LEGISLATIVE ASSEMBLY OF MANITOBA

Monday, May 2, 1994

The House met at 8 p.m.

ORDERS OF THE DAY

(continued)

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(b)(1) on page 81. Shall the item pass?

Hon. James McCrae (Minister of Health): Mr. Deputy Chairperson, I think at five o'clock I was just explaining to the honourable member for Crescentwood (Ms. Gray) some of the changes that we brought on to Home Care just last September when I was appointed to this position. Just for a moment, if the honourable member for Kildonan (Mr. Chomiak) does not mind, I will just finish up.

I think I dealt with assessments and reassessments and things like that, and then we were talking about my talks with the Ostomy Association of Manitoba, and we determined that we would immediately remove any public signs that suggested that ostomates should somehow be singled out for different sort of treatment at the supply depot. I did not know that existed, and I was somewhat horrified when I heard about it, and we did something about that right away.

The department and the ostomates' society have met since that meeting I had with them to resolve the issue of that small number of people who might be affected financially in a difficult way. Certainly we discontinued any thought of charging people up‑front should they not be able to deal with it that way. The problem being that if there is anybody who is being encouraged to use supplies longer than they should or reuse them or some such thing when that is not the best thing from a medical standpoint to do, we would not want our policy to encourage that. I have not received any report on how many people might have been affected, but I was led to believe by the association it was a very small number. I understand that matter has been dealt with satisfactorily between the department and the Ostomy Association. We appreciate their input.

I believe, yes, we also met with organizations representing disabled Manitobans, and the policy was discontinued with respect to them and services provided to disabled Manitobans.

Those were basically the changes and, from all of my consultations, seem to have dealt fairly with the issues, as far as that went. There remained the issue of doing something with respect to a more formal appeal procedure for people so that they do not have to appeal to the same department that made the decision about their care. If there is a need for a change in a person's assessment or for a fair hearing, that should be made available, and that will be happening in very short order. It was announced in the throne speech, and I expect in a very short period of time to announce the panel for home care recipients.

So I think that basically is what happened. There are more things to happen, but those are the things that happened at that time.

Mr. Dave Chomiak (Kildonan): Mr. Deputy Chairperson, the minister made his comment. I certainly appreciate the fact that the minister, upon assuming the portfolio, made some changes to the policy and recognized the unfairness of the approach and dealt quite quickly with some of the more obvious inequities in the decision that had been made. But, notwithstanding those changes, the fact remains that people who require home care equipment have to pay the first $50 of each individual item, and that is cumulative, so that in some cases the cost is quite prohibitive.

The minister indicates that he has the support of the ostomy society with respect to the equipment issue and that he has done something to deal with the money up‑front. I appreciate that, but notwithstanding that, there are individuals who require not only ostomy equipment who now have to pay but home care equipment who have to pay. I have encountered several individuals in my own constituency who, in addition to that, were confronted by cuts to the cleaning and laundry as well.

I guess my question to the minister is, notwithstanding that he changed the policy with respect to cutting people off of cleaning and laundry so that an assessment is made by an individual personally rather than over the telephone, has he changed the policy with respect to eliminating people from cleaning and laundry service that was instituted in the last budget?

* (2005)

Mr. McCrae: Mr. Deputy Chairperson, the policy was found by the people with whom I consulted, with the appropriate adjustments, to have merit because everybody whom I spoke to made the point that, yes, indeed, home care is an important service. Yes, indeed, the government has increased its commitment to the program very, very significantly over the years, and that if the government is indeed working on accelerating the process of putting into effect support services for seniors organizations and continuing its support for the nursing and attendant care services that are part of the program that everybody recognizes that we are in a time when fiscal problems are more difficult than previously.

Everybody recognizes that, and they want to continue to have a health care system. They want it to be as fair as we can make it, and that was something we tried to address. But I think that maybe not everybody is aware that since 1988‑89, the first budget we brought forward, the budget amounts for Home Care services in Manitoba have grown back from where the previous government left off at $33.5 million all the way up to this year, which is something around $70 million. It is a significant increase in not only units of service, but number of people being served and the quality of service.

You have to be careful when you are talking about people being cut off. Some people recover from their illness, and that is a cause for a reassessment which might indeed terminate home care services, might reduce them. Sometimes, they are increased depending on a person's condition. If their condition deteriorates, more services are laid on by the program, and so we have to be fair about that. That is always the problem when we take individual cases and try to make them examples of the whole program.

Obviously, when you look at these numbers, and the cost per person served and the dramatic increase over the years in that amount, it goes way beyond any level of inflation or any level of funding that might be required to offset an aging population. It is well beyond that.

You have to remember too that when last year over 230 personal care spaces in the city of Winnipeg were opened up, when that happens, you take from the home care service rolls 230 people who are placed in personal care. That is going to show up as well.

The honourable member for Kildonan (Mr. Chomiak) shakes his head. Maybe he can explain why he does that. I say those things to‑‑and with all of these things happening‑‑[interjection] The honourable member suggests that I have my facts wrong. I will be happy to hear in a moment from him in what way I have my facts wrong because we should, of course, be dealing with facts that are correct, both of us. I am certainly willing to deal with facts that are correct, and I sure hope the honourable member is too.

But some of the points that he raises, and maybe the honourable member for Crescentwood (Ms. Gray) raises, does point to the need for an appeals system whereby you have some independent body looking at the criteria, which have remained the same since they were the criteria used in the days of the New Democrats in Manitoba. You look at all that, and there are still some people who are going to be dissatisfied. They need someone they can tell that to, and we respect that. That is why we feel that an appeals panel is going to be necessary.

Mr. Chomiak: Mr. Deputy Chairperson, several points that I want to point out. Firstly, the former minister argued that those personal care home beds were being utilized by people who had been moved from acute care facilities to replace those beds, not people who were receiving home care in the community that were thus shifted to personal care home beds. While I appreciate there could be a mix of that, the previous minister always argued that was a shift from acute care beds to personal care home beds, and that is where the shift to the 230 beds took place.

* (2010)

The second point that I wish to make is that, notwithstanding what the minister said, he clearly stated in the first part of his discussion that in fact, no, the policy had not changed, that the criteria that were put in place to cut off approximately 3,300 people from cleaning and laundry services did not change. The criteria being used did not change. All that changed was, the minister saying now that perhaps an appeal will be put in place one year later, and, secondly, that personal interviews took place. Having said that, it is clear the policy continues, and the minister acknowledged that, that they are cutting down this particular service in order to fund money into other services.

The minister also talked about the fact that the per unit cost had increased, and the minister's own documentation shows that home care is far more economical per day in its application than utilizing more expensive treatment facilities or more expensive beds. My question for the minister is, the program supervisor's minutes that were circulated in August of last year indicated that approximately 16 categories would not be considered exceptions to the elimination of individuals from cleaning and laundry services. When the minister changed the policy, he said the young disabled would not be any longer on that list of exceptions, and therefore the young disabled would still get the cleaning and laundry services. That left the other 16 categories for which people were being eliminated. Have those criteria changed?

Mr. McCrae: Mr. Deputy Chairperson, the honourable member refers to young disabled people. I only referred to disabled people, and I take that to mean someone other than seniors who are on the Home Care program, and we reinstated those cleaning and laundry services for disabled people. We reinstated that. I think maybe we are getting into some numbers debate here, and it may not be necessary because I do not think the honourable member and I disagree all that much on the whole issue of acute care, personal care and home care.

It is true that home care and personal care are there to replace unnecessary or inappropriate acute care. I agree with the honourable member on that point, and I think that the honourable member has to agree that length of stay at our hospitals is shorter today because of various things, not the least of which is home care.

If you look at the hospital statistics, you will see reduced length of stay in many, many categories, and you have to ask yourself: How are we able to do that? It is a combination of personal care and home care services available in the community and other services, like support services to seniors and so on.

The honourable member talked about criteria, and the thing that I have discovered is that‑‑and I hope the honourable member understands this and is not doing this intentionally, because if he is arguing in favour of criteria that are applied, same criteria everywhere but applied differently in different places and he is saying that we should continue with that approach, because we know it exists and has existed‑‑and it is wrong in my view‑‑if the honourable member is arguing that we should continue to do that, and that when we make changes to address that inequity amongst our fellow Manitobans, he wants to be critical about it, I hope he will think very carefully about that.

I do not think that is fair of him to say: Well, it is wrong for you to try to make this system more equitable and fair to people. If the honourable member is saying that, I will have to debate with him about that, because we have found, I have found that the application of the same criteria is not uniform. Now, if the honourable member will accept that, he can be critical that it is not uniform and I will accept that criticism, but I am telling him that he should let the government try to address that to make the program fair for all Manitobans. If a group of clients in area A gets treated better than a group of clients in area B, and if he wants to defend that, I am sorry, I disagree with that because it is not fair to the people in the area that does not get the fair treatment.

The honourable member needs to know that, in 1992‑93, 24 new support services projects were added to the existing 141, and expansions to 19 existing projects have been funded by reallocation of personal care home funds to the new and expanded programs for a total of 165 support services projects in the province. I can tell him, if the honourable member wants to hear all about it, about the distribution of those new support services projects and those enhanced ones. These are all positive improvements that extend the time of wellness, if you like, that people if they are active and living lives that these support services projects allow them to live, it is not so soon, so quickly that they require more intensive home care services or personal care services.

* (2015)

Mr. Chomiak: Mr. Deputy Chairperson, I am not going to argue the point with the minister, except to state that it is a reductionist argument in my view when the minister talks about A and B. My impression of the government's decision last year was that if services were better in A and services were less extensive in B, the government reduced the services down to B, not moved the services from B up to A. That was my impression. That remains my impression, and I have yet to be proved otherwise.

But, to resolve the problem, can the minister table the criteria used by Home Care to determine who is eligible, when they are eligible, when they will be provided with cleaning and laundry, when they will be excluded, et cetera? We have never received formally ever those particular‑‑those documents have never been formally provided to us. They were not last session, and they have not to this point in time.

Mr. McCrae: I thought that we did make those criteria available. We did to other groups out there, so we will make them available to the honourable member. They are certainly no different from what they were when the honourable member's people were running the Health department. So he could go back to that time and have a look at them as well, but if he likes, I will make available to him the criteria that have not changed since the days of Howard Pawley and Larry Desjardins and that bunch.

We have had for some time in Manitoba quite a debate about home care. The whole issue is one of making available appropriate resources in our communities so that people can live with more dignity in their homes, stay in their homes longer, which is where they want to be. But you see, you cannot just be critical for the sake of being critical. At some point, the issues become such that people understand what is going on.

I am happy that people in Manitoba are beginning to understand what is going on, but I just wish the honourable member would be a little more helpful. The reason I say that is that he uses tactics which are not new, but in health care, it is particularly disturbing to me. You see, these are my fellow citizens, and they are his fellow citizens, too. If my family members or my friends need appropriate services, I want them to have them. The honourable member would lead people to believe that I have some other agenda.

I can speak personally about this and tell of personal tales and how delighted and pleased people close to me were when appropriate services were available at a time when they were needed. The idea is to have resources there for those who need them.

Some people do get reassessed; there is no question about that. Their services are decreased either because they do not need them anymore or because they have recovered or they have gone on to some other form of service. These things happen. The honourable member ought not to confuse that with some heavy hand of government taking with a bad attitude. That is certainly not the case. These Manitobans are his fellow Manitobans and mine too.

* (2020)

There is no particular corner on compassion here that the honourable member can lay claim to. I mean, if we were going to play that game, we would just simply go back to the kinds of funding arrangements that were made available by his party when they had the opportunity and did not do anything, and look at that record compared with the record of the last six or seven years in terms of commitment.

In terms of percentage of budget that goes to health care, no government, no NDP government in Manitoba ever put 34 percent of their total spending into health care, and that is what is happening now. The honourable member should remember that when he is addressing health care issues.

If he wants to be helpful, we are delighted to have some advice from him. I look for alternate policies if there is something wrong with ours. I look for constructive criticism if there is something wrong with what we are doing. We are quite prepared to acknowledge that we can do better, and we are trying to do that, but I think to use health issues for the purposes that the honourable member is using them is somewhat off‑putting, to say the least.

Mr. Chomiak: Mr. Deputy Chairperson, it was not the opposition who promised to put health care and community services in place prior to making the changes. I think it is quite inappropriate for the minister to question the motives of members in terms of raising health care issues.

His predecessor quickly gathered a very poor reputation in this province for that kind of an attitude, for an attitude wherein any criticism against the government was somehow misconstrued or construed to be that of a political basis or somehow of an agenda different from that of the government. I have never questioned the integrity or the compassion of any member of the Chamber, including the former minister or the present minister, in dealing with the issues; however, I believe that the minister should afford the same kind of attitude toward members of this Chamber.

We are certainly used to that kind of an argument in terms of‑‑and it certainly will not deter members from this side of the House from criticizing the government for its actions, but I again remind the minister, it was not us who made the promises. It was this government and this cabinet who put in place the promises that were not met and that had faced such severe opposition in terms of the public's approach and the public's view of this government as it regards to health care.

My question for the minister with respect to the‑‑the minister is indicating he is going to give us the criteria of the decision of the home care qualifications‑‑can the minister outline‑‑will those be public and will those be criteria that will allow individuals who feel aggrieved by the decision to appeal them to the soon‑to‑be‑announced‑‑not yet in place, despite the fact the program has been in place for a year‑‑appeal commission?

Mr. McCrae: Just to finish off the last point, maybe the honourable member will not be deterred. I feel I do not expect him to be deterred. He wants to do his work as best he knows how, but he will note the absence of the same kind of comment from me directed at members of the Liberal Party.

The Liberal Party has been critical, and that has been appropriate. They have done their work, too. It is simply a question of the honourable member and his particular approach and that of his colleagues that I am talking about. It is nothing personal. It is a question of getting the real truth out there that I see as my challenge, and I find that sometimes it is made more difficult by the misinformation that the honourable member frequently makes available to the public.

That is difficult, but I am not deterred either, because, you see, I am completely committed to our health care system. I am completely committed to ensuring that there is one for the next generation. If I followed the advice and some of the utterances of the honourable member, there would not be a health care system.

In terms of promises and attitudes and so on, I remind the honourable member that I have another personal experience to draw from, and that is the experience of 1987, when, without any thought for services in the community, the honourable member's colleagues closed 42 beds permanently. The first bed closures, by the way, hit the Brandon General Hospital. I remember that very well. I remember how nothing else was arranged for, so I am not going to take all that many lessons on that side of it from the honourable member or members of his party, because they are the ones who brought in the first permanent, massive bed cuts in Manitoba.

I must say that in more recent years more money and commitment have been directed at the community so that kind of health reform could go forward.

* (2025)

Just in terms of redirected funds from acute care to the community, I refer the honourable member‑‑in the past year, $1,915,000 has been redirected from hospitals to adult day clubs; $1,787,500 has been redirected to breast cancer screening; $440,000 has been redirected to prenatal community public health services in the area of nutrition; $45,000 has been redirected to prostate care; $1,056,500 has been redirected to support services to seniors projects; $2,956,000 has been redirected to Winnipeg mental health acute‑care alternatives; and $774,000 has been redirected to Winnipeg mental health child and adolescent and psycho‑geriatric services. That amounts to a total of nearly $9 million redirected in the past year.

Let not the honourable member suggest that no provision is being made in the community.

The honourable member asked about appeal panels and advisory panels. I did not ever hear any suggestion from the honourable member that we should have one, and now that I am proposing it, it is too late and overdue and so on. Well, it is never too late to do the right thing. I suggest, Mr. Deputy Chairperson, and I say that appeal panels will be useful for those who feel aggrieved by the bureaucracy, if you like, of the Health department.

We think that an advisory committee on home care can have a look at the honourable member's criteria, but he has a lot of complaints with them. Maybe we should address those complaints that the honourable member has with his own party's criteria, and we should do that through the aegis of an advisory committee, and through the experience of an appeal process we can learn as well. Nobody knows it all; I certainly do not. We are quite happy to learn from these processes.

Mr. Deputy Chairperson: Order, please. At this time, maybe I can ask the advice of the committee, but other than provoking debate between the two honourable members, maybe you could explain to me where we are within the book that is dealing with Executive Support (1) Salaries and Employee Benefits?

Mr. Chomiak: It is 1.(b). It is quite obvious to me that if you look at the Activity Identification and the Expected Results on page 24, of your supplementary Estimates book, it, quote, provides for the development and implementation of health system renewal; develops comprehensive strategies, et cetera. It is far ranging and quite all encompassing.

Mr. Deputy Chairperson: That is what I was looking for. I was just asking you for clarification.

Mr. Chomiak: I am tempted to argue these points with the ministers and use up valuable time, because I think the minister has been‑‑it is ironic that he indicates that there is no change to Home Care, that it is the same criteria as utilized in 1987, but admits that people were cut off and now an appeal process is necessary for the people who got cut off, et cetera. It is clearly not in the best interest of time to continue on this course of action because clearly the government is not changing its approach to home care with respect to the decisions made last year.

They are putting in place an advisory committee. They are putting in place an appeal committee, and that be what it may, my question to minister is: Will the criteria be clear so that individuals will not have to appeal cap in hand, and will they know the basis upon which they are being judged to be cut off home care or put on home care, et cetera? Will they have the criteria clearly in front of them to determine what the grounds of appeal are and how they can appeal those particular decisions?

Mr. McCrae: Mr. Deputy Chairperson, I would like very much for consumers of these services to understand what services are available and publicly funded. I would like people to be aware and understand what services they can access on their own without resort to public funding. What I am trying to say is, I would like the consumers of home care services to be very informed consumers of health care services. I also want them to be able to have choices, that they are not at the mercy of a rigid system that sets out certain criteria beyond which you cannot go and things like that.

I think when people are in circumstances of distress and they are not well, it is a bad time to impose difficulties on them which they do not need. The point is that many people have opinions of their own about their own care, and I think that a government‑run system has limitations in that regard because governments have rules and regulations. It is not an easy sort of thing to be dealing with, especially when you are not well or you are needing care. You tend to be at the mercy of whatever there is out there.

* (2030)

No matter how good I might claim it can be or is, you are at a time when nothing makes you as well as you were before you needed those services. I think that we should all try to be mindful of the circumstances people find themselves in. That is what I am trying to do. That is why I am also kind of excited about self‑managed care. The small number of people who have been part of that program are urging the government to get on with as massive an expansion of it as we can arrange because it gives them such a feeling of empowerment. I just know the honourable member is going to be supportive of as much self‑managed care as we can make available to people.

It has been independently evaluated and found to be successful and proper and appropriate and good and everything, and so those who have taken part in the program are really urging us to get on with making it available to others. Even though we are expanding it, my indications are that people who need services would like to see it expand further and faster. I would like to know what the honourable member's view is of that because I am certainly‑‑one client actually sent the government a couple of cheques.

The way it is set up is that the client sets out with the government or they work with the government to decide on a budget for their care. The client receives the cheque, and then is set free to make decisions for himself or herself about the kind of care that they should be getting. One client has sent us back two cheques, saying it is a great program, hurry up and expand it, and here is the money I did not need. I thought, wow, this is something that we should be looking at because the consumers are our clients, our customers, if you like. They like it, not unlike the services provided through this pilot project. The patients like it. Those are the people I am working for, and I am not always clear whom the honourable member is working for, but I wonder what he thinks about an expansion of the self‑managed care program because that can be part of a response to some of the complaints that he brings forward.

Mr. Chomiak: The minister has established a task force to look at personal care homes. Who is that task force reporting to, and what is the mandate and will the minister table the terms of reference?

Mr. McCrae: The honourable member has very suddenly changed the subject. Why is that?

Mr. Chomiak: I believe in the Estimates that we generally ask the questions. If the minister wishes to know my strategy in terms of how I am planning to deal with this, I will provide my strategy to him. But, frankly, if the minister wants to know, I thought my line of questioning was useless because the minister was going back to his pat answers of self‑managed care, and then the minister has a series of responses that he makes in terms of questions, does not provide the information, goes back to the pat answers.

Frankly, I thought it was useless to continue the line of questioning, given the minister's repetition for the second or third time today in only a few hours of Estimates to tell us about the self‑managed care issue. In fact, the minister has probably spent more time on it today than has been done in the last year in terms of talking to the public about it. Notwithstanding that, that was why I decided to turn to another line of questioning at this point in time.

Mr. McCrae: I would be happy to discuss the things that the member asked, but this is not a courtroom where I am the witness and he is the prosecutor and demands that I answer the questions. It is not like that, I did not think. I thought we would have a useful discussion of the issues, and, to me, self‑managed home care is one of the initiatives that we have announced in our throne speech and there is provision for it in our budget.

I think the consumers of home care services want to hear us talk about this. They are not happy with us. I was led to the conclusion very quickly when I met with a group of people representing disabled Manitobans that we are not going far enough with this self‑managed home care, and so I just needed to know if I have the approbation of the honourable member and his colleagues to go further with this. If it is possible to do, I would like to be able to do that. I want to do it carefully so that we do not make mistakes along the way, but I really think self‑managed care is something that consumers of health services want to see us get into.

The honourable member refuses to say‑‑all he had to say was, yes, I think it is a great idea, and then we could get on to answering his question. So maybe he does not want to say one way or the other, but if not‑‑he appears not to want to respond to the self‑managed care issue‑‑I will talk about the question that he has asked.

The question that he asked was about the process we have set up to examine standards and regulations and staffing and all of the things that go to protect the people who are resident in personal care homes in Manitoba. We, through our department and the Family Services Department, led by the Seniors Directorate, will do a review of standards and regulations.

The timing for this is appropriate because, as a matter of fact, reform is happening. The honourable member suggests it is not. But reform is happening because levels of care required in our personal care homes, I am told in all my visits‑‑I cannot remember how many personal cares I have visited; it must be in the dozens by now. Everywhere I go, I am told and reminded that, you know, many of the residents here, Mr. Minister, are at higher levels of need than a few years ago. Some of these people who are now 85 and 90 came here 10 years ago or whatever, and they are getting on. They are getting so that they need more care.

So it is an appropriate time for a review to be held. This review will include consultations with regulatory agencies and bodies like the College of Physicians and Surgeons, like the Manitoba Association of Registered Nurses. We will bring the MHO into the discussions, and I just cannot remember what all other groups. But certainly anybody who has any concerns that they want to be made known, they can let it be known through my office, and I will pass it on to the task force so that when we do hear from them, the advice that they give us will be backed by as many interested and competent parties as possible, so that we can go forward from there and make whatever improvements are necessary.

Mr. Chomiak: Will the minister table the guidelines for the task force?

Mr. McCrae: Yes, Mr. Deputy Chairperson.

Ms. Avis Gray (Crescentwood): I, too, have a number of questions about Home Care, but I think I will leave them until we get to that section. I wanted to go back and talk about some of these committees that the minister has established and look a little bit at health care in rural Manitoba.

I am wondering, first of all, if the minister could tell me, is regionalization of services, particularly in rural Manitoba, but not to exclude urban areas of Brandon and Winnipeg‑‑is that a fait accompli? What is the department's position on regionalization, and where is that in terms of looking at regionalization of health services?

Mr. McCrae: It is not a fait accompli because, as I said earlier in my comments, the process has been slowed down a little bit but not stopped because it is the right thing to do in my view and in the view of all the others with whom we have been consulting.

When we look at other provinces, I think of New Brunswick, Saskatchewan, B.C., Alberta‑‑I think, Alberta‑‑those provinces, without prior consultation, or very little, passed legislation drawing new lines on maps. I think it was in Saskatchewan where they had 133 hospital districts; they reduced it to 30. They reduced it with a stroke of a pen to 30 and closed 52 hospitals in the process. Well, that is not the approach we decided to take, even though we too have pressing fiscal problems with which to deal.

I do not know if I will get my whole chronology right, and if I do not, maybe Mr. Maynard will stop me. The first process is about to draw to a close, that being proposals for the regions, for regional association boundaries basically. We extended the date for closing all of the appeals and so on to the end of April. That date has now come, and the Health Board will look at all of the appeals, if any.

I should go back. Initially, there were about 20 proposals that came forward. The Health Board and the rural and northern health advisory committee determined that that should be reduced to eight regions, and that was appealable. That is where I have been going around the province, inviting people to make sure they do appeal if they are not happy with that, and so we can get to the next stage.

After the appeals have all been dealt with‑‑and that will be a very inclusive process, where even those not filing appeals but having an interest will be welcomed to make their views known, so that when we finally do get the regions sorted out, it will be the subject of more approval by the boards and trustees and community people and service providers that have been involved in the process. So I expect‑‑I do not know how long it is going to take; I do not expect it to take too terribly long, though, before we will be able to say where the regions are and how many there are. I have speculated that there will probably be fewer than the 20 initially, and probably a few more than the eight that were arrived at, at the last round, but that is just speculation on my part.

* (2040)

So then, from there, the regions would then be asked to form associations, and that should take some time. I think it will be about the spring of 1996 before we can get serious about‑‑between now and approximately the spring of '96.

Those associations and boards will be advisory in nature. They will not have legislative capacity until we get legislation passed for them, and advisory in the sense of what form and structure of governance they should take up.

We want to make sure that the people understand, and I have gone to some lengths to go to a lot of places in Manitoba to explain that this whole regionalization process means a whole lot of things, but there are a few things that it does not mean.

I wanted to point out what it does not mean, because there are some trustees and others out there who either were given to believe or for whatever reason believe there might be some problems associated with things like where you would go for your care. If under a new system, does it change the way your care is delivered. If it is an acute‑care situation, are you force marched to a certain place or driven by ambulance against your will to a certain place you do not want to go. I have been giving them assurances that is not what it means.

Another one was hospital boards. Does it mean the disappearance of all our hospital boards, like in Saskatchewan, and the answer was no, that is not what it means. We do encourage amalgamations. We have already seen a number of amalgamations of personal care administrations with hospital administrations in some small communities, but decisions about the future of boards, we think, ought to be made more locally than right here in this building on Broadway Avenue in Winnipeg, so I have made that clear.

Hospital closures: With all those hospitals in Saskatchewan‑‑I think 52 altogether hospitals closed there by the stroke of a pen‑‑that is not our approach. I have been making that clear, too, that that is not our approach. If in the future a region decides that a hospital should deliver services differently or not at all, if that is what they want, that will be something that would come from them and not from the government of Manitoba. I do not expect to see any hospital closures, other than maybe Brandon Mental Health Centre, which we can discuss later.

The other thing that was of concern to one of the communities was what about foundation monies, what about money that people‑‑this happened in Minnedosa, by the way, and I see the Minister of Culture, Heritage and Citizenship (Mr. Gilleshammer) is here, and he might want to hear this. Concern was raised, if we form into a larger geographical group and association, then monies that you might donate to the Minnedosa Hospital for supplies or to decorate a room or some such thing, would that be swallowed up by the association. I said no, and if it makes you more comfortable, we will make sure of that by giving you whatever comfort you need in the legislation or whatever.

So those are some of the things that this regionalization does not mean, but what it does mean, and what most participants are in agreement with, is that it means a better co‑ordination of services in an area. It means that we bring in not only hospital administrations and personal care administrations, but also public health service people, mental health service people, home care people, the whole range of medical health services together and discuss and co‑ordinate and integrate‑‑these are words that get used all the time in this discussion, but those are the things that the goals are.

In other words, there is a very widespread acknowledgement that we have not been as efficient as we should be, even in rural Manitoba where they suggest they are more efficient than they are in the bigger centres. Even there they agree, not even reluctantly anymore, but they agree that something has to be done to rationalize our services better so that we put focus on the patient. That seems to be one of the guiding fundamentals that everybody has bought into, and we are glad they have.

Some now are saying, well, there is general agreement in our area; let us get moving. So right now, I am just trying to hold them back, because they want to move ahead. I commend them for that, but if they will just wait a little while longer while we finish off this appeal process so that others who do not feel quite so happy the way things have happened so far, they can have those issues addressed. Then we can all move forward together with association building in the future.

It takes a lot of consultation regionally, locally, and the government's role has been, I think, to help facilitate. Sometimes we have maybe gone a little overboard as a government in laying out guidelines to the point where some people have felt that, well, you know, we are just being involved in a process, like as the member for Kildonan (Mr. Chomiak) pointed out, it is a monologue disguised as a dialogue. But I think my efforts in the last few months have been to try to re‑establish what has been going on as a dialogue, and there is far less sense out there now that there is a preconceived result here and we are getting you to play the game. I think there are a lot of reasons out there for people to believe that their input is very determinative of what things might turn out like in the future.

Ms. Gray: I thank the minister for that.

Can he tell me, with this first phase of looking at regionalization completed, when exactly did this whole process begin? Is this something that has been recent in the last year or so, or has this been ongoing for a number of years?

Mr. McCrae: Through the aegis of the Northern/Rural Health Advisory Council, I think the more formal parts of this whole process began about a year ago. The Westman Integrated Strategy for Health had been in existence for two or so years even before that. That was a group that I think basically on its own initiative began discussions.

They did get funding under the Health Services Development Fund, so they were self‑starters out there, and through the Health Development Fund, they received some assistance from government to sort of show everyone else that through dialogue and consultation, progress can be made. We are grateful to the efforts of the WISH, as it is called.

* (2050)

Ms. Gray: Mr. Deputy Chairperson, for the record, to let the minister know in terms of regionalization and how he has explained it, I support regionalization of health services, as well, and think it is very important that the various communities involved within a particular geographical area identify what they see as their health needs and not only health needs, but social services needs, as well, at some point, if that aspect could be looked at so that the community is basically controlling the kinds of services that they are delivered, given that there has to be minimum provincial standards.

I would ask the minister, how does this regionalization process and these advisory groups that would be involved‑‑who is going to be making the decisions as to what are core services?‑‑because I know that the core services committee that is looking at health care services, particularly in rural and northern Manitoba, is now involved, and I am not quite sure which is coming first. Are the committees and the government first going to be determining what core services are in a community, or is it these new regional boards that are going to be looking at that?

Mr. McCrae: Certainly for the next year, the dialogue will be an advisory sort of capacity. I am not sure what the member means by core services, because in some very small communities you will not find any services actually located in those communities but delivered into them from somewhere else. It is a combination right now.

I think if you look at the average rural hospital you will see that core of services in the hospital that are fairly standard from one place to another.

I think, though, that with the help of the Centre for Health Policy and Evaluation over the next year‑‑and years plural, too‑‑regional boards and associations will be focusing, as I have said before, on the consumer of health care, looking at the determinants of health in a particular region, examining what the needs are.

For example, in some areas you will see a greater need for dialysis services. You might not see that in another region, so that region A might have it; region B might see fit to use their envelope funding to establish some other kind of service that they feel is important in their area‑‑obstetrics or whatever it happens to be.

Nobody, I think, has a really clear picture today, but I think those who have a clear picture of how the process should unfold are the leaders here, because we are going to be guided by fact and data‑based needs assessments in the future in developing health policy and health services. We are not just going to have a‑‑I do not know what kind of example to use because I will get in trouble if I try to do it, but a diagnostic technology that is popular, let us say.

You are not going to want to have them in every region necessarily. One region might have a diagnostic tool of one kind, and another will have the other kind. I do not expect to see the proliferation of all the fancy equipment and everything that you see at the Health Sciences Centre, for example. You are just not going to see it everywhere.

I do not think you are going to be able to have open‑heart surgery everywhere in the province. That is not what this is about either, because there is still the issue of cost to be dealt with. But a lot of the decision making, a lot of the needs assessing will be done regionally and locally and wherever asked for, with the help of centres like the Manitoba Centre for Health Policy and Evaluation.

Ms. Gray: Perhaps I can ask the minister then, the committee to establish core services for northern/rural health associations, the one where there are five physicians, 11 Manitoba Health staff, two hospital staff and no nursing staff, where is that committee at? Is that just formed? Where are they at in terms of defining core services?

Just to repeat, the committee that I was referring to was the Committee to Establish Core Services for Northern/Rural Health Associations. I am wondering, I would think that committee would be fairly integral in terms of looking at what kinds of services should be available in a particular community, what types of health services should be available, what types of health services then would not be available necessarily in your own community but might be available within the same geographical regional area, what kinds of specialized services does a person have to come to, let us say, Winnipeg for, and what kinds of services does a person have to go out of province for.

Mr. McCrae: Among the committee members there are nurses in that group. The terms of reference basically set out what the committee's role and function and mandate is. Amongst the people listed as committee members in the right‑hand column, I do not know how many but a number of these people are nursing professionals.