑pass
surgery a couple of years back, we found that even though there were only two hospitals
offering the program, we found common patients on both hospital waiting lists
and that may well exist here too.
Mr. Gaudry: Yes, I thank the minister for his answer, and
I will give him a copy of the letter so he knows which one we are talking
about.
Changing‑‑not gears, because I
will go too fast‑‑the minister knows very well that we have met
several LPNs in the last six weeks to eight weeks and met some again last week
from St. Boniface. Their concern was the
fact that, to me there are rumours that they want to close down the LPNs in St.
Boniface and do away with them. Can the
minister indicate what is going to happen with the LPN, firstly for my own St.
Boniface Hospital?
Mr. Orchard: I guess we could go over this ground for the
fifth time in these Estimates and about the tenth time in the House, but that
is all right. I have all kinds of
time. The issue came up at St. Boniface
because of a discussion in, I believe, late November 1991 at the board level at
St. Boniface, where consideration was given to curtailing enrollment in the
licensed practical nursing course as offered at St. Boniface.
I believe members from the MALPN were
either at the meeting or were informed of that meeting. That led to a significant concern over the
issue, a press conference by the association in mid‑December. I answered at that time that I was aware that
the issue was being discussed at St. Boniface Hospital at the board level, but
they had not asked for direction from government or approval from government
even though government is not necessarily the final decision‑maker there.
Subsequent to that discussion and some, I
think, requests for information, et cetera, the issue did not conclude with the
closure of the
* (2025)
Mr. Gaudry: I will ask one more question, because my
associate here has asked me if I was taking over. Mr. Deputy Chairperson, to the minister, has
the minister arranged a meeting with the LPNs in the near future?
Mr. Orchard: When that question did not come up this
afternoon, I provided an answer without being asked. I indicated that I am attempting to set up‑‑I
wanted to have a meeting as soon after their Thursday general meeting of the
membership back about three and a half, four weeks ago. My time schedule has simply not allowed me to
get together, because we have been in Estimates and I was away for that week.
Yes, I want to meet as soon as
possible. As a matter of fact, my
appointments‑‑my secretary and I discussed it again and she is
attempting to fit the schedule in the very near future.
Mr. Gaudry: One final comment. Yes, the fact that in the last couple of days
the honourable member, well, the official Leader of the Opposition (Mr. Doer),
has been waving the flag to me that there is going to be a layoff of some 500
employees in St. Boniface. I was
wondering if the minister maybe can indicate to me where those 500 jobs are
going to be affected in St. Boniface in the health care services?
Mr. Orchard: You have a rumour that I have not heard.
Mr. Gaudry: I just wanted to put it on the record, because I
do not think anybody wants to see 500 jobs lost in the health care, and I think
the minister himself, and all my other colleagues in the Legislature.
I thank the minister for his reply.
Mr. Deputy Chairperson: Item 1.(c) Evaluation and Audit
Secretariat: (1) Salaries.
Mr. Gulzar Cheema (The
Maples): Mr. Deputy Chairperson, I do have a few
questions. I was sort of worried there
the member for St. Boniface was really taking over. Everybody wants to be a Health critic, and I
would love him to have this portfolio.
Can the minister ask his staff to get this
information ready for the Health Services Commission Estimates? Discussion on the waiting lists in various
hospitals of the various surgical procedures, because that has been an issue
that comes up many times. Each and every
person has his own waiting list and each and every person who is affected by
the delay in surgery has a number of other reasons to ask for. I think it will be worthwhile to have the
full discussion on how the waiting lists are taking place, and if there is any
co‑ordination and how this system can be improved. I think it will require some modification to
the staff.
My question on the issue of the nursing
education, that part of this evaluation branch is to provide support to the
minister's Council on Nursing Education.
During the last week's debate in the nurses' union, it was clear that
they wanted to know where the nursing profession is going. Even though I did not get any particular
sense from the floor also whether which direction they wanted us to ask him
questions, because it was probably not very clearly defined in my own mind, I
just want to ask the minister: What is this government's policy in terms of the
nursing education, whether the minister's own policy direction is to go along
with to have the BN by the year 2000, or is there a different approach by the
Minister of Health?
* (2030)
Mr. Orchard: The nursing education issue is one which is a
very complex one. There is a whole
dynamic of requirements that are impacting on the system. Move to community care‑‑that is
why we are moving for instance with the registered psychiatric nurses towards a
new curriculum in both the two‑year and the four‑year baccalaureate
program, because we see in mental health and we have the lead time and the
window of opportunity to craft an educational course which is reflective of the
move towards community‑based care.
I do not think there is any question that
that will require a differently trained nurse in psychiatric nursing, and the
association has taken up the goal and the challenge and has been working with
government for over two years, probably two and a half years, to try to get
some sense around the educational programs for psychiatric nursing.
We had to agree to disagree about this
time last year, budget time, with the consolidation of Selkirk school into
Well, I think we have clearly indicated
that that is the exact opposite of the agenda of the government in terms of
psychiatric nursing.
I will try to deal with the nursing issue
in general, and generalities are all I can offer, I think to maybe try to get
some sense of where we are heading. When
I came into government in '88, amongst many issues there was the overriding
issue of a report which was endorsed by MARN as our professional body for
registered nursing in
I was unable and am still unable to endorse
that as a goal for registered nursing.
However, what we have done in the past four years is set up what is a
process which I do not think necessarily was there in the past to try and bring
as much professional expertise around the training program as possible so that
we develop curriculum, training program and capacity to meet future needs.
The key question is: What are the future needs? I mean, what kind of trained nursing
professional do we need five years out, 10 years out in the
That is not a perfect process, but it is
really the only process that I know of that can maybe give us some clear
direction on where nursing as a profession ought to set its goals in terms of
curriculum and graduate capacity.
One thing I want to avoid, and I started
alluding to it before the break at five o'clock. I think there are a lot of people who are now
questioning, asking the very direct question: What happened to the shortage of nursing? As we sat in Estimates two years ago, there
was no question that we were being told almost weekly, if not daily, that there
is a shortage of nursing, that they are leaving the province, that conditions
for nursing are terrible.
Part of it, I will admit, was build‑up
to the contract negotiations, and that is fair.
I mean, that is the kind of dynamic that we will always have. You are not going to avoid that. What we did do in June, I think of '90, was
we launched in co‑operation with MARN an advertising campaign on television
to try to encourage individuals into the nursing profession.
Within two or three months of the new
contract coming in, all of a sudden we did not have a nursing shortage in the
What is happening‑‑and this is
a very real problem. I have had phone
calls from concerned parents who have daughters or sons that are in the nursing
programs, and they are questioning, you know, where did the job opportunities
go, because we understand new graduates are not facing a buoyant job market,
and I think that is right.
It is not only the fact that maybe the
shortage was overstated two years ago, but I think economic conditions has a
lot to do with it. More nurses are
coming back into the labour pool. Maybe
the spouse has been laid off or is unemployed or between jobs. The sheer financial pressure of families are
bringing, I think, maybe more nurses into the work force, and secondly, those
that are already in the work force are taking more hours of work or as many
hours of work as they can. Clearly, the shortage is no longer there.
Now let us speculate. Would there be a shortage, if the economy was
booming and there were lots of job opportunities in the private sector? I think you might see, as has happened in the
past, nurses opt for careers outside of nursing‑‑real estate,
whatever‑‑because they are skilled people. But right now we do not have a shortage of
nursing that I have been informed of in the
I think there are applicants for jobs,
vacancies on a pretty regular basis, but that is quite a different contrast to
two years ago. If at all possible, and I
say if at all possible, I would like to be able to develop some sense of two,
three, four and five years out as to what our needs are going to be and the
market survey demonstrating what our training needs are going to be. If government is going to have a role in
providing the training and if the professional associations are going to have a
role in terms of encouraging people to take nursing as a career option and
train for it, there has to be some attachment to employment and the needs of
the system.
The system is not going to perfectly
identify those needs, but we are certainly hoping the survey gives us a good,
decent indicator so that we can use that information in our planning of
educational capacity, and, indeed, depending on what the survey says, it may
well guide us in terms of the type of professional training that is needed,
whether there will be the emphasis by the system in one area or another on BN
versus diploma versus LPN versus nurse's aide.
Mr. Cheema: Mr. Deputy Chairperson, in his opening
statement, the minister made a remark on the mix of services and the mix of
health care providers. Can the minister
tell us now how the role of nurses will fit into the new community‑based
program, because some changes have to be made?
More specifically, is the province thinking of having the role of RN as
a nurse practitioner?
So there may be some changes that have to
be made. I just want to ask the
minister, what are his government's views on the role of nurse practitioner in
* (2040)
Mr. Orchard: I want to tell my honourable friend that I had
heard the terminology but, I have to be very blunt, I have never had a
reasonable explanation of what a nurse practitioner was and what their role was
until, as luck would have it, I am at Agape Table this fall and while I am
there, an individual, a woman, came over to me, introduced herself as a nurse
practitioner. She had trained as a nurse
practitioner out of
Basically a very interesting conversation,
and this individual made the case that the nurse practitioner as she was
trained would offer a significant amount of pre‑patient screening for
instance in the physician's office, and considerably enhance the ability for
quality patient flow through the office because they were doing certain
things. Now, that intrigued me, and
although there are many issues on the go, this one has not been specifically
fast‑tracked or identified, but I have made enquiries within the ministry
as to whether the nurse practitioner role should be investigated, similar to
nurse‑anesthetist, because nurse‑anesthetists practice just to the
south of us here in the
I think in a reformed health care system
offering more community care, I do not think there is any question that the
nursing profession will pick up a much larger role. I do not think that is even questioned. The one thing that we do not know, and this
is always the classic $64 question, is what sort of training standards various
care providers ought to have in providing those community‑based services,
because I just want to remind my honourable friend that one of the very
interesting recommendations coming out of the British Columbia Royal Commission
on Health Care was their observation that one of the greatest concerns or one
of the greater concerns‑‑I will not say greatest‑‑they
could foresee in the health care system and its affordability and its ability
to deliver services is the overprofessionalization of care giving.
That clearly sends a pretty direct
message, I think, to all of us that, as we move toward, say, community‑based
care that we do not insist on, for all cases, an unaffordable professional
trained individual. That is going to
require quite a little bit of discussion and insight into how we staff and how
we deliver care in the community. That
being said, I see a fairly insignificant enhanced role for the nursing
profession in community care.
(Mr. Gerry McAlpine, Acting Deputy
Chairperson, in the Chair)
Mr. Cheema: I have a few other questions, but I have to
make a phone call, a very urgent one. If
the member for
An Honourable Member: Sure.
Mr. Cheema: Otherwise, I do not want to lose the floor.
An Honourable Member: No, go ahead.
Ms. Judy Wasylycia-Leis
(
Let me go back to an area that we touched
on this afternoon and ask if the minister has had time to review the
Mr. Orchard: My staff inform me that they were unable to
put together that information, but we will have it for Thursday. So if that would be acceptable to my
honourable friend, we can have that sort of discussion even if we have to
revert back temporarily.
Ms. Wasylycia-Leis: Since we are dealing with this whole area of
evaluation, I am wondering if the minister can give us an indication of the
impact and the evaluative process that would have been undertaken presumably
with respect to the recent fairly sizable increase in personal care home rates.
Mr. Orchard: You mean the per diem? [interjection] We went
through the calculation as has been done since 1974 or whatever to establish
the per diem. The per diem is
established to leave something in the neighbourhood of, give or take, depending
on the days, the length of the month, because it varies between a 28‑day month
and a 31‑day month, approximately $110, $115 above the pension.
You start from the basic starting point;
then you set your per diems based on sole source of income being pensions. That is the way it has always been done,
leaving the individual with somewhere in the neighbourhood of, for average
figures, $115 maybe $120 per month for personal needs.
Ms. Wasylycia-Leis: I appreciate that explanation. What accounts for the fact that such a
significant increase occurred in one period of time? Is it the fact that there was no regular
increase on a year‑to‑year basis or that there was a change on the
pension side to account for the jump from roughly $20.50 a day to $25.25 a day?
Mr. Orchard: April 1, 1992, the rate is $24.90‑‑do
we have the schedule that goes back?
That represents 35 cents a day.
It has not been $20 as a per diem probably since maybe '85 or '86. The increase has been quarterly now for about
seven years, I think. It used to be adjusted on an annual basis, but now the
process when I came into government in May of '88 was that it was adjusted on a
quarterly basis. That had been the
process for three or four years prior to that on the criteria of allowing so
much minimum disposable income.
* (2050)
There has not been an increase overnight
from $20 to $25. Here are residential charges in effect since July 1973. They started at $4.50 in July of '73, and now
20 years later are $26.30. To give you
an example: They have increased by 25
cents quarterly to 35 cents quarterly in the last little while.
The last time it was $20 would have been
in November of '88, actually August of '88‑‑1990.
Ms. Wasylycia-Leis: Perhaps it is just my own confusion around
this issue. I am certainly not trying to
raise an issue here that the minister has to worry about in terms of a hidden
agenda. All I am trying to do is
understand the current Order‑in‑Council, which set the rates in the
beginning of May of 1992 at $25.25 a day, and then going up some 35 cents a
quarter.
My question is basically, prior to this
Order‑in‑Council and the increase for May of 1992, the last
increase by Order‑in‑Council was February 1989, where it went up to
$20.50 a day.
Mr. Orchard: There would have been an Order‑in‑Council
circa this time last year to set the rates. I have brought in one Order‑in‑Council
per year, and we try to bring in that Order‑in‑Council so that it
is passed, I believe, by March 31, so that there is a month of notice time
until the effective rate increase, I believe, on May 1 of each year, and then
thereafter every three months there is a quarterly increase reflecting one
month after there is a quarterly increase in the pension.
That is the circumstance that has been‑‑as
I say, that was the process that was in place when we came into government in
1988 of quarterly increases reflecting.
That was brought in shortly after the federal government changed the
pension to a quarterly increase. I think
that goes back seven or eight or so years ago.
Mr. Cheema: Mr. Acting Deputy Chairperson, the issue of
the RNs, I would like the minister to look into the issue of nurse
practitioners from
There is one more issue there: whether the nurse practitioner is going to be
paid fee‑for‑service per patient, or are they going to be on a
salary basis? I think that is where the
Canada Health Act comes in. There may be
some changes that have to be made or some kind of amendment, or the regulation
has to be changed in terms of are they going to be paid fee‑for‑service,
and specifically when we are going to have a mix of services.
You do not want to add on services. You are going to have the role of nurse
practitioner, a very specific one, and especially in a community clinic
setting. They will be screening patients
and doing a specific job, so that job should not be added on, as has been in
the past. You release a patient, and the
three health care providers who were serving the patient in the hospital, they
are doing the same thing in the community.
That does not really save any money in the
long run, so I think those things have to be qualified and make sure that their
role is specified, and I would like the minister to look into the issue from
Mr. Orchard: Yes, we will try to get some details from
I would never give consideration to nurse
practitioners coming into the system as a fee‑for‑service potential
arrangement. It would be under the basis
of a salaried position, like for instance, in most of our community clinics‑‑no,
I should not say this, but a goodly number of our community clinics have
salaried positions even, let alone the other care professionals that they have
there. I do not think that is an issue;
however, I will see whether it is. I
will try to seek advice on that.
Mr. Cheema: When the system is changing and if those
things are not taken into account at the beginning, those things become an
issue in the long run. I think that is
why it is so important to have a clear idea on the role of nurse practitioner
and how that role will fit into our system because, as the minister has said,
and many people are asking, there even has to be compensation changes for the
physicians.
(Mr. Deputy Chairperson in the Chair)
So if we are going to have add‑on
services on what we are already paying, then it is not worth it, so it has to
be a specific role, a defined role, and should be a substitute to some extent,
not an add‑on cost to the system.
When the system is in the community care, those roles have to be
explored and a very essential one it has to be because, when so many patients
are going to come to the community, their visits to the physician probably are
going to increase if we do not have another alternate midway system put in
place.
I think that is why it is so essential to
look into that aspect from the beginning, so that you do not end up in a system
where you are paying three times the normal stay in the hospital, the same
thing, as many people have said, when you release a patient into the community
who would need 24‑hour high‑care services, so basically it is
costing the same money as it would cost in the hospital, because all those
services were never meant to be a total replacement. They were supposed to be a substitute for
some of the services. I just want the
minister to realize that is a practical problem that has to be taken into
consideration.
Mr. Orchard: That in a way is reflective of the discussion
we are into in terms of midwifery, because that can be a valuable replacement
service and I have stated, I think quite clearly, that my consideration of
midwifery as a professional discipline of choice for women is that it be made
available, not as an add‑on cost, but as a replacement cost to the system.
The same kind of criteria would apply to
consideration of nurse practitioner, or for that matter any other new
professional discipline that might come into the system. They have to replace a regime of service in a
more economic fashion. That is the only
way that I think we can have some sense of ensuring that the patient receives
care and that the taxpayer is not unduly burdened.
That is always tough because when you get
into these kinds of discussions, there is always someone on the higher level of
tier delivery in training who believes that their opportunity to provide
services and earn income are being compromised by the additional skills being
offered by nurse practitioners, or BNs versus RNs versus LPNs versus‑‑and
I mean it is right through that whole spectrum of training turf protection.
* (2100)
Mr. Cheema: The reason is that the many individuals and
the many organizations are really worried.
They are saying, well, each and every person is talking about community
care, and when you do not define it properly and you do not have the system put
in place where each and every group has a specific role and at lesser
cost. Otherwise, we will end up in a
major problem and we may end up spending the same amount of money. So I think those things are a very real
concern.
You want a different system, you wanted a
system which more efficient, that will cost less, but the roles have to be
defined from the beginning. Otherwise it
may take another five years to change what we have started now. So I just want the minister to know. Many health economists are saying that is a
real possibility. That is why people are
not jumping right away. Let us start the
community care without doing all the research, without putting everything in
place, making sure that the health care provider who will fit into the program
will have the training, they have a future in the long run, and have something
to fall back on. So I think that those
are the very real and major concerns because it could cause ministries to fall
very easily if you have 200 patients released in that community, and 200 of
them are seeing a physician every day, and it is costing more than would have
cost in the hospital in the long run. So
I think those things have to be taken into account.
My next question is in terms of
midwifery. The minister has made some
comment about the issue of midwifery.
Can the minister give us an update where we are in
Mr. Orchard: Mr. Deputy Chairperson, as we dig out the
status on midwifery, I want to just indicate to my honourable friend that
community care and community‑based services have a wide range of
interpretation and understanding. There
is no question that in some individual circumstances the provision of care in
the community for independent living is probably more costly than an
institutional care regime. We have made
the choice in some cases that this is an initiative we are going to take
because there is a quality‑of‑life factor there that cannot be
replicated in the institution, and recognize that these are costs that are
probably higher than institutionalization would be.
Those are exceptional cases. I think where you will see the movement of
patient from our high‑cost institution to lower‑cost institution in
community, I think you will find that there is an assessed need of the patient
that is very adequately met in the community and, in fact, that the admission
to hospital or the occupancy of an institutional bed in an acute care hospital
or otherwise is inappropriate. There is
more cost‑effective care delivery in the community which, as well as
being more cost effective, is also very much superior care and more desirable
to the individual.
Now, midwifery, let me just flip down to
the bottom line. Right now, the working group that was struck in June of last
year has four subcommittees formed. They
are practice, curriculum, legal and consultation.
Currently the working group is identifying
and exploring key issues pertinent to the introduction of midwifery in
We are hoping that the working group in
the subcommittees will be receiving their input from the key stakeholders as
well as the public and will be submitting a report to me in fall of '92 as to
whether we implement and, if so, how we implement and what sort of process they
would recommend to us.
Mr. Cheema: Mr. Deputy Chairperson, after the report in
the fall, when can we expect the legislation to be brought forward after the
consultation to make sure that midwifery becomes a legalized practice of health
care professionals in
Mr. Orchard: Mr. Deputy Chairperson, I cannot give my
honourable friend that kind of indication because I do not know what sort of
recommendations the report is going to make to me but, as I indicated to my
honourable friend earlier on, one of the preconditions I put on this is that it
become not an add‑on to the cost of the system, but rather a replacement
of service which has all of the regular attachments to it of assuring safe and
quality care delivery so that I simply am unable this evening to prejudge what
sort of recommendations we would make.
I will say this to my honourable friend,
that the reason we are proceeding with a working group is with the obvious
desire to bring in midwifery as a care option in the
Mr. Cheema: Mr. Deputy Chairperson, one of the functions
under this secretariat is to draft a new health discipline legislation. Can the minister tell us, are we going to
receive during this session The Mental Health Act II, the community component
which was supposed to be coming forward, because when we are changing the
system as the minister would see it, there is going to be a need to have a
community mental health regulation put in place to make sure that the reform
becomes effective in the community.
Mr. Orchard: No, Mr. Deputy Chairperson, we are not
anywhere close to having that sort of legislation. I have to say to my honourable friend that
the pressures on my staff over at the Mental Health Division are such in terms
of advancing the mental health reform process that I think they are putting
modest effort only into the consultation and meeting process on part II amendments
that we discussed last year.
Mr. Cheema: Mr. Deputy Chairperson, can the minister tell
us if he is bringing any other legislation during this session in terms of the
health care professionals, not only physicians, but the other health care providers? So many of them have expressed their
intentions that some of the regulations are very old, that some of them may
need some amendments and some of these changes. We are hoping the minister will
bring such a legislation so that those concerns can be heard and the changes
can be made. Without real change in
health care delivery in terms of the health care providers, it will be
difficult to get the best possible care eventually, because when we are
changing so many things, you have to make sure that the health care
professionals are also along the same line.
* (2110)
Mr. Orchard: Mr. Deputy Chairperson, it is my intention to
advance amendments to the professional acts of dentistry, optometry, this year,
and hopefully they will be introduced very shortly. I just indicate to my honourable friend that
the pattern for amendment was the pharmacy professional act that we passed last
year, a process involving a more effective disciplinary screening process and
then the option of the public hearing process and of course often increase in
fines because they are out of step, but basically the path laid down with the
successful pharmacy legislation will be emulated as closely as possible if not
identically in both dentists and optometrists, in terms of their professional
act.
Then my honourable friend is aware of the
minor amendment that we are making to The Denturists Act to remove me as the
person responsible for advancing complaints against individual members.
Mr. Cheema: Mr. Deputy Chairperson, a final question on
this section is can the minister tell us if there is any internal audit going
on in any of the major branches within the department?
Mr. Orchard: You are asking for something other than the
normal audit process that they go through, like whether we have any special
audits ongoing. I will have to seek
advice on that.
For this fiscal year, we propose major
audits for mental health, environmental health, a registration system,
administration and finance, continuing care and personal care home panelling. Those are the five areas that we are
proposing major audits on.
Mr. Cheema: Mr. Deputy Chairperson, a final question. As a politician you always say
"final," but it is never the final one.
Can the minister tell us what is the
complement in terms of the affirmative action at the senior level within the
Department of Health, in terms of how many visible minorities, how many women's
groups, and how many aboriginal people have reached the middle management or
the higher management levels in the Department of Health?
Mr. Orchard: I will give you a summary of target group
representation as of March 1992, and bear in mind that in some of these areas
the designation is by choice of the individual.
If an individual chooses not to be in one of the categories, they are
not; 76.8 percent of our total employee complement is female, 4.6 percent is
native, 3.1 percent disabled, and 3.5 percent visible minority.
Mr. Cheema: Mr. Deputy Chairperson, are we meeting the
target set by the Department of Health in all those areas?
Mr. Orchard: I guess, yes and no, not that I am wanting to
make light of the issue. We are
significantly over the long‑range target.
I do not know how we have a long‑range target of women, 50
percent, in the ministry, but that is what it is, or I guess that is across
government. We are significantly above
that, but we are below by approximately one‑half on native. We are better than one‑half way there
for visible minorities, and we are slightly under the half in terms of
physically disabled.
Ms. Wasylycia-Leis: A few more in this area‑‑I am
still confused, I must say, about the personal care home rate increase. The Order‑in‑Council that was
passed on April 8, 1992, refers to amendments to regulation 506/88R, and that
regulation brings us up to date to February 1, 1989, at $20.50 a day.
Mr. Orchard: Mr. Deputy Chairperson, I do not know why my
honourable friend would not have access to the regulation that would have been
passed effective for the '91‑92 fiscal year.
(Mr. McAlpine, Acting Deputy Chairperson,
in the Chair)
There has been regulation passed each
year. This year the rate is 35 cents per
quarter. Last year it was 55 cents per
quarter because all residents received a GST rebate which we factored in to
leave disposable income roughly at the‑‑well, it ranges, depending
on the month, from a low of just under $100 to over, well, one month $175, but
that is an exception. The average is
closer to $120. It works out to a yearly
average of $118 projected for this year.
It was $141 last year; it was $130 the year before; it was $128 the year
before; it was $122 the year before that; it was $120 the year before that,
$133 before that.
Last year was exceptional in that even
with a 55‑cent quarterly increase versus anywhere from 25 to 35 that it
has been over the last few years, the average disposable income last year went
up, even with the 55 cents which was reflective of leaving that kind of average
income in the individual's pocket. The
decision was made for policy reasons that we would increase the per diem
reflecting the GST rebate, the argument being quite frankly the same as it has
always been‑‑I do not think it has changed significantly‑‑that
all the individuals' shelter, food, pharmaceuticals, and all their needs are covered,
and the per diem is only approximately, maybe‑‑it would not be a 20
percent offset of the total costs, somewhere between 15 and 20 percent of the
total offset of costs.
There is obviously an Order‑in‑Council
missing in my honourable friend's files, because the Order‑in‑Council
last year reflected 55 cents per quarter.
I believe, if I am not mistaken, the first triggering of that, because
of sheer timing and getting Treasury Board approvals and whatnot, I think, was
June 1 instead of May 1. It was one
month delayed last year.
Ms. Wasylycia-Leis: I appreciate the patience in correcting my
information. I had simply looked at the
regulation listed on the covering page of the Order‑in‑Council
indicating 506/88R being the most recent regulation. I will ask the minister afterwards, and
perhaps we can clarify that.
* (2120)
Mr. Orchard: Mr. Acting Deputy Chairperson, that covering
letter, I think, has to be incorrect because I have passed that Order‑in‑Council
every year about this time of the year to make the new regulations, in fact,
and always accompanied by a letter to the personal care home facilities
indicating what the new per diem rates will be, because this is a source of
income to the personal care home program.
I do not know why that would say 88 because I know I have passed one
each year, maybe not at exactly the same time but at approximately this time of
the year.
We will try to straighten that out for
Thursday as to what was the reason for that reference in the covering
department. I never noticed it when I
brought it in.
Ms. Wasylycia-Leis: Just a couple of other questions. Based on the role of this branch in terms of
analysis and evaluation, can the minister indicate what the increase in
supplies is expected to be for health care facilities this coming year?
Mr. Orchard: I do not know whether we have an estimate‑‑can
I provide that information on Thursday?‑‑because I think clearly
there is going to be a difference between the estimate and what we are
funding. I do not think we are going to
be in a position to fund the complete supply increase, I think that is fair to
say, but I will try to provide firm information on Thursday.
Ms. Wasylycia-Leis: The minister references a concern that I have
raised in the past and obviously is part of my question now, and that is with
the roughly 5 percent increase that the minister says is going to
hospitals. It does get back to my
question and ties into what analysis has been done by this branch in terms of
impact, how hospitals will handle a 5 percent increase if one accepts what the
minister said previously, that out of that must come pay equity adjustment, and
I am still waiting for the minister's figures on that.
Out of that must also come the regular
adjustments for increments, reclassifications, adjustments, benefits and so on,
as well as, of course, any negotiated settlement, not to mention the increase
to cover inflation vis‑a‑vis supplies and hospital equipment. So all of those figures are important in this
whole exercise, and we look forward to the minister's information because, as
it now stands, it would appear that in fact the government has not moved much
from its position of zero percent for wage increases as a basic guideline when
one considers all those different factors.
Could the minister indicate how soon we
could expect to get some of that information and be able to have some
understanding of just how serious the situation will be with respect to our
health care facilities?
Mr. Orchard: My honourable friend wanted a projection on
supply costs, and I am going to try to get that for her, but I did it at the
risk of getting my honourable friend back on the process of let us deal with
hospital budgets tonight and the next request being the exact dollar that we
are providing every hospital. Clearly the roughly $53‑million increase to
the hospital line is representative of approximately a 5 percent budgetary
increase on the hospital line. I mean,
that is irrefutable. You cannot get away
from the mathematics of that.
It is, as I have indicated to my
honourable friend, not what the hospitals requested. They want more. We are unable to provide them more, but for
relative comparison, approximately 5 percent more to be allocated across the
board for all purposes in the hospital system of
Now,
We have been significantly more generous
in our base line funding so that, when it comes to a relative comparison, I
will put our funding this year and past years, our funding commitment to our
hospital system, in comparison with anybody else, but clearly, from the
standpoint of monies available, we are asking hospitals to provide us with
options as to how they can provide patient care with limited budget
dollars. We do not have unlimited money
to put in. We do not have $l06 million
additional to put into hospitals; we only have $53 million. That is going to mean some management
choices. We have talked about those
management choices in Estimates before, and some of the policy directions that
I think are to be explored will be explored in terms of managing our hospital
system.
I think one of the issues that came up
last week at
I believe similar decisions can be made in our funded